Category: Corporate Health

Population Health – The Pentagon Approach

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

 

 

 

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

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

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

Therefore Population Health in Morecambe Bay is defined as:

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

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

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

Prevention

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

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

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

Detection

Detection means early recognition that:

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

Protection

Protection means:

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

Management

Management means:

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

Recovery

Recovery means:

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

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

Share This:

Share

Facing Our Past, Finding a Better Future – Adverse Childhood Experiences

This week I had the privilege of listening to Prof Warren Larkin, advisor to the Department of Health on Adverse Childhood Experiences. This is something I’ve written about on this blog before and Warren has made me more determined than ever to keep talking about this profoundly important issue. This blog draws on his wisdom and learning.

I believe that Adverse Childhood Experiences are our most important Public Health issue. So I want to be really clear about what they are, how and why they affect us so deeply, where we can find help if we’ve been affected by them and how together we can change the future, by preventing them.

 

What Are Adverse Childhood Experiences?

 

• Physical abuse
• Sexual Abuse
• Emotional Abuse
• Living with someone who abused drugs
• Living with someone who abused alcohol
• Exposure to domestic violence
• Living with someone who was incarcerated
• Living with someone with serious mental illness
• Parental loss through divorce, death or abandonment

 

How Common Are They?

 

The answer is – far too common. There have been some really wide ranging studies across the UK and USA into the numbers of us who have experienced ACEs, and it’s not just in our “most deprived communities” but in predominantly white, middle class areas where we see the stark statistics. Depending on the study you read, between 50 and 65% have experienced at least one ACE. And shockingly 1 in 10 of us have experienced more than 4.

 

How and Why Do They Effect Us?

 

Firstly, they affect us by quantity. The more ACEs we experience, the worse our physical, mental and social health and wellbeing is. If you have experienced one ACE, you have an 86% chance of being subject to several. If you experience more than 4, your health and wellbeing is significantly affected. If you experience more than 6 then you have a 46 times higher chance of becoming an IV drug abuser, a 35 times higher chance of committing suicide and an overall 20 year decrease in life expectancy.

 

Secondly, the toxic stress levels significantly change the way in which our brains grow and function. This has a profound impact on our day to day functioning. ACEs are a massive cause of absenteeism from work, high cost to the health and social care system and highly predictive of time behind bars. That is why so many of us have complex relationships with things like food. Losing weight, for example, is not as straight forward as eating less, exercising more or ending up with a gastric band. Did you know that suicide rates are massively increased after bariatric surgery? By removing the ability to eat, the very thing that takes away or comforts the pain, we expose the underlying issue, but provide no healing into that void.

 

Thirdly, our bodies literally keep the score of the negative experiences. So, we become more likely to develop chronic pain, inflammatory conditions, heart disease, cancer and mental health issues.

 

Fourthly, the toxic stress actually alters the way our DNA works and therefore changes the genetic information that we pass onto future generations. As an example, domestic violence in pregnancy is predictive of child developmental issues and offspring of the survivors of the holocaust or genocide are far more likely to develop chronic anxiety. This highlights just how important our family history really is.

 

Fifthly, there are proven things we can do a) to help our brains learn how to cope in the midst of really difficult circumstances (resilience) and b) therapeutic interventions that can genuinely heal us.

 

Where Can We Find Help?

 

Here’s the thing – this is where the rubber hits the road.

 

Many of us, who have experienced difficult things in childhood/adolescence never talk about them. Sometimes that’s because we can’t remember the experiences – they happen to us before our memories fully form. But perhaps more frequently we bury them because we don’t want to talk about the deeply painful memories, we don’t know how to or we’re worried about what might happen to us, or the people who caused us the pain if we do. And how do you start a conversation like that anyway? What? Are you going to just blurt it out to someone? And what on earth will you do if you just start crying in the middle of a restaurant when you talk to your girlfriend/boyfriend about what happened to you? And what about all those complicated associated feelings of shame, guilt, fear, thoughts of rejection? So…..we keep the lid on….even though it’s to our own detriment because we don’t know how to bring it into the open.

