Tag: poverty

Black Swans and Poverty

Here is a copy of the speech I recently gave at Morecambe Food Bank when Heidi Allen MP and Frank Field MP came to be with us and to listen to the community here in Morecambe Bay about our experiences of poverty. There were some incredibly moving testimonies from community commissioners of the poverty truth commission. This was my contribution:

 

“First of all I would like to start by saying thank you. Thank you to all of you for being here to talk about these really important issues. Thank you to my friends, Karen, Emily and Daniel for being brave enough to stand up today, to tell your stories and to allow yourselves to vulnerable and to be heard. Thank you to my friend Siobhan for being willing to speak out consistently about the realities that children in your school and this surrounding area are living with, and for doing so, despite unfair and untrue things being said about you in the public domain. Thank you to Annette and the team here at Morecambe Foodbank for your hospitality, generosity and welcome here today and for all the ways in which you provide for people in this community.

 

Thank you to Si Bellamy from the Eden Project – we’re so grateful for the hope that your partnership brings to this area and for the common values we share in wanting to uncover and deal with our deep systemic issues and injustices and co-create an economy and way of being as community that really works for humanity and the planet. Thank you to so many of our friends across the voluntary and public sectors for being here today and demonstrating our sense of unity in working together with our communities. And thank you Heidi Allen and Frank Field for choosing to work across your differences and to come and be with us today and to listen.

 

Today is not only about Morecambe. Morecambe is an amazing town full of wonderful people and there is a huge amount to be celebrated here. In fact, we could be having this same conversation, with similar but different and important communities across the water in Barrow, or over in Scarborough or down in Hastings because these same issues are found everywhere. Today is about coming together to really listen and to the reality of just how complex some of the issues we’re facing really are, like poverty, and the way it intertwines with many other aspects of our lives, for example our health and wellbeing.

 

Until 1791 people in England believed all swans were white. That was until a black swan arrived on these shores, brought here from Australia. Sometimes we can hold extremely fixed positions and ideas in our minds, until we are confronted by something which causes us to see the world differently. One of the truths about poverty is that it is an incredibly complex and wicked problem. And so it doesn’t help to entrench ourselves in our positions and throw stones at one another once those ideas are challenged.”

 

Robert Peston was right in his devastating analysis that we have become divided. So quickly we enter a blame game over poverty. “It’s your fault I’m poor”, “no, it’s your fault you’re poor”. But all this does is create more polarity, more distance between us as we become ever more entrenched in the certainty of our own arguments and perspectives. But that way of being is failing us, the 3 million children living in poverty and the hundreds and thousands of people who are now destitute. Trying to solve complex issues with overly simple questions is landing us in a mess! We want quick answers and we want to fix things but we do not appreciate the unintended violence of our policies and projects because we have not taken the time to listen, to understand or learn together. But when we do, we discover that not all swans are white and we begin to realise that we can longer continue to see the world that way.

 

The theologian, Samuel Wells, speaks of poverty as not being primarily about deficit, a concept that leads us into blame and heroism. Rather, he recognises that it is our dislocation, our isolation, our separation which is the real root cause of our issues. And so, here in Morecambe Bay, not only through the poverty truth commission, with the mantra that “nothing about me without me is for me”, but in many facets of our life together, including in the NHS, where I have the privilege of working both as a GP and as Director of Population Health that it is in togetherness, through relationship in which we are creating the space to build trust, to ask some really difficult questions and in the process we discover the reality of our pain and despair in one hand and in the other, as Barack Obama would say, we hold the audacity of hope, despite it all.

 

There are things to which together we are saying, “Enough now”. Enough now that some children in our communities cannot afford to eat, despite their parents being ‘back in work’ – and we are so grateful for the youth and community projects that open early to ensure kids get breakfast on the way to school and tea on the way home, despite a real struggle for resources. Enough now of the adverse childhood experiences or traumas through which many of our children our living, massively impacting their physical, mental and social health for years to come. Enough now of the reality that some children living in this Bay can expect to live at least 10 years less than children growing up just 6 miles down the road, with a far poorer quality of life along the way. And as we say enough now to those things and many more human and environmental injustices, we discover that the answers are not found in our current opposing political or economic models. Rather we are finding that together we can begin to create new possibilities of how we can re-imagine and build a future that works for every person and the planet.

 

In actual fact, learning to live well together is really difficult. It takes humility, forgiveness, kindness, breaking down hostility and replacing it with love. It means taking a good hard look at ourselves rather than pointing a finger of judgement at others. It means letting go of mechanistic thinking to fix things and embracing the reality of complex living systems. It means recognising that change starting with us. For me that means dealing with my own ego, my wounds, my root needs, my genealogy, my white male privilege, our colonial history and discovering that it is in encountering the ‘other’, someone utterly different to me that I am changed and I encounter in that person, the very face of God.

 

And so not only are we saying “enough now” to things which must change, but won’t change with our current ‘go to’ solutions, we are also finding that “together we can”. Here in Morecambe Bay, through working together as communities, we are seeing many dozens of initiatives emerging, like our food poverty project, our mental health cafes, community choirs and new partnerships forming across the voluntary, faith and public sectors working on issues like addiction and early intervention in neighbourhoods.

 

We are finding that together we can break down walls of division and find kinder ways of building society. Together we can see different perspectives and change our opinions and views. Together we can discover models of business based on mutuality and sustainability. Together we can help each other take more personal and corporate responsibility, whilst recognising how much easier that is for some than others and so together we can create compassionate communities.

 

Together we can face up to the challenges we see in our NHS and social care with the eye-watering savings we are being asked to make. Together we can ensure every child has a great start in life, we can build an education system that works for every child and face up to the growing mental health crisis in our young people.

