Category: Corporate Health

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

 

Share This:

Share

To Hull and Back

Last week I had the complete joy (except for the awfulness that is the M6 and M62!) of heading over to Hull to speak at a gathering of Public Health and Public Sector people from across Yorkshire, The Humber and The East Riding, called “Minding the Gap”, hosted by the amazing Ian Copley. In my next blog, I will give the podcast of what I said and written piece, for those who prefer that format, about Population Health and the realities we are currently facing.

 

However, I thought it just worth reflecting on a really interesting lecture I heard by Prof Franco Bianchini from Hull University (https://www.hull.ac.uk/work-with-us/research/institutes/culture-place-and-policy-institute/culture-place-and-policy-institute.aspx) on the impact of Hull being European City of Culture 2017. It was amazing to see this little video, presented by the excellent Director of Public Health, Julia Weldon (https://www.yhphnetwork.co.uk/about-us/julia-weldon/), and to hear of so many wonderful, creative, life-giving, community-building initiatives that happened all over the City and the beautiful stories of people celebrating the history and many facets of this place. 

 

The sense of wellbeing and happiness in the City increased significantly during that year (not much of a surprise) and the injection of finance into Hull gave opportunity for some creative regeneration and fantastic projects. Unfortunately, since 2017, the overall sense of Wellbeing and happiness has now fallen to below what it was in the years preceding Hull as the City of Culture. What a shame! And interestingly, if you study other Cities that host Olympics, Commonwealth Games, or have other similar initiatives, you see the same pattern over and over. The hype wanes, the carnival moves on and what is left?

 

There is so much we can learn from this, if we want to. Firstly, if we only plan for an event and do not think about it as an agent of transformation for the future, then we risk sowing huge promise and then once the event finishes, things just go back to being the same old, breeding disappointment and disillusionment. This must be taken into account in the planning. Becoming a City of Culture gives the opportunity for a City to come together, not only for an event, but to turn the future of the city, releasing dreams of what it can become. This requires much wider ownership and community conversations about keeping the momentum and building on it. Secondly, leaders across the city need to own the future and hold true to the principles, especially once the funding is withdrawn. It’s really sad that the vast majority of schools have not felt able to continue the great initiatives in the creative arts or sports, which began and were having a great effect on children and young people’s physical and mental health, due to the pressures they feel around delivery of the curriculum. Surely there was an opportunity to reimagine the whole realm of what education might look like in the City of Hull, aligned to the values of the City and its hope for the future?

 

In the Jewish tradition, at certain points along their journey from Egypt to Israel, the people would build an ‘Ebenezer’. It was a pile of stones to mark a certain point on their journey that would help them remember what was past and what they were looking forward to. It was more than a monument. It was a stake in the ground which called to memory where they had come from, what they had been through but also opened up an altogether different future. My hope for Hull, is that 2017 City of Culture becomes an Ebenezer for the city, something they can look back on and say – “that’s when things really began to change, that’s when we celebrated our past but began to build a new future together, a city that really works for everyone and the environment we live in!” I fear, however, that the opposite will be true….a temporary flash in the pan and then back to the same old, same old……

 

I hope with all my heart that it isn’t too late for Hull to regain this momentum and despite the lack of funding (although this begs whole new questions about devolution) for the city to take hold of the promise of what could be. I also really hope that Coventry (the city of my birth) really hears and learns from the lessons of Hull and begins now to think of being the City of Culture 2021 to springboard into a new future for the city, rather than have yet another event that feels good in the moment, but does not bring the transformation of the City that is so desperately needed. Now is the time for Coventry to dream and to think creatively about what this opportunity really might become. 

Share This:

Share

Obesity – Genetic or Environmental?

Obesity has become part of a serious blame culture. “Just eat less and exercise more”, seems to be the simplistic argument these days. Social media is full of ‘fat shaming’ and the public opinion has shifted much more towards it being people’s own fault if they are fat – “they should just make better choices and take more responsibility for themselves”. It makes sense right? People just need to be a whole lot less greedy and a whole lot more restrained…..Well – just for a minute, let’s suspend our judgements, put away our pointing fingers or indeed, our shame and let’s examine the evidence….and then maybe we can have a much better and kinder conversation about the obesity epidemic we’re in and what might need to change.

 

A few weeks ago, I listened to the excellent Prof Sandro Galea, Knox Professor of Epidemiology at Boston State University, give an excellent lecture on: “What Do Obesity, Opioids and Guns all Have in Common?” the answer: They are all really complex and hugely important! I am shamelessly going to use his slides from that lecture to explore the issue of obesity in this blog, which Sandro has kindly shared with me.