 

And here in lies the starting place. It’s vital that we learn this in the world of health and social care, but actually we all need to hear this incredible truth. Various studies have shown that it takes 9-16 years for people to be able to talk about trauma/abuse they experienced, but most never do. Fraser and Read found that in their patients struggling with mental health issues, only 8% of them volunteered that they had experienced ACEs. However, when they were actually asked about this, 82% then talked about ACEs they had experienced. So? So, we find it almost impossible to talk about, but when someone asks us about what we have lived through, it takes the lid off the box, peels the sticky plaster off the deep wound and allows us to begin talking about our pain. And here’s something really remarkable……Felitti and Andra found in a study of 140000 people that simply by routinely asking all patients about ACEs, they saw a 35% decrease in visits to the GP and an 11% reduction in use of the Emergency Department!

 

What does that mean? It means that giving someone the chance to talk about their journey, what they have been through, breaking the cycle of shame, fear and rejection is, in and of itself, deeply healing! Knowing that you’re not a freak, knowing that it wasn’t your fault, knowing that it doesn’t mean that you yourself will become an abuser/alcoholic/poor parent and many more realisations can make a significant difference to a person’s wellbeing. Maybe it doesn’t have to wait for a GP’s surgery or a counsellor’s chair. Maybe, just maybe if we all care enough to ask each other deeper and more caring questions we can help to heal each other. I know this is true of my own journey and that of many of my friends.

 

But let’s not be naive. For some of us, the experiences we have had are so horrific that we are stuck in a moment and we can’t get out of it. And this is where good therapy really comes in. I wonder if we invested more in therapy and less in drugs to numb our pain, how much more healed we might be – perhaps more expensive in the short term, but overall the cost is far less, both for the individual and society as a whole. There is help available and it can take many forms. EMDR, Trauma Focussed-CBT, Bereavement Counselling and even things like working through a forgiveness process. Unfortunately, many of the waiting lists are very long, and private options are way too expensive for most people to afford.

 

So, Can We Change The Future?

 

You know that I believe together we can! But it’s not going to be easy, especially not in the context of our floundering social services, restrictive school curriculums, reduction in numbers of health visitors and school nurses, eye watering cuts to public health budgets and significantly stretched CAMHS and Adult Mental Health Teams. And I think we have to very real and honest about that, because if this is such a massive issue in our society (and the data and evidence is astounding) then we need, as Warren Larkin so eloquently argues, genuine commitment from leaders and organisations to shift towards a culture of learning and collaboration to bring about change.

 

Here are some things we need to do together:

 

1) Own up to what a massive issue this is.

2) We need to learn how to ask our friends better questions and care enough to listen to each other’s experiences and journeys because it is really hard to know how to start talking about ACEs, but is more possible when someone bothers to ask!

3) We need to recognise that by bottling things up, we do further harm to ourselves. Perhaps some of our complex addictive patterns of behaviour, our mental health issues, our physical pain and symptoms might well be linked to the ACEs we have experienced. So maybe we don’t need a life on painkillers, cigarettes or with a complex addictive behaviour patterns. Maybe we can find a way to deeper healing.

4) In health and social care, we need to adopt REACh (routine enquiry about adversity in childhood) – we need to change the way we take histories from patients and ask better questions. Remember that even by asking, it doesn’t open up scary and messy consultations that we don’t have time for, actually it opens up a therapeutic space which can massively alter how a person goes on to use the health service in the future.

5) We need to ensure schools are more vigilant 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. 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.

6) Parenting classes should not just be for the well-motivated or struggling. They should be for all of us – a routine part of antenatal care and alongside our children’s education and include help in dealing with previous ACEs, so they are not repeated for the next generation. Prevention is possible. And that means we need to learn to be a whole lot less judgemental and a great deal more open, honest, vulnerable and restorative with each other. One of my best memories of growing up, was going to a “foster home” for families that my mum used to work with and seeing parents being given the chance to learn how to love their kids, rather than have them taken off them. I know sometimes there is no choice, but helping people learn how to be family and to love and cherish their children is a really beautiful thing. When there has been generational abuse, it is is also of the upmost importance. I’m not saying that a child should never be removed, but we can hardly say that our care system is a rip-roaring success story.

7) We need to find a way of working with men and women in our prisons that enables them to find a way to healing and restoration, not retribution for what are often extremely complex stories.

