HARRY BURNS: I vividly remember a guy coming in with acute pancreatitis and this was his fifth or sixth event, and I said to him, “Look, this is the booze. How much do you drink?”
And he said, “Well, about fourteen pints.”
“Fourteen pints a day?” I said.
He said, “No no, at lunch time.”
“Wait, so you drink fourteen pints and you go back to work in the afternoon? What’s your job?”
“Well, you know those big high cranes on building sites? I drive one of those.”
I thought, “Bloody hell, are there toilets in these things?
But that was the kind of attitude: “Life is crap and this is what I enjoy, so don’t tell me to stop doing it.” That was the attitude.
MIC CAVAZZINI: Welcome to Pomegranate, podcast of the Royal Australasian College of Physicians. I’m Mic Cavazzini, and today you’ll hear from two inspiring speakers in the field of public health.
But before we do, I’d like to invite you to join our new editorial group. We’re looking for podcast listeners who can help us develop topics of interest to physicians and provide feedback on the show’s content before it’s published each month. It’s not a huge time commitment and would be a fun way of earning a few CPD points. Please send an email to email@example.com to express your interest by January 15th.
Today’s episode was recorded at a special lecture at the College held in November. Sir Harry Burns and Dr Ruth Hussey OBE were invited to Australia to speak about their work on “whole-of-system change” to health care delivery in Britain.
As the former Chief Medical Officer of Scotland, Sir Harry Burns has drawn attention to how poverty and social disruption result in poor health outcomes. He focuses on empowerment of individuals as a means to what he calls “salutogenesis.” Sir Harry continues to comment on health inequities as a professor of global public health at the University of Strathclyde.
Dr Ruth Hussey was until recently Chief Medical Officer for the Welsh Government Assembly, and prior to that she was Medical Director for the NHS in Wales. In these roles she has pushed for a local and sustainable approach to delivering high quality clinical services termed “prudent health care.”
HARRY BURNS: For the first fifteen years of my career I was a surgeon, 5 or 6 of them a consultant surgeon in the east end of Glasgow. When I went to the Royal Infirmary, the first thing I noticed within a couple of weeks was they took longer to heal their wounds. You know, you would do a cholecystectomy or something, and that’s an old fashioned operation now—they don’t do that anymore. But eight days, stitches would come out and they’d go home. It was 10 days in the Royal because the wound just didn't heal as quickly. And these subtleties convinced me that living in deprived conditions actually affected your biology.
And if you look at the rate of growth and life expectancy in the richest percent 20 per cent of the populations since the 1950s, and the poorest 20 per cent of the population, the sort of 12-year gap now was much narrower 50 years ago. Poor people have not grown on life expectancy as fast as the rich.
When we began to look in detail at what was causing the inequalities we saw a stark picture. This is work done by a colleague at the Social and Paediatric Research Unit, Alistair Leyland. Alistair did a clever thing, he looked at inequality in death rate in each five-year age band of the population, and he reduced it to a single number and that gave you a clue as to how steep the slope was between rich and poor—the slope index of inequality.
You do that across the whole population and it shows the inequalities are not at their widest in the elderly—yeah, there are more people dying in the older age groups, but relatively speaking of inequality in death rates, it’s a feature of teenagers and young working-age people. It’s not heart disease and cancer that’s causing these inequalities, it’s things that affect young people: drugs, alcohol, suicide and violence, socially determined causes of death. And that is not going to be fixed by a reduction in the saturated fat content of the diet, nor by a sugar tax.
RUTH HUSSEY: Good morning to everybody and in Welsh, “Bore da pawb.”
So the first thing I want to talk about is being conscious that we’re part of a generational shift. Are we consciously embracing a different way of thinking about the health of the public? Something’s really happening and Phil Hammond and my colleagues talk about the “fifth wave” of public health, and we’re in that fifth wave where people are increasingly talking about well-being, shifting the focus from acute infectious diseases—although hugely important still—to that sense of chronic ill health, chronic diseases, and a need to think about physical and mental well-being as part of that process.
So that's the sort of consciousness shift I think that's been going on and it requires us to think differently, to frame health differently and think about not just the immediate causes of why somebody turns up in hospital—but where’s it come from, what are the roots of those problems. And also you’ll be well aware of the shift to asset-based thinking—you know, we’re very good in epidemiology of thinking about all the things that are wrong, whereas have we consciously embraced the type of epidemiology that talks about assets, people’s strengths.
