David Pencheon is a public health doctor and Director of the NHS Sustainable Development Unit. His interest is, as he puts it, in “promoting health in the best sense of that phrase, rather than just as a large illness treating machine”. He is one of the people behind the NHS Sustainable Development Strategy, and one of the key people trying to embed Transition ideas into the public health setting. We were delighted that he agreed to speak to us to close our month’s theme on Transition and health.
Jamaica Plain New Economy Transition in Boston have started a process of asking “what would a cancer free Jamaica Plain look like by 2030?”. Most of the things that you would do to make it a cancer free are actually the same that you would do to make it a low carbon and more resilient place. How do you see that coming together of the two things?
It’s a very strong message. It’s one lens through which the health service can really add value in that to make this transition to a low carbon, sustainable world. The health system doesn’t actually need to do anything differently. It just needs to do what it’s already doing much better and in a transformationally better way because exactly as you say, so many of the things that we would do to make health better, even if climate change were not happening, give us so many short term health benefits that there are very few trade-offs.
In public health terms, there are two very obvious examples of this: the first is in travelling. Never before have we moved our bodies around the world so much without moving our bodies. It is absolutely extraordinary. If you think about low carbon transport systems, they both serve our needs in terms of climate change and low carbon transition but also serve our immediate health very well in that we would raise our physical activity rates much, much more leading to a reduction in diabetes and heart disease and so on.
The other area is clearly around food. We know that a low carbon food system, which is essential for the future, is actually very beneficial for our health now. So the decision co-benefits: what’s good for the future is also good now. It’s a very important message and an important framing of the significant overlap between public health and the transition into a low carbon society.
In the editorial for this theme I speculated that hospitals could be reimagined as market gardens, power stations, co-operatives and so on. Through the Clinical Commissioning Groups that NHS Trusts have, in theory those they now have the potential to make such radical shifts if they chose to. Do you think the obstacle to really embedding a Transition take on public health in the NHS in a very practical way that’s rooted in local community is prevented from happening from a lack of vision or a lack of agency?
I think it’s much more a lack of agency. The phrase I use is that lack of “aligned incentives”. All the things you described about what hospitals could be as health enhancing civic structures and civic systems, i.e. supplying energy through district community heating systems, biomass, combined heat and power. Could they provide allotments, could they provide green spaces, could they provide places where people could actually see what it looks like to live healthy lives? Could they have good food shops in the concourses, could they have fair trade coffee in the concourses? All of those things sound quite visionary. But actually every single one of those things is happening now, but sporadically in isolated examples.
We know all those things are possible. There’s nothing to stop any of those things from happening. As we often say, “the future has already arrived, it’s just a little unevenly distributed”. So that is perfectly possible, but we do not see it at a system-wide level. What we see is stars in the night sky, not the dawn, to be blunt about it.
Why does it not happen? Part of it is cultural. We are a rescue system, we wait until people get ill, and we know hospitals for instance are quite unhealthy places to be both for patients and staff. It’s quite a brutal environment to be in. People sometimes say “if you’re not ill when you go into hospital you certainly are when you come out”. People put up with it because they feel like some good is being done.
We tend to pay hospitals and we tend to pay professionals in hospitals for activity not outcomes. The more you do, the more you get paid. The more operations that are done, the more the hospital gets paid. That means that all these visionaries who are working in hospitals promoting care closer to home, they are losing the Trust or the hospital money.
That’s not a good idea, because the hospital can see that although there’s an obvious merit to keeping preventable illnesses away from hospitals, promoting health, promoting resilience, adding social value in the community, they tend to look at their financial bottom line and think “if we don’t get the patients through our hospital we ain’t gonna get paid and we’ll have to think very carefully about downsizing, closing wards or even closing the hospital”.
That is seen as a sign of failure sadly, not as a sign of success. Very rarely would you get a Secretary of State for Health standing up in the House of Commons and saying “I’m proud to announce we’ve done fewer operations this year because we have needed to do fewer, because we have prevented this whole range of preventable illnesses”. Normally politicians will congratulate themselves on the NHS undertaking more activity, which is not necessarily the vision we want.
You wrote “the system needs to help build resilience into people, families and communities, particularly in the light of increasingly frequent weather. This depends on supporting effective networks within communities locally and globally that enable the health system to provide support and services with people rather than just to people.” If people are reading this are part of an active community with lots of project going on, what’s the best way to reach out and try to interact and build those kinds of relationships with local health providers?
It’s important to remember that most healthcare is not delivered in hospitals, just in the same way as most health is won or lost outside the healthcare system altogether. Primary healthcare, that’s healthcare that’s delivered outside hospitals, in GP surgeries and elsewhere in the community: pharmacies or community psychiatric nurses or district nurses is absolutely the root of where a Transition healthcare system would be based.
The practical answer to your question is if one as a citizen feels very strongly about a much better model of health and healthcare, then logically the first people to engage are one’s GPs, one’s primary healthcare centre. There are an enormous number of GPs – in fact the Royal College of General Practitioners is one of the royal colleges that’s actually devoted a lot of time to thinking what would a sustainable health system look like. They know very well that much of it would be outside hospitals. In fact much of it would be outside primary healthcare.
Some GPs have over 50% of their calls done by telephone. Some hardly use it at all. And sadly, variation is something the NHS does very well. We shouldn’t do variation. If we know what the best way in which we can take care much more directly and much earlier to people, then we should be doing it more universally.
