Population Health – The Pentagon Approach

Here in Morecambe Bay, thanks especially to the excellent work of Marie Spencer, David Walker, Jane Mathieson, Hannah Maiden and Jacqui Thompson, we have together developed a way of thinking about population health, which we call the ‘Pentagon Approach’. It draws on learning over a number of years from Public Health England and the World Health Organisation, and synergises nicely with the vision and approach of our excellent Directors of Public Health in Lancashire and Cumbria. It forms part of our overall population health strategy, which I want to give some focus to over a few short blogs. In this blog I will focus on the Pentagon and what we mean by each bit of it!

 

 

 

Population health means different things to different organisations, groups and individuals. However there is agreement that population health is determined by a complex range of interacting factors e.g. social and economic, lifestyle, access to services, including health, as well as our genes, age and sex.

Most of these factors lie outside of the health care system but have significant impact on individual and population health. Lord Darzi recently wrote in the 2016 WISH report (https://www.kingsfund.org.uk/publications/articles/healthy-populations) that we have talked about making a difference to population health for decades, but no-one has really grasped the nettle to make the changes we need to see, particularly around health inequalities. Responsibility for addressing these issues are fragmented. Therefore we need to ensure that we work with a multitude of partners to:

  • Understand the problem and set clear goals for improvement
  • Focus on the determinants of health and not just health care
  • Generate shared accountability
  • Empower people and communities and develop their capabilities
  • Embed health equity as a core element.

Therefore Population Health in Morecambe Bay is defined as:

The health outcomes of our citizens as a group, including the distribution of those outcomes across the geography of Morecambe Bay.”

In Morecambe Bay, we have developed a way of thinking about Population Health through the means of five key strands, namely – Prevent, Detect, Protect, Manage and Recover.

Various definitions currently exist around these words, but in Morecambe Bay, the definitions will be used as follows:

Prevention

Prevention means preventing disease or injury before it ever occurs. This is done through:

  • Working with communities and other partners to tackle the underlying social determinants of health (e.g. living and working conditions, social isolation, health literacy etc.)
  • Encourage the development of health in all policies
  • The promotion of positive behavioural choices which improve a person’s health and wellbeing (e.g. stop smoking, reduce alcohol, take regular exercise, eat healthily)
  • Preventing exposures to hazards that cause disease or injury (e.g. through hand hygiene, health and safety )
  • Increasing resistance to disease or injury, should exposure occur (e.g. immunisation programmes)

Prevention can be primary (before a diagnosis) or secondary (after a diagnosis), but always refers to creating an environment that supports healthy choices, lifestyle changes, rather than medical intervention.

Detection

Detection means early recognition that:

  • a person is developing increased risk factors which may predispose them to a more serious condition (e.g. obesity, rising cholesterol, high BP, low mood)
  • a person has developed a chronic condition, for which they will need further protection (e.g. COPD – chronic obstructive pulmonary diease, Type 1 Diabetes Mellitus)
  • a local population are more at risk of developing a particular condition/set of conditions (e.g. detection of childhood obesity rates, high rates of smoking, high rates of alcohol use, poor housing or air quality )
  • a local population has worse health outcomes than another, requiring appropriate resource allocation (e.g. poor cancer survival rates, high rates premature mortality, low access to preventative interventions)

Protection

Protection means:

  • to protect someone from developing a condition of which they are at risk, through medical intervention (e.g. starting antihypertensive medication) – this would also go hand in hand with some further prevention measures
  • to reduce the impact of a disease or injury that has already occurred (e.g. ensuring protection after a first MI of having a second MI through strict treatment of BP, cholesterol and kidney function, smoking and dietary advice)
  • to soften the impacts of an ongoing illness or injury that has lasting effects (e.g. helping a person to understand a chronic condition they are living with, through structured education and ensure best evidenced treatment, to help them live at optimal health)
  • to protect someone from developing a more serious condition, through surgical intervention (e.g. prophylactic bilateral mastectomy)

Management

Management means:

  • to provide appropriate advice, treatment or referral for a single episode of a health complaint (e.g. minor ailments )
  • to intervene at the time of a medical or surgical emergency with best evidence-based practice (e.g. transfer to a cardiology centre for management of a STEMI – [heart attack])
  • to treat an exacerbation of a chronic condition through a best evidence-based intervention (e.g. an acute exacerbation of COPD)

Recovery

Recovery means:

  • helping people manage long-term, often complex health problems and injuries in order to improve as much as possible their ability to function, their quality of life and their life expectancy (e.g. through cardiac/pulmonary rehabilitation, community integration, support groups, social care provision, vocational rehabilitation programmes, links to financial advice)
  • recognising where people will not recover and enable good palliative care and a good death

This Pentagon describes our ‘population health approach’, but is not the complete picture of how we think about population health. More on this in some follow up blogs and vlogs.