What I want to talk about is nation-building, how a small country can shape its future, and how policy can help to create a context for the response in communities to be developed and nurtured. What we’ve been doing in Wales is to develop some goals for a nation. The other big thing that we did around this was to engage people, a whole range of people across Wales, with a strapline “the Wales we want”—not the one we’ve inherited, but the one we want to create for the future. And this inspired a huge amount of connectivity, young people especially engaging with it, trying to shape the legislation in a way that it mattered to people.
HARRY BURNS: You know, what we are consistently told in Scotland is that we’re all desperately unhealthy. It’s because we eat too much fatty food, we smoke too much, we drink too much and if only we'd get a grip on ourselves and do the right thing everything would be fine. It’s that model of “Poor people don’t listen, so we shout louder at them.”
That’s not true—well most of it’s not true, the bit about the booze is actually slightly true. But the drink is an interesting story because it begins to tell us something about the time course of these events. From 1950-1970 Scotland had one of the lowest alcoholic death rates in Western Europe. Our culture of alcohol was pretty straightforward in those days. Who drank? Men drank. What did they drink? They drank beer. Where did they drink it? In the pub. And when did they drink it? Friday night, the end of a working week.
So from 1950 to 1990 it went up a bit, but was still below the European average. And then from 1990, we were leading Europe.
So who drinks now? Everybody drinks now—women in Scotland still have the highest liver disease mortality in Western Europe. What do they drink? Everything they can get their hands on. Where do they drink? Everywhere: home, pub, out in the park. And when do they drink? All the time. It’s a seven-day-a-week occupation.
The interesting thing about that is the time course—it’s emerged in the past few decades. And what colleagues and the Public Health Department in Glasgow are saying and pointing to is the fact in the 70s and 80s there’s a huge collapse in employment in central Scotland, as well as a radical change in the pattern of housing. Traditional communities were blown apart and were replaced by out of town developments or high-rise developments or whatever. If you take people living in a traditional pattern of life and dislocate them from that all around the world we see them turning to drink, drugs and fighting.
So I began to think, “Well, if life is that bad the answer must be in creating a better life.” And I came across the notion of “salutogenesis.” Pathogenesis is what we doctors think about all the time. Salus was the Roman goddess of well-being and safety.
And underneath the umbrella here there are 25 different theories as to what creates wellness, and of course I've read every single one of them and I’ll just distil them down for you. Basically, the key features of all of these are that people who grow up to have a positive optimistic outlook, who feel they have a sense of control which is internal to themselves—they are captains of their own fate. They have a sense of purpose and meaning in life that usually comes from having a productive job that you enjoy doing. They are confident they are resilient in their ability to deal with problems and crucially, they are surrounded by a supportive network of friends and family. And that has been in place since the early years.
The evidence around social connectedness has a very powerful net analysis, 150 studies. People who had a complex pattern of social integration were almost twice as likely to be alive at the end of the studies as people who were isolated. And the optimistic outlook stuff—lots of studies for that, I like this one in particular. Relative hazard ratios in men who were in a very highly negative mindset had about three or four times death rates from heart disease, death rates from cancer. The negative outlook was an independent predictor.
RUTH HUSSEY: So these are the goals that we developed, and I was pleased that a healthier Wales became one of the goals, and right next to it a more equal Wales as an independent issue within it. So crosscutting integrated thinking is the gist. We talked about how do we measure success, and one of the points people made was you mustn't end up with measures that a single Health Minister or an Environmental Minister could pick and say, “Well, those are my bits,” and in fact I'm pleased that we probably didn't end up in that space. We have a whole government commitment to a range of indicators. There are 46 and I've just highlighted a few where the people perspective might be there.
So the development of young children was recognised as being one of the most important things that government needs to focus on – looking at how children can get the best start in life. So that was one angle. People who are lonely – you know that’s an incredible measure for governments to pick, but again it’s so integrating in terms of who’s responsible, there isn't one single agency. And as I say, all the other measures are environmental issues—energy consumption and prevention. And again you'll all be familiar that prevention is often the thing that’s the last to be considered because the payback is seen to be so long.
Many of you will be familiar with annual budget-setting. The deliverables never look beyond a couple of years, if that. Well this is about saying, “We’re really going to invest for the longer term, so this actually requires public bodies including government to consciously think about and weigh choices in that regard.”
HARRY BURNS: Scottish Government has a purpose which it articulated when it came to power some years ago, and its purpose is to create sustainable economic growth shared equitably by all. We’re dealing not just with the complex system that creates health, but the complex system that deals with offending, that deals with poor educational attainment—you know, employment and so on. So we’ve got a complex system of complex systems all interacting. And at the centre of it is the individual, where he’s surrounded by people who want to do things to him and they have protocols and guidelines, so they care about applying the protocol.