In communities which are very fragmented, where people don’t know their neighbours, where people don’t have these formal and informal networks of support, when things go wrong and sometimes quite trivially wrong, where traditionally they would have leant over the garden fence or spoken at the coffee morning or gone to speak to their vicar or other faith leader, they would now go immediately to their GP. That’s completely inappropriate. It’s disempowering, it’s not local, it doesn’t breed a mutual trust and reciprocity which we know healthy and resilient communities are based upon.
You wrote in something else that I read that “The default location of healthcare should be at home.” But the trend in the health service has been very much towards centralising into bigger and bigger regional hospitals and so on. Is there a case, do you think, are you arguing for localisation of healthcare in that way?
There are probably some things which we should centralise. If we have a superb hospital that does hip replacements superbly well, you want to travel to that hospital because you’re probably only going to have it done once or a maximum of twice in your life. So you should be prepared to travel to the very best place to do it. What we tend to have is a sort of sad compromise where most hospitals address most conditions.
But we know well that if there’s a specific condition, especially a specialised condition like, let’s say, heart surgery in young children, you actually really want to go to the very best places. We probably only need a few of those in a country the size of England. You do not want every hospital dabbling with children’s heart surgery.
You would want to concentrate some services which are highly specialised. But on the other hand, other services like blood pressure management, diabetes, rheumatology, many other things should be taken much closer to home. Certainly the preventable issues should, and certainly the public health issues around smoking, physical activity, excessive drinking, those sorts of services. We shouldn’t even medicalise those. They’re not medical issues – these are social issues, they’re political issues, they’re economic issues.
The short answer to your absolutely appropriate challenge is some things highly specialised we should concentrate and you should travel further to them. Most things you should travel less far and should be done default in the house or primary care. Primary care should be done in the house, secondary care should be done at your general practice. Specialist care should be done at the most appropriate hospital. We shouldn’t have every hospital doing every thing. It’s not safe, it’s not cost effective, it’s not sustainable and it doesn’t have good long term outcomes.
You have written that “doctors over-medicate almost all human conditions.” In terms of one of the key ways in which the NHS can reduce its carbon footprint is reducing medication a key part of that, do you think?
Yes, although I’m not sure it’s reducing medication. It’s realising and understanding that there’s not a pill for every ill and that pharmaceuticals are not the only intervention that can be effective. Like most powerful things, pharmaceuticals in the right place can be very effective and I suspect that I probably wouldn’t be alive if it wasn’t for pharmaceuticals.
So first of all, it’s just that there are many other very effective interventions like talking therapies, psychological therapies, cognitive behavioural therapy, many other non-pharmaceutical therapies which are equally effective and sometimes more. Don’t forget physical activity. Brisk walking a few times a week is a very effective way of keeping well physically and mentally.
Secondly, it’s not that pharmaceuticals in themselves are bad, but we waste them by the ton-load. Again, coming back to your earlier question about agency, there are very few incentives in the system to have a very much more judicious use of pharmaceuticals. We prescribe pharmaceuticals like there’s no tomorrow and if we do that there will be no tomorrow because of the resource use, because of the post-use environmental effects, because of the huge financial cost.
One of the big challenges in terms of a transition to a more sustainable system is that – and pharmaceutical companies know this – sadly, many of the ways we’ve evolved the health system tend to monetise illness, i.e. the system makes money out of people being ill. Very rarely do people make money out of people being healthy. It’s a much more difficult concept to monetise health. You can do it, you can reward systems for improving health, but it’s very rare.
How about paying pharmaceutical companies not to produce drugs to treat diabetes but paying them on the basis of preventing diabetes. How about that – how good would that look like? That would be a much more circular economy within the healthcare system.
I wondered if you had any last thoughts for people who are involved in Transition who are thinking along these lines, or any thoughts for practical next steps that might be taken in terms of trying to bring these two strands close together and more overlapped? If we really wanted to make the case in quite a high profile way and say – a community energy company is good for public health, what’s the best way to make that case really persuasive?
I wish I knew. It’s a 64,000 dollar question. My guess is that we need to think and talk and conceptualise health in a different way than we’ve normally done. Not just living without mental illness or physical illness but living truly fulfilling, meaningful, connected lives, depend on roughly four things if you put things like your genes aside:
- Do you have a house, do you have somewhere to live?
- Do you have a job, are you in education or do you have a fulfilling role in your community?
- Are you connected socially, do you have friends, do you have a community you’re part of?
- Do you have access to services which are the icing on the cake for health which deliver things which none of the first three can do?
That’s about social care, it’s about healthcare, it’s about welfare. It includes culture and libraries and all those other things that make life worth living. If you take that as your concept of public health or community health or holistic health or health in the broader sense, then it’s absolutely clear that public health is by far the best investment we could make in local, meaningful, resilient, sustainable communities where it is just a much better place to live.
Part of the challenge is that we’re so addicted to what we currently know, that we don’t have the vision to see that it could be much better. It could be so much better for the present and for the future. Sometimes we do lack vision and we do lack courage. Things do not have to be this way and to live sustainable lives we don’t have to resort to living in caves.
There can be very much better ways in which to live which have the great added advantage of being future proof. That linking of all those issues directly with health and maybe bypassing the environment word, may actually be one way in which public health practitioners, public health professionals, people who are public health minded might be able to make that connection and make that frame to engage politicians, to engage policy makers, to engage the public and certainly would engage professionals.
This article is abridged from the complete interview. You can hear our full conversation below: