‘Folks have lost half their body weight by singing. ‘ The GP doing things differently
Why do we keep sending people back to the conditions that have made them ill in the first place? This question is at the core of GP Dr Mark Spencer’s radical new approach to health care in Fleetwood, Lancashire, where communities are taking charge of their own social and health enrichment – with significant results.
TRANSCRIPT: One of the main things that struck us about four or five years ago now was that no matter how much we try to address illness in the town, and no matter how many advances there were in the NHS: how many new medicines that came out to treat depression, to treat heart disease to treat any disease you could name – and any amount of guidance from NICE and others, if all we were doing was managing illness actually we weren’t making a difference to our community.
The health of the residents of Fleetwood was getting worse, there were increases in long-term conditions, particularly mental health problems, and the reasons for that were rooted within the community itself. We started to take an approach that rather than purely manage illness – and we’re still doing that in a very integrated way – but rather than that be the only thing that we do, how can we create a healthier community; how can we start to address those things that make people ill in the first place?
I’ve been particularly inspired by Prof Michael Marmot in the same way I’m sure that millions of other people around the world have been, and there’s a saying of his that has really stuck in my mind: ‘Why do we treat people’s illnesses and then send them back to the conditions that make them ill in the first place?’ and that is something that is always at the forefront of my mind.
We’ve created this movement across Fleetwood around four years ago, something that we call ‘Healthier Fleetwood’ and its sole purpose is purely that: how can we create a healthier community.
There are three really quick, clear words: connected, confident and control. That’s three really simple words but they are really so powerful.
So: connecting: simply connecting human beings together. We are social animals we thrive when we’re connected in the same space as other human beings and our health deteriorates when we are socially isolated. So a lot of what we’ve been doing at Healthier Fleetwood is literally connecting residents together.
Within the NHS we are constantly doing to people. We’re constantly telling people what to do: ‘have this test’ ‘go and see that specialist’ ‘take that drug’.
We’ve got about 28 ‘Try Something New’ activities for folks to get involved in: singing, gardening, tea and chatter groups, crochet, art, fishing – anything that the residents themselves want to be involved in. Because the second ‘c’ of confidence – we can only become more self-confident by becoming ‘doers’. If we are continually ‘done to’ then our confidence goes down, and yet within the NHS we are constantly doing to people. We’re constantly telling people what to do: ‘have this test’ ‘go and see that specialist’ ‘take that drug’. All this time we are patronising people; we are lowering their own self-confidence.
Now it’s all about self-care, you know the big mantra that ‘self-care will save the NHS’ – well how do we expect people to take on self-care when for the last 20 years we’ve been patronising them, telling them to only do what we tell them to do?
And then the third ‘c’ stands for control, and this to me is the most important aspect of this and that is people being genuinely in control of their lives; people being genuinely in control of their own health; genuinely in control of their streets; genuinely in control of their communities.
Nothing is ‘done to’ residents of Fleetwood because all of those partners organisations – including the NHS, including the local authority – have all signed up to this way of working, where we are genuinely resident-led.
The Men’s Shed is a great example, where in response to a spate of male suicides in the town a group of men decided they would set up a self-help group for men with mental health problems. And that’s gone from strength to strength – they are in control of that, not only have they set up and run it themselves but they are now pursuing charitable status. They’re getting income and the number of men getting involved is getting wider and wider. But if Wyre council for example had set up the Men’s Shed it would not have succeeded in the way – it succeeded because the men themselves have set it up.
I suppose the one word that sums up Healthier Fleetwood is ‘hope’.
When these three c’s come together there is a real sense of hope, and I suppose the one word that sums up Healthier Fleetwood is ‘hope’.
One of the things that really got me thinking – there was a consultation with a patient about five years ago, when all this change was starting to materialise. The patient was in his 30s, he’d been drinking very heavily since a young age – I’m talking maybe 12, 13 years old – and that was a consequence of a really unpleasant childhood that he’d endured. He’d been drinking so much for so long he was having severe liver failure. I said something that probably every GP has said, and it is so trite, it is so patronising. I said to him: ‘If you don’t stop drinking it’s going to kill you’. And he said to me ‘You know what Doc, I know you’re trying to help me but it’s not the fear of dying that frightens me, it’s the fear of living.’ And you know, he was drinking to get through the day, and he didn’t want those horrid memories coming back to him. The shorter his life was the better. And that real sense of hopelessness really hit me when he left the room.
And yet, when you are connected confident and in control it generates hope. It moves you from a situation of hopelessness to a situation where actually tomorrow might be a little bit better than today – next month might be a little bit better than last month.
Our public health messages just don’t work in disadvantaged communities, and they don’t work on people who have no hope that life is going to get better
Where my thinking is at the moment is where people are in a hopeless situation their behaviours become quite self-destructive – we take on habits that help us get through the day and that might be drinking, it might be taking prescription medication that might be taking illicit drugs, that might be overeating, but those behaviours are very destructive. I think all the public health messages that have come out just don’t work in disadvantaged communities, and they don’t work on people who have no hope that life is going to get better.
One of the things we don’t do [at Healthier Fleetwood] is we don’t talk about those public health messages. We never say to people ‘stop smoking’ we never say ‘you’re drinking too much’ we never say ‘it would be great if you lose some weight’. But what starts to happen, instead of behaviour becoming destructive, behaviour becomes health-promoting, and they themselves start to make healthier choices. They require less of those comfort foods, snack less, have less chocolate, smaller portions – those are choices people make because there is that hope there that ‘actually I quite want to live long enough to see my grandchildren grow up’.
We have seen folks lose half their body weight by singing. By going singing! We’ve seen folks move from being completely socially isolated to starting their own groups, we’ve seen folks come off their mental health medication.
The use of hospital services by Fleetwood residence is going down. Over the last two years [there’s been] something like a 20 percent reduction in A&E attendances and acute emergency admissions from people registered with a Fleetwood GP, whereas across the rest of the geographic area the activity is still going up by 3 or 4 percent like the rest of the country.
So there’s something very different going on that is improving hospital utilisation and also reduction in prescribing medicines as well. And it’s that the NHS is interested in. So folks are coming to have at what’s going on.
What’s interesting is we never set out with those outcomes, we simply set out with outcomes of connecting, confidence and control. And when we are engaging with residents nobody has ever said ‘I know – let’s reduce A&E attendances’. That’s never been a focus; it’s a happy side effect but it’s never been the focus.
I think the NHS often gets it wrong because they focus on outcomes, over which they’ve got very little control of themselves.
If all the NHS does is manage illness it is always going to require more and more funding and more and more staff
If all we do is manage illness, no matter how well we do it we’re still going to get busier and busier and busier as – thankfully – the population lives longer, but also with more long-term conditions. So if all the NHS does is manage illness it is always going to require more and more funding and more and more staff and we don’t have those staff.
We have still got a very hierarchical, command-and-control bureaucratic, from-on-high-leadership. I think a leader should create an environment what everybody else is able to make a difference; where everybody becomes a leader. And until we get away from this hierarchical leadership things are never going to change.