 

Together we can ensure that our elderly citizens are respected and cared for. Together we can live in streets that are clean and safe, with every person having a warm, dry home to sleep in. Together we can face up to the environmental disasters which lie ahead if we don’t change. Together we can build a social movement for change with a different kind of power and discover a politics and economics that works for every person and the sustainability of the planet, based on self-giving, others-empowering love, empathy and kindness. And as we are here together today, together, through policy and through partnership we can ensure that no child goes hungry and every life matters. So, I am looking forward to listening and to learning together, through our conversations here today. Thank you.”

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Truth about Poverty

One of the best things I have been involved in over the last few years, is the Poverty Truth Commission and it has helped me to learn just how utterly complex and wicked poverty is as an issue. I’m currently reading an absolutely brilliant book by the theologian Samuel Wells, called ‘The Nazareth Manifesto’. In it, he makes the most accurate diagnosis of poverty that I have ever seen and it rings true of my work in clinical practice, my years of helping out in homeless projects in Manchester, my time spent in Sub-Saharan Africa, the poverty truth commission and my involvement in projects around food poverty.

 

Wells recognises the biggest issues in our society right now are caused by our massive obsession with mortality and our drive to overcome our human limitations. Using poverty as an example, he goes on to demonstrate that none of our current under-girding political or economic philosophies will get us even close to addressing the real issue. Our real issue is that we are isolated and dislocated and our breakdown in relationship leads to the deep sickness that we have in society right now. I don’t think I have ever seen this United Kingdom so utterly divided and truthfully, none of our current available options will bring us the unity we need to heal, forgive and find an altogether kinder and more sustainable future, together. It is our division which leads to the stark contrasts in life expectancy of people who live just six miles apart in Morecambe Bay. It is our dislocation that leads to such different life stories in Chelsea from the people who so tragically lost their lives in Grenfell. It is the disconnection between the City of London and Tower Hamlets that allows such gulf between the rich and poor.

 

When we look at the NHS 10 year plan, (apart from the fact that there isn’t the workforce around to deliver it and our local government budgets have been so utterly decimated that the gaping hole in public health and social care will ensure the plan fails), it is based on a defunct philosophy of needing to overcome our limitations. The NHS cannot save us from our current sickness of separation and isolation and nor can we expect it to.

 

Taking the example of poverty, Wells examines our current motifs for explaining this very complex issue and what it shows us about society. Poverty is currently explained through either Deficit or Dislocation. The ‘deficit metaphor’ can be illustrated in three ways:

  1. The desert narrative explains that people are poor because the do not have enough (of whatever) and so this can be ‘fixed’ by transferring resources. However, he shows this is deeply flawed as a parable because it dehumanises those who live in poverty, creating an ‘us and them’ mentality in which the rich/powerful try and fix the issue via ‘quasi-colonial’ approaches or use things like food aid to effectively control local populations in abusive ways.
  2. The defeat narrative focuses more on winners and losers and takes quite an unhealthy emphasis on the role of ‘personal responsiblity’ without really considering the other very complex factors like public policy and housing prices….
  3. The dragnet narrative is what the Millenium Development Goals are actually based on (see ‘The End of Poverty’ by Jeffrey Sachs) and considers poverty to be a dragnet/trap which makes it impossible for the poorest to even get onto the bottom rung of the ladder so people can climb out. It focuses on redistribution of wealth via 0.7% of GDP but is very paternalistic and is about doing to or working for, rather than a collaborative ‘together with’ approach.

The ‘dislocation metaphor’ likewise can be understood in triplicate:

1. The dungeon narrative explains poverty not as scarcity but as sin. It is either due to the sin of people who unjustly lock up the poor through their own greed and unfair policies. Or it is understood as the sin of people through making bad choices and therefore ending up trapped in their own prison. However, it still relies on external factors to fix it and so generally remains highly paternalistic.

2. The disease narrative explains poverty as a sickness which lives in our relationships, communities and societies. It recognises that, just like disease, poverty is extremely complex and multifactoral and so does not focus on apportioning blame.

3. The desolation narrative focusses on symptoms>causes, for example how the reality of poverty has a far greater effect globally on women than men – leading to major injustice, oppression and abuse of women across the globe.

 

Wells argues that the reality of poverty, whether local or global is primarily due to isolation and our obsession with mortality and overcoming human limitation is actually making our isolation even worse and therefore making us more sick. And for Wells, poverty is not fundamentally about the absence of money or the lack of conventional forms of power (although this is a part of it), but it is far more about the impoverishment, the industrialisation, the manipulation, the breakdown or the perversion of relationship. It is our isolation from one another that leads to exasperation, impatience, the pointing of fingers, blame and the villifation of ‘the other’. Just look at the polarisation on twitter between the right and left and the appalling name calling and slinging of mud and you see exactly what I mean.

 

The reality is that neither of our increasingly polarised political options is going to heal us or help us find a future that will be good for humanity or the planet. Our political ideologies are so opposed between liberty (right wing) and equality (left wing) but neither is equipped to help us break through this curse of isolation and find a new way forward together. I believe that we have reached a critical point in which we need to find an altogether kinder, more compassionate and collaborative politics and economics that is based first of all on humble listening and genuine democratic conversation to help us find a way forward together, rather than this current division and hatred. I believe as we find each other and build relationships (something which social media can so easily rob us of), we come to appreciate our different perspectives, learn from each other and find that we actually care about each other. I know, for sure, that by learning to BE WITH rather than DO TO or even WORK FOR has really changed how I see others and how I believe we can build a fairer and kinder society for everyone. It demands humility and forgiveness, based on a self-giving, others-empowering love as we build positive peace and requires of us, personal change and the dealing with our own self-centredness as we discover the beauty of connectedness to all people and all things. Theology shapes a great deal more of our philosophy and life together than many of us would care to accept! Well’s thesis is that the character of God is first and foremost discovered in these four words: ‘God is with us’. So often we think of people having a ‘God-complex’ who are people who think they know everything and do things to people because they know how to fix things. It smacks of arrogance. What if God isn’t like that at all? What if the most important thing to God is being with people? What if ‘being with’ is where it’s at and ‘doing to’ and ‘working for’ is to miss the point of what it means for us to be human and whole?

