Determinants Health In All Policies Public Health

The anatomy of a healthy city.


I did a seminar last week. I was very nervous going into it, was a packed house.

slides are here online:
This is the “full set”. I actually presented a very cut down version. 

Use and abuse these as you wish. You can have the ppt file so you can use the slides, email me.


The video is also here. It’s a good job I’d done my hair.


The questioning was gentle at times, but a bit tough at others


It was largely focused on environmental sort of stuff. Unsurprising given the provenance of the seminar series and audience.


I hope I didn’t upset the GP community by my comments about over medicalisation doing harm and waste. It’s true I was ovefcharacterising a little, but it is a serious deal this one, and very real. I do see both sides of it – in a resource constrained environment what’s a time pressed GP to do other than adopt the path of least resistance, I would. The TV programme – the doctor who doesn’t use drugs – aptly demonstrates the dilemmas.


I hope I didn’t upset the mental health community by picking on antidepressant prescribing to illustrate some of the above. Again, unintended upset if I did cause it. 

I agreed with (almost) all the comments and points made in questioning afterwards.


I left with 7 reflections. 



I don’t have “the answer”

There probably isn’t “an answer”, it needs to be built from little bits and from big strategic bits

I certainly don’t have a button on my desk that is the ‘sort out x’ button. If I did, I’d have pressed it long ago. Neither does the chief exec, nor the leader.

The problems are devilishly difficult, often intractable, multi faceted and as history has shown us difficult to solve. 



There isn’t a single thing that will achieve the goal of a “healthy city”

The right kind of environment matters as much as the right services as much as the right policy context.

Some things are not in the control of the city per se.

The environment people will care most about “environment sort of stuff”, mental health advocates will care about that, community advocates, ditto. And so on. 

Given that 1) we don’t know “the answer” & 2) all of the above matter, it becomes a giant spread bet informed by intuition, experience and evidence.




Many say if only we had the resources they would be readily solvable. 

There was a time in the past where there was a great deal of resource sloshing around, we didn’t solve the problems then – to be fair we did make a few tangible inroads but the problems remain.

Maybe it’s NOT ONLY about resources, it’s certainly not only about resources at the margin, it’s about what we do with the whole that matters.

 In times of plenty, we didn’t make the mainstream better, we funded stuff at the margins to correct the deficiencies of the mainstream. And thus we never corrected the problems in our view of allocative value in the mainstream (in everyday language we failed to shift upstream).


If only you invested in xxxx then things would be better, the value of small investments in communities is incalculable.

I agree.

I doubt doubt the value. I also don’t doubt it’s incalculable.



The return on investment for xxxx or yyyy is excellent, why don’t we use the resource we free up to make that investment.

I agree.

I’ve blogged a lot on this in the past. See references.

The evidence around ROI is indeed excellent.

There is a need for “I”. This requires cash now. We’re all busy having a tough time here.

And the “R” bit implies free cash. The cash is locked into other things – buildings, staff, equipment etc….it’s not readily freeable in cash terms.



Belief vs evidence

Linked to the above, but also standing in its own right a point about evidence base.

Often progress is not really about the “evidence” per se, it’s about belief, different views on the same problem, power base, vested interests, freeing up resource from within (see above point) and other things.

To address those issues one has got to be a trusted ally and part of the system or able to shape the rules and the system in some way. Shouting from the outside isn’t a way to build trust.



Evidence, data and rational argument vs narrative and angriness

The converse point, we explored, also holds. The world isn’t full of neat rational logic. Political will to act doesn’t exist by magic, it is grown. Creating alternative narratives for change requires multiple means.

This is Mark Gamsu’s point. He’s right.



Stuff that didn’t crop up is also important

We barely touched on the political, ideological or commercial factors that have a bearing on the health of individuals and populations. In the light of subsequent events in Grenfell tower, we ought to have.






The limits of Return on Investment analysis –

 Beyond ROI – 

The asymmetric approach we have to expecting cashable returns on investment - 


This excellent blog is also well worth a read, from Rethink Health – The Sense–and Nonsense–of Using ROI in Population Health –


2 replies on “The anatomy of a healthy city.”

What about the environmental ‘stuff’ that doesn’t require additional resources and would be so easy if one arm of the council talked to another? Your licensing dept just upheld an appeal by an ice cream van to park directly outside our primary school, despite the school Head and governing body having rejected his application to do so. Disappointed is not the word!


Learn something new every day
Didn’t know Ice Cream vans needed licences
Sorry to hear of your experiences
Licensing is an interesting experience, often the obvious grounds to decide on the blindingly obvious are not as obvious from a different perspective, or legal grounds
Which school was it
I’ll investigate.


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