Public Health England, Health Trainers and Health Inequalities
Recently I was lucky enough to speak at the the annual Health Trainer conference organised by the Royal Society of Public Health. All credit to the RSPH who have been steadfast in their support for this service, building on the early work from Leeds Beckett University – in particular my colleague Judy White.
Around since 2004
Health Trainers have had remarkable staying power – here is a bit of history from the Health Trainers England website:
The role of health trainer was first outlined in the 2004 White paper Choosing Health. Since their inception they have generated a great deal of interest from commissioners, provider services and the public. From the start they were intended to offer support from next door rather than advice from on high and their aim was to:
- Target ‘hard to reach’ and disadvantaged groups
- Increase healthy behaviour and uptake of preventative serviceProvide opportunities for people from disadvantaged backgrounds to gain skills and employment
- Reduce health inequalities
The different approach taken by two of the key speakers at the conference unintentionally highlighted some of the tensions that exist with regard to Health Trainers. This tension is set out in a good report (Indicators of Change – the adaptation of the health trainer service in England) produced by Emma Lloyd the Policy and Research Executive for the RSPH
In the paper Emma notes that:
“There is a growing polarisation of services, between on the one hand services adopting more clinical work and on the other services consciously resisting this move and instead, placing a far greater focus on the wider determinants of health and community development”
Clinical Model
The first major presentation was from Kevin Fenton who is the National Director for Health and Wellbeing at the government agency Public Health England
If I understood him correctly his presentation focussed on the way in which the evidence base has developed – and the opportunities that are presented by bringing ‘behavioural insight theory’ which is to some significant degree informed by the work of the Behavioural Insights Team – formerly the Cabinet Office Nudge Unit.
The presentation dispirited me – it highlighted the disconnect between Public Health England and the experience of citizens – particularly the most disadvantaged. There was no mention of health inequalities at all and little understanding shown about the connections that exist between poor mental health and vulnerability. Instead we had the usual rather technocratic sets of interventions targeted at particular behaviours (smoking) or conditions (obesity). It felt as though Public Health England are trying to shoehorn Health Trainers into an older clinical model of behaviour change – the person as a collection of conditions.
Social Model
The second presentation was completely different. It was by Sam German – who is supporting an initiative called called The Healthy Villages Partnership. He told us stories of connection and relationships. For example a story of an elderly woman who was isolated and depressed following the death of her husband and how a community health worker helped her reconnect with one of her passions – dancing – and the difference this made to her health and wellbeing.
The key for me was that people – their circumstances, histories AND skills and hopes were at the centre of Sam’s narrative.
I find this dissonance between these two views quite shocking. One is about ‘the other’ as though we are a just a collection of behaviours to be triggered and the other is about seeing us as human beings who want to be creative, who want to give and whose circumstances are one of the things we have to recognise and address if we are to be fulfilled.
Coincidentally at around the same time as this conference Citizens Advice produced a report in association with the Behavioural Insights Team called “Applying behavioural Insights to regulated markets” which looks at how behaviour change theory can help people take control as consumers of financial and utility services. Unlike the Public Health England presentation it does recognise the impact of inequality and vulnerability on our ability to change our behaviour and take control.
What needs to happen.
- Public Health England need to change their paradigm. At the moment they produce too much material that feels disconnected from the lived experience of people – they urgently need to develop a whole person narrative rather than a condition focussed one.
- PHE must raise their game with regard to the science – it is frankly embarrassing when a charity can produce a more coherent narrative on behaviour change than the governments leading Public Health agency.
- We urgently need an assertive position on the person centred role of health trainers, health champions or community health workers that affirms the importance of this approach to counterbalance the a-contextual science of the Public Health England model.
What do you think?
Hi Mark
I agree with your comments on the inappropriateness of viewing people as simply a collection of behaviours that can be manipulated and changed in isolation of thinking about their life history and circumstances
As an ethnographer I am passionately interested in understanding people and communities and cultures and all of the complexity attached to them that makes them so fascinating and multifaceted.
I have recently been particularly interested in the writings of a group of medics who absolutely are against the separation of the practice of medicine and understanding disease from understanding the person and their world. William Osler, a physician writing in the late 19 Century observed ‘It is much more important to know what sort of patient has a disease than what sort of a disease a patient has’.