 

I wonder if we are brave enough to let go of that which is actually killing us and the planet and begin to find an altogether different way forward, together. Isolated, we die. Together we live.

 

 

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Health and Society

Every year I get to give a guest lecture at UCLAN medical school on health and society. Here is my lecture from this year – always a moving feast and next year it will be different. It’s about an hour long, so makes good as a podcast, if you’re interested! Mainly aimed at doctors in training, but I hope is interesting for all! I cover the wider issues like: why we’re currently losing, social determinants of health, poverty, choice and responsiblity, social movement, new power, humility, kindness and various other things! UCLAN is a new medical school and I love their approach to teaching. You’ll need to copy and paste the link below into a new browser to hear the lecture and view the slides.

 

https://vls.uclan.ac.uk/Play/34633

 

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A Vision for Population Health and Wellbeing – All Together We Can

If you haven’t yet had the chance to read the Kings Fund’s vision for population health (and it’s the kind of thing that interests you) then I would heartily recommend that you do so. (https://www.kingsfund.org.uk/publications/vision-population-health). It is a real ‘Tour de Force’ and deserves some significant consideration. I like it because it doesn’t hold back from bringing some hard-hitting challenge, but also creates hope of what is possible. 

 

Last week, whilst I was in Hull, I unpacked some of my (many) thoughts about population health, drawing on the wisdom of this report, the significant challenges we face and the opportunity we have to reimagine the future, together with our communities. I was hoping to offer it as a podcast, but it didn’t record well! This is quite a long read, but I hope encapsulates the key issues and gives us plenty to wrestle with and discuss, reflecting on the great piece of work from the Kingsfund. 

 

When it comes to population health, we have to remember, especially when we look at a global stage, that the UK has had some of the best public health in the world. We have so much to be grateful for and have had some incredible breakthroughs in our health and wellbeing over the last 200 years. Consider how our life expectancy has increased, initially through the great improvements in clean water, sanitation and immunisations and then the emergence of the NHS, with free healthcare for all, no matter of ability to pay, and subsequent lifesaving interventions in the areas like hypertension and diabetes – we’ve come a long way, though there is still plenty of work to do! 

 

However, there is a lesson in humility that we need to take from the All Blacks (consistently the greatest sports team in the world). After successive world cups, which they should have won, they had to take a good, long and hard look at themselves and face up to this uncomfortable truth – they were losing! (and I imagine after the mighty victory of the Irish against them recently, they may be having the same conversation again). We have to face up to the fact that right now, in terms of population health, especially around health inequalities, we are losing and we’re losing BIG. 1 in 200 of us is currently homeless. Childhood poverty is increasing year on year and many of our children go hungry on a daily basis. According to the Food Foundation, our poorest 5th of households would have to spend 43% of their entire income to eat the government’s recommended ‘healthy diet’. Much of our housing stock is unfit to live in. Our healthy life expectancy gap between the rich and the poor is nearly 20 years, with a shocking difference between the North and the South. We have a mental health crisis in our young people, with suicide the leading cause of death by some mile in Males under 45. And to top it all, we have a severe shortage of staff in the NHS and our public services which make it actually impossible to continue the level of service required by the heavy target-driven culture of Whitehall. 

 

To continue trying to deliver the same services in the same way, when these issues are so starkly in front of us, is beyond insanity. We simply cannot continue to continue with business as usual and think that we will achieve anything different or new. This is why I like the 4 interlocking pillars the Kingsfund recommend when thinking about population health and I will unpack some thoughts about each one. 

 

The Wider Determinants of Health

 

Before I start on this section, it is really important for me to state that despite what others have at times accused me of, I am not actually a member of any political party and so when I write things which challenge current government policy or praxis I am not trying to score political points. In fact, I believe it is one of the key purposes of (health) leadership to call out when decision making processes are harming the health and wellbeing of the population (whether intentionally or not). Indeed, the same would apply, whoever was in (seeming) power. 

 

When it comes to tackling the issues of population health, dealing with health inequalities and ensuring that the health and wellbeing of all people and the planet is taken into account in every government policy, the current administration is found sorely wanting. No matter what is peddled out about the “successes” of Universal Credit (which I do actually believe was introduced with some good intentions), it is failing and will continue to fail as necessary safeguards are not being put in place. Since the introduction of UC, we have seen a staggering rise in the use of food banks. Families, especially children are going hungry and the financially poorest in our society are not having their basic nutritional needs met. Since 2010, we have seen childhood poverty rise and the health inequalities gap widen. Much of this is owing to the burden of austerity being carried primarily by our poorest communities. In this same time period, we have seen the loss of overall goals for population health and no clear directives or measures to encourage change. In fact, many of the more project and target driven approaches to population health are often the very things that cause a worsening of health inequalities, like child obesity initiatives, because they do not focus on the wider determinants of health like poverty, housing and planning. 

