the things that will make a difference to population health outcome

I’ve noticed this crop up a lot of late,

If only we could find out what to do, things would be better.

It’s hard to not answer without saying things I’ve said many times before. You can only repackage the memo in so many different ways

My stock answer (fairly consistently) is to focus on the risk factors and assets in that population or place (note I’m avoiding talking about services here). These are consistent. So the quest becomes a question of how good the story is, and the mechanism for improving and accelerating, on key risk factors:-

• proximal (cigs, obesity, lack of sweat and booze), these are framed as “commercial determinants” and NOT lifestyle choices of individuals. See here for a sense of major risks
• further upstream (poverty, skills and employment, homes, community led stuff, economy, poor quality air, educational attainment).

in any town there is plenty going on. It’s never quite as perfect as we want it to be, and there are always improvements to be made and trade offs to be struck. It’s often said there’s “nothing happening”, this isn’t true. I can send you six pages detailing our approach to say obesity, the same for pretty much everything else.

Of course we can do more. I’m told Amsterdam has an amazing approach to obesity, I don’t know whether it’s true but it has been in the telly. I watched the programme, there’s nothing in the Amsterdam approach that isn’t in the Sheffield approach – apart from more cash: £6/ head v £.080/ head. I could spend £6 a head on obesity, but I’d have to slash spending in other services people think are essential. Nobody wants me to do that!

the ever erudite Dom Harrison also suggested two extra thoughts:

1.Parity of investment between ‘incidence management’ and ‘prevalence management’ in NHS system investment

2. Creating healthy (and just) public policy, social systems and organisational structures

He is dead right

Kate Ardern added 3 & 4

3. Seeing people as “strengths” with skills, talents, ideas & experience instead of “problems” to be fixed by professionals ..ie @CormacRussell #ABCD .

4. Go back & re-read Derek #Wanless seminal reports of the early 2000s ..it’s his ” fully engaged scenario”.

Everyone “wants more preventive stuff”. This is sensible. Nobody much seems prepared to invest.

It is worth reflecting that whilst there is plenty going on, we have spend 7 years massively stripping out funding for local government that pays for the stuff focused on “the determinants of health” and 4 years stripping out the narrower range of services people thing of as “public health”.

Of course this will have impact on health and thus demand for services.

it’s worth a read of this assessment of the Impact of the “Saving Gotham” era in NYC – Bloomberg era’s emphasis on ‘health in all policies’ improved New Yorkers’ heart health. The paper is here. You’ll note the focus on upstream policies, not downstream service and behaviour change interventions focused on individuals.

The key takeaway “Saving Gotham” lesson wasn’t about telling people you can’t drink fizzy pop, it was about public health duking it out for a market share in the battle for people habits with industry, and changing the way people think using the same tactics they do. Nobody tells people they HAVE to buy a large pizza and chips for dinner, but it gets subtly suggested to them all the time through all kinds of contacts, relationships, advertising, media etc. To quote Mark Schatzker of the NYT : “by all means keep Beyoncé on cans of Pepsi, just make it a morbidly obese Beyoncé in a wheelchair glugging from a one-litre bottle. But something tells me Pepsi won’t take up the challenge”. (Thanks @drchrisgibbons)

I’d encourage you to read Saving Gotham. It is amazing.

Upstream matters, often a lot more

And in case you tell me I’m being all a bit downstream lifestlye drift, let me be clear upstream social, economic and environment factors matter a lot, often a lot more. If you need some background on it, I’d suggest digesting this thread. @brianrahmer

I’d say compulsory reading for anyone with anything more than the vaguest passing interest in what upstream structural stuff determines the health of populations. USA context but many principles exportable.

Arguably all after primary and maybe secondary prevention is palliative.

Go upstream in age terms

Upstream doesn’t just apply in interventions coverage and design terms (ie clinical vs social policy focus). The earlier the start in terms of creating health the more impactful. Barker told us this 40 years ago, Heckman 20 years ago, and many others before and after.

Mostly the search for population health outcomes comes from the health care sector.

For health care – for me the critical issue is to focus on:

• communities & neighbourhoods and whole population approach to risk and assets, person centred approaches, primary care investment – esp in toughest parts of town etc.
• MORE investment in primary care is a pre requisite. We can’t solve this by building bigger hospitals. We have a great system for managing multi morbidity. It’s called Primary Care. It’s incredibly asset stripped in the last 20 or so years as we’ve built bigger and more powerful hospital institutions and super specialist stuff. I should be clear that’s not an anti hospital line, but just an observation. Witness the inexorable growth of Specialised spend, a great deal of which doesn’t pass muster cost effectiveness wise. Which areas do you think have borne the opportunity cost of this.
• move the focus away from sole focus on “high risk, top of triangle”, virtual ward, etc – the prevalence of this model of thinking is startling
• Multi morbidity obviously critical. The evidence is crystal clear – person centred approaches, managing risk not individual conditions, prevention and delay are the only way to go

Seemingly our whole approach in health care certainly is focused in a different way. Focused on the expectations of DH, NHSE etc. I often wonder why the whole infrastructure of the NHS is focused on it.

Just saying