Another medic, Oliver Sacks, writing later says ‘In examining disease, we gain wisdom about anatomy and physiology and biology. In examining the person with disease, we gain wisdom about life’.
Life is meaningful because it is a story. In more recent time the neurosurgeon Paul Kalanithi has written ‘Science may provide the most useful way to organise empirical, reproducible data … but its power to do so is predicated on its inability to grasp the most central aspects of human life: hope, fear, love, hate, beauty, envy, honour, weakness, striving, suffering, virtue’.
It is this sense of the person, their history and their stories that is missing from the Public Health England work that you describe, They could learn much from the writers quoted above
(quotes taken from an article that appeared in the Guardian newspaper entitled ‘Medicine begins with storytelling. Patients tell stories to describe illness; doctors tell stories to understand it, ‘writes Siddhartha Mukherjee, one of a new wave of doctor writers investigating the mysteries of their profession. Andrew Solomon explores the vital intersection between science and art).
Hi Robert – good to hear from you again. Really helpful thoughts – I suspect that part of the challenge is that Public Health England assume that national analysis and action – which are largely divorced from personal narratives and experience – can translate into local solutions – where it is possible to respond to personal narratives much more directly – as you will know through your Healthwatch Work. All the best Mark
Excellent piece Mark. While “…it is frankly embarrassing when a charity can produce a more coherent narrative on behaviour change than the government’s leading Public Health agency.” It is not surprising.
Public Health England’s mission since its formation reminds me of the classic joke – a tourist asks a Londoner how to get to Buckingham Palace and the Londoner replies, “If I was going to Buckingham Palace I wouldn’t start from here!”
Like the hapless tourist Public Health England started from the wrong place. From day one it lacked any coherent or up to date theory of public health. Its thinking then and now, is jumbled and old fashioned. Don’t believe me – take a look at their ‘Strategic Plan for the next four years’ published in April this year. It is cluttered and lacks coherence. By page seven it has already simplified its health improvement challenge into five discrete ‘domains’ and on the next page a list of the usual ‘diseases’ to be prevented appears. Has nobody at PHE heard of ‘polycentric and complex adaptive systems’? Where in the real world do social circumstances and behavioural patterns act separately and can be quantified by their proportional contribution to premature death? I suggest that two of the reasons many people ignore even basic public health promotion messages is because they lack credibility and are not related to the everyday narrative of their own lived experiences.
PHE continues to be organised on a slightly modified ‘domains of public health’ model. Has anyone apart from me actually read the seven page paper ‘Public health in practice: the three domains of public health’ published in 2005 with its 18 references, 8 of which are UK government publications? Is using this approach to public health in 2016 really speaking “to the evidence and our professional judgement”? What continues to drive PHE’s continued use of a simplistic, linear ‘cause and effect’ model? To quote their strategic plan, “just under half of the disability adjusted life years lost in the UK are attributable to diet, smoking, high blood pressure, being overweight, and alcohol and drug use.” It goes on to make the usual assertion that, “…estimates suggest (my italics) that if we reduce these risks, through effective investment in prevention, we can reduce premature deaths and long-term illness…” And their ‘doughnut’ (how appropriate) tells them that behavioural risk patterns explain 40% of ill-health in England. Their solution, to change people’s behaviour is ridiculously simplistic and often ineffective.
So if these are some of the problems what are some of the solutions? You helpfully set out three areas for change in your blog. While there are more changes needed: in public health training; in redressing the huge imbalances in funding health services; in recruiting a more socially and culturally diverse public health workforce; and the reorganisation of public health away from a model that isn’t working well enough, especially for the most disadvantaged. Let’s start with your three.
1. Public Health England needs to change their paradigm. At the moment they produce too much material that feels disconnected from the lived experience of people – they urgently need to develop a whole person narrative rather than a condition focused one.
Your language in the blog of, ‘otherness’, lived experiences, social context, connection and relationships emphasises that a ‘Social Sciences’ approach could be more appropriate to this challenge than the ‘natural sciences’ model that leads to the focus on conditions and technocratic interventions. I’m gratified to read his comments above, as an ethnographer Robert Dalziel comes from this discipline.
Dichotomies of otherness are set up as being normal, often taken for granted in everyday life and presumed to be natural. But social identities are not natural – they represent an established social order – a hierarchy where certain groups are established as being superior to other groups. It is assumed that individuals have the choice to create their identities and in this case lifestyle and behavioural choices according to their own beliefs. Yet the negotiation of identity equally depends upon existing power relationships.
