How public health + grassroots creativity = innovation
By rob hopkins 2nd June 2014
Mark Dooris is Professor of Health and Sustainability at the University of Central Lancashire. A lot of his work is about managing the delivery of programmes related to public health, wellbeing and sustainability. We started by asking him “would it be fair to describe you as somebody who is trying to bring Transition thinking into the public health arena?”
“Yes indeed it would. I think my own journey with that has been I suppose over many years now. I started off working with NHS and local government really around health promotion and public health from very much a community development level and moved to combine that with working at a policy and strategic level, but very much trying to bridge environment, health and sustainability and this is going back more than 20 years before the Rio Earth Summit.
That was my grounding that led to a passion for bringing agendas together. More recently I’ve done a lot of conceptual work as well as trying to get some thinking going in the public health world, working particularly with Blake Poland from the University of Toronto.
Speaking of Blake Poland, there was a paper that you wrote with him where you wrote “as the converging crises of Peak Oil, climate change and environmental degradation intensify and inter-connect, much more radical action will be required.” What do you see as being the key challenges in the public health field to responding adequately to the scale of those challenges?
There’s several points to make. I think if we actually look at where the convergence and connections between climate change, sustainability and health have begun to be made, a lot of that has been made within what a lot of people see as the health system, so working to green the NHS, to look at the footprint of the NHS etc.
That’s really valid work and really important work, because clearly the NHS is one of the world’s largest organisations so its leverage and clout is potentially very big. But I think we need to go beyond that and really embrace the understanding I think that’s come out through specially commissioned research in The Lancet, in The American Journal of Public Health, The British Medical Journal and other prestigious research publications, showing that actually climate change and, I think it’s been recognised, resource depletion and environmental degradation generally are actually themselves public health threats. They’re not just something that we need to engage with and talk about but are potentially the biggest challenges that we’re facing.
How would you rate the level of awareness of those issues though in the health field? There are more and more organisations like the World Health Organisation who are really starting to flag that up, but where does it feel like it’s got to?
We’re seeing more and more of that awareness coming out in publications from the World Health Organisation down to the UK Faculty of Public Health through to individual professional associations. But there’s a real challenge in that filtering down to and informing the day to day work of people in broadly public health.
Some of that is to do with very pressurised workloads, but some of it is to do with silo thinking. People have been trained in particular ways where if they do embrace the issues around climate change, resource depletion, environmental degradation then it’s quite peripheral to their training. There’s a lot that’s going on within nursing education, increasingly medical education and certainly where I’m working looking more generally at health promotion and public health training to try to bring these issues in. But I think it is a real challenge and the way in which the delivery organisations are still set up now in local authorities still doesn’t help that.
Having said that, we’ve seen public health in England at least move from the NHS into local authorities in the last year. That offers real potential for public health to be bridging across a whole range of different agendas and different professional areas and interests so that we can be bringing into the mainstream the way in which agendas not only overlap but have what’s increasingly being talked about as co-benefits so for instance when you’re looking at urban planning how do you plan in ways which maximise walking and cycling thereby hitting the policy agendas both for carbon reduction and for increased physical activity and working on obesogenic environments.
That’s just one example and we could say the same for local food growing and healthy and sustainable food policies. There’s lots of really good stuff happening but I think there’s still a long way to go before we’ve got that real joined up approach happening in delivery organisations.
You’ve written that sustainability and work on health operate largely in parallel. What would their converging look like?
To take an example, I head up the Healthy Settings Unit at the University of Central Lancashire. Broadly, a settings approach is trying to take a whole system approach within organisational and geographical settings so there’s a healthy cities programme, healthy schools, healthy universities. If you look at schools, and I’m not as up to date with that now as I was a few years ago, but certainly going back a few years you had a healthy schools programme run by a government department, you had an Eco Schools programme, you had the emergence of a sustainable schools programme.
Actually I think you get to that point where there’s initiative overload. If you could somehow bring those together so that we’re actually talking about schools or other settings which were promoting an understanding of a good future, really, and what’s needed, in that sense you’re not having this duplicated effort but actually finding those nodes of convergence where you can work around issues that are meaningful to people like food.
You begin to talk about what would good food look like – now actually that has benefits for health, for wellbeing, for sustainability I think, if it’s organised appropriately also in terms of equity and social justice. That’s for me that kind of thinking that requires people to have an ecological framework where they actually understand and acknowledge that things are connected and interdependent.
On paper at least, Clinical Commissioning Groups have the potential to make a more Transition approach to public health happen. When I spoke to Angela Raffle, her sense was that that looks unlikely to happen. Is your sense that it could and if so, how?
In this whole brave new world that we have of a new public health system that’s emerged as part of the reforms that have emerged under the coalition government I think we’ve got several different structures which potentially can have real influence. One is the clinical commissioning groups in terms of the commissioning and procurement of services and who is actually going to deliver them, but also the vision of what type of services and how connected those services are. Some of the things you mentioned about taking a much braver approach to how land can be used and managed around a hospital is a really good example of that.