 


If we take any given population, let’s start by asking this question: What percentage of obesity is determined by genetics, compared to the environment? Go, on, give it a go – write a figure down, or make a mental note of what you currently presume!

 

 

 

 

In any give population, there will be a percentage of people who have a higher genetic risk of becoming obese. In the diagrams which follow, these, dark grey represents those with a high genetic risk.

 

 

 


 

There will be some people who will be obese, with or without a genetic risk. In the following diagrams, these people are represented in red/pink.

 

 


The environment is represented in green. everything that is not ‘genetic’ is considered to be environmental. This includes, air pollution, adverse childhood experiences, advertising, sugar in products, transportation, access to shops, types of shop available, family income, affordability of food, use of food banks, etc etc. The more green there is, the less healthy the environment represented.

 

So…….if we take a population with the same genetic risk factors and number of obese people, let’s see what happens to those people with a higher risk of becoming obese, when the environment is less than ideal, e.g. high stress, poor air quality, high index of deprivation, low educational opportunities, high unemployment, poor access to shops, poor transport links, high numbers of junk food outlets…….etc – here is the population in a poor environment and those with a genetic risk factor are marked with grey dots:

Look at what happens to the obesity rate in that population!! All of those with a genetic risk factor become obese! The odds are stacked against them, because their choices are significantly reduced!

But take the scenario, with the same population in an environment which is much more positive, where there is less sugar in foods, where there are more healthy opportunities for good eating and exercise, where there is no need for food banks because employment is high, jobs are well paid and the welfare state is functioning appropriately.

In this scenario – the odds are in favour of those genetically more likely to become obese – BIGTIME! Obesity rates are far less and overall the population is much more physically healthy. People who are genetically at risk of becoming obese have far less chance of actually becoming obese!

What was your answer to the percentage question at the start? It was a trick question! the worse your environment is, the more your genetics come into play! So, now there’s a complex argument about who is responsible for the environments in which we live and who creates an atmosphere of choice!

 

If we take the food industry to start with, just look at what has happened to the calorie intake of foods sold in fast food outlets over the last 20 years. If you want French Fries now, you’re eating triple the calories that you were 20 years ago, due to larger portion sizes – always upsold in McDonalds (and other like minded companies)!! TRIPLE the calories! Who’s fault is that?! A turkey sandwich, which some might consider a ‘healthy option’ is now packed with more than DOUBLE the calories that were in that same sandwich just 20 years ago! Do the maths! The way this has been allowed to happen is appalling. The government, so keen on not being a ‘nanny state’ have allowed a deregulated ‘nanny food industry’ to lovingly shove calories down our throats without most of us even realising! Prof Susan Jebb, one of the leading experts in this field, globally is really clear – if we taxed cakes and biscuits and made healthy food more affordable, we would be in half the mess we’re in.

 

The same is true of exercise, and so opportunities to exercise, created by culture and environment are really important:

If you look at how much the advertising industry is spending on obesogenic foods, or you examine where junk food cafes are placed (disproportionately higher in our most deprived communities); if you consider the profound effect of adverse childhood experiences on our eating habits or look at the affordability of health food for low income families, as shown by the food foundation, then you begin to see that this over simplistic argument that people ‘should just take more responsibility for their own health’ is total nonsense. We need to take an altogether more kind and considered view to what is an incredibly complex situation.

 

Sandro Galea talks powerfully about this principle: Small changes in ubiquitous causes may result in more substantial change in the health of populations than larger changes in rarer causes.

You can feed your goldfish the best food, ensure they swim their mile a day, help them practice mindfulness every morning and decrease the amount of time they spend on screens……but if you don’t care for the quality of the water – they will die!

 

Health inequality between the rich and poor in the UK is worsening. Health inequality between the north and south is worsening. Life expectancy overall and healthy life expectancy are both beginning to fall. Our mental health crisis is deepening. Now is not the time for loads more programmes that benefit the already healthy and make the inequalities even worse. Now is the time to ask some fundamentally deeper and more difficult questions about what we have built our society on, what the point of the government is and how, together, we might work for a future that is better for everyone. Unless we do so, the NHS continues to stare into an abyss, as indeed do all our public services.

Share This:

Share

Cuts and More Cuts – a Disaster for our Population’s Health and Wellbeing

It amazes me, in this 24-hour news world that we live in, that a further £1 BILLION of cuts to our county councils doesn’t remain on the BBC front page until much past lunchtime! It feels a bit more important than some of the stories being picked by the editorial team instead!