 

On one level, we should applaud Matt Hancock, Secretary of State for Health and Social Care for encouraging the NHS to get into the game of prevention. However, a mirror then needs holding back up to the government to examine what this really means. It is clear that the current ‘rise’ in funding for the NHS, won’t even enable business to continue as usual (and one might argue that’s a good thing, because we need to change business as usual – except for the fact that there is no letting up on the drivers and targets from the Department of Health that continue to maintain the current modus operandi). The £3.4 billion per year increase won’t even touch the hole in our acute hospital trusts, let alone account for the whopping >49% of total cuts from local government (more than £18 billion in total, with more to follow), who are absolutely instrumental in tackling the wider determinants of health and wellbeing. Public Health, which has always been so vital to the work of prevention has been decimated within local governments, who are struggling to keep their statuary services up and running. So, no, it’s not actually that straightforward for the NHS just to now take on the responsibility of prevention, as the social determinants and wider economic issues, including funding aspects, are an absolutely vital component of getting population health right and asking the NHS to do so, simply piles more pressure on an already stretched and burned out workforce. An ending of austerity and an appropriate level of funding is vital if we are to achieve population health, uncomfortable truth for the government, though this may be.

 

Our Choices, Behaviours and Lifestyles

 

There is a worrying rhetoric finding voice that ‘people should just make better choices and take more responsibility for themselves’, but this is simply far less possible for so many of our communities than others, as a direct result of policy decisions and economic models over which they have no power or control. 

 

One one level, no one would argue that each of us has at least some level of responsibility to make positive lifestyle choices, make good decisions about what we put into our bodies and how much exercise we do or don’t take. But we must remember that this is so much easier for vast swathes of our population than others. 

 

There is plenty of evidence though that helps the NHS think about where to focus when it comes to population health management – where we can make the most difference. These areas include: smoking, alcohol, high sugar intake, high blood pressure, atrial fibrillation, high cholesterol (currently hotly debated!), healthy weight and positive mental health. Remember though, Sandro Galea’s work on ubiquitous factors! It is possible to focus in on projects like these and make health inequalities worse! These things cannot be done in isolation, but must be part of a wider vision. The temptation will be for governments to focus on these narrow interventions and claim great statistical significance whilst still not dealing the root issues. 

 

It is in this that again, we need to see the government come up trumps. Targeted and smart taxation can have a massive impact on the choices we make – we know this through the massive breakthrough we’ve seen in smoking in recent years. The same now needs to be applied to the highly influential, powerful and dangerous sugar industry. A best next step, according to Professor Susan Jebb, from Oxford University, would be to put a substantial tax on biscuits and cakes. Like it or not, along with our carb obsession, these are our biggest downfall and if the government are actually serious about tackling our ‘obesity epidemic’ then they need to break any cosy ties with this industry and stop the nonsense about being too much of a nanny state. Public opinion, which apparently hates the nanny state, thinks the smoking intervention was fantastic and the benefit is clear. The role of government is to see what damages our health and work with us to help modify that behaviour. 

 

An Integrated Health and Care System

 

There are plenty of places around the country where we can now begin to see the potential and power of working together differently. In the UK, Wigan, with great leadership from the likes of Kate Ardern, tells a powerful story of how incredible things can happen when population health is owned by everyone and a social movement is born. Manchester, with its devolved budget, political stability and holistically embedded view of population health championed by the Mayor of the City, Andy Burnham is a fine example of how working together differently can really offer some exciting possibilities. He recently said this:

“As Secretary of State for Health, you can have a vision for health services. As Mayor of Greater Manchester, you can have a vision for people’s health. There is a world of difference between the two!”

 

In Morecambe Bay, as an integrated care partnership within the wider Lancashire and South Cumbria ICS, we have already found some huge benefits in working more closely together. It gives us an opportunity to find solutions to the wicked issues we face through collaboration and combined wisdom, rather than through competition and suspicion. 

 

The integration is important at the macro level (where decision making and budgeting occurs), as well as in the micro level in our neighbourhoods. Our Integrated Care Communities in Morecambe Bay are without doubt one the instrumental building blocks we have to reimagining how we can deliver care more effectively for our communities. In each of our 9 areas around the Bay we have teams involving GPs, the hospital trust, social workers, allied health professionals (physios, OTs), police, fire service, community nursing, community and voluntary teams, faith organisations, and councillors working together for the good of our local neighbourhoods. 

 

The Places and Communities we Live in and With

 

Place is hugely important and so is community. Isolation literally kills us. We have certainly found in Morecambe Bay, that choosing to work differently WITH our communities, rather than doing things to them is fundamental in being holistic when it comes to Population Health and Wellbeing. It has meant learning to take our lanyards from around our necks, getting out of our board rooms (where traditionally we take decisions on behalf of people) and embracing humility as we learn to listen to and partner with our communities. One book I have found really helpful, personally has been ‘The Nazareth Manifesto’ by Samuel Wells. He is considered by some to be the ‘greatest living theologian’, and I consider it to be of vital importance for us to think and engage with these issues of heath and wellbeing as widely as possible, including theology, philosophy, sociology and economics, to help challenge and inform the necessary mindset shifts which are needed. Wells writes that for him, the entire Christian story is encapsulated in these 4 words: “God is with us”. Whatever, you happen to believe about God, there is certainly a majority view that if there is a God, he tends to be quite aloof, distant, hierarchical, dominating, controlling and power-crazy, if not seriously vengeful at times – and interestingly, we often refer to some leader-types as having a ‘God complex’! But if God is not like that, but is primarily about being WITH people, not over them, working WITH them rather than doing things to them, that has huge implications on much of western thought and how we set up leadership and governmental institutions! 

 

Hilary Cottam’s book, Radical Help and Jeremy Heiman’s and Henry Timms’ insights in New Power are both vital reading in really engaging with this whole concept. We need to radically embrace the fundamental truth of relationship as an agent for good and change in our society. Our public services have become devoid of real and genuine relationships with our communities. 