Social identities are relational; groups typically define themselves in relation to others. This is because identity has little meaning without the ‘other’. So, by defining itself a group defines others. These definitions of self and others have purposes and consequences. They are tied to rewards and punishment, which may be material or symbolic. Power is implicated here, and because groups do not have equal powers to define both self and the other, the consequences reflect these power differentials. (Andrew Okolie (2003) https://othersociologist.com/otherness-resources/)
Institutions like PHE hold the balance of power through their representation of what is accepted as ‘normal’ or healthy and what is considered ‘Other’. I’m reminded of a brilliant paper ‘Reasons to be cheerful’ by Lynne Friedli in 2011 where she comments, “It’s perhaps a cheap point to note that income in the higher echelons of public health situates these professionals well within the top decile, where the feeling that life is meaningful is daily reinforced by material reward. And the social and emotional distance between those who design interventions and those who experience them widens.”
The other ‘paradigm’ change would be to move away from a ‘pathogenic’ model of health towards a ‘salutogenic’ model. The salutogenic model is connected with the lived experiences of families, communities and the whole person, where their “circumstances, histories AND skills and hopes are at the centre of the narrative.”
The salutogenic model was first proposed by Aaron Antonovsky in the 1970s and developed more recently, particularly in Scandinavia, by Bengt Lindstom, Monika Eriksson and their followers. It highlights the resources and capacities that positively impact on peoples’ health and wellbeing. Although separate to, its theories underpin ‘asset-based’ or person centred approaches.
2. PHE must raise their game with regard to the science – it is frankly embarrassing when a charity can produce a more coherent narrative on behaviour change than the government’s leading Public Health agency.
Various attempts have been made in recent years to re-write the science behind public health to produce a more relevant and coherent narrative. The first being, for reasons explained above, that much of Public Health is not a natural science.
In a 2013 seminar for the Glasgow Centre for Population Health, Jane Macnaughton, Professor of Medical Humanities at Durham University explained the history. “There have been four main waves of public health intervention …(municipalism, the refinement of the scientific approach, the welfare state and risk theory of disease).” Research and evidence suggests that the effect of these is diminishing and that a new fifth wave is needed.
The rest of her seminar considered the best recent attempt to introduce a new ‘science’ for public health in 2011 by a group based mainly in Glasgow. In their ‘Integrative Framework’ for public health they challenged the natural development of a ‘fifth wave’ of public health from the traditions and challenges that led to the first four. Their “alternative view is that the nature of the challenges facing public health in the early 21st century are such that a fifth wave of public health will not appear from its accumulated traditions but rather will emerge from radically different ways of thinking, being and doing.”
What they recommended was that a future integrated model of public health would be ‘beautiful, good and true’. While this is very interesting it clearly had no resonance with UK public health leaders and strategists then or now. What is even truer now than it was five years ago is their conclusion that “Public health may require a new and more appropriate paradigm with which to navigate the turbulent present and (as yet) unknowable future.”
3. We urgently need an assertive position on the person centred role of health trainers, health champions or community health workers that affirms the importance of this approach to counterbalance the a-contextual science of the Public Health England model.
To be honest Mark, I bow to your superior knowledge and experience in these areas. I still occasionally dip into ‘People-centred Public Health’ the book that you co-authored with Jane South and Judy White in 2103. Your recommendations on a citizen-centred public health system seem more relevant today than ever. The first two are particularly apposite to this blog:
• “Citizens need to be at the centre of the public health system. A culture change is required to shift from a deficit to an asset-based approach that recognises the contribution that can be made people in the places where they live and work.”
• “Public health action should shift from an outdated biomedical model still focused on health behaviours and targets, to addressing the social determinants that impact on people’s lives.”
I sense some strong recurrent themes that senior public health professionals might or should have noticed over the last 10 years. But then we are not in charge of Public Health England’s Health and Wellbeing Directorate, and unlikely ever to be. Perhaps we have the wrong type of ‘insight’!
Hi Trevor – sorry to be slow to respond to your passionate and well argued comment – I think it deserves more attention than lurking down in the comments section – would you like me to put it on the main blog page?
Best wishes – Mark