 

https://www.bbc.co.uk/news/education-45573921

 

Anyhow….these cuts will be utterly devastating for our population’s health and wellbeing and the “extra funding” for the NHS is simply not going to be enough to undo the damage. Local government will have lost 60% of it’s budget by 2020, with devastating consequences and no amount of local taxation will replace the difference, especially in poorer areas of the country. And just look at what will be cut:

 

  • 58% of councils said highways and transport (including road improvements, streetlights, pothole filling)
  • 47% said libraries
  • 45% said early years and youth clubs.
  • 44% ear-marked public health services like smoking cessation, sexual health, substance misuse
  • 36% said children’s services.

 

 

So:

  1.  We will have far higher risk of road traffic accidents, especially for cyclists/motorcyclists (I’ve seen the effect of people hitting potholes and fracturing their spine).
  2. there will be less access to shops and leisure facilities for our poorest communities, meaning a worsening of the obesity epidemic.
  3. We will have increased social isolation and reduced learning opportunities for our elderly (therefore increasing risk of dementia and depression).
  4. We will have decreased social support for our young people, leaving them far more vulnerable to gangs and substance misuse.
  5. We will have less support for young families, struggling to cope and so less opportunity for parental support and an increase in Adverse Childhood Experiences – with devastating long term consequences for physical and mental health.
  6. Smoking continues to affect 1 in 5 people in a hospital bed, and is still the biggest cause of death in many parts of the country – yep good idea to cut that.
  7. Our drug crisis is rising exponentially, and we’re seeing an increase in STIs and yet councils will not be able to provide services to help.
  8. Children’s services, those vital safety nets that work to prevent serious safeguarding incidents will have to be reduced also!

 

WHAT?!

 

There isn’t a council in the country that wants to make these cuts and the lack of foresight by the government to drive these further cuts through when the ones we’ve had already have been so deep, is utterly ludicrous. I’ve sat with council officers in tears over the choices they are having to make – these are people who love the communities they serve and are trying to do as much damage limitation as possible, whilst being left to take the blame.

 

What does it tell us? It tells us a few things. Firstly, there is a serious lack of joined up thinking about the long term consequences of these cuts. Save money now, but pay for it 5-fold in the future. Secondly, there is a genuine lack of concern for the poorer communities in our country. Thirdly, our current political model is broken and more than ever we need a politics of love/compassion. Fourthly, our current economic model is caput and cannot give us the regenerative and distributive future we need for humanity and the planet. I feel so despairing, sad and am grieving what this is going to mean for so many of our communities. We need to feel this pain and face up to this and find hope in reimagining how we might do things radically but necessarily differently.  This piece in the Guardian is worthy of serious reflection:

 

https://amp.theguardian.com/politics/2018/sep/16/the-eu-needs-a-stability-and-wellbeing-pact-not-more-growth?__twitter_impression=true

Share This:

Share

Let The Children Play!

In The Guardian today, there is an article in which the Children’s Commissioner, Anne Longfield, is calling for more adventure playgrounds across the country, especially in our ‘poorer’ neighbourhoods. She believes we need more play schemes across the country for the long summer holidays which she argues are having a profoundly negative effect on children’s physical and mental health. Most starkly, she cites a study in which “primary school children lost 80% of the fitness levels gained during term time. The poorest 25% experienced a drop in fitness levels 18 times greater than the richest 25%”. Sadly, this undoes some of the great work of schemes like ‘the daily mile’ in schools and has hugely negative consequences in terms of future health risks.

 

I would personally therefore welcome such a move – it is absolutely the case that increased active play and exercise improves a child’s physical, mental and social health. There is no doubt that more facilities, especially located closer to home would be better than having none at all….but I don’t really think it’s quite that simple (and for the record, I don’t think Anne Longfield thinks it is that simple either, she is a great champion for children across the UK). There is a danger, that by saying children need to play more, that it gets oversimplified by policy makers and could perhaps sound a little too Marie Antoinette! Yes our long summer breaks are becoming like ‘battery hen’ experiences for many children across the UK, but simply building them more parks is not going to change this, and I can give you few reasons why.  To understand why kids are spending more time indoors and on screens, we need to dig a little deeper into some pretty uncomfortable truths and wrestle with the complexity of them.