8) We must learn from best practice around the world. For example, did you know that the vast majority of paediphiles begin offending at the age of 14?! Most of them do not go on to become prolific offenders, but the damage caused to the child they abuse is obviously significant. There is some amazing work now going on in Pennsylvania which has shown that you can actually prevent young men from becoming offenders in the first place. Simply by doing some better sex education, explaining to boys about testosterone, the urges they are having and who it is appropriate to perform sexual acts with; alongside creating a really safe space where they can come and talk about feelings they are having (a bit like AA – with no ridicule or judgement) – data shows that you can decrease the incidence of child sexual abuse. We have to learn from this kind of approach and find a better way of talking about difficult issues. Prevention IS possible!

9) We need to find a way to fund more psychological therapies and become much less reliant on drugs to numb the pain with the associated colossal bill paid to Big Pharma.

 

 

This is an area I am really passionate about. I am committing to keep this conversation alive, to ensure that we make a shift in our organisations towards a REACh approach, to find a deeper and more effective partnership with colleagues in education, social services and the police and to create space for more training and awareness for all our staff teams. I know how painful this conversation is, but I also know how utterly damaging it will be if we don’t change the future and prevent this from being a perpetual story through the generations. It is time for the hearts of the elders to turn to the children. Together we can reimagine the future. Together we can.

 

 

Here is a really helpful film:

Share This:

Share

Never Let a Good Crisis Go to Waste

So, the NHS is in another winter crisis.

The Oxford English Dictionary defines a crisis  as:

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

Mass noun ‘the monarchy was in crisis’

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

 

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

 

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

 

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

Share This:

Share

Health Spending in The North vs The South

A few months ago, I wrote a couple of blogs exploring the social justice issue that is the vast difference between the health spend in the North, compared to the South.

 

This week a graph was produced by HM Treasury to show how overall spending has changed across England since 2012. Here is the evidence:

 

 

So, in the North, we already have the worst health outcomes in England with an underspend of around £800m per year, per head of population, compared to the South. Yet, over the last 5 years we have seen further disinvestment here at a time when we’re also being asked to make substantial savings! Why the Northern MPs do not seem to think this is worth making much noise about, I’m not quite sure. This is an economic issue, a political issue, a social justice issue and a humanitarian issue. As I take the conversation to our public about the difficult choices ahead of us, here in Morecambe Bay and Lancashire over the coming months, I wonder what the response to this information might be?

 

 

Share This:

Share

Healthy Schools

Last week, I had the privilege of being at Morecambe Bay Community Primary School. The school is a beacon of hope in this area. I found it extremely moving to walk round, with Siobhan Collingwood, the visionary and big-hearted headteacher and see the incredible love displayed by all staff towards the amazing children there. It made me realise again how centrally driven targets often make no sense for so many of our children and communities, especially when the base from which they start is so very different. Siobhan and her team are doing the most incredible job at caring holistically for the children here, dealing with complex behavioural issues with such kindness and brilliance that it brings tears to my eyes, even writing about it. Not only so, but the standard of teaching to then try and help these kids come up to the ‘required standards’, being creative with the resources available, is nothing short of miraculous. I would defy any school inspector to rate this school as anything else than ‘outstanding’.

 
Siobhan and I had a great discussion about the need for health, social care, the voluntary and faith sector, the police and education to work more closely together for the wellbeing of children and young people in our communities. This is already happening in part, through our health and wellbeing partnership and ‘better care together’, but there is far more we can do. We thought about what it might be like if we parachuted fresh into the community now and had to start from scratch, what we might do together…….

 

We would start with stories – we already have many, from the conversations we’ve had in the community, but we want to really listen and be changed by the responses that we hear. We’re so grateful for the work of the ‘poverty truth commission’, helping us to do just that. We would also definitely pool our resources and prioritise key services that would not be taken away once the community begins to thrive, such as parenting classes, cooking lessons, early support services, a radically caring housing sector, preventative policing strategies (now emerging powerfully in partnership with our town and city councils), social care, mental health champions (something Siobhan has already been part of recruiting 150 locally!), children’s centres and adult education centres as a starter for 10. We would overlay this with the things that are working now – there is so much goodness happening and we don’t negate this. We want to ensure that we could see the health inequality gaps close.

