Better Health For All

The 2010 Marmot Review was a landmark, evidence-based, review into public health and inequalities. Ten years on, Sir Michael Marmot has demonstrated that overall life expectancy has stalled and even decreased in some groups. Levels of deprivation have not improved, and people are spending more of their shortened lives in poor health.

Poor health and inequalities are expensive to the public purse, creating a clear logic to tackling this issue, beyond the moral imperative. The timing of reform to public health organisations in England may have been surprising but does present an opportunity for change. The recent consultation on public health systems sets out proposals to split health security and health improvement into two bodies – the UK Health Security Agency and the Office for Health Promotion. The covid pandemic has devastatingly shown the value of each.

The reforms present an opportunity to approach commissioning differently. Too often decisions are made on the immediate need of the health system to cope, such as with winter pressures. This defers public health decisions, yet every tomorrow the problem is bigger. We need significant public health programmes, with wide remits, over a multi-year cycles. Rather than expecting immediate returns, we need to recognise that quality and benefits can take time.

By way of comparison, energy supplies and sustainable energy plans are designed over decades. Targets set in 2007 were designed to be achieved by 2050. The commissioning, building, and eventual decommissioning of a nuclear power plant is not designed to meet the energy needs of the upcoming Christmas holidays. The benefits of building a power plant will be delivered over decades. Public health should be no different.

The evidence for tackling modifiable risk factors has been known for years. Yet prevention is routinely not adequately funded. Whether this is smoking cessation services being decommissioned, EHC services being restricted, or great ideas to tackle weight or blood pressure never getting past the first hurdles – opportunities are being missed. Changing the public’s health is not a quick fix, nor is it solely the responsibility of healthcare professionals. Public health stretches from education to housing to diet to social activities. There is often talk of the benefits of a “system”, but the absence of an inclusive, truly integrated system means we miss the full potential of public health to reduce poor health and tackle inequalities. Clear lines of communication, shared objectives, and co-designed plans are essential.

Community pharmacy is an obvious partner in any national strategy. Community pharmacy’s role within public health, health security and prevention has never been more visible. Covid vaccinations and testing kits have reinforced the importance of accessible healthcare teams within communities. There is a network of over 14,000 pharmacies across the UK who can work with local leaders, their communities, and patients to change the health of local populations. Changing behaviours and culture is not a quick fix, and objectives can be no less rigorous even while recognising this.

Balancing the needs of local and national is never easy. Although all populations are unique, they often have similar requirements. The public need to know what support they can expect and how to access it. Individual services may not be prolific if there is little need in one area, but there is no need to ‘redesign the wheel’ in every area. Universal demands such as emergency contraception should be nationally commissioned from every pharmacy, eliminating any element of ‘post-code lottery’. But even services that may be more tailored to local need, reflecting specific priorities, should embrace an overall framework. There are gold standards for much of healthcare, but commissioning remains firmly patchwork and inconsistent.

During the height of the pandemic, when pharmacies were under immense pressure, local interpretation of guidance added confusion and inefficiency. There is a need to balance universal principles and key actions, whilst accounting for local implementation. Various national bodies have been criticised over the last year for the clarity (and timeliness) of their communication. Local leaders need to have both the confidence to implement locally and the discipline not to create local variation unnecessarily.

Whether seen through the lens of “levelling up” or reducing health inequalities, local and national leaders need to build on the amazing ‘can do’ spirit of the healthcare sector during pandemic and seize the opportunity that public health presents to achieve lasting change. Community pharmacies are placed within communities, trusted, and accessible. The ”inverse care law” does not apply to community pharmacy, and commissioning just a few well designed intervention programmes would make a material difference to our nation’s health. Moving the prevention aspect of public health into the remit of the Chief Medical Officer presents an opportunity to supercharge our collective efforts. Pharmacy has the expertise, the national network and local reach. All we need is the opportunity to use them.