 

I have a friend, who is one of the kindest and best people I know. On top of his very heavy work schedule, he invests an enormous amount of time into young people, who are often living with really challenging circumstances. Every summer, he runs activities for them, right through the summer break and does extraordinary things. Ten years ago, when he applied for funding through a variety of grants (and let me tell you he is a seasoned wizard at winning bids for such things) he was getting £20k for a packed out summer programme. These days, he struggles to raise £4k. That leaves the situation in which he is having to ask families to contribute more for the care of their kids over the summer. What this leads to is a drop in numbers and more kids stuck in at home.

 

I have another friend, who runs a school in one of our most deprived communities. Throughout the summer break, her school opens up to ensure the kids from the locality do not go hungry and so that families can afford to eat. There have been emergency appeals from many food banks this year. Many working families are seriously struggling to provide both childcare, through the long summer breaks and food….there are some really tough choices to be made. Out of 50 young people on a local holiday scheme, that I know of, 19 of them were relying on daily food parcels, meaning they have no idea from one day to the next what they will be eating and actually no choice about it. When you are working two jobs and struggling to make ends meet, what else can you do with you kids? Just let them roam the streets?

 

I know a police officer who works on some of the toughest estates in the UK. He tells me that the war on drugs has utterly failed and the gangs are absolutely running the show. Cuts to the policing budget and massive stress levels in the force, as a result, are seeing whole neighbourhoods overrun with crime. The play parks in these places are totally unsafe. No parent in their right mind would let their child out to play in such an environment. It’s a bit different in leafy Surrey or middle class suburbiaville. Without police to build relationships with young people and keep the streets safe, simply building new parks or putting on play schemes will not be enough. Without children’s centres, youth centres and health facilities readily available (many of which have been closed or privatised and so less affordable to communities who need them most), there are less places to go.

 

If I’ve learnt anything over the last few years, it is that we have to stop coming up with schemes that we think are good for communities and simply delivering them. We have to really learn to listen to people’s stories and the complexities of their situations and from that place hear what it is that they want and need and then create real partnerships to bring about that change together. Hilary Cottam is all over this in her brilliant book ‘Radical Help’, which is a must read.

 

I love that Anne Longfield, Tanni Grey-Thompson and Sarah Woolaston see this whole issue as being so massively important. Play schemes and parks and cutting sugar (though all excellent) will simply not be enough in and of themselves to get kids out doors and playing in them. We need a a very holistic approach which starts with communities, hearing what their dreams are for their kids and hearing the hopes and desires of the kids themselves. Next we need to understanding what the steps will be to get there. Then we have to build that together. I would suggest a great place to steward this kind of resource would be through health and wellbeing partnerships, like the ones we have in Morecambe Bay. Cross public and voluntary sector partnerships, rooted and working well in their local communities. But I can also guarantee, that this idea will require the right kind of resource – appropriate funding of the required schemes, affordable access to facilities, work that pays a decent wage so families can afford to eat and taking the safety of our streets seriously. That is going to take both a reimagining of youth work/social provision and appropriate help and resource to a diminished and struggling police force. Bring on the parks, but first listen and make sure they can be used!

Share This:

Share

Population Health and the NHS 10 Year Plan

https://www.kingsfund.org.uk/publications/nhs-10-year-plan

 

This is an excellent blog from Sir Chris Ham and Richard Murray at the Kingsfund and highlights some important issues that deserve real consideration and debate. Get a cup of tea, reflect on it and then join the discussion. Here are my reflections on it.

 

Improving population health and closing the health inequlaity gap are the two most important things for the NHS to focus on, if we are to have a heath and care service that works for everyone and is sustainable long into the future. It is not an easy nettle to grasp and is full of complexity, which is highlighted in this paper, but fundamentally, if we do not see a cultural shift, and ownership of these issues across the public sector, with population (and environmental) health written into every policy combined with a collaborative social movement for change, we will still be talking about this in another 15 years.

 

The reorganisations of the last few decades have been exhausting at so many levels and have not achieved what we have needed them to. It is indeed vital that we learn from these lessons and commit to at least a 10 year focus on improving population health, tackling health inequalities and integrating services, ensuring that we embed a culture of joy, kindness and excellence as we do so. We have reached a pivotal moment and we must break through our silos and see things tip towards a new commitment to improve the population’s health, together.

