How the public thinks about health, and why it matters – with Dr Jacqui Dyer and John Hume Episode 21 of the Health Foundation podcast

Jennifer Dixon: Ask the public about health, they put the responsibility on the individual, then point to the NHS to help out. And yet we know the context in which we live and make choices really matters. The context that governments, businesses, employers and investors have a big hand in shaping. The pandemic may have shifted things. Polling shows the public now sees the government as having an important role in improving people's health. About 80% of us think that, particularly on smoking and alcohol. And there's public appetite to reduce inequalities in health between different groups shown up by the pandemic. Meantime, we await the government's forthcoming public health strategy, but the strong instinct of the current government is already revealed not to nanny and intervene, instead, rely on individuals to take control. We saw the government recently row back on plans to ban BOGOFs. That's buy one, get one free, junk food promotions. Yet the evidence is overwhelming that relying on individual choice just won't dent the current alarming trends on obesity. So how to make progress? In today's podcast we'll be exploring if public opinion can be moved to spur the government to act more on health. With me today to discuss, I'm pleased to welcome Jacqui Dyer, who is the co-founder and CEO of Black Thrive Global, a community interest company, established in 2016 to address the inequalities affecting mental health and wellbeing of Black people in Lambeth. Among many other things, she's also a local counsellor in Lambeth. And John Hume, who's the Chief Executive of The People's Health Trust, a charity focused on reducing health inequalities through community development. He's also a proud northerner, who's lived in the south for 25 years. Welcome both. So our recent work seems to show that the public believe that the onus on staying healthy is on the individual, and when you get sick, it's a matter for the NHS. I was wanting to ask you both, given the community you work with, is that your understanding and experience of the people you are working with, that it's really, you're on your own really, it's not really government's responsibility or business to shape things?

Jacqui Dyer: I think that there's many ways of looking at this, but for me, it's very difficult in the past couple of decades to really, especially some of the communities that I work with, which are some of the most deprived communities, communities that are vulnerable, they experience vulnerabilities. It's very difficult when you are in a state of poor health or developing some ailment to think about something else being the source of that problem. And I think that the way that society has developed over the past few decades where, actually, the position that you are in, your socioeconomic position, for example, and we know that the social determinants have a significant role to play in one's health, the way that society has developed over the past couple decades means that you think that it's your individual responsibility for your health status, where I would argue strongly against that. Whilst I think that there is individual responsibility to do things to actively take care of yourself, some of the source of those issues actually emerge from your employment situation, your education situation, your housing situation, your access to opportunities that might allow you to have a reasonable income for yourself and your family and your loved ones, in order to eat properly, to exercise properly. When you're under stress and strain, those choices get minimized. I think that the way that society has gone from being one, which is around really about communities or society, to one where it's more individualistic, gives people the impression that it's only about individual responsibility, and I counter that.

Jennifer Dixon: The communities that you represent and actually work a lot with, through your role as counsellor, Jacqui, and also Black Thrive, if you were to assess the public, their opinion on how far health is down to them as opposed to wider forces, what would you say?

Jacqui Dyer: I think some of my communities are very much aware of the systemic discrimination and systemic oppression that they are living through and would source some of that impact on their health, particularly in the context of mental health. Source that on systemic racism and systemic discrimination. It's different for different communities, and it's quite difficult, as I said, to think about when you are actually in that state of unwellness, you're not necessarily going to ascertain, ‘Oh, that's the source of some policies, or the source of my distress.’ So I think it's different for different people. Some would say, ‘Yes, of course, it's my own problem that I've got to resolve,’ and others would take a different view, depending on how much they understood the context and its impact, the environment, and its impact on their everyday lives.

Jennifer Dixon: And John, how would you respond to this question?

