Transition as Social Medicine?: health leaders discuss
By rob hopkins 3rd June 2014
One of the following quotes comes from the Transition movement. The other 3 come from public health professionals. Can you tell which is which?
A: “A sustainable system protects and improves health within environmental and social resources now and for future generations. This means reducing carbon emissions, minimising waste and pollution, building resilience to climate change and nurturing community strengths”.
B: “We need a new vision of cooperative and democratic action at all levels of society and a new principle of planetism and wellbeing for every person on this Earth – a principle that asserts that we must conserve, sustain, and make resilient the planetary and human systems on which health depends by giving priority to the wellbeing of all”.
C: “Changing light bulbs, sharing cars and flying a little less is not going to get us to these targets.They are all necessary actions to take now, necessary but NOT sufficient. We need a radically low carbon society (and a health service to match – which will mean that health care will need to be delivered in radically different ways)”
D: “Our wellbeing is determined to a greater extent by our community assets than any other health and well being determinants. However, community building rarely features as a priority in the current sickness model. But that’s all about to change because more and more health care radicals are shifting their focus from what’s wrong to what’s strong”
Actually it’s a trick question: none of them come from Transition writings. In order, they come from the NHS Sustainable Development Strategy, The Lancet, British Medical Journal and Cormac Russell of Nurture Development. Hard to tell though, huh? This month we have been exploring the overlap between Transition and public health, and arguing that in many ways they could be seen as being one and the same thing.
Let’s get a quick snapshot of some of the things that Transition groups do from our latest monthly roundup: creating new community markets to bring local food into communities, mobilising people to come out and recreate their bus stops as ‘Edible Bus Stops’ where people can graze while they wait for the bus, running energy festivals where people can learn how to save energy and more about renewables, putting up polytunnels in schools, trying to support their local traders to become plastic bag-free, setting up community energy companies and projects, enabling skillshares, planting community orchards, organising river bank clean-ups, fixing local bikes, planning developments of affordable homes built with local materials, running repair cafes and so on. I would argue that there’s a strong case for seeing all of those as being public health.
A new vision for public health
The term ‘social medicine’ was the term used before it was replaced by ‘public health’. I rather prefer ‘social medicine’. For me it better captures that sense of skillful health interventions in the right place, remedies suited to people and place, as well as the fact that it’s as much about people and communities and people as it is about community farms and renewable energy.
While Transition and public health have, until now, largely run in parallel, there is a strong case for moving the two closer together. It’s certainly a link that Prof Janet Richardson, Professor of Health Services Research at Plymouth University in the School of Health and Human Sciences, and the first person to do a Health Impact Assessment for a Transition initiative, sees:
“Public health has a huge remit for health promotion and primary prevention and a lot of the work around Transition is capitalising on staying well”.
For a growing number of people in public health, the need for such an approach is clear. Martin McKee, Professor of Public Health at the London School of Hygiene and Tropical Medicine and one of the authors of The Lancet’s remarkable ‘Manifesto for Planetary Health’, told me:
“Those people who want to promote a healthier, safer, higher-quality environment as well as the health of the population have much in common. We should be working together in some coalition of the willing to try and make the world a better place”.
What would it look like if the two agendas were to merge more successfully? Mark Dooris, Professor in Health and Sustainability and Director of the Healthy Settings Unit at the University of Central Lancaster, shares his vision:
“We’d have something a lot more seamless. We’d have health 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. 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.
We’d be moving away from that kind of negative needs-based culture to something which is actually celebrating and harnessing the assets and potentials of communities. We’d also have a real balance and mutual learning, where we acknowledge the importance of government and other policy and delivery instruments, but also bring that together with the grassroots creativity, innovation and energy that I think characterises the Transition movement”.
For David Pencheon, Director of the NHS Sustainable Development Unit, this coming together is already happening, just not yet at the scale required:
“Hospitals could be health-enhancing civic structures … could they supply 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 … it 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.
So how might we help move towards this? Firstly, what are the opportunities? Janet Richardson again:
“If we can look at the win-wins and sell the healthcare benefits of living in a way that is good for the planet, i.e. not eating too much meat, growing our own vegetables because that gets us outdoors, we’re exercising, we’re growing healthy food, cycling, all of those things. Those behaviours that are good for the planet are also good for health and wellbeing”.