 

The funding question will not go away and it is really important that we are honest and open about what is actually going to be possible within the new funding agreement for the NHS and what will not be, especially if there is not a substantial investment into Social Care. Much of what we mean by prevention in Population Health relies heavily on other public sector partners, like Public Health, Education and the Police and the reality of their funding decline will make the transformation we need to see, especially in young people’s mental health very difficult, especially as the new deal for the NHS is not what it needs to be. For many Integrated Care Systems, the savings still required are so colossal that doing the simulataneous transformational work of population health and tackling the widening health inequality gap is a very hard task. It is a huge ask of finance directors to meet the constant demands of the regulators whilst also trying to be brave and shift resource towards more long term gains that do not meet the short termism of yearly budget requirements. The increase in demand due to more frailty and complex health issues, eye watering cuts to local government budgets (with profound knock-on effects to social care and public health), a target driven environment and low staff morale is making this all very difficult. It is not impossible but it is going to need realism and pragmatism about what can be achieved, by when. The choices being made about the funding of our public services are ideologically driven, and we need to ensure that feedback about the reality of austerity leads to necessary changes, so that we can have truly evidenced based policies.

 

Here in Morecambe Bay, we have recently launched the ‘Poverty Truth Commission’, one of several around the country. Many leaders from across our region sat with tears streaming down our faces as we heard story after story about the reality of poverty and destitution for people in our area. We heard from one young man, Daniel about how the closing of the youth centre on his estate and his local high school (both the only places where he knew he belonged and was safe), left him and many of his friends vulnerable to gangs. Moved, again and again through private rented housing, in order to provide for his siblings, he ended up selling drugs and guns, simply to put food on the table, ending up street homeless, with serious addiction problems himself. Many of us wondered how often we think about the short and long term consequences of the cuts being made and what kind of risk assessment is done in these situations. In her very powerful book, ‘Radical Help’, Hilary Cottam writes of need to put relationship back into the heart of our public service care provision, as we grapple with the joint issues of funding constraints and human need.

 

The points raised about improving productivity are important. Where we can be more efficient, we must continue to be so. Let’s pause to recognise, though, just how much has been achieved already. Culturally, we must learn to celebrate the positives and recognise the great work already being done in this area, which will inspire more of the same. The sharing of best practice and creating environments where we can learn from one another is absolutely key. This will most effectively happen through collaboration not competition. So, yes – integration must be a priority, but it comes with a health warning – if we don’t get culture right from the start, everything else will ultimately fail.

 

A Population Health approach is the only game in town. Wigan have achieved some really wonderful things, but there are some important things to understand about the context of Wigan that have made it more possible there. Firstly, there is clear political unity. The idea of population health is owned across all spheres and levels of government, and “safe seats” have led to a political continuity that has made long term planning far more successful. The ongoing politicisation of health and social care in other contexts makes this kind of transformation much more difficult. Secondly, there is a real humility in style of leadership that has been willing to a) openly share the complex issues and choices being faced, with the people of Wigan and b) deeply listen to the communities and therefore find a way through the problems together with a profound sense of joint ownership. It is this two-edged sword of necessary culture change and brave leadership with a social movement that makes it possible to cut into new ground together. We must be brave in talking to people in our local communities about the choices ahead of us and understand the importance of agreeing together who is going to take responsibility for the various pieces of th jigsaw which need to occur.

 

We know that 40% of our health depends on the every day choices we make as individuals, for example around what we eat or how much exercise we take. However, it is not as lovely and simple as this. There is far less choice available for our most deprived communities. Supermarkets do not stack the same amount of healthy food in their shops in our more deprived areas. Children have little choice over the adverse experiences they go through, how much sugar is in their breakfast cereal nor what is pushed at them through targeted advertising. The number of junk food outlets is far higher in areas of greater deprivation (see Greg Fell’s excellent analysis of Sheffield). So, when we talk about choice, especially in the context of poverty and education, we need to take a reality check and not simply point the finger of responsibility. This is where a people’s charter can be really powerful. Those in leadership play their part in taking care of the needs of the population and bringing in appropriate governance and a fair distribution of resource, whilst citizens commit to playing their part in staying healthy and well, and learning about conditions which they live with, so they can play an active role in being as well as possible, dependent on their circumstance.

 

Given the lessons from Wigan, or from global cities, like Manchester, and Amsterdam and what they are beginning to achieve around population health, there is a powerful argument, not only for combined health and social care budgets, but also for increased devolution of budgets. If we see what has been achieved in the Black Forest of Germany, with a very holistic transformation of services, including the connecting of communities through far improved transport links, we begin to reimagine what might be possible at a larger scale. Devolved budgets though must be a fair deal and not an opportunity for central government to make further cuts and then leave the blame in the locality. Devolution, if it is to work well, must come with new and fair legislation around taxation and proportionate allocation of resources.