John Hume: I would say that with the communities that we work with, their initial response to what health means would almost certainly always be about the NHS, and about major diseases, and truthfully, things that are readily produced as stories across the media, and therefore are consumed by the public at a rate of knots across social media as well. But I think that once you're clear that what you don't mean are the major killers and you don't mean the NHS, and once those communities feel really confident that, actually, what you're not doing is judging them, I think they really quickly open up. I think it's particularly the case for communities that have got significant disadvantage where class, race, material disadvantage is a factor. I think you rarely get people talking about health in a way which is about disease. They might start off about that, but really, what they start to talk about is the housing, the lack of jobs, the low pay, and they talk about people being in poorer schools or no places for their kids to play, and really often, about bygone industry, which hasn't been replaced. They understand, I think, that there's a connection between these dimensions of life and the impact on their health, because it's as old as the hills and I think there's lots of examples of that, of people experiencing poverty. I think, for generations, truthfully have talked about the impact of stress from living conditions and how those impact their health and how that includes discrimination. There are communities that are – we work with people in the bottom 30% in terms of indices of multiple deprivation, so you're talking about some of the poorest communities in the country.

Jennifer Dixon: We commissioned some work from a group called Frameworks Institute last year and they asked the public, focus groups, surveys, all sorts of work to get underneath opinion, and the opinion, at least on the face of it, was very strongly that it's the individual. It's my fault. It was almost a blame.’ It's my fault if I'm ill’, kind of thing, was quite a prevalent finding and some of the researchers were mooting whether or not this is almost about a desire for more control. A belief that things are down to you and your choices can, perversely, be quite comforting because it means that you've got control. We know there's a, ‘take back control’ meme in some communities, isn't there? I wondered whether you felt that there was something in that.

John Hume: Yes, I mean, I do think there's something in that freedom to choose argument. The idea that the state shouldn't be intervening too much on people's lives and choices, et cetera, but the truth is, the state already does that in so many ways and in so many ways that are really good for people, whether it's about telling people they can't work X number of hours without a break or wearing seat belts. There're vast numbers of ways in which the state intervenes, which have vastly improved population health. But I counter it by saying that I think talking about individual control is just easier. It's simple for government. It's simpler for the media. It's simple for people to understand, because the complexity of the issues, when you're talking about things with multiple causes, is really hard, that multi causation thing. The idea that obesity is not just about what people choose to eat or whether they choose to exercise, but it's actually about policy decisions and regulations and trade deals and free markets and poverty and, and even town planning. All of those things are difficult. So I think the issues to me feels like it's more about one is controllable and understandable, which is the individual thing. I can do something. And the other one is unfathomable, it's too large, it's overwhelming. There's those elements to it, and that's without bringing in the other side of it, which is about the stigma that people experience in poor community. That feckless shirking poor idea. It's still prevalent. It's very much there.

Jennifer Dixon: And Jacqui, I mean, you were saying earlier that you thought that people felt that things might be within their control if they were ill, because that's what they were focusing on, their own individual health. But do you see some benefit to thinking about health for individuals that it is under their control? Do you see a trend in your communities to think that or not?

Jacqui Dyer: I actually agree with the sense of, what can I do? Yes? So a sense of your own agency in taking care of yourself. The underlying reasons as to whether or not you might feel confident enough to do that, for whatever reasons, is another question but, for sure, people would want the agency to be able to say, ‘I can lead my life in a way that is healthy, and I would really like to do that.’ The question then is the how and the access to be able to enable that to materialise. That's now when you start encountering the limitations of your opportunities to be able to have the best possible healthy life, because a lot of it is resource dependent. Many of the communities that are most impacted, especially I would say, non-white communities, it's much more of a struggle to do so. Then you're challenged with the shame of not being able to improve your health, which acts, I suppose, that's what John is saying about stigma, because you start believing that it's purely about you. It's very complicated and it gets distorted, so when you separate that it's just about yourself making a – individual responsibility, that's a naive way of presenting it because it doesn't take into consideration the other factors that determine how an access to better health outcomes, you can't do it in isolation.