That whole idea has been constructed on the back of what was Adam Smith’s idea of an economy: the system needs “needs.” So we create social work departments that depend on need for their existence, and that's maybe the wrong way round to be doing things. The alternative is where people get together to solve their own problems, associations of citizens, and that led to the notion of asset-based community development. People get together to share their assets—their personal assets, their personal capacities and so on. They decide for themselves what their problems are, they decide how to solve them, and we can bring in experts to help them solve the problems that they can’t solve for themselves—rather than tell them what to do.
RUTH HUSSEY: We also started thinking about how we integrate services, how do we bring public sector services around the issues that face people. The other big message in the legislation is this is not one single agency. Health doesn’t belong to one person. And it’s really embedded in the citizen-centred prevention approach, giving people more say about what matters to them—discretionary pooled funds. This is not about telling people what they have to do, there are no rules set out in this legislation. It’s actually designed to be emergent in terms of the how to do this. It’s about saying, “If you want to do some of those things, if that helps, this legislation enables you to do some of that work.”
In the health system again, alongside all of this we started to talk about “prudent healthcare” and shifting building on the literature around shared decision making. I've been using the term “coproduction,” so it’s wider than individual practice—it’s communities working together as well. The equity principal: caring for those in greatest need first. And then finally, reducing inappropriate variation driven by the chance of supply or the chance that somebody can do a particular procedure. So how do we lock that in more systematically?
HARRY BURNS: So some of the examples of things that have happened. Stoke Council in the north of England decided that they were going to try and apply this sort of approach and they decided they’d stratify the population into those that needed the approach most, and that was about 6 per cent of the population they looked at, and they decided to start and ask the question, “What can we do to help them first?”
The key thing they did was they decided not to do things to people, but to go out and empower their staff to say, “What matters to you, what is it we can do to help you today?” You know, “Help me to manage my finances, I'm struggling, I've got debt, what can I do?” “Help me with housing; help me with opportunities for employment.” And over the space of about three months, gradually people began to realise that with the expert help, they could take control around things like housing. They began to interact in a different way.
RUTH HUSSEY: The other trend if you like, or emergent thing, that came through this process was how do we measure? How do we measure the system? How do we shift to outcomes as opposed to how many hours you've waited in an accident and emergency department? And I shared a story yesterday of a colleague who looked at a Parkinson's disease clinic and what they found was that what people wanted and their carers wanted when they came to clinic had little connection with what was being offered. Similar situation they found that 25 per cent of people that had knee replacement actually didn’t think they'd done the right thing and hadn't got the benefit they wanted.
So redesigning it so that people better understood what they were going into better prepared and came out with a better result. And I’ll just pick out one example where a social care team they actually redesigned everything they did using these principles and they reduced the waiting times, reduced the people coming back into the system, because they weren't satisfied with what was going on.
HARRY BURNS: And you saw very quickly changes. Just to show you, evictions usually for non-payment of rent that began to disappear. When someone is evicted that’s a whole family that is then struggling, and the demand on services increases exponentially the more that happens. But you allow people to keep their houses, you allow them to keep a sense of control and demand elsewhere in the system is not increased. I can show you the same type of graph around antisocial behaviour, around criminal events, you know, arrests and so on. Significant falls within the space or four or five months in this community.
Beacon, an old estate in Falmouth—two health visitors transformed this place. Around 2,000 people living in an estate where employment disappeared because a dockyard was closed down, a naval dockyard was closed down in Falmouth. And over the years it became a hot bed of crime. The chief constable of the area admitted later on that his policeman had turned their backs on this place because it was just completely lawless. And two health visitors, one of them a lady that height, decided to change it. And they knocked on doors and they got five or six citizens willing to work with them to change things.
And in the space of a few years by going out, their finding people doing things like time-banking, sharing expertise, helping each other out. People began to respect themselves and respect other citizens and they transformed the community. Post-natal depression, crime, unemployment, teenage pregnancies fell dramatically, child protection registrations fell by 65 per cent.
Domestic violence is a symptom. Treat it as a symptom, and try and find out what’s causing it, and you transform society.
RUTH HUSSEY: The underpinning issue of measurements, measuring differently, is integrating data. We’re lucky we have something called SALE which integrates education, housing, administrative healthcare data in a very powerful way so that we understand why things are happening—not just describe them.
So turning to the health service then, this is a report that came out about six weeks ago now. And it basically sets out on a budget of about seven billion pounds spent on health and social care. We’re looking in the next five years another pressure about seven hundred million for healthcare, and social services are facing similar pressure about 4 per cent growth pressure a year. And so it’s becoming urgent, that sort of reaching our natural resource limit, if you like.