 

In order to build on this idea of ‘healthy schools’, we would see kids being active every day – despite, limited grounds space, this school, like many others locally are running a mile a day. There is a great scheme here in which all the kids are learning to cook healthy, nutritious food, building vital life skills needed now and in the future. The breakfast and after school clubs are providing many healthy meals each day for the kids and throughout the summer holidays the schools cook – another woman with an incredibly big heart, opens the hall to feed families, who cannot afford to eat during the long breaks. A huge amount of work is being done around gender equality (have you seen the amazing documentary series “No more boys and girls: can our kids go gender free?” On BBCiplayer?). Kids are also given a huge dose of self esteem and know that they are loved and belong. If only the same level of caring support could be afforded through the transition to high school…..

 

Over the coming months, we hope to co-host some conversations with the community, not on our terms but shaped together with them. Siobhan spent years trying to think of great ideas to get the parents to come into school and interact with her. It wasn’t until the parents set up their own coffee morning in the old garage of the school playground, that she went to meet with them on their terms and started to build some staggeringly life-changing relationships. We know we are changed every time these kind of conversations happen and it blows our world view up so that we can collaborate effectively and co-design services with them. We want to share data with them about health and educational outcomes in order to create a passion for change and do some appreciative enquiry about all the great stuff already embedded in the community. Through these conversations, we want to connect people together and see a social movement for positive change.

The future of Morecambe is bright and full of hope. The communities are strong, the place is beautiful and the people are amazing. Siobhan is just one of many incredible headteachers in this area, committed to one another and this geography through bonds of friendship. If a genuine partnership between health and education can develop here (and it’s part of my vision and ambition to see this done) then who knows what might be possible over the coming months and years?

 

It is time for Morecambe to find its joy again. It has been the joke for too long, but soon it will become the place where the joke is found and everyone will want to know what we’re laughing about.

Share This:

Share

Please get your Flu Jab this Year!

We are heading for a massive flu outbreak this winter across the UK and Europe, USA and Canada. Australia have had a seriously nasty outbreak of a strain of flu called H2N3. It held their health care service to ransom over their winter and we need to be ready for it. The best thing you can do is have your flu jab – free on the NHS, here in the UK for those who are most vulnerable. If you get flu this winter, don’t worry, we’re on it! Public Health England are masterful at making sure we are ready and in partnership with the NHS, we will be armed and ready. But the best medicine is preventative. So, PLEASE, get your flu jab as soon as possible and make sure it is the QUADRIVALENT type that covers the strain we are most at risk from! Let’s stay healthy and well this winter.

Share This:

Share

Who is Responsible for Your Health?

Who should take responsibility for you health? Sounds like a straightforward question, doesn’t it? But I get so frustrated when complex issues get squashed into simplified, silo-thinking, ready for twitter or media sound bites, or the under-girding of political ideologies.

So….just as the economy is not just made up of the interplay between business and the household, but is in fact far more rich and complex, so too the interplay of responsibility for our own health.

Kate Raworth, really helpfully uses the following diagram to help us rethink the components of the economy. I would like to suggest that we use it to think about health, also.

So…who is responsible for your health and wellbeing?

  1. Your Family/Household
  2. Society/The Commons
  3. The Market
  4. The State
  5. You

In some ways, I feel like all of these are obvious, in their own way, but I will just unpack each one a little bit more.

 

Your Family/Household

We all have needs. We need to know we are provided for (water, food, clothes etc), safe, loved, welcome, encouraged, disciplined and given place to dream and live those dream out. It is the role of our families or the household to which we belong to ensure those things happen as we grow. So much of our ill-health, our brokenness and our long term physical and psychological pain is because these basic needs were never met and left us without a sense of wholeness. The lack of met need, has a huge impact on the development of our personality and character. When we speak of ‘personality disorders’, each type has it’s roots in early life when needs were unmet and therefore parts of the personality remained undeveloped. Let’s face it – no family is perfect! And so, I would argue, that all of us have ‘disordered personalities’, and until we confront the shadow parts of ourselves that are trying to overcome this sense of loss or inadequacy, we continue to project an ego version of ourselves to those around us. We do so to cover over this pain, but facing it head on and allowing ourselves to fess up to our deepest needs, would actually lead to us being a great deal more healthy.