Jennifer Dixon: Yeah. Also, polling within the pandemic showed that public attitudes did shift in terms of thinking how far governments had agency to protect our health. I mean, for obvious reasons. Not just to say that government has a role, a big role, in securing public health, but also there was concern and appetite amongst the public to address inequalities in health. Is that going to stick or is it not?

Jacqui Dyer: I think it's really quite important to think about the complexities because there's national role that government plays in terms of policies to support having a healthier population, which I think is their responsibility, but there's also, on a regional level, around what can be done regionally, and leadership shown around supporting a more healthier population and what can be done locally.

Jacqui Dyer: So we start thinking about the workplace, we start thinking about employers, we start thinking about access to green spaces, access to better housing, access to all of those other things that, at each different level, of our society and investment and better attention to, would help to alleviate some of the risk factors that create poorer health outcomes for communities, particularly if they lived in deprived areas. I would then say, how does local stakeholders, regional stakeholders, work with those populations that are experiencing the worst outcomes to address the inequalities and the inequities in their whole life experiences that lead to these poorer outcomes? So there's activation that's required at different levels and a really different way of addressing the population's health than what has being invested in previously.

Jennifer Dixon: John, I was just looking at some of the films on your website of the communities that you've worked with at The People's Health Trust. I was thinking of the community in Wales, in Birmingham and in Liverpool, in particular. I wondered if you could just talk a little bit about how those communities have been raised into greater consciousness, in a sense, of how they can collectively work to improve the health of the community.

John Hume: Yeah. I mean, we've got some long-term funding in some areas, which has been the key to it, I think. In some places we funded for 10 years because it takes that amount of time to be trusted and helping things to move. So in up in Gateshead, we've got a particularly good area in Edwards House, a community which is in the bottom 10% in IMD. Largely ignored, I've got to say, for many, many years. It really started with people determining what health meant to them, so when we went in and did a year with them and saying, ‘What does health mean to you?’ The things they came up with weren't about the NHS or sickness. They were employability, money management, the local health, and then bringing the community together. Those were the things that they felt were the most health protective things that they could have. That meant we built activity around them, and this moved into then getting partnership with the statutory services and started to understand the language that was required with those services, and also started to have a... In the theory of change, there was the idea that they built up knowledge, but they also built-up confidence and a sense of what they wanted to achieve as a community. So they became a place for statutory services to work with, and also, that they were unable to ignore, and that meant that places started to offer fewer top-down ideas, and they came up with a community linking project, which was working with the GP services. Not social prescribing, but just having this linking worker in there for things where people turned up with, which were non-biomedical, where they knew that actually what they needed to do was to be working elsewhere. They didn't need to be medicalised for what was going on, and it was actually debt management they needed. That project, which we've part funded with government, ended up being evaluated, has now been rolled out to something like 25, 30 different GPs across the area, because it was so successful. And they're now part of a system. What started off as a small group, and I'm talking about a group with a turnover of about £30,000 has ended up getting multiple grants, it's working with the local authority, with the PCNs, with the ICS. It's now part of developing those system wide plans for their neighbourhood. But what the statutory services have learned is that local people have got huge amounts of skill, knowledge, wisdom that they're now being able to apply, and it's starting to pay dividends, but it is focusing on the social determinants of health. It plays into this idea that Michael Marmot said once, which was, ‘You can't treat people and return them to the conditions that they came from, and hope things will get better. It's just madness,’ and it is. I think there, you start to see things turn around quite significantly in that neighbourhood.

Jennifer Dixon: Yeah, and Jacqui, are you seeing this type of, I mean, it sounds like old fashioned community development, this, to me, doesn't it? Do you see neighbourhood groups working in the same way in Lambeth?