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Never Let a Good Crisis Go to Waste

So, the NHS is in another winter crisis.

The Oxford English Dictionary defines a crisis  as:

1 A time of intense difficulty or danger.
‘the current economic crisis’

Mass noun ‘the monarchy was in crisis’

1.1 A time when a difficult or important decision must be made. As modifier ‘the situation has reached crisis point’
1.2 The turning point of a disease when an important change takes place, indicating either recovery or death.
Origin
Late Middle English (denoting the turning point of a disease): medical Latin, from Greek krisis ‘decision’, from krinein ‘decide’. The general sense ‘decisive point’ dates from the early 17th century.

 

A crisis is still a crisis, even if you see it coming. What is vital, as per Winston Churchill, is that a) we don’t waste this moment, but allow it to be a true tuning point and b) we don’t rush prematurely to actions to try and solve it, but ensure we look deep enough and far enough and then move towards collective steps for an altogether different kind of future.

 

I think there are some difficult and inconvenient truths that we need to face up to together. If we can do so, then we can move beyond sensational news cycles into co-producing something really exciting. Here are my incomplete thoughts about where we might want to think about starting:

 

  1. We need to get some perspective! One of the dangers of believing everything is bad is that we start to believe that the NHS is over. It is not over. It is 70 years old and it is transitioning, but it is not over! In the crisis we find ourselves in, let’s remember why the NHS is such an incredible thing and why its integration with social care is so vital. The Commonwealth Fund rates the NHS as the BEST healthcare system in the world, when it comes to equity, care and accessibility. However, our outcomes are significantly worse than that of our peers – there are some really important reasons for this, which we need to understand better. One of the major reasons is that our goals are so short term, that we cannot bring the long term changes to the health and wellbeing that we need – and this is caused by the way the NHS is run and the nature of our political cycles.
  2. We need to stop the boring, binary, partisan nonsense that is the political boxing match. It really is grow-up time when it comes to our arguments. There are some very different perspectives on why we’re in the crisis we’re in, what we might do about it and how we should go about those things. However, shouting our perspectives ever more loudly, whilst never encountering or deeply listening to the other perspectives in the room make it impossible for us to find an effective 3rd way forward together. We are well versed in the blue vs red options, but let us be honest, please. Neither the reds nor the blues are wholly right, and neither is wholly wrong! It is absolutely OK to hold different perspectives, but the manner of our arguments is astoundingly pathetic. Whilst all this shouting goes on, there are several perspectives that are not being heard, important voices, those of the patient, the carer, the poor etc. We need to stop our reactionary, swing left, swing right steering of this great ship (and that’s not to say a centrist approach is best either!) and learn to have some humility. Humility starts with listening and being willing to change. This is being so beautifully demonstrated by the Rose Castle Foundation and Cambridge University through their work with the vastly differing world views of Conservative Islam, Judaism and Christianity and offers us much learning and hope for the NHS and indeed any other of our deeply held belief systems. Anyone willing to have better conversations and find a way forward?
  3. The maths simply doesn’t add up. We need some honesty.  A few weeks ago, the head of NHSI Jim Mackey, said that by April the NHS will be in around £2.2billion of debt. That is a very conservative estimate. It is a mathematical impossibility to close wards and scale down the size of our hospitals at a time when district nursing numbers have reduced by 28% over the last 5 years and social care is on its knees AND sort out the deficit! We know what the direction of travel needs to be, but the equation is simply unworkable, due to time and workforce pressures.We need to understand the true scale of the problems we’re facing and be real about how much money is going into health and social care spending compared to what is actually needed.
  4. The reason for this is that health and social care funding is becoming more costly and more complex. Our population is growing in size and people are living longer – this is great, on many levels (although we still need a much better conversation about death and why sometimes we keep people alive, when we could allow them to die well and peacefully). However, as we grow older, we develop more health conditions, and social needs, which require more costly treatments and packages of care, which we’re simply not accounting for, especially when we know the predictions of how our population will grow and age over the next 20 years.
  5. We therefore need to have a long term vision of how we want to build the most safe, excellent, effective, equitable, efficient, compassionate and kind health and social care system in the world whilst recognising in order to so, we will HAVE to make some upfront, BIG investments. It is simply impossible to have double austerity on health and social care and then believe we can do the transformational work necessary for the future change we need. Austerity has woken us up to the fact that there are some inefficient ways of working and some things we could definitely do more effectively in partnership. We’ve learnt that now. However, as a philosophy it is now defunct for where we need to go.
  6. This means, we have to put significantly more money into the system now. Once we have done some more work on the vision and plans for the future (the 5 year forward view is too short and although sets us up a good trajectory, is not ambitious enough), we need to ensure there is a sufficient injection of cash (not removal of it) to make this possible. So, we have some options available to us. A) We could increase tax for everyone – something that 67% of our population seem to be willing to pay. B) We could close tax loopholes and ensure that companies like Amazon and Google pay the tax that is owed. C) We could also increase our GDP % spend on health and social care – remember, currently, we have one of the lowest % spend of any of the other OECD nations. Perhaps a combination of all of these things is necessary.
  7. Creating long term health and social care solutions means that we have to put population and public health as the foundation of the system. We know that prevention is better than cure. We know that if we promote health and wellbeing, disease will be far from us. The disinvestment in these areas and the over reliance on a very stretched and struggling community-voluntary-faith sector is a recipe for disaster. There is huge work to be done in deeply listening to and working with our communities to improve the health and wellbeing of everyone, using the best research, evidence and data available to us through our public health bodies in order to make this shift.
  8. This means we need to continue to tackle the wider determinants of health and think radically about these things as being serious public health issues. This is how the city of Glasgow has gone about tackling knife crime and London has much to learn. We need to apply wisdom and learning to things like smoking, sugar, alcohol, pollution, drugs, road traffic accidents, domestic violence, suicide and adverse childhood experiences. We also need to develop a radically generous philosophy to the areas of job creation, housing, land rights and the care of the environment of which we are stewards not lords.
  9. We have to take greater responsibility and care of the health and wellbeing of ourselves and of those around us. It is not possible for us to have a national health and social care system that is sustainable if we think we can live exactly how we want whilst thinking someone else will simply mop up the mess or pay the tab. Our sugar, food and alcohol consumption, lack of exercise, driving, smoking and drug habits are all areas where we do have to take greater responsibility. NHS staff need to lead by example here. They are also areas where government give those lobbies far too much power and where we need better legislation to help bring about change. It is a both/and not an either/or approach.
  10. We need to create a much more shared-care approach with patients, co-partner with patients to enable them to understand the conditions they live with so that they are able to self-manage/self-care more effectively and create community support groups.
  11. We need to use digital solutions to full effect. We need to widen the access to patients having their own online records, the sharing of data across the system and getting savvy with better apps and technology for the benefit of patients and communities.
  12. We need to change our expectations of what we believe our ‘rights’ are in terms of health and social care. As an example, people phone up a GP surgery and want to see a GP. But there are MANY other allied health and social care professionals who may be better placed to sort out the problem. However, a recent survey in Gosport showed that of the people who phoned up wanting to see their GP, only 9% of them actually needed to see their GP and the rest would have been dealt with more effectively by someone else. We need to get used to the fact that we don’t have enough GPs available for everyone to be able to see one every time they would like to, but there are other professionals who are equally able to help. Another example is that everyone wants to safeguard their local hospital and we tend to have a fixed belief that being in hospital when we’re ill is the best place for us. Actually, especially when we’re older we can receive just as good care at home or in a nursing home and being admitted to hospital adds very little benefit. However, in order to have smaller and therefore more affordable hospitals, we really do have to ensure we have the necessary infrastructure and staffing around community nursing, social care and General Practice. Currently this is not the case and it takes time and investment to grow this workforce.
  13. We need ensure we are training and recruiting the right skill mix of people for the right jobs. This means we need to think at least 20 years ahead with the predictive statistics we have available to us and do some proper workforce planning. We’re are far too short sighted. This will take financial investment now, as stated above, but if we get it right, will leave us with a far more effective and efficient living system in the future.
  14. Our medical, nursing and therapeutic school curriculums therefore need to ensure they are training students for the kind of future we need. We need a complete redesign of some of the curriculums and we need to change the way training is done. As part of this, we need to ensure we are raising good human beings, not just good professionals, with values, culture and great communication skills built into all of the process.
  15. We have to redesign the contracts, as unfortunately without this, some of the behaviour changes simply will not happen. The current contracts across health and social care are the very antithesis of what is needed.  This will take some bravery and leadership, but it is time to grasp this nettle. Without this, we will behave perversely because the incentives driving the system and the nature of competition laws are detrimental to the collaborative future we need.
  16. We can only do all of this together. This means our staring place in all of this is to own up to the fact that in all of the above, we simply don’t know. From the place of not knowing, we can ask great questions, bring our bits of expertise to the table and build a jigsaw. There is expertise in national and local government, but certainly not all the answers. There is expertise in the health and social care clinicians, practitioners and managers. There is expertise in our communities and with people who have lived experience of the various complex issues we face. It is only together that we can face the future. Let’s break out of our camps, our deeply entrenched belief systems and find a new way of dancing together. The future belongs to us all. Together we can.