Nick Thayer
Professional Research and Policy Manager
Company Chemists’ Association

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None of us can envisage how the complex adaptive system of planet Earth and its ecosystems will develop over time, but one thing is certain – that our planet, and the human societies, animals and plants which inhabit it – will change in ways which are unknown and unknowable. The dominant cultural paradigms of modernism and postmodernism which have defined public health practice are being replaced by a new paradigm which is increasingly referred to as ‘metamodernism’. Public health leaders are ideally placed to shape this slowly evolving cultural revolution, and will also need to attend to their own development to thrive.

Human beings have lived in societies and created culture for at least 40,000 years. Cultural  ‘memes’ (non-biological units of cultural transmission) are spread between human beings by communication: similar to a virus becoming endemic, some memes take off within a society and become dominant. Memes which become dominant may go on to define a broader paradigm (‘meta-memes’) and thus define a society, we regard such meta-memes as being the symbols and signs of a society’s ‘culture’ (as represented by their forms of art, literature, music, philosophy, religion and science etc).

The spread of cultural paradigms is not even within a society, nor can a paradigm be readily contained within specific time periods as discussed by the authors under the pseudonym of Hanzi Freinacht. The cultural paradigm which has increasingly dominated Western society for the last few hundred years (‘modernism/scientific rationality’) has its roots in the 17^th and 18^th Century Renaissance, Scientific Revolution, and Enlightenment periods. While one cultural paradigm may dominate a society, nation, or group of nations, as in the example of modernism, there are actually multiple paradigms co-existing globally – and also within a nation or even within a local society – at any one time. For example, the range of cultural beliefs within societies and individuals across the planet currently spans from ‘animistic’ (tribal society with magical and ritualistic thinking) through multiple paradigms to ‘post-modern’ (criticism of the rational, scientific thinking of modernism). This presents a challenge to public health leaders, whose endeavours to improve the health and wellbeing of local communities and national populations cannot, as we know, ever be a one-size fits all. This is before we even consider the additional issue of stage of adult development of individuals within a society.

Each new cultural paradigm has brought some degree of improvement to the health and wellbeing of people and the planet. However even the most well-intentioned moral projects resulting in new and seemingly ‘better’ paradigms have brought unintended negative consequences of their own: every paradigm contains ‘the seeds of its own destruction’. Freinacht reminds us that modernism has led to further inequality, alienation and ecological collapse, and that while postmodernism has provided a narrative in response to oppression and inequality, it has largely failed to have impact.

There is evidence, especially in Nordic countries, of an emerging new cultural paradigm which public health leaders may wish to consciously pay attention to, in order to shape its direction, to enhance the benefits and to mitigate the unintended, inevitable, negative consequences. It is a paradigm evolving under the names including post-postmodern, TEAL, integral, and increasingly referred to as ‘metamodernism’.

Metamodernism is a perspective which transcends and includes many aspects of previous paradigms, and is based on complexity, emergence, and dialectical thinking. Individuals are seen in the context of transpersonal networks integrated with the planetary ecosystem, ie both autonomous and indivisible from others and the whole.  Descriptions of a possible metamodern society are based on ideas of cultivating new forms of social welfare – building societies where people feel heard and valued, with a focus on adult development and psychological wellbeing. Metamodern politics focuses primarily on process, in order to ensure that all people can flourish and thrive – and all of this in a way which is open, democratic and without ‘being controlled’. As public health leaders, we know that this must be underpinned by the essential needs of food, security, income, and other key determinants of health: and yet there is also increasing evidence that people with, for example, poor mental health can also experience high levels of wellbeing, and vice versa.

Public health professionals have always worked at the forefront of new ideas and new paradigms, working across systems, organisations and communities in service of their populations. In order to lead in the context of new, post-postmodern cultural paradigms, public health leaders will need to grow their own forms of mind to embrace the metanarratives of metamodernism.

Dr Fiona Day is a former Consultant in Public Health Medicine, now working as an Executive Coach offering world-class coaching for senior doctors, medical and public health leaders in the UK and internationally. She specialises in using adult development theory in the context of complexity to enable leadership development.

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