 

All of this is only possible with the right workforce. I completely agree that we need both short-term and long-term strategies. I am not yet confident that enough work is being done at a predictive analytical level to really work out what kind of workforce we will require, if we shift to a fully integrated, population health model. This is the kind of workforce we must then build and it will by its very nature, be much more community and relationally focussed. This will allow us to build culture from the ground up and create the kind of working environments that are healthy and well, enjoyable to work in and therefore with a high retention level of staff. Perhaps our short term solutions need to be less reactionary and more proactive in building towards the future we need. Perhaps there are also more short term international opportunities and partnerships to be built whilst we plan for our reimagined future.

 

In making all of this happen, I think we need a little caution in too much over-comparrison with the American insurance-based systems. The ICS development we see there is based on a very different model and can look very appealing, because it overlooks too readily the 50million Americans who cannot afford a decent level of care. Yes, there are some impressive things to learn and some very data savvy things we can apply into our systems, but the fundamental differences between our ideologies and practices must cause us to pause and think about what is transferable and what we can do diffferently to ensure that everything we do works to close the health inequality gap, rather than widen it. This is where our greatest test will be. It is too easy when creating new agreements with the public to work with those who are already highly motivated to change. In so doing, we might actually make things worse, rather than better in terms of inequality. It is going to take determined effort and brave focus to ensure this doesn’t happen.

 

In short (!) I am very grateful for this paper and the issues it highlights. It deserves real contemplative reflection and a commitment by all to embrace this future together. We cannot achieve population health and the tackling of health inequalities alone, but together, we can.

Share This:

Share

Health and Society – Part 3 – Can We Make a Difference?

On the 70th Birthday of the NHS, here is the 3rd and final part of this mini-vlog-series. In this one I look at how we can make some positive steps for our own health and wellbeing and explore the issues of choice and responsibility, whilst we also tackle health inequality and issues of social justice.

 

Share This:

Share

Changing the Future of Adverse Childhood Experiences

Applying a Population Health Approach to Adverse Childhood Experiences

 

Adverse Childhood Experiences are one of our most important Population Health issues due to their long lasting impact on the physical, mental and emotional health and wellbeing of a person and indeed the wider community. It is therefore really important that we apply a ‘population health’ approach in our thinking about them so that we can begin to transform the future together. This is an area of great complexity with several contributing factors and will take significant partnership across all levels of government, public bodies, organisations and communities to bring about a lasting change. There are things we can do immediately and things that will take longer, but with a growing awareness of just what a significant impact ACEs are having on our society, we must act together to do something now. Here in Morecambe Bay, we have developed a way of thinking about Population Health in what we call our ‘Pentagon Approach’. It can be applied to ACEs as a helpful framework for thinking about how we begin to turn this tide and cut out this cancer from our society and feeds into the already great work being done across Lancashire and South Cumbria, lead by Dr Arif Rajpura and Dr Helen Lowey, who have spearheaded so much!

 

Prevent

 

When we examine the list of things that pertain to ACEs (see previous https://reimagininghealth.com/facing-our-past-finding-a-better-future/ blog), it is easy to feel overwhelmed and put it into the ‘too hard to do’ box. This is no longer an option for us. We must begin to think radically at a societal level about how we prevent ACEs from happening in the first place (recognising that some ACEs are more possible to prevent than others). Prevention will entail a mixture of community grass-roots initiatives, changes in policy and a re-prioritisation of commissioning decisions for us to make a difference together. Here are some practical suggestions:

 

  • The first step is most certainly to break down the taboo of the subject and continue to raise awareness of just how common ACEs are and how utterly devastating they are for human flourishing. ACE aware training is therefore vital as part of all statutory safeguarding training.
  • We have to tackle health inequality and inequality in our society. ACEs, although common across the social spectrum are more common in areas of poverty. Although we now have more people in work, many people are not being paid a living wage, work settings are not necessarily healthy and child poverty has actually increased over the last 5 years in our most deprived areas https://www.jrf.org.uk/blog/poverty-taking-hold-families-what-can-we-do.
  • Parenting Classes should be introduced at High School in Personal and Social Education Classes to help the next generation think about what it would mean to be a good parent. These should also form an important part of antenatal and post-natal care, with further classes available in the community for each stage of a child’s development. Extra support is needed for the parents of children with special developmental or educational needs due to the increased stress levels involved.
  • There needs to be a particular focus on fatherhood and encouraging young men to think about what it means to father children. Recent papers have demonstrated just how important the role of a father can be (positive or negative) in a child’s life and it is not acceptable for the parenting role to fall solely to the mother. www.eani.org.uk/_resources/assets/attachment/full/0/55028.pdf
  • We have much to learn from the ‘recovery community’ about how to work effectively with families caught in cycles of addiction from alcohol or drugs. Finding a more positive approach to keeping families together whilst helping those caught in addictive behaviour to take responsibility for their parenting or learn more positive styles of parenting, whilst helping to build support and resilience for the children involved is really important.
  • We must ensure that our social services are adequately funded and that there is continuity and consistency in the people working with any given family, especially around the area of mental health. Relationships are absolutely key in bringing supportive change and we must breathe this back into our welfare state.
  • Hilary Cottam writes powerfully in her book, Radical Help that we must foster the capabilities of local communities, making local connections and “above all, relationships”. As Cottam states, “The welfare state is incapable of ‘fixing’ this, but it has an important role to play. It can catch us when we fall, but it cannot give us flight.
  • Sex education in schools needs to be more open and honest about the realities of paedophilia and developing sexual desire. Elizabeth Letourneau argues powerfully that paedophilia is preventable not inevitable. We must break open this taboo and start talking to our teenagers about it. (https://www.tedmed.com/talks/show?id=620399&utm_source=rss&utm_medium=rss)