There is interest in what’s termed ‘social prescribing’, where rather than looking at prescribing medication a good example that links up with Transition agendas is the green gym, where people are doing environmental conservation, horticultural work and that’s actually seen and evidenced to have positive impacts both in terms of physical activity and mental health and wellbeing. And for instance, my team is leading work across North West prisons where that green gym approach has developed. We’ve got strong horticultural work where car parks are being turned into gardens with polytunnels.
But the other structure that’s potentially really interesting is Health and Wellbeing Boards. They have a role in developing overarching health and wellbeing strategies for the local authority areas. Again, I think what we need to be doing is identifying areas where there really is that interest and engagement to join things up and to have a brave vision so that they can almost be seen as pilot areas to develop new ways of thinking and articulating how we could move forward.
Part of your work is around policy. What would health policy designed to support this and to meet the aims of Transition and responding to the crisis set out in the earlier question look like?
I’d come back to some of the words I’ve already used. In some of the conversations I’ve been having recently with people who are working in some of those policy organisations, they are talking about that need for joined up narrative and I think narrative’s a very trendy word that’s replaced strategy in a lot of cases by this government.
What we tend to see is still this fragmentation, so we will have discussions about fuel poverty, we’ll have discussions about transport planning and about the obesity epidemic. Elsewhere we might have something about the need for preparedness for climate change in terms of the risks related to flooding etc, which are perhaps the most obvious public health risks that have confronted people in this country.
But actually what we don’t have very often is an articulation of how it all comes together and why there are things you can really be focusing on that are going to be hitting a number of different priority policy buttons. In the health field we’ve seen an emphasis on techniques like health impact assessment and certainly at an EU level and certain states such as South Australia where they’ve done some real trailblazing work around this idea of putting health into all policy areas so that we move out of this mindset where health is seen as the delivery of health services.
Actually if we can do that so we’re not just talking about health, but talking about this tripartite thing of health, wellbeing, environment, sustainability, resilience and equity, then I think we can do an integrated approach to policy that could have really far-reaching effects.
For people who are in Transition groups on the ground, how can they best engage with this shift in agenda in the public health field?
I think already some of them are in that I think some of the very tangible work that’s being spearheaded by Transition groups or in partnership with Transition groups are things like in Lancaster, the sustainable food cities work that’s coming out across Lancashire, looking at different sizes and pockets of the population.
To take Lancaster again because I know it better than some, they’re hosting a conference looking at fuel poverty and looking at a joined up approach. So already some of that work is happening. Perhaps some of the reservations that some people in public health would have if I was to talk to them about Transition would be firstly around the extent to which it’s successfully embraced a commitment to equity, social justice and diversity, and I think that’s something which has had more and more discussion in the last few years in a really positive way.
I think the second thing is around the way in which health tends to be articulated. I think there tends to be quite a strong emphasis on what I suppose for some people would be called spiritual wellbeing, so the inner transition focus. Whilst I think it’s important to engage with that, I think the perception of that from outside can be seen as offputting and can seem to be focusing so much on the micro inner that it fails to be dealing with the population and real determinants-level stuff that impacts on the health and wellbeing of people at large.
Just following up on that I think it’s quite interesting because if you look at an organisation like Public Health England which was set up after the health reforms last year, it’s got quite a strong programme within its health and wellbeing directorate, healthy people, healthy places. Part of my vision would be to add in a third ‘p’ there, so it’s healthy people, healthy places, healthy planet. The healthy planet bit tends to be dealt with by another section, and I think that’s probably symptomatic of where we’re at with how health is linked and joined up.
There’s quite a lot that Transition groups can engage with but I also think there’s quite a lot we can learn from in terms of the cutting edge work that might not be called health but is dealing with fundamental health issues.
You write and think about this a lot and are involved with it on the ground and making things happen. If everything were to fall into place beautifully over the next 10 years or so, what would public health look like in 10 years for you?
What it would look like is that actually we’d have something that was a lot more seamless, that we’d have health being seen as a core value and function within delivery organisations. We’d have that being seen as intricately related to and interconnected with other agendas rather than separate from them. I think we’d have a really balanced focus on acknowledging that there are very real needs and problems out there but there are also huge assets, capabilities and potentials so we’re moving away from that kind of negative needs-based culture to something which is actually celebrating and harnessing the assets and potentials of communities.
I think we’d also have something where there’s a real balance and mutual learning where we acknowledge the importance of government and other policy and delivery instruments but also bringing that together with the grassroots creativity, innovation and energy that I think characterises the Transition movement. At the moment I think there’s some way to go before that’s fully connected.
Here is the full audio of my conversation with Mark: