Transition Culture

3 Jun 2014

Transition as Social Medicine?: health leaders discuss

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”. 

 Final thoughts

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”. 

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2 Jun 2014

How public health + grassroots creativity = innovation

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:

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2 Jun 2014

Meet the man bringing Transition to the NHS

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:

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30 May 2014

Can we assess Transition’s health impacts?

Is Transition good for a community’s health?  Janet Richardson is Professor of Health Services Research at Plymouth University in the School of Health and Human Sciences and is the first person to do a Health Impact Assessment of a Transition initiative.  In 2011 she did a “rapid” Assessment for Transition Town Totnes.  What did it discover, and what can we learn from that?

What is a Health Impact Assessment?

A Health Impact Assessment is a framework which includes a number of tools to assess the potential health impact of something like a planning decision, it could be around the building of a major supermarket or a housing estate. It’s a mechanism for looking at the potential health and wellbeing impacts on the community who are likely to be directly affected by the changes.

You did one for Totnes in 2011 that looked at the health impacts particularly around the Transition Streets programme that was running at the time. Could you tell us a bit about that and what its findings were?

We looked at one of the major Transition Town projects, the Transition Streets initiative and we applied a Health Impact Assessment framework, but particularly looking at sustainability. Obviously the focus on the Transition Streets is around building resilience and looking at sustainability around peak oil and the effects of climate change.

We used that framework and allied that framework to a Health Impact Assessment decision making tool. It was a rapid Health Impact Assessment, so we looked at desk-based material and we also interviewed key informants in the community who would potentially give a different view, so they were purposely selected in order to provide a range of views about the project.

What we found was that on a range of health and wellbeing measures the initiative itself had enormous capacity to increase the health and wellbeing of the people who were participating in that particular project, the Transition Streets initiative.  Primarily that health and wellbeing benefit was through community engagement and engaging with immediate neighbours.

The health and wellbeing benefits of increasing socialisation and increased capacity to engage with the local neighbours who the people involved in the project might not ordinarily have engaged with, because there was a focus to that engagement. Other benefits were around exercise, so increasingly the people involved with the project were spending more time outdoors, working in their gardens, sharing food, cycling, those kinds of benefits.

The potential health and wellbeing benefits were associated with the people who were engaged in the project. One of the issues that we raised was the need then to look at people who are not engaged in the project like that in the town, and how those benefits through engagement can filter out across the town to other people who are perhaps harder to reach groups. That’s one thing that’s quite a challenge to do anyway, in any kind of project – a Transition Town project but also a health promotion project or community engagement project. It’s really how you have a mechanism for engaging those hard to reach groups who potentially could have much more benefit than the ones who are likely to engage.

How big a piece of work would it be to do a Health Impact Assessment of the impact that Transition Town Totnes has had since it started?

That would be a really interesting piece of work because what you’d be looking at is not just the impact on the local community but the impact on the infrastructure as well. Health Impact Assessments do also look at the impact on the development of infrastructure so it could be small scale, large scale, but I think so many years on that would be an interesting retrospective. The thing with the impact assessment framework and the process is that often the process is done retrospectively. It’s much better, particularly for planning development if the process can be done prospectively, so what you can do in terms of benefits is look at potential mitigating factors.

If you see that the likelihood of changing traffic flow to accommodate a housing estate or a supermarket is going to potentially increase the risk of road traffic accidents, you can mitigate for that. So it’s a really good framework to develop mitigation strategies for developments. Also, retrospectively you can look at what benefits you might have had from the impact of the project as a whole.

If you look across what a group like Transition Town Totnes does, you could argue that pretty much everything it does benefits public health, like being involved with a community energy company, having a greater sense of agency as to where the future of your community is going – it’s hard to think of anything involved with Transition that doesn’t have a benefit. How do you see that overlap, that merging of the two?

There are overlaps at different levels. If you start with an end point such as a disaster: major flooding for an example that we’ve seen recently and are likely to see more of. There are obviously disaster management plans in place. Those could potentially overlap with the social capital in the town.

If you know where the social capital is in the town and the skills, particularly in a town like Totnes with such a range of diverse skills, if there’s the potential for at that point in time within your disaster planning to know what the social capital in the town is.

More broadly with the health service which is a huge consumer of energy, there’s lots of overlap there in terms of how we manage it.  The NHS Sustainable Development Unit is doing sterling work on that, focusing on the estates management and being more energy efficient. But 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.

The challenge is behaviour change. With behaviour change it’s harder to change behaviour for the benefit of some things that are going to happen in X number of years. Climate change is a bit like smoking. Obviously the long-term benefits of giving up smoking are phenomenal. The short-term benefits are good as well.

But it’s about educating and supporting people to change their behaviour in a way that is going to be good ultimately for the planet and for our children but also will have immediate impacts on health and I think those are the kinds of messages around Transition and working alongside public health that can be quite positive.

There is huge potential and particularly with the ageing population and the need to look at loneliness and how we support people with long term conditions.  Building social capital and community resilience can really be mobilised to support some key public health issues. 

[This is an abridged version of the full interview, which you can hear below]

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29 May 2014

EcoBricks and Education

Here is the latest blog I have written for The Guardian’s Live Better Challenge section:

EcoBricks and education: how plastic bottle rubbish is helping build schools

It began in Guatemala, and now a South African town is using recycling bottles as building material as part of an inspirational and regenerative campaign against rubbish

Take a two-litre plastic drinks bottle, a heap of plastic bags, crisp packets and other non-biodegradable waste (roughly one week’s worth of plastic waste), and a stick. Pack the bottle full of the waste materials, packing it as tightly as you can, using the stick. That’s it. You have an EcoBrick. 

Next time you hold a plastic bottle in your hand, try thinking of it not as rubbish to be disposed of, but as the building block for something extraordinary. The story of EcoBricks starts in Guatemala, and takes us, via the Philippines, to South Africa. Susanna Heisse, horrified at the level of plastic waste around Lake Atitlán in Guatemala, first came up with the EcoBrick idea. She built a wall out of them, which became an inspiration to others around the world.

There are now 38 EcoBrick schools in Guatemala built by an organisation called Hug It Forward, Vida Atitlan (Susanna’s organisation) and others, with many more planned. In the northern Philippines, ecobricks.org created an open source manual, distributed to local schools. As part of the curriculum, students are asked to bring in a completed EcoBrick each week, having written their homework on the side of it.

EcoBricks represent a different approach to waste management. Plastics recycling is an energy intensive, polluting business, often involving long transportation distances. How might it be to find alternative uses for them at the local scale? Construction is one obvious approach. EcoBricks turn waste into a highly insulating, robust, affordable, building material, which simultaneously tackles problems of unemployment, waste and lack of housing. They can be used vertically as infill in timber-frame building systems, or horizontally, where they are mortared together with clay or cement.

Greyton in South Africa is the first Transition initiative in the country. Greyton is a town, like many in the country, struggling to deal with the legacy of apartheid, wide social inequalities, lack of affordable housing, and a waste management system that is virtually non-existent.

Nicola Vernon, one of the initiative’s founders, found the Transition model adapted beautifully to the setting and challenges of Greyton. “As a driver for social integration it’s the best I’ve encountered in 30 years of working in social welfare,” she told me. A whole raft of projects are underway: community gardens, working with local schools, and Greyton is set to become South Africa’s first plastic bag-free town this July. A new eco-village settlement is being designed, and 18 jobs have been created already through the group’s activities.

Joseph Stodgel, a US artist, musician and entrepreneur, who heard of what was underway in Greyton and went there to see how he could help. A trip to the town’s dump provided the inspiration. “The dump is the first area you come to if you are walking from town,” he told me. “It is really a beautiful place, that has such a striking contrast between the pristine nature and man-made pollution. Pristine sites are usually host to festivals, but sadly enough are often degraded and polluted as a result of them. I wondered – could we reverse this process and actually use the medium of celebration to drive rehabilitation? Could we use a festival to turn dumping sites into pristine gathering spaces?”

The Trash to Treasure Festival was born, hosted in Green Park, the first part of the dump cleared by the festival, and the part closest to Greyton. Bands play on a stage built from reclaimed tyres. Every year (the third festival just took place in April), EcoBricks are made and exchanged for prizes donated by local stores, and new buildings are created with them. Already a composting toilet block has been built, and future plans include a kitchen, shower stalls and even on-site accommodation. An outdoor classroom is currently nearing completion, with each wall having been built by a different local school. 

How does he feel launching these ideas in the context of a town-wide Transition initiative helped? “Greyton Transition Town has been instrumental in uplifting the local community, launching and sustaining a several wonderful initiatives and bringing great attention to wastefulness. Altogether they have been a truly positive force in the area in a number of ways. So many people across the community are into the journey to zero waste. It has been a hugely positive force”.

One of those who caught the EcoBrick bug in Greyton is Ian Domisse, an architect based in Port Elizabeth. He was so inspired by the potential and possibilities they offer that he quit his job and set himself up as an EcoBrick architect. While he waits for planning approval for his first building, an EcoBrick classroom for the Penguins Play and Learn nursery, he has started an EcoBrick Exchange in order to generate his building materials.

The Exchange is a network of local business partners who are happy to offer storage space and discounts in exchange for EcoBricks, as well as community swap shops, where second hand items of value are exchanged for EcoBricks. This idea of EcoBricks as a form of local currency is one of its more intriguing recent developments. Ian gave a series of talks at local schools, inviting them to make EcoBricks for the Exchange. For four months he heard nothing, then suddenly 900 completed EcoBricks turned up.

As the world groans beneath the growing mountains of plastic waste and its toxic legacy, perhaps the solutions lie closer to home than the recycling plant. Perhaps the seeds being planted in Greyton, and the potential, as spotted by Domisse, of EcoBricks to catalyse a local economic renaissance, is an idea that could go to scale quickly. By keeping waste local, it is perhaps the creativity and imagination that it stimulates that could turn out to be its longest lasting and durable legacy.

Interested in finding out more about how you can live better? Take a look at this month’s Live Better Challenge here.

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