And then the only other thing I’d mention is the outpatient question. We have more and more chronic illnesses; we have more and more people spending much of their time going round and round a system. It's not a wise thing to bring people for a couple of hours to a 10-minute appointment and then they do that every few weeks because there’s actually a clinic on every disease that that person happens to be suffering from. We've got to redesign that. Now there are a few beacons of “one-stop shop” thinking, but actually we’re going to have to look at that hardwiring of an outpatient model and develop a different way of supporting people in their communities.
HARRY BURNS: What they did was they costed—this is Stoke again—they looked at the cost of each individual case, they costed the time spent over a year with social care. That fell dramatically, other local authority services fell, health service costs fell. On average, each contact that they had as a council with the people in that area—that 6 per cent—the costs fell over a space of a year from about a 100,000 pounds per person to 2,000 pounds per person. So the existing system, by which we don’t pay attention to what people want and need, is costing us a fortune.
We need to move away from this provider-citizen thing, you know, where the provider defines need and the citizen is disempowered by it and says, “Well, they’ll provide for me, I don't need to take responsibility,” into one where we build a confidence in the citizens that they can be captains of their own fate.
RUTH HUSSEY: The solutions to people’s health issues and concerns are not in the healthcare system most of the time. And what we’re seeing I think is the coming together of what in the past has been very different paradigms—the medical model of health and well-being and the social model of health and well-being. And as clinicians we have a job to integrate services and not stand alone any longer.
So finally then, the other piece of the jigsaw for us was revisiting primary healthcare, so building on a different level of planning a sort of 25,000-100,000 -size community, and that's come from the literature. There’s lots of evidence that’s about the right size to plan those local services. So that became the basis for our clusters.
We think that’s probably a viable building block for really designing services. Mainly the GPs coming together to start with, but increasingly a multi-disciplinary approach and a multi-sectoral approach talking about what matters in local communities. So what works in the middle of a rural part of north Wales is not going to work in the centre of Cardiff.
But the big thing we did with clusters was give money directly to the clusters—not to the health system, not to the health organisations, directly to these groups. And it unlocked a whole pile of innovation, they started developing things like bringing tests out of hospital, working with older people and their families about their advance care plans differently, and recognising about 20 to 25 per cent of a GP’s workload is prescribing. They invested heavily themselves, they said, “We want pharmacists as partners in practices to help us manage that.” So starting to realise how we can integrate a different set of professionals into primary care.
But what it really did was and a signal from the Health Ministry was, “We trust you, we know that you know what some of these issues are, we want you to start working together.”
HARRY BURNS: And I just want to finish with a quote. This chap with the beard and the black suit is a Catholic priest, a Jesuit priest, who was sent to a parish in central Los Angeles, the poorest parish in Los Angeles, 30 years ago. And he was told he would survive a week. If he tried to change anything, the Latino gangs would kill him.
And he went out and he made friends with them, he talked to them. He learned their names; he learned their histories, found out what they needed, what mattered to them.
And what he found out was: jobs. They had no jobs and they were never going to get jobs. And he got this guy to buy a disused bakery and he started Home Boy Bakeries. And he started employing them all. And he said within a couple of weeks he realised he had to start a second business called Home Boy Tattoo Removal, when one day one of the guys walked in and he sat down in front of him and he said, “Greg I need help. I'm desperate to find a job, I've got qualifications, but nobody will take me seriously.” And he looked at him and he said—OK, so he had earrings and rings in his nose and so on, but the most obvious feature of him was he had tattooed in two-inch-high letters across his forehead “FUCK THE WORLD.” And Greg said, “Well John, I think I may know what your problem is.”
But that’s the thing—you see that need. You know, no public policy can create a service that takes tattoos off guys who can’t get jobs. And what Greg tells the kids is, what we need is a compassion that stands in awe at the burdens the poor have to carry, rather than one that stands in judgement at the way they carry them. Our system judges people. And I have seen transformation of the lives of people who have been at their absolute bottom, because folk have helped them and that allowed folk a sense of self-efficacy and self esteem and they've moved on. And that is really the pathology we have to try and tackle.
MIC CAVAZZINI: You’ve been listening to Sir Harry Burns and Dr Ruth Hussey. The views expressed in these lectures are their own, and may not represent those of the Royal Australasian College of Physicians.
To find resources relating to the program, visit the Pomegranate website at racp.edu.au/pomcast. And if you’re short on CPD points, take a look at the other 17 episodes in our back catalogue. Feel free to email us with your feedback, or if you’d like more information about joining the podcast’s editorial group. And please share the conversation round using the Twitter hashtag RACPpod.
I’m Mic Cavazzini and I hope you've enjoyed the show.