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A 3 Fold Approach to Population Health

Here in Morecambe Bay, we are trying to develop a strategy around Population Health – by that we mean we want to take a much broader view of the health needs of those who live in this area, ensuring that we try to tackle the disparities we see in the health of our population. In my opinion this needs a three fold approach.

 

Firstly, we need to get our own house in order. We know there is work

© www.stevenbarber.com – Dr David Walker

for us to do as a health system when it comes to ensuring we’re proactive with people’s health. With the resources we have available, we need to ensure that we are treating preventable conditions as well as possible and use the best evidenced-based approach to the care we are delivering. That is why, the excellent Medical Director of UHMB, Dr David Walker, with his vast experiencing in Public Health, is helping us focus on making a significant difference to preventing Strokes (CVAs – Cerebro-Vascular Accidents) across the Bay this year. We are making a concerted effort to ensure that all our patients are getting the necessary pulse checks, blood pressure checks, blood tests and appropriate medications to monitor and manage conditions which can lead to devastating consequences if left untreated or mismanaged. Within this, we are encouraging people to know more about the conditions they live with, understand them and take responsibility to ensure that they are caring for their own health.

 

Secondly, we are working with people across the Bay to live more healthy lives. We continue to see more and more children running a mile a day and hope that this will soon become the Morecambe Bay Mile, in which it becomes the norm for everyone who lives here to move a mile a day. Our sedentary lifestyles are hugely affecting our health and we’re wanting to encourage all business owners and leaders to ensure that staff have time to be active every day. On top of this we’re starting to work with schools around healthy eating and involved in projects with supermarkets to enable people to make more healthy choices in the face of fierce advertising. We’re also working with high schools around mental health issues and seeing many community initiatives springing up, run by the community for the community, which will improve the wellbeing of all. All of this is backed by our ‘Flourish’ work in our hospitals and ‘Let’s Work Well’ in the community, in which NHS staff are leading by example in changing the way that we work and live.

 

Thirdly, however, we need to dig deeper. We keep trying to put a sticky plaster over the great pus-filled abscesses that are the leading causes of ill health in our country. Traditionally we have paid much of our attention to dealing with the symptoms of ill health, and whilst thinking about the root causes, we have simply not putting anyway near enough time, energy, or resource into tackling them. The reason for this is two fold: firstly, health and social policy is directed far too much by the political cycle and the short term gains that can proven in small time windows – so we keep tackling symptoms because we can then prove how effective we are!; secondly, in truth, we don’t actually know how to tackle some of the issues and those of us in leadership roles are far too clever and proud to admit that we don’t know how to fix them and that we need to find a new way together, with the communities of which we are a part.

 

I was having a conversation with Cormac Russell the other day, via twitter, and he gave me this beautiful quote by Ivan Illich: “I believe it is time to state clearly that specific situations and circumstances are “sickening”, rather than that people themselves are sick. The symptoms which modern medicine attempts to treat often have little to do with the condition of our bodies; they are, rather, signals pointing to the disorders and presumptions of modern ways of working, playing and living.”

 

The reality is that many of the determinants of our health and especially of the health inequalities we see in our society have little to do with the availability or quality of services. No, the biggest factors affecting the health gap in this (and every) area are poverty, housing, loneliness, hopelessness and adverse childhood experiences. If we’re not careful, we end up thinking the real issues are waiting times in the ED, difficulties discharging people from hospital, breaking the 18 week target for hip and knee operations and ensuring there are enough GP appointments at weekends. We must not look at the symptoms and believe that if we tackle these surface issues then we will automatically have better health outcomes for all. Here in the Bay, we are trying to be brave enough to take off the sticky plaster and gaze into the festering wounds in our society, so that we can begin to really do some deep debridement of them and allow real healing to ensue.

 

That is why my team are focusing on hosting conversations that matter across our communities and seeking to co-create a social movement. Using the ‘Art of Hosting’ we are holding spaces open in which rich conversations can happen. “We don’t just want people to be more healthy and well – many people don’t even know what that means”, as an amazing woman called Gill, from the West End of Morecambe told us recently, “No, we want everyone to be able to experience life to the full, whatever that means for them”. We can’t do this simply by having good clinical strategies – we need something far more holistic and it will involve all of us.  We need to start our conversations together with appreciative inquiry. What is already going well? What can we learn from here? Knowing what is good, however, is not enough – we must go further, dig deeper and get to grips with some extremely difficult issues.