When I work with head teachers and ask them what the biggest need they have in their school, the answer is almost always ‘parenting classes’. However, there are very few providers of this available (due to cuts at a county council level) and the classes available are often very ‘middle class’ in their approach. We need to completely rethink parenting classes in the context of the poverty-truth commission and think about less twee ways to really engage with communities about how we raise happy and healthy kids. The truth that Adverse Childhood Experiences are our greatest public health crisis is not going away. Grasping this nettle is going to be painful but really necessary if we are to breathe health and wellbeing into our society.

 

Society/The Commons

Just as we get our needs met by those in our immediate household, the same is true of society. The way we treat children, the things we expose them to, the way we love them and educate them has a massive impact on their current future health and wellbeing. It’s becoming clear that social media is causing significant harm to our mental health as a nation, particularly our young people, and yet we don’t know how to curb our enthusiasm for all our technology…let alone the rise of the robots…

The commons is fast disappearing, too easily privatized and made available to those who can afford it. How do we safeguard the commons and use it for the benefit of all? What would the Diggers say to us now? The breakdown of our communities, with increasing isolation and loneliness is having a detrimental effect on our wellbeing. What can we do to recover the spaces that belong to us all and help us rediscover the joy of connecting and being together?

The commons is also about our corporate voice. It is only really vast people movements, speaking with one voice that can really cause governments to sit up, listen and take heed of the needs of the people. It is only together, that we will make enough noise to change the health and wellbeing of all of us for the better. How might we speak and act together in a way that will take corporate responsibility for all our health and wellbeing?

 

The Market

Oh the benevolent hand of the market! If only…. But the Market plays an absolutely key (though currently over played) part in our economy and our health and wellbeing. We know for a fact that advertising is deliberately trying to misinform us so that we make irrational decisions. A key component is to make people feel worse about themselves so that they buy things they simply do not need. Supermarkets are being challenged for the ways they deliberately place products and arrange their stores to cause people to buy more unhealthy things and food chains are constantly trying to ‘up-sell’ their unhealthy products and downgrade our health in the process. They evangelize the masses with the idea that we are all free to make our own choices, but if this were so, they would not spend the billions of pounds involved in socially engineering our choices, so that we ‘freely’ choose that which harms us! Oh for a market that might redefine it’s moral code! The market could do SO much good, but unharnessed and left without true accountability or consequences, it serves to damage our health – something it is truly responsible for.

 

The State

The state has a vital role and responsibility in caring for all of our health and when it washes it’s hands of that responsibility or tries to pass it over, we see a massive rise in health inequalities and overall worse-health for all. The NHS in the UK is one of the great triumphs of the state. Providing brilliant healthcare for those who need it whenever they are unwell is truly amazing. Imagine not being able to afford this because it depended on keeping up with insurance bills. It is not uncommon for us to see people in General Practice, who literally cannot afford to feed their families any more and are having to make some incredibly difficult choices (made far worse by long school holidays). Easy to point the finger and start creating a narrative about how it’s “all their fault”, but far harder to hear the truth of what it is really like to be a lived-expert in poverty and the trap it creates and harder still to look to alternative solutions, rather than believe the austerity narrative. There is clear evidence that the more unequal a society becomes, the worse the health outcomes – both physical and mental. When the market is allowed to behave exactly as it wants, we also see the health of people suffer. It is only through the right kind of government that the market can be tamed. It is only with the right kind of legislation that the economy can be skewed towards redistribution and regeneration of the resources needed – this would need to include a radically feminist approach that works on behalf of women, in particular, for equal opportunity, pay and recognition of just how much the ‘household economy’ contributes to the overall wellbeing of the nation. It is only the right kind of leadership that will tackle the inequalities we see and refuse to be wined and dined into maintaining the status quo. It is only brave leadership that will take the ecological issues, like plastic in the oceans, massive over antibiotic use in animals, and ongoing air and river pollution that will give us a healthy planet and human population in the future.