 

Over the last 3 years as we have had many conversations around Morecambe Bay, being honest about the financial predicament we find ourselves in (needing to save £120m over the next 5 years, 1/5th of our total budget, whilst still meeting all our targets!) and listening to each other as we try and work out how we can be more healthy and well together, so many beautiful and amazing things have started. These include: mental health cafes, community choirs, the Morecambe Bay poverty truth commission, walking groups, the daily mile in our local schools, new ways of working between the police, council and local communities, the voluntary sector working differently together, dementia befriending, mental health courses in our schools, a new focus on adverse childhood experiences and many many more. 

 

So Where from Here?

 

I believe we find ourselves in an intersectional moment in which we can unlock a very different kind of future than the one we appear to be currently heading for. It is time for deeper listening and a reimagining of how we really might live in a way together that cedes health and wellbeing of humanity and the planet through everything we do. This means we can honour previous ways of doing things, recognising where some of them have been detrimental and contradictory to true population health, letting go of our insanity in the process and find a new, more healthy way forward. It is vital that we consider these four interactive pillars of population health and embed them into every facet of our life together in society. This means ownership and resulting policy change by the government with funding that actually works for the kind of integrated, living and flexible systems we need to co-create. We need communities to find new ways of being well together, take responsibility for our own lifestyles and behaviours, with compassion and kindness for whom this is less than easy.

 

From my perspective this would mean a reimagining of politics – a rediscovery of how we live well together – away from binary competition and white male privilege and towards collaborative inclusivity and equality, based on love, kindness and compassion aka “kenarchy” in which we renegotiate our relationship with power. It would mean a reimagining of economics – a recalibration away from transaction and a ‘use and abuse biopower’ towards a ‘doughnut economics’ in which we learn to live in the sweet spot of environmental sustainability and human justice and mercy. 

 

There are so many things that we have accepted and reports we have ignored. It is time for us to collectively say “enough now” to that which is dividing and killing us and hold together the reality of despair and hope in our communities, as we allow the reality to sink in that together WITH each other, we really can begin to find an altogether better future for us all and the planet. It won’t be easy and means there are many of our own personal ego structures, deep wounds and problematic behaviours that will need healing and changing along the way, but let’s open our eyes and allow new eye light to help us see the future which in our hearts we are longing for. 

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Choice and Responsibility

There is growing rhetoric in the media and within the NHS that the public needs to make better choices and take more responsibility for their own health. Who wouldn’t agree with that? Surely, we are the ones who ultimately choose what goes into our bodies – we choose our sugar intake and decide how much exercise we take, don’t we?

 

Well, given Philip Alston’s damning report on the the state of poverty and human rights in the UK, perhaps we should think a bit more deeply about this!

 

When we say that people ‘just need to make better choices and take more responsibility for their own health’, we need to recognise that it is far easier for some people in our communities than for others. When you’re living in poverty and you would have to spend over 42% of your income to eat the government’s recommended healthy diet, your choice is reduced. When you live in an area in which there is a far greater number of high street take-aways, due to how licencing works in your town and you can fill the hungry belly of your child with a £1 sausage roll or bag of chips, and you don’t have a microwave, or you can’t pay the electric bill because you’re on a scandalously expensive meter – then your choice is reduced.

 

When the transport you reply on to get to the shops has been cut and your nearest shops don’t sell much fruit or veg, so you fill up on carbohydrates and sugars, which meet your hunger, but increase your risk of diabetes – your choice is reduced. When you suffered several adverse childhood experiences in your early years and have never been able to get healing for the trauma and continue to find comfort for your pain in the food that you eat – your choice is reduced.

 

When the products you buy are now filled with a much higher calorie load than they were 20 years ago, and hidden sugars you didn’t even realise you were eating – then your choice is reduced. When you are one of the ones ‘back at work’ (because let’s remember there are more people in work now than ever before), but you’re on a zero hours contract and so you’re working 2-3 jobs a day, just to pay the rent, let alone the bills and getting no breaks in which you can sit down to actually digest your food, let alone make healthy choices from the work canteen that doesn’t actually supply any healthy choices – then your choice is reduced. When you are scraping everything together to make sure you don’t fall into more debt, whilst you are sitting with a benefit sanction for something that really wasn’t your fault and you are using a food bank for your meals and so healthy options are not in abundance (and let’s not even go there with sanitary products and how utterly dehumanizing the tampon tax is) – then your choice is reduced. When you have been kicked out of school because a no-tolerance policy left you in isolation or no-compassion and then you’re a drug runner for a local gang, where you feel like you fit in, but in fact, they own you….then your choice is reduced.

 

Let’s be a little more kind, can we? Let’s stop stupidly over-simplistic comments like – people should just take more responsibility for themselves. This is actually pretty impossible for nearly 14 million people in the UK. I’m not saying there is no choice and nor am I saying that people have no responsibility. I’m simply reminding us that it is a great deal easier for some than others and we are seeing child poverty on the rise and the health inequality gap widen – this isn’t because people in poverty are making bad choices – they simply have far less choice available to them!

 

So what needs to change? Government policy around austerity and universal credit, licensing, pricing, advertising laws, a living wage, the way we work with communities rather than doing things to them, a total renewal of our education system and a bunch more kindness in society as a start.

 

 

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Goldfish and What They Teach Us!

Last week, I had the privilege of listening to Prof Sandro Galea, from Boston State University talking on the subject: “What do guns, obesity and opiates have in common?!” It was an amazing walk through the world of epidemiology – and the answer? Well – all three things are hugely important problems, they are all complex and therefore simple solutions cannot fix them! 