Jacqui Dyer: So if I focus on the Black Thrive partnership, that is a partnership between systems, stakeholders ie. the local authority is the lead. The Mental Health Trust, the police and Black led community organisations, to identify the areas across the life course, which need attention in order to improve the Black, and I mean the Black experience. So if you think, for example, in Lambeth, if you are Black, you are 13 times more likely to be in temporary accommodation. Your likelihood, as a young person, a child, to be excluded from school is high. You are likely to find yourself in impatient and secure mental health services to a much greater degree than your white counterparts. These are reflections of deeply embedded structural racism, and so, on one level, some of the work that we're doing is similar to what John speaks to, but the other work that we're attending to is, actually, that systemic racism that means that you have to pay attention to those particular barriers and obstacles that an anti-Black system puts in the way, so it's not one size fits all. It's actually dealing with the differential experience that you have as a Black body, in terms of access to employment. We've got a male population that 50% are unemployed, 50% employed. We've got a white male population where the figures are more like 90% employed. These are figures that have been present for several decades. If you actually ride on one bus from one part of Lambeth to the other part of Lambeth, a vast majority of what you will see is so visible in terms of Black poverty, because they have nowhere else to go and they are literally, in groups, right along that journey from the north of the borough to the south of the borough. We have to pay deeper attention to these things that create poor mental health outcomes and poor lives.

Jennifer Dixon: And are you seeing Jacqui, the kinds of community development that John is describing, that can help tilt some of it? I mean, it can't tilt the balance of very deep-seated issues that may require a national intervention, but there's certainly a lot of good that can be done locally. So are you seeing local groups becoming more empowered in the way that John is describing, and is that tilting the balance locally, at all, in your view?

Jacqui Dyer: I think it's a big tilt and it takes time, so I think the short-term answer is yes. We're having community groups much more engaged in helping us to shape the interventions or the support that they require, because they are core producing. They are involved in identifying what the response needs to be in order to support them. So for example, accessing peer support and culturally appropriate advocacy is a service that's been core designed with communities to give them the support that they actually need when they're experiencing that kind of vulnerability. So that helps to change the narrative around how services manifest that they can be better at meeting the needs of diverse populations, because those diverse populations are helping to shape them. I think that that's really something that's been catalysed even further as a result of COVID because we've got loads of neighbourhood level community groups that are eager to work with us as our local authority in helping to shape what their neighbourhoods need to be like in order to keep them healthy.

John Hume: Jennifer, can I just come in on that is that, because I think what it does is, it is exactly what I think Jacqui is describing. It shifts a mood. It makes people pay attention and there are some great examples of it then, that can get used as ways in which you can do meaningful – really meaningful community involvement, not consultation, but really meaningful involvement. However, it does only go so far, and it does require significant local national government business. It needs other voluntary community sector organisations because they're not all good at this as well.

Jennifer Dixon: If you think of the waves of challenge that are ahead, not just with the cost of living, but the economy and what might happen to communities, and then you see in here, the fabulous work you've both described at local level, presumably, it's got to be a patchwork here because there just aren't enough community development groups or charities to go around. How do you boost this type of activity? Is it, as you say, John, to coordinate a bit more with the voluntary sector and with the local government?

John Hume: It's difficult, isn't it? There's the call for the community act, which is a call for a stronger role for volunteering community sector organisations, really, in developing and delivering some of those public services, and therefore creating stronger local accountability. But it's rooted in things that are pragmatic, things that people really want to do, but that will mean that you're part of a system. But I think there's also got to be. What I think we're really, really bad at is just pulling together enough of that evidence as well, that this is not just about problems. How many times do we have to reframe the same problem over and over again? And when are we going to start really talking about, there are some solutions here and these are not just about individuals, but they're about population level changes and those need to involve businesses and they need to involve other organisations, anchor organisations, and institutions and governments making some of those decisions. There has to be an economic argument behind that, that it actually, economically, does not make sense to continue to do what we do. You can't have the chief executive of the NHS saying, ‘The NHS is at winter level pressures.’ I mean, that doesn't make sense at this point in June. We can't continue like this. So I think there's a need to galvanise funders behind this, so that funders are funding all of those local organisations. There feels like a need for stronger legislation to allow local organisations to be able to take on some of this role. But most of all, I think the thing to me that is really going to start shifting the dial on this is, there needs to be a much wider public awareness that what healthy life expectancy and life expectancy really means. And that's a big communication piece, which I know the Health Foundation, Jennifer's, doing and leading on, which is fantastic. What health really means are all of these things in the system that affect us, this discrimination, the unemployment, the lack of green spaces, etc., as long as the public's not saying that it's the perfect opportunity to reach for the low hanging fruit and not fund a systemic approach to this, which involves voluntary community sectors as well.