 

You

And where possible, and for some given various health issues, this is more possible for some than others – we do not all have an equal starting place or a level playing field – where we can  – we do have a responsibility to ourselves and to the wider society to care for our own health and wellbeing, so that when the health and social services are needed, they are available for all. It also means using the health and social care services in a way that creates sustainability, being grateful for them and ensuring they and the people who work in them are not abused.

 

It’s complex, but it’s vital that too much emphasis is not put on any one area. We must not play the blame game, especially not towards individuals when we haven’t taken the time to hear their story, nor understood the wider context of the role of the other vital players on the field. Each aspect of the economy plays a massive role in the health and wellbeing of the nation, and it is high time that each plays it’s relevant part to its fullest ability.

Share This:

Share

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?!

 

 

 

Share This:

Share

The Rules of Engagement

I am increasingly concerned by the use of the word “customer” to describe people who use the NHS and social services. I hear it often in meetings and it is, in my opinion really dangerous. It is dangerous for 2 reasons: firstly, it assumes that people “buy” services, which they do not (because our services are not and must not become based upon ability to pay); and secondly it creates a very unhelpful understanding of how we expect people to behave in relation to their own health and the health service i.e. as consumers, rather than participants.

 

I heard recently about a practice in Columbus, Ohio, in which before beginning an operation, each member of the team: the patient, the surgeon, the anaesthetist the nurse, the ODA and the recovery nurse all stand in a circle and agree who is responsible for which bits of the healing process. It takes into account the ‘checklist’ idea of Atul Gawande and expands it further. Each person, including the patient (except in emergency settings when they are unconscious) have some responsibility to take for the healing that is about to ensue. It is vital that the patient themself understands that they have a key role to play in their own recovery.

 

If people think of themselves as the ‘customer’ or we think of them that way, we can all too easliy exclude them from taking an active part in their own health journey. The NHS is not a sweet shop or a passive experience in which you have things done to you – at least it shouldn’t be. Creating a ‘customer base’ is the antithesis of a social movement for health and wellbeing and we need to stop this really unhelpful language now!

 

There is a step-ladder approach to thinking about engagement and participation which is really helpful. I’m not exactly sure who first drew this, so can’t give credit where it is due:

 

 

We are actively producing and encouraging a society of passivity and consumerism and we need a sizmic shift in our thinking to create a totally different approach to how we think about our health and wellbeing.

 

If we think of, or encourage people to think of themselves as customers of our health and social care services (and this applies across the public sector, so this could equally be written about education, the cleanliness of our streets etc) then we assign people to the bottom two rungs of the ladder as victims and consumers. It is no wonder that we are facing some of the issues we are. It has created an incredibly unhelpful and unhealthy power dynamic and has caused an enormous strain on our services.

 

I’m not talking uncompassionately here. I know that many people have to live with long term conditions that can be utterly debilitating and difficult to cope with on a day to day basis. What I’m talking about here is how we respond to people who live with those complexities every day. We don’t have to treat them as victims, nor as consumers. Surely, we want people at least to be able to translate what their choices are – what’s possible for me or even what is in this for me? It would be one step better for people to be able to actively participate in their own care – this can be both active and reflective. But what about people being able to shape or co-produce the kind of care they would like to see and what might their role be in this?

 

Co-production calls for a double accountability. What is the responsibility of the person who has a certain condition and what is the response ability of the service to work with that person or group of people around that condition/situation? It is not for us to be taking power away from people. We have to learn to work differently and to work with people.

 

People using the NHS and Social Services are not customers and we must stop talking about them in this way. They are active participants in their own health and social needs, who should be able to shape and co-produce the kind of services we all need to improve our health and wellbeing. This kind of approach is vital if we want to see an end of the consumer mentality and an embracing of a greater sense of corporate responsibility.

 

That is why I am so passionate that we take our financial difficulties and conundrums out to community conversation. It is not for those of us in positions of power to make decisions on behalf of our communities, (even though this is our statutory responsibility) because if we do, we will only deepen the victim/consumer mentality. No, we must be honest, change our language, share our problems and engage together to recognise that the future of the NHS and Social Care belongs to us all and is our shared responsibility.

 

Share This:

Share

A 3 Fold Approach to Population Health

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

 

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

© www.stevenbarber.com – Dr David Walker

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

Share This:

Share