 

Virchow, one of the earliest and most influential thinkers in the realm of Public Health famously said, “Medicine is a social science and politics is nothing else but medicine on a large scale.” Sandro Galea takes this idea and modifies this slightly, suggesting that, in fact, politics IS health on a large scale. In other words, if we don’t get health and wellbeing (of ALL people and the planet) written into every policy, then we will never tackle the huge issues of health inequality and environmental disaster. 

 

Sandro gave an amusing analogy about his pet goldfish. He told us that every morning, he goes downstairs and sees his lovely goldfish swimming in their goldfish bowl. He cares for them, makes sure they are well fed, doing their exercises, having time for mindfulness to build resilience and ensures their contraceptive needs are catered for. Sadly, one morning, he goes downstairs and finds all his goldfish are dead. He’d forgotten to make sure the water was clean. The fish were, in effect, swimming in a cesspit (needless to ask whether or not fish are meant for a glass bowl!).

 

He has developed several principles when it comes to thinking about epidemiology. Principle number 5 states: “Small changes in ubiquitous causes may result in more substantial change in the health of populations than larger changes in rare causes.” His goldfish illustration shows that the goldfish are surrounded by water and everything they do is influenced by the QUALITY of the water they live in; therefore water is a ubiquitous factor in influencing the fish and needs to taken into consideration EVERY TIME we want to improve the lives of the fish. His point is this: if we don’t care for the environment and the external factors that give us life and wellbeing, then our other little interventions are futile. The problem is that we spend so much of our time making interventions that we can measure and feel successful about, like giving people statins, getting kids to run a mile a day, encouraging breast feeding, getting people through the ED in a timely manner or even giving them smart technology to nudge them towards better health outcomes, but we pay little attention to tackling the much bigger issues of poverty, poor housing, or air pollution.

 

The biomedical model for tackling the huge issues of population health has failed and will continue to fail. Our politics and economic model is broken! We have simply not written health and wellbeing into every aspect of our lives and have developed patterns of education and work that are actually doing more harm than good and driving health inequalities and the health of our planet in the wrong direction. Therefore, where there is evidence that policy is actually making health inequalities worse, or damaging the environment, we must challenge them with the evidence base, and plain common sense!

 

I do believe that communities can together make a massive difference, and increasingly I recognise just how vital policy is in helping us shape a just and fair society and in stewarding an environment, which is sustainable for the future. Policy and law can be love-fuelled and compassionate, and they need to become so, because politics IS health and we need to re-imagine it as such.

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Four Circles of Population Health

In my previous blog in this series, I wrote about the ‘Pentagon Model’ which we have developed in Morecambe Bay to help us think about how we manage Population Health. The Pentagon approach actually forms one of four parts of some over-lapping circles, based on 4-Ps (Population Health Approach, Partnerships, Places, People Movement), which give a more holistic view of what is involved.

 

At the heart of the model we are working with, sits the people and communities who live in Morecambe Bay. Communities can be geographical, communities of interest (e.g. faith-based/workplaces etc), or transient (e.g. students). We are absolutely passionate that we do not do things TO people and communities, but rather, guided by the brilliant principle that ‘nothing about me, without me, is for me’, we do things with the people and communities we are trying to serve. We look to co-design, co-create and co-produce our services, because the services belong to the people. This takes culture change and some new thinking on our part and we are learning to work differently.

 

Our Venn-diagram gives us a framework with which to think about Population Health more clearly. The Population Health Approach Pentagon of prevent, detect, protect, manage, recover really forms one of the circles. Included within this, also, are a few other important factors. Firstly culture. If we don’t get culture right, then we don’t get care right. I’ve done three separate vlogs on the kind of culture we are trying to embed across the health and care system in Morecambe Bay – Joy, Kindness and Excellence. Secondly, we are redesigning work around various different health problems, for example, diabetes or respiratory problems WITH people who actually live with those conditions and use our services on a regular basis, building pathways for people that actually make sense and work for everybody. Thirdly, we are taking time to really understand the data available to us through many sources and using it to enable both the leadership team and our local teams to make informed decisions about where we need to focus our efforts to improve care.

 

More than ever before it means that we need to share resources with other organisations in order for us to be able to cope with current budget constraints. It also means that we have to think very carefully about where we align our resources. One of the issues for us in population health is that we have never really tackled the growing health inequalities in society. It is simply NOT OK that some people in this Bay die 15-20 years earlier than people who live 6 miles down the road. It is also NOT OK, that it is in these areas of higher deprivation, where we also see more complex medical and social problems, but do not allocate the money or the staffing to cope with the increased demand. And yes – it is true, that the problems are complex, and so money and resource is not the only answer, but it is definitely a part of the answer! If we’re ever going to make an inroad into changing the health of our population and tackling health inequality, we need to apply the triple value approach of Professor Sir Muir Grey – of how we prioritise our resources. (http://www.nhsconfed.org/blog/2015/05/the-triple-value-agenda-should-be-our-focus-for-this-century). Here is a short clip about it, if you’re interested! (https://vimeo.com/155569869).

 

Partnerships are absolutely key in improving the health of the population. There is so much cross over between county and city/district councils, the police, the fire service, the NHS in it’s various guises (including mental health, GPs, acute hospital trusts and community services), the CVFS and indeed the business sector. The relationships at strategic-leadership level and within each locality are the oil that allow us to work effectively together. It is only through honest, transparent vulnerability that we learn to trust each other and to share the resources we have to serve the needs of the population. As social care continues to sit under the remit of the County Councils and Health remains under the NHS, increasingly devolved into the regional Integrated Care Systems, without a deeper and more shared accountability and effective working together we will not have the necessary leadership to enable local team to transform the future of care.