For Angela Raffle, public health worker and co-founder of Transition Bristol, having been immersed in both worlds for some time, the overlaps are obvious:
“I see health as wider than the NHS. Health is an outcome really, and everything that the Transition movement is doing is good for health because it’s about clean water, clean air, good food, safety, security, connection with nature and towns that are liveable”.
Martin McKee believes such an approach already enjoys a lot more support than one might imagine:
“The public health community should be seen as a group of people who have a particular set of skills who may work in many different settings, but they’re united in the belief that we do need to look at the broader determinants of health in the population”.
If it is clear that both perspectives would be strengthened by a more explicit overlap, where to begin? Firstly by acknowledging the great work that is already underway, such as the NHS Sustainable Development Strategy, and secondly by looking at the obstacles we need to overcome if we want to see a move in this direction. For example, it is useful to understand the possible reservations people working within public health might have about a more explicit connection to Transition. Mark Dooris identifies two key ones:
“The first is the extent to which Transition has 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.
The second thing is around the way in which health tends to be articulated. 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”.
For David Pencheon, trying to shift the NHS in the same direction as Transition faces the same cultural inertia as in any sector of society:
“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”.
Angela Raffle identifies the difficulty of enabling a concerted push in one direction due to the huge pressures the NHS finds itself under:
“At the moment it’s a very difficult environment to work in because it’s going through enormous structural changes and the 2011 Health and Social Care Act which led to the 2012 Health and Social Care Bill has really fragmented the NHS a lot. It’s become a really heartbreaking field to work in, to try and get unified change”.
For Mark Dooris, “the way in which the delivery organisations are still set up now in local authorities still doesn’t help that”. He also sees cultural inertia as a problem, adding “some of that is to do with very pressurised workloads, but some of it is to do with silo thinking”. Yet it is clear that there is huge potential, if the right interventions can be made in the right place.
What needs to change?
Mark Dooris argues that one of the places this needs to start is some joined up thinking at government level, rather than the current rather schizophrenic approach:
“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”.
For David Pencheon, at the moment, our current health system incentivises the wrong things:
“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. Also, 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”.
Mark Dooris sees openings that are already underway, foundations on which such a shift could be built.
“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. 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.
As David Pencheon puts it: “There’s nothing to stop any of these things from happening”. So where might the best leverage points within the public health system be? For Transition initiatives seeking to engage their local public health professionals, where best to start? One potentially interesting foundation is Health and Wellbeing Boards. According to Mark Dooris:
“They have a role in developing overarching health and wellbeing strategies for the local authority areas. 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”.
Another possible inroad is Clinical Commissioning Groups who are now responsible for each NHS Trust’s procurement. But as Angela Raffle told us:
“They are very stretched, short of skills, criticised daily by politicians, and under threat of judicial review for any decision from people who quite understandably want to throw a spanner in the works with the current reorganisation which they see as simply selling the NHS to the private sector”.
But at the same time new opportunities are emerging. She adds:
“It’s familiar territory to the Transition movement because in a way what the Transition movement is doing is setting up new prototypes that work at a local level irrespective of what’s going on in the big multinational corporations. In a way health will start doing that. We’ll start seeing community-owned companies saying “this is really fragmented, we’re going to set up to take over community care for old folk” or whatever”.
As Transition initiatives on the ground, where’s the best place to start? Who are the best people to make first contact with to suggest finding imaginative new ways to collaborate? David Pencheon suggest starting with your local GP’s practice:
“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”.
It’s been a fascinating month. We’ve explored the idea that the agendas of public health and Transition would be best served by working more closely together. For Transition this could be a great way to accelerate impact and influence, while bringing additional support and relevance to what it is already doing. For the public health sector, engaging with Transition could offer a different approach, a more skillful way of achieving a range of their goals. For now we leave it hanging as a question, as a proposal, one we will return to. Perhaps the best way forward would be to run one of our occasional ‘Thinky Days’ to explore it in more detail? For now, we leave the last word to David Pencheon:
“Living truly fulfilling, meaningful, connected lives depends on four key things:
- “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?
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”.