 

When it comes to Poverty, here in Morecambe Bay, we are trying out new economies (like time banking) and having challenging conversations. The Poverty Truth Commission is causing is to really listen to those with lived experience of poverty and learn to co-create and co-commission services, rather than presuming that the ‘experts’ know best.

 

When it comes to homelessness, inspired by the work in Alberta Canada (https://www.goodnewsnetwork.org/find-out-how-this-canadian-city-has-eliminated-homelessness/) and the Manchester Homelessness Charter (https://charter.streetsupport.net/) – we’re beginning to explore ‘housing first’ for Morecambe Bay, but imagining what it might be like with extra support in place from a caring community like ‘The Well’ in Morecambe and Barrow (https://www.thewellcommunities.co.uk/). I’m so pleased that Dave Higham is provoking this conversation for us here and I’m excited to see where a conversation between those with lived experience of homelessness, poverty and addiction, along with some of us in the public sector, might take us. There’s a challenge to all of us in society – we like the sound of these kind of things, but not in our own backyard….our values must begin to align with our actions. Love without action is not really love.

 

And what about loneliness and hopelessness? More than ever, we need connection across the generations, turning off our screens and actually being together as humans. In Morecambe we are seeing the launch of the new Morecambe Fringe in September, bringing people together around Comedy and the Arts. More Music are doing incredible work with young people. There are amazing community initiatives right around the Bay. We have loads of festivals connecting people across the district. And what is the role of business here? We need businesses to think abut what kind of enterprise we could see emerge for the youth in our area. Are there more opportunities for mentoring? We have left many of our young people to boredom and with few aspirations. With the help of Stanley’s Youth Centre and the great heart of Yak Patel, we hope to host many conversations with young people to really listen to what it is we could create together to break these problems and build community and hope.

 

What are we together going to do about the huge issue that is child abuse? We don’t have answers, but we do have questions – and we need to keep asking them. We know that the mental and physical consequences of abuse are utterly devastating and we find it hard to talk about because it affects so many of us. But our interventions are happening too little, too late, and we are missing the vast majority of cases. Our services simply cannot cope with the volume and serious case reviews tell us the same lessons nearly every time. So what? What are we going to do differently? There are definitely things that the public services can do better – but not when our resources are being stripped. What is especially terrible about the cuts to services in our most deprived areas is that ACEs cause poverty, homelessness, isolation and ill health! As a team, we take this really seriously and will be hosting discussions in our schools and local communities about how we raise happy, healthy children. Where is help needed? We’ve become so focused on grades and outcomes in schools…..but do we teach people what to do with their anger? Do we focus enough on values? Are there enough parenting (the hardest job in the world) classes – and if so, are they hitting the mark? What do we need to do differently? We know the situations in which children are more likely to suffer – so what? Have we become so focused on getting people into work that we’ve forgotten just how important parenting is? And if we know that ACE is such a massive issue, are we really making the right choices in terms of what therapies we’re making available for those who have suffered them?

 

Is it the role of those of us in healthcare to get involved in these discussions? YES! It is the role of all of us in society. Together, we must reimagine the future. We all know that prevention is better than cure, but our short-termism is stopping us from finding the kind of positive solutions that will really make a difference. In face of downward pressure from hierarchical powers, it is tough to make brave decisions to invest in the future, rather than cut our way to balancing the books. But if we really care about the health and wellbeing of our communities, then we have to stop the sticking plaster approach and clean out the gangrenous wounds in our society. We have to deal with the root and not the fruit.

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Doing the Impossible – Turning the Tide!

It’s time to do the impossible. It’s time to turn the tide.

imgres.jpgIn my last blog, I talked about the exponential potential of what could be possible if clinicians worked together in a more collaborative way. However, far more can be achieved if we work together in and with our communities to create a social movement together around being more healthy and well. I’ve talked previously about the “battle royale” that occurred between Béchamp and Pasteur over whether we should promote health or fight disease. The answer is, of course, that we need to do both, but the clinical community is not equipped with the resource or power to do it alone.

What we cannot accept, though, is our current apathy or malaise that some of the health imgres.jpgcrises we now face are too much for us to do anything about. We are in the midst of a battle, which we are currently losing and it is time to gird our loins for a turning of the tide. Here in Morecambe Bay, we have started a conversation, not just among the Clinical Community but with the wider population about how we might become the healthiest place in the UK. Yes, we mean this in a very holistic way, but there are also some specific foci we have so we can together reverse some of the appalling health statistics we are facing.

For too long, we have simply laid down and allowed exercise to be taken out of schools, whilst our kids consume a bath full of sugar every year. All the time our own work and eating habits have become significantly unhealthy. We have relied on expensive drugs to fix our problems, rather than tackling the root causes of our excesses. It has lead to 1 in every 5 pounds in the NHS being spent as a direct result of our lifestyles and 1 in 11 pounds being spent on diabetes. We say we value the NHS above anything else as a nation (maybe an issue in it’s own right…..) but we do not behave in ways that show this value to be true. We have not been brave enough to challenge the status quo and together make a wholesale change both about how we promote health and look to aggressively reverse it when things begin to go wrong.

images.jpgI suggest that within a generation, if we wanted to, we could render Type 2 Diabetes a rare diagnosis. We can do this through encouraging far more healthy lifestyles in our children and young people now, like running a mile a day and learning to eat food that doesn’t actually harm them! I believe we could significantly reduce the need for so many people to be taking medication for hypertension and diabetes now, prevent many strokes and heart attacks, by being violent towards these conditions with major changes in lifestyle, though diet and exercise, rather than the prescription of drugs, using coaching, peer support and local champions to give psychological motivation and encouragement. We are beginning to have some excellent discussions and develop some exciting plans around this.

Our NHS health checks should serve as a major motivational opportunity for someone toimgres.jpg pull themselves back from the brink of a lifetime of medication and we should use all medication reviews as a chance to help people adopt lifestyles that might reverse the need for such drugs. In the process, we would also significantly reverse our number of cancer diagnoses – many of which are linked to our lifestyle choices. We simply can’t afford for our current and failing approach to continue. We need to be braver together! And this means the NHS must be willing to partner in new ways, not only with local people, but also with businesses like the major supermarkets to help reverse our current direction towards the abyss, in which there is no longer a healthcare system that serves the needs of everyone, no matter where they come from or how much they do or don’t earn.

Don’t get me wrong! We should absolutely use medication to its fullest use for those who are at risk and have not responded to major lifestyle changes. For example, we can wage war on Atrial Fibrillation, ensuring far more appropriate use of anticoagulation, in the most cost effective and safest way, therefore preventing many life-changing strokes in the mean time. And for those who, despite lifestyle measures, still have a high blood pressure or continue with diabetes, we should not withhold medication that would prevent major issues later on. It’s just at the moment, we’re reaching for the prescription pad too readily and not looking to reverse conditions completely before they set in. We need more education out there around the early signs of cancer, so we can hit it early and reverse it’s effects when we have a better chance. Respiratory disease is another area where we could seriously make a change. We need to think of ourselves as one big respiratory team, tackling smoking, housing damp and carpeting, whilst ensuring every person has an understanding of their condition, how to use their medication effectively and what to do when things flare up. A cohesive clinical community really could deliver something special in each of these disease areas.

We could also be a great deal more effective in how we care for the frail elderly. We don’t need anywhere near as many hospital beds. We can provide care in residential and nursing homes, avoiding double payment for beds, by shifting resource out of our acute hospitals and into the community. We need to have a far more grown up conversation about why we admit people to hospital when there is very little proven benefit of doing so.

Taking a strategic shift towards a social movement for health, significant lifestyle changes and treatment only after these things have been given serious attention, but unapologetically so once they have, we can turn back this battle at the gates and change the health of this nation for generations to come. We can undo the unaffordable situation we find ourselves in and discover together a much more healthy future.

images.pngWe can absolutely do this!! It’s going to take some serious resolve and we’re going to have to withstand the fear and pressure of some pretty powerful lobbies, like the sugar, alcohol, tobacco and pharmaceutical giants, and perhaps even the government itself, but it is time for us to do the impossible. With love, hope and faith, we can do this! Yes we need to focus on schools and work places. Yes, we need to partner with organisations we’ve never worked with before. Yes, we need a far more effective media strategy and yes, we need to allow clinicians to work very differently. But we cannot do nothing. So let’s try something a whole lot more radical. That’s what we’re going for in Morecambe Bay – not just better care together, but better health together – you can watch and wait, and see if we sink or swim, or you can join us!

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A Collaborative Clinical Community 

*Warning – this blog contains swear words (not that I’m usually a potty mouth!)

This last week we had a gathering of clinical leaders around Morecambe Bay – Nurses, Occupational Therapists, Health Visitors, Midwives, Doctors, Surgeons, Physiotherapists, Pharmacists etc. We were gathered from across primary and secondary care to look together at the financial deficit we are facing as a health community across the Bay where we are seeking to serve our population.

The debt we’re facing (a hole of around 38 million of our English pounds!) is no small thing. Most of it is historic and much of it had nothing to do with us. I spent my first eighteen months as a commissioner feeling furious at the government. I wanted to rail against the machine, the injustice of working in such an oppressive, top down and hierarchical system, which feels like being among the Hebrew Slaves in Egypt when they were told to make the same number of bricks with less resource available to them. I felt so angry with the fact that we invest so little of our GDP into health and social care compared to similar countries and when further unthought through policies were dictated from Whitehall, I felt a total rage. It doesn’t help being politically pretty far to the left and working under a regime to which I feel ideologically opposed.

But one day, I realised two things. The first thing I realised is that the government are not going to change their position or policy. Our systems of government are not set up in a relational, collaborative or solutions focussed way. It doesn’t have to like this, but this is the way it currently is. Our systems have become the very antithesis of their purpose. Rather than serve the needs of the people, the people now serve the systems. The second thing I realised was that my anger didn’t achieve anything except to make me feel tired, disempowered and stressed. I had retreated into the less healthy parts of my personality in which I was keeping false joy alive and feeling burnt out in the process.

Truth has the ability to set you free. When we face truth, no matter how painful, it gives the choice of being more free. Facing up to the truth that the government are not about to change their modus operandi and that I was feeling angry and stressed allowed me to step out of rather childish thought processes and step into something altogether more wholesome. It allowed me to step out of a false sense and rather oppressive noun of responsibility and gave me the space to think more creatively about how I am part of a community of people who can respond to the situation we find ourselves in. We can respond (verb) once we step out of the oppressive yolk of responsibility (noun).

So, those of us in clinical leadership may have not created the financial situation, but there are some stark realities for us to face up to. Whether we like it or not, our current ways of working carry much waste, caused partly by the way the finances of the system operate, but also because we have not thought of ourselves as one. There are ways we behave within the system that create more financial problems and do not serve the community as well as we could. And so it is time for us to do what we can, within our gift by being much braver in our approach. I am suggesting that there are three Cs that are vital to our future.

  1. Collaborative

imagesWe need to reimagine ourselves as all being part of a team who are together tackling the health crises we are facing. We know only too well that, as just one example among many, we are failing kids with asthma because we have not joined up our resources or thinking adequately enough. Yes there are major issues with housing, smoking and pollution, but let’s not point the finger or push the problem somewhere else. Let’s use the phenomenal brains God has given us to pull the right people round the table and work out what we’re going to do about it. Let’s change the way we spend our time so that we’re in schools, we’re listening to our communities and we’re partnering together outside of our normal comfort zones to change the health of the generations to come. We know only too well, that if we don’t shift our focus towards population health and work more intentionally with our communities, doing things with them rather than too them, we will never win this battle. We’re not about playing political games. We are about working with our communities to create optimal health for every person no matter who they are or where they are from. We need to be braver, push the boat away from the shore we know and face the uncertain waters of working altogether differently. In my next blog I will explore some of the possible ways we could work differently.

2) Clinical

In order for the NHS to adapt and become sustainable for the future, we must not be afraid of clinical leadership. Our managers have a phenomenal set of skills, which we must draw on, but there is a trust we have amongst the communities we are embedded in that means they will trust us, if we engage with them properly that will allow us to turn this ship in a new direction. We must partner with our managerial colleagues, but be braver about the direction in which we know deep down we need to head in. We have gained so much expertise and trust and this is not a time to waste it or bury our heads. We must be braver and bolder in our vision of what we can really achieve together.

3) Community

iuAs clinicians we must, as many have stated this week, build bridges not walls. There is far too much division, suspicion and competition amongst us. (Here comes the swearing)…..I was in a conversation with a consultant colleague recently and he was relaying to me that another consultant referred to GPs as a “bunch of Fuck Wits”. In a separate conversation, one of my GP colleagues referred to consultants as a “bunch of arrogant Shits”. These kind of attitudes pervade the NHS and have created a culture of dishonour, distrust and division. Honestly! We’re better than this. How are we going to create the new workforce of the future that works across our currently artificial boundaries if we don’t teach them basic respect? This week a patient came to see me because he was dismayed at having to have seen a nurse at the hospital after suffering a significant condition and wanted to check that I, as a doctor, was happy with what he had been told. I could have laughed it off, but I wanted to stand up for my nursing colleague, who actually has far more expertise in this area of medicine than I do. The advice he had been given was perfect and completely in line with the best guidance available. We must not be afraid to challenge attitudes that are antiquated and out of place. More than ever, we need a culture of honour. A culture of honour is one in which we believe the best of each other, speak well of each other and appreciate our brilliantly necessary but differing gifts and expertise. We need to work out how we work effectively together for the best of the people we serve. We need to connect with each other and rehumanise the system in which we work. When was the last time you met as a cross cultural or multidisciplinary team and simply told each other what you love and appreciate about each other and the work you do? If we can’t learn to be more relationally whole, we will continue to work in the midst of serious dysfunction and strife. Come on – amongst us we have some remarkable gifts of wisdom, healing and hope. Let’s build the kind of culture and community amongst us that stands shoulder to shoulder, changes the story in the media and speaks with one voice to the powers that we are about the a new way of working together through relationship not hierarchy and fear. What might we really achieve together? It is this kind of collaborative clinical community that can change the future of healthcare, not just in the UK, but right across the globe.

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Solutions Focused Thinking in Population Health

My last blog focused on how we can think about solutions instead of problems in the NHS. Well the same is true in thinking about the health of our whole population. Yes there are some problems! We have growing health concerns with obesity and diabetes. We imageshave huge health inequalities. There are major issues with housing, economic policies that are not working for huge swathes of our population, with more people having to use food banks, struggling with fuel poverty, living in damp houses and unable to make ends meet. Yes, our kids are spending more time on screens and less time in activity. Yes, the sugar lobby, alcohol lobby and advertising giants have far too much power. Supermarkets are designed deliberately so that we buy things that are bad for us. And sometimes, we just make poor choices (if you can call them choices, which for some people, they aren’t always) – we do not all live as healthily as we could – we eat the wrong stuff, work highly stressful jobs, and exercise less than we are recommended to. Mental health issues are on the rise, especially for teenagers, due to crazy targets and league tables, with all the pressures they face. We are less happy and more separated than we ever used to be, despite the rise in social media…..(or maybe because of it……)…..Man, I can paint a negative picture – it’s like storm clouds and darkness everywhere……..

 

imagesBut what if it wasn’t that way? What if we got a bit angry about it, but instead of finding someone to blame and pointing the finger; instead of getting all tribal and throwing stones at others, we chose to use our energies creatively to find solutions, to work together and make positive changes?! Let’s put away our pointing fingers and our ranting tongues and let’s work together for a better future for everyone! Doesn’t that sound good?! It’s what we’re trying here in Morecambe Bay, and I’m hoping it spreads like wild fire so that we can become a place where health abounds and beauty surrounds (that’s the motto of this place!). That doesn’t mean we stop speaking truth to power, but we also let our actions (and maybe our votes) speak louder than ever before.

 

imgresWe’re talking together, taking time to dream about what it would be like if we were the healthiest area in the UK. We’re training up many people to host conversations, so that we break down walls and learn to collaborate for the sake of everyone. We’re not just dreaming about physical health, but mental, social and systemic health as well. We’re encouraging those who want to rise up and take some leadership, to be pioneers in the stuff they are passionate about. Even in my little town, we now have a mental health cafe that is literally saving people’s lives, because a lady called Jane wanted to make a difference. We have a cafe for all the people who have circulation problems because one of our nurses wanted to break people’s isolation and improve their healing rates at the same time. imagesWe’ve got a carers cafe, a dementia cafe and will soon have a breathing cafe for those who have severe COPD, sharing ideas and diminishing anxiety. We’ve got exercise classes to help with pain, a community choir, dog poo wardens to help us take more pride when we walk down the street and food banks to help those who can no longer afford to eat.

 

image[1]We have 2000 kids aged 4-11 running a mile a day at school with staggering results for our children here in terms of physical, mental and educational health. We’re hoping over time, this becomes the Morecambe Bay Mile, part of a cultural shift towards being more active. We are working with local chefs and supermarkets to enable people with pre-diabetes or weight struggles to eat more healthily.  We’re choosing to lead by example in the NHS to work well and flourish in our work places. We’ve made a commitment to see the 5 ways to wellbeing in every NHS organisation and we’re hoping many other systems and businesses will follow us in this. We’re finding radical ways to help people who are struggling with alcohol and drug addiction, get free and stay free with amazing results. We’re helping people live well with and beyond cancer.015c74b06779fe8d8496d585fb9865ea We’re changing the way consultations happen in the NHS to enable people to make more informed and better choices about their own health and conditions, so they feel empowered to make changes that work for them rather than beaten up when they go for an appointment! We’re launching the Morecambe Bay Poverty Truth challenge, learning from those who are lived NAWIFUexperts in poverty to help us work together and care better for those most struggling in our society. We’re having difficult conversations about death to help people be prepared for every eventuality.

 

All of this has started in the last year! What else might be possible? What other dreamsimages will be awakened? What other partnerships, collaborations and relationships might be formed? Being all tribal and accusatory of others saps our energy and stops us being creative. Mud slinging and blame will achieve little. We have to work from where we are. We have to build bridges and work together. We have to build a future of positive peace and that means binary thinking is over! The future doesn’t have to be full of doom and gloom. It is alive with hope! What resources might  we find? What talents might we discover? What might we see develop over the next 12 months/years/decades as we look for solutions together for a better future for everybody? Don’t you feel just a little bit excited?

 

 

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