 

This is where Place becomes really important. It is harder to get culture right, and build relationships that really work well if we’re always talking about “working at pace and scale”. As services are reconfigured, it is important that team structure allows for small enough teams to enable good working relationships to happen and that the necessary work is done to get culture right! I was in conversation with Professor Sir Chris Ham, CEO of the King’s Fund, and he is adamant that it is at this local neighbourhood level where the real change takes place, because this is where we are able to work with people and our communities in a very real way. That’s why we are so passionate about our Integrated Care Communities (ICCs). This is where, in a very relational way, traditional barriers between organisations are broken down and new bonds are formed in working together for local communities across the public and community-voluntary-faith sector (CVFS). There is a real danger that we focus so much on the ‘super structures’ and put huge time and energy into reorganising the system and lose sight, in the process, of the very thing we are trying to do, which is to make care better! Our ICC teams must feel the full permission and receive the resource needed to do this transformational work.

 

The reality is, however, that unless we have a people movement for improved health and wellbeing, nothing will change. The issues we are facing health and care-wise are incredibly complex and multi-faceted. In Morecambe Bay, we currently spend £1.20 for every £1 we receive. We are doing our very best to try and reimagine how we deliver health and social care, working more efficiently in partnership and redistributing resource where we can – but when we are all in financial deficit (and in our local NHS we need to cut our cloth by £120 million over the next 3 years – 1/5th of our total budget) when we have already had some eye watering cuts to the county councils budgets, especially in the area of public health, there is only so much we can achieve! We understand the frustrations that people feel when it comes to health and care, but we cannot fix it from within the system alone. There is a need for us all to recognise that things we could provide a few years ago may no longer be available or not within the same time frame as previously. It would be wrong of us as health leaders to simply make changes without the communities having a say. But for example, if we are to improve our Children and Adolescents Mental Health Service in South Cumbria (which is desperately needed), we might, as an example, need to do less knee and hip replacements……we simply can’t afford it all, with our current allocations of resource and staff, and therefore we need local people to work with us on this, and help us work out where our priorities should be. We know, if we don’t involve our communities in these decisions, complaints will go through the roof, which drives down morale and is utterly exhausting for teams to deal with. However, we are going to have to be brave in some of our decision making.

 

As a society, we also need to all be more healthy and well, taking care of ourselves and each other.Some might argue this is all down to personal choice. Of course, there is some choice involved – however, when you read the National Audit Office report (https://www.bbc.co.uk/news/education-44468437) into the huge difficulties Universal Credit is causing, and the Joseph Rowntree Foundation Report into Destitution in the UK 2018  (https://www.jrf.org.uk/report/destitution-uk-2018) then you begin to realise that it is easier to make healthy choices in some communities far more than in others. These are inconvenient truths, and need to be reflected upon with due diligence. There is a danger that we choose to work with highly motivated communities to improve health and wellbeing and actually make health inequalities worse. However, if we really listen to what is going on with local communities and work together, we can do some great stuff . Work from the University of Birmingham shows that if we can see a change in just 3% of our population, then this will have an effect on 90%. As the work in Canterbury, New Zealand shows though, this takes time and relationship – the process is actually more important than the end product. And for an under-resourced, already exhausted community, supporting any social movement requires investment at many layers. The NHS 5-year forward view and the learning from the Institute for Health Innovation both recognise that social movements/people movements are key to transformational change. We must press on with this work, and base it on a foundation of love and collaboration if we are really to change things together. So, this is why we are so passionate about really working with our communities, here in Morecambe Bay and will continue to host  and hold space for community conversations. We are talking about many things, from economic development,  to childhood, education, loneliness and mental health. These spaces are vital for us to connect together, hear one another, meet people who are different from us because it is only together that can reimagine a future that is good for the planet and socially just for humanity.

 

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A-Z of Health and Wellbeing

Happy New Year!

 

We often start a New Year with resolutions, things which we would like to change for the better. so, I thought I’d start this year of blogging with a vlog about my perspective on the A-Z of what affects your Health and Wellbeing the most.

 

It’s longer than most of the videos on my new YouTube Channel (Dr Andy Knox), at nearly 15 minutes long, but it is pretty tricky to talk through 26 different aspects of health and wellbeing in under 3 minutes!

 

So…..he is a list of the things I talk about……and if you don’t want to watch the whole thing, then you can find the bits in the video that are of interest to you, in helping you think about some changes you might want to make or help you might want to access this year.

 

A is for Alcohol

A is for Adverse Childhood Experiences

B is for Blood Pressure (140/90 – the magic numbers)

C is for Cigarettes

D is for Don’t want to live anymore

E is for Exercise

F is for Fluids

F is for Food

G is for Glucose (Sugar)

H is for Housing

H is for Heating

I is for Irregular Pulse

J is for Joy

K is for Kindness to NHS Staff

L is for Loneliness

M is for Money (Debt)

N is for Narcotics (Drugs)

O is for Obesity/Overweight

P is for Pollution

Q is for Quarrelling

R is for Road Taffic Accidents

S is for Stress

T is for Temper (Anger)

U is for Underweight

V is for Violence (Domestic Violence)

W is for Worry

X is for Xenophobia

Y is for Your Ego

Z is for Zzzzzzzzzzz (Sleep Deprivation)

 

 

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Building Healthy Towns and Regions

The other week, I was phoned by a BBC producer to ask if I would take part in a discussion on the Victoria Derbyshire show about how we can build healthy towns. It’s partly due to the work we’re doing here in Morecambe Bay with our communities around being more healthy and well, especially working with schools. Unfortunately, I was away on holiday and missed the call and so didn’t get on the show! But it did get me old grey cells thinking about this whole idea. Here at Lancaster University, we have the Health Innovation Campus, which is helping to design a new ‘healthy town’ in Lancashire. The “Imagination Team” are also hosting a conference this week called “Does Design Care?” But what do we mean by a healthy town and what ingredients might we need to see in our cities in order to say that they are, or are becoming “healthy”?