 

Detect

 

If we want to make a real difference to ACEs and their impact on society, we need to be willing to talk about them. We can’t detect something we’re not looking for. Therefore as our awareness levels rise of the pandemic reality of ACEs, we need to develop ways of asking questions that will enable children or people to ‘tell their story’ and uncover things which may be happening to them or may have happened to them which may be deeply painful, or of which they may have memories which are difficult to access. Again, our approach needs to be multi-level across many areas of expertise. We need to be willing to think the unthinkable and create environments in which children can talk about their reality. For children in particular, this may need to involve the use of play or art therapy.

 

  • Whole school culture change is vital, with a high level of prioritisation from the school leadership team is needed to ensure this becomes everybody’s business.
  • School teachers and teaching assistants need to be given specific training, as part of their ‘safeguarding’ development about how to recognise when a child may be experiencing an ACE and how to enable them to talk about it in a non-coercive, non-judgmental way.
  • Police and social services need training in recognising the signs of ACEs in any home they go into. For example, in the case of a drug-related death, how much consideration is currently given to the children of the family involved, and how much information is shared with the child’s school so that a proactive, pastoral approach can be taken. There are good examples around England where this is now beginning to happen. (http://www.eelga.gov.uk/documents/conferences/2017/20%20march%202017%20safer%20communities/barbara_paterson_ppt.pdf)

 

For adults, we need to recognise where ACEs might have played a part in a person’s physical or mental health condition (remember the stark statistics in the previous blog on this subject). Therefore we need to develop tools and techniques to help people open up about their story and perhaps for clinicians to learn how to take a ‘trauma history’.

 

  • Clinical staff working in healthcare need to be given REACh training (routine enquiry about adverse childhood experiences – Prof Warren Larkin) as part of their ongoing Continuous Professional Development (CPD). In busy clinics it is easier to focus on the symptoms a person has, rather than do a deeper dive into what might be the cause of the symptoms being experienced. A wise man once said to me, “You have to deal with the root and not the fruit”. Learning to ask open questions like “tell me a bit about what has happened to you” rather than “what is wrong with you”, can open up the opportunity for people to share difficult things about their childhood, which may be profoundly affecting their physical or mental health well into adulthood. There is a concern that opening up such a conversation might lead to much more work on the part of the clinician, but studies have shown that simply by giving someone space to talk about ACEs they have experienced, they will subsequently reduce their use of GPs by over 30% and their use of the ED by 11%.
  • We can ask each other. This issue is too far reaching to be left to professionals. If simply by talking about our past experiences, we can realise that we are not alone, we are not freaks and we do not have to become ‘abusers’ ourselves, then we can learn to help to heal one another in society. Caring enough to have a cup of tea with a friend and really learn about each other’s life story can be an utterly healing and transformational experience. When we are listened to by someone with kind and fascinated, compassionate eye, we can find incredible healing and restoration. One very helpful process, ned by the ‘more to life’ team is about processing life-shocks. Sophie Sabbage has written a really helpful book on this, called ‘Lifeshocks’).

 

Protect

 

When a child is caught in a situation in which they are experiencing one or more ACE, we must be vigilant and act on their behalf to intervene and bring them and their family help. When an adult has disclosed that they have been through one or more ACE as a child, we must enable them to be able to process this and not let them feel any sense of shame or judgement.

