Taking collective responsibility for a healthier society
This is an adapted version of ADPH President Jeanelle de Gruchy’s speech in the conference plenary: ‘The future of care, health and wellbeing: opportunity, risk and ambition’ at the LGA Conference, July 2019.
As a junior doctor, I once saw a woman in my medical outpatient clinic with diabetes teetering on out of control. I spoke with her about the seriousness of the situation and about how she could better manage her diet to reduce her high blood sugar and avoid admission. After my clinic, I headed off to the local shop for lunch – where I met my patient, tucking into a large portion of fried chicken and chips.
It was vividly clear to me that it was unrealistic to expect people – even, or perhaps especially, at the point of imminent health crisis - to act differently on the basis of simple information and encouragement. Instead, what my patient probably needed over her lifetime was an environment – family, school, workplace, high street – that encouraged healthy eating and being physically active. And I could see this was true of so many more of the people I was seeing with major health problems.
This sense, that we needed to help people more effectively than the current system is set up to do, impelled me into public health as a discipline. Public health seeks to understand how we as a society create the conditions for people to develop diabetes in the first place – and then to help them manage their diabetes effectively to prevent it getting worse.
Public health in local government
Since moving from the NHS in 2013, public health teams are now firmly at home in local government – developing vital links across the council, the NHS and other local partners – with children’s and adults services, community safety, housing, planning and economic development, focused on addressing the social determinants of health.
This helps us work collectively with communities to create healthy, thriving places, to get people moving and connecting – for people to live a good life. This is the work that local government can and should be doing; it should be our ambition – and our strength.
Just as importantly, public health has maintained strong outcomes for the specific services we commission – drug and alcohol, sexual health, health visiting and school nursing, smoking cessation, physical activity and more. These are vital services and we’ve worked hard with the providers of these services to innovate and deliver improved outcomes despite government cuts to the public health grant of £850m in real terms.
The risk of further cuts to these preventative services is high – and the negative impact will be felt by other services, by our families and communities and will, of course, be expressed in our country’s health outcomes getting worse.
Challenging fatalistic thinking and championing prevention
We face some serious inequalities in health. Men and women living in deprived areas can expect to spend 19-20 fewer years in good health compared to those living in the least deprived areas.
By 2050, 1 in 4 of us will be over 65; between 1 in 2 or 1 in 3 will have a long-term limiting illness. This isn’t a good scenario for our society, or economy, or a sustainable public sector. But this is not inevitable. We don’t have to accept as fact an inexorable rise in poor health and ‘demand’. Because it’s not aging per se that’s driving demand, it’s unhealthy aging.
And we know that prevention works. Even dementia is not inevitable. The recent Lancet Commission on dementia identified nine modifiable risk factors across the life course which could prevent more than a third of dementia cases, including low educational level in childhood, obesity, smoking, social isolation, diabetes and physical activity. These all play to local government’s strengths, provided we’re effectively funded.
And we had great news this week about continuing drops in smoking prevalence, so we know we can do it. But the stats are not great for the other factors. Take physical activity – by the age of 75, only 1 in 10 men and 1 in 20 women are active enough for good health.
Taking responsibility for a healthier society
How are we organising ourselves as a society so that we end up with this grim statistic? This isn’t happening by accident. Our society is currently being socially and economically shaped to give us these poor results.
Our burgeoning epidemics of things like frailty, diabetes, heart diseases and cancers are not driven just by a lack of willpower – or ‘personal irresponsibility’, if you will – as if every succeeding generation since 1948 has worsened its diet because we’ve got progressively less good at self-discipline.
This is driven by a complex mix of social and environmental factors like poverty, access, advertising, food formulation, inactivity being the default option for many, and an assumption that the NHS will just fix whatever is wrong with us regardless of the cost.
Public health is about the art and science of improving our health and wellbeing through our organised efforts as a society – it’s not about blaming individuals for their so-called ‘lifestyle choices’.
It’s no good blaming and admonishing my patient with diabetes for going into the nearest chicken and chips shop if that’s their overwhelming, or cheapest, offer on the high street.
Everyone taking personal responsibility for their health has never worked as a population strategy. We know that policies which rely on people to know what’s required of them and do it, can lead to widening health inequalities.
The health and wellbeing problems we’re dealing with are complex societal issues, and they require approaches which work across systems. A simple single agency intervention is generally just not going to crack it. Whether it’s poverty, county lines and serious violence or domestic abuse, air quality, childhood obesity, unhealthy aging and increasing long term conditions… this is about people living and thriving in a place – it’s about good schooling, good homes and jobs, a decent income, it’s about community and connections, and sometimes health and care services.
Individualistic, silo thinking about services or ‘lifestyle’ takes the focus away from the socio-economic determinants of health, and detracts from the effective solutions we need to come up with.
We also need to shift to an approach that’s a positive one about people. Too often we refer to ‘system pressures’ or increasing demand or see our aging population or families with increasing needs as fundamentally the problem. Arguably, it’s we as public sector agencies who are creating the system pressures by not taking heed to do prevention effectively or develop a more fit for purpose system – or society in which people can thrive and grow old well.
The NHS Long Term Plan and Prevention Green Paper (which we hope to see in the next week or so) both herald the importance of prevention, and the latter, we hope, champions a focus on the wider determinants of health – and this is to be welcomed. This new dawning provides an exciting impetus and potential for a shift to a more sustainable population wellbeing focus.
Our ambition should be for a ‘Spending Review for Wellbeing’ which sets a test that every department puts wellbeing at the heart of its investment decisions (as is being done in New Zealand) and a sustainable funding package for local government and for public health. That’s why the ADPH supports the recent call by the Health Foundation and The King’s Fund for the Government to reverse £1bn of real-terms per head cuts to the public health grant.
We need to acknowledge that in 2019, your health and wellbeing is overwhelmingly dependent on who you are and where you live – this is unfair and drives inequalities. We need to challenge the way things are, maintaining a stubborn focus on prevention for the long term.
And I have an ask of local leaders - to recognise the role of the Director of Public Health with their knowledge of and responsibility for the health and wellbeing of their local population; their understanding of the evidence of what works for prevention, and their strong links across the council, the NHS, voluntary sector and many other partners in our local systems and places.
Our collective ambition should be a population wellbeing approach, with policies that create healthier places and fully funded, integrated and innovative services delivered in a place-based way.