 

We must get beyond thinking that a healthy town is simply one where there is clean air to breathe and everyone is out jogging, smiling at each other and eating quinoa salads for lunch – it’s all a bit middle class! I would like to make some fairly radical suggestions of what it might mean for a town to be truly healthy, especially having been so inspired by the amazing ‘Doughnut Economics’ by Kate Raworth. I think if we don’t have a vision for what we want our future towns, cities and regions to be like in 50 years, we will not build them! I am often told that you cannot eat an elephant in one go, and we must focus on the small things we can do – eating it one bit at a time – true enough, but we need to hold both things in tension. We need a vision big enough to inspire us to change and then we need to pick up the knives and forks and begin the process of eating it!

 

So, what might healthy towns of the future be like?

In healthy towns:

There are no homeless, not because of social cleansing, but because everyone has a home in which to live.

Design cares enough to ensure that spaces are built which encourage communities to spend time with each other, connecting and collaborating, breaking down isolation and loneliness and facilitating new political space.

There is a creative commons, with plenty of space that belongs to all.

The economy of the town/region is designed to ensure that resources (including land) are redistributed, breaking cycles of poverty and enabling all to flourish. This increases the happiness and health of all and allows a society in which the wellbeing of all matters to all.

The economy of the town/region is designed to ensure regeneration, thus taking care of the environment for future generations. Towns like this will not only be carbon neutral, they will in fact, as Kate Raworth says, become generous in their approach to humanity, other towns and the planet itself.

Children will be nurtured, as part of communities, not as fodder for the economic machine, educated as socially adaptable human beings, understanding their place within the ecosystem of which they are a part.

There will be a culture of positive peace, made possible through non-violence, in which architecture is used to enable communities to live well in the midst of and celebrate difference. Facilitation and mediation will be normative practices when relationships become strained or difficult and the lust for competition and war will be quelled.

There will be a culture of love, in which all are welcome and accepted for who they are. This does not encourage selfishness, nor does it mean that there is no challenge. In fact, love, at its best, is self-giving and others-empowering (Thomas Jay Oord).

There will be a culture of kindness, displayed through humility and respect.

There will be a culture of joy in which people know that they belong and are trusted.

Justice will be restorative, rather than retributive, something which does not negate the need for discipline, but hopes for a better future through grace.

Refugees are welcomed, cared for and also allowed to flourish.

Equality and diversity is celebrated as a norm.

Farming practices are kind to the land.

Business is changing it’s goal, becoming agnostic about growth, but obsessed with how it plays it’s part in improving the wellbeing of all through regeneration, redistribution, repair, reuse, refurbishment, recycling and restoration.

People are valued in their work place and the workplace is a healthy place to be in.

Physical activity and healthy eating are a normal part of every day life. (Thought I’d better add that one in!).

Wherever possible, people die well, surrounded by community who love them.

 

Wouldn’t you love to live in a happy, healthy, wholesome town?! It’s not beyond our grasp. We simply need to adapt the ones we have and build the ones we want! Building together a future that is good for all. Which bit shall we eat first?!

 

 

 

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Hosting Conversations That Matter

In my last blog, I was exploring how some of the biggest determinants of our health and wellbeing have very little to do with healthcare at all. They are societal issues, with huge implications on how we live together. Issues like poverty, homelessness, loneliness and adverse childhood experiences are far greater drivers of health inequalities and outcomes than many of the other things we spend an inordinate amount of time and energy focusing on.

However, it is only a social movement of people, willing to face up to and do something about these kind of injustices in our society that is going to bring about real and lasting change. Our old ways of operating, in which public servants try to find the answers and ‘do things’ to communities to ‘fix’ the problems simply are not working. The change we need is only going to come from the grass roots, when communities get together, ask difficult questions, give space for really important discussion and learn to forge new ways ahead in collaboration.

 

Do we know how to ask good questions? Do we know how to explore complex issues? Do we know how to create the kind of spaces in which we can have really important conversations about the future we might like to co-create together, a future based on values we hold dear, like love, trust and kindness? How much more healthy and well might we all be, if we found a new way of being together, based on collaboration and cooperation? People talk about a new politics – politics is in essence about how people live together, not about how decisions are made in government. A friend and colleague of mine, Ian Dewar, is helping to host a health festival in Lancaster in a few weeks time and he is calling it – ‘The Lost Art of Living’.

 

The team I work with are committed to training and creating a network of people who would like to co-steward spaces in which we could host these kind of really important conversations. Our hope is that everyone in our area is able to live life more fully, in the best possible health and wellness for them. Here is an example of a training we did in Morecambe in February:

 

 

Together, we are are sharpening our skills and using these techniques in a variety of ways to help build this social movement for change in our health and wellbeing. Here are some more ways we are using it:

 

 

We are creating a community of practice, unashamedly using these techniques to help shape the cultures of our own organisations and communities and hope to further spread this practice as a method of holding space for new ideas to emerge. Taking time to connect as human beings, asking good questions and using techniques that can really help explore the issues at hand can be truly transformational. the ‘Art of Hosting’ is not a social movement in and of itself, but it helps give the tools and prepare the ground in which one can emerge and flourish. If you live in the Bay, come and co-create with us……if you don’t why not be a catalyst for change where you are?

 

In the months ahead, we will be offering more training and hosting conversations such as: how do we raise happy, healthy children? How do we live well? How do we work well? How do we age well? How do we die with dignity? Come and be a part of this and let us shape a better future for everyone.

 

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