 

  • We need to ensure school teachers are more naturally prone to thinking that ‘naughty’ or ‘difficult’ children are actually highly likely to be in a state of hyper vigilance due to stressful things they are experiencing at home. Expecting them to ‘focus, behave and get on with it’, is not only unrealistic, it’s actually unkind. Equally, children who are incredibly shy and easily go unnoticed must not be ignored. Simply recognising that kids might be having a really hard time, giving them space to talk about it with someone skilled, teaching them some resilience and finding a way to work with their parents/carers via the school nurse/social worker could make a lifetime of difference. It is far more important that our kids leave school knowing they are loved, with a real sense of self-esteem and belonging than with good SATS scores or GCSEs. The academic stuff can come later if necessary and we need to get far better at accepting this. A child’s health and wellbeing carries far more importance than any academic outcomes and Ofsted needs to find a way to recognise this officially. In other words, we need to create compassionate schools and try to ensure that school itself does not become an adverse childhood experience for those already living in the midst of trauma.
  • In North Lancashire, we have created a hub and spoke model to enable schools to be supportive to one another and offer advice when complex safeguarding issues are arising. So, when a teacher knows that they need to get a child some help, they can access timely advice with a real sense of support as they act to ensure a child is safe. These hubs and spokes need to be properly connected to a multidisciplinary team, who can help them act in accordance with best safeguarding practice. This MDT needs to incorporate the police, social services, the local health centre (for whichever member of staff is most appropriate) and the child and adolescent mental health team.
  • For adults who disclose that they have experienced an ACE, appropriate initial follow up should be offered and a suicide risk assessment should be carried out.

 

Manage

 

For children/Young People, the management will depend on the age of the child and must be tailored according to a) the level of risk involved and b) the needs of the child/young person involved. Some of the options include:

 

  • In severe cases the child/YP must be removed from the dangerous situation and brought under the care of the state, until it is clear who would be the best person to look after the child/YP
  • Adopting the whole family into a fostering scenario, to help the parents learn appropriate skills whilst keeping the family together, where possible.
  • EmBRACE (Sue Irwin) training for safeguarding leads and head teachers in each school, enabling children/YP to learn emotional resilience in the context of difficult circumstances.
  • Art/play therapy to enable the child to process the difficulties they have been facing.

 

For adults who disclose that they have experienced ACEs, many will find that simply by talking about them, they are able to process the trauma and find significant healing in this process alone. However, some will need more help, depending on the physical or mental health sequelae of the trauma experienced. Thus may include:

 

  • Psychological support in dealing with the physical symptoms of trauma
  • Targeted psychological therapies, e.g. CBT or EMDR to help with the consequences of things like PTSD (post traumatic stress disorder).
  • Medication to help alleviate what can be debilitating symptoms, e.g. anti-depressants
  • Targeted lifestyle changes around relaxation, sleep, eating well and being active
  • Help with any addictive behaviours, e.g. alcohol, drugs, pornography, food

 

Recover

 

Again, this will follow on from whatever management is needed in the ‘healing phase’ to enable more long term recovery. There are many things which may be needed, especially as the process of recovery is not always straightforward. These may include:

 

  • The 12 step programme, or something similar in walking free from any addiction.
  • Revisiting psychological or other therapeutic support
  • Walking through a process of forgiveness (https://www.youtube.com/watch?v=JQ-j7NuhDEY&list=PLEWM0B0r7I-BXq6_wO4sL0qIwzTWwn_vx&index=9&t=0s, https://www.youtube.com/watch?v=EtexaUCBl5k&list=PLEWM0B0r7I-BXq6_wO4sL0qIwzTWwn_vx&index=9)
  • We may need to help children go through development phases, which they have missed, at a later stage than usual, e.g. some children will need much more holding, cuddling and eye contact if they have been victims of significant neglect.
  • Compassionate school environments to help children and young people catch-up on any work missed, in a way they can cope with and reintegrate into the classroom setting where possible, but with head teacher discretion around sitting exams.

 

To complete the cycle, those who have walked through a journey of recovery are then able, if they would like to, to help others and form part of the growing network of people involved in this holistic approach to how we tackle ACEs in our society.

 

Hopefully this is a helpful framework to think as widely and holistically as possible. There is much great work going on around ACEs now and we must develop a community of learning and practice as we look to transform society together. We can’t do this alone, but together we can!

Share This:

Share

Health and Society – Can We Make A Difference? Part 2 – politics

In the second of this (actually 3-part!) series, I’m looking at how politics and social movement are vital at changing the health and wellbeing of our society, communities and the environment we live in. Together We Can!

 

 

 

 

Share This:

Share

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.

 

Share This:

Share