Jennifer Dixon: Yeah. Jacqui.

Jacqui Dyer: I suppose I'm saying, similar to you, is that there are actors at deep different levels, national, regional local. If we think on a local level, local government have a key coordinating role to play on this and within their portfolio, a range of levers to be able to assist that agenda and that's what we're doing. I lead on inclusive economies and equalities. So what that means to me is taking a very systematic approach, and systemic approach, to our equality, diversity, inclusion, agenda, which is really, essentially, about improving health and wellbeing of our population and threading that into every aspect of what it is that we do as a local authority, so pulling on all those levers that we've got available to us. And then the expectation that all our partners, all the stakeholders that engage with us, they have health equity right at the centre of their negotiations and their engagement, and the highest possible standard of commitment to the population where we are located is infused through the work that they do with us. That pulls in the voluntary sector, the community sector, the populations that we serve to be able to help to shape what that looks like, and actually, really identify what their needs are in order for everybody to thrive and flourish within a local economy. So that pulls in the anchor, the bigger employers, like the local Mental Health Trust, the primary care networks, the small and medium sized businesses. The larger businesses, where it's set this expectation that actually we would want all parts of our communities to flourish. What are you going to do in relation to contributing to what it is that they're asking of you? It's about ongoing community involvement and community engagement. Changing the power imbalance so that the voice of our populations that we're serving become much more influential in shaping where the public person spent, because one of my concerns is always that we can ask for more from voluntary sector and community groups, but actually, the resource isn't going in that direction. So we need to change some of that imbalance in terms of the resource floors.

Jennifer Dixon: Yeah. So Jacqui, you are a counsellor and you'll know more than anyone about the resource squeeze going on. And I get quite few emails in my job where people are asking – voluntary sector groups are just saying, ‘All the local authorities want to have evidence shown about the impact of what we're trying to do,’ and if you think about the wider determinants, it's really, really difficult to show. And you need long term studies, which are fiendishly expensive. So how do we get over this issue where it's kind of obvious, isn't it, that if you empower people, if you help them in the type of projects you've described and John has described in Gateshead and Liverpool, Wales. How do we get beyond this need for hard evidence? Because we're not going to be able to unlock resources otherwise, are we? How do we describe the complexity to give trust and cover to people who are trying to give resources to these communities?

John Hume: It's quite an interesting thing, isn't it? Because in some ways I don't think the responsibility in the burden for collecting evidence can sit at the very local level. One, because, as you say, Jennifer, it's just too costly. It's too difficult. It will consume organisations. But I'm just wondering, sometimes I think, where are the measures, the really good local authority measures, and the government measures? So we see endless measures about people, individuals, weight, alcohol intake, tobacco consumption, et cetera, but you don't see measures which are about commitment to the treasury in terms of health benefiting fiscal policies, do you? Or very specific, hard commitments on housing, but I think there's some emerging examples. I don't know if you've seen the stuff that the Institute Health Equity's done with Jessica Allen and Michael Marmot around Greater Manchester, but I think they build back fairer recommendations, which work across a number of dimensions, but for the first time, they've also put these beacons in, so these indicators of success, which is going to point to some data. It's going to demonstrate, just as Coventry, as a Marmot city, was able to use proxies of. Things such as they were able to use, I think, they increased by 4% fewer neighbourhoods were in the 10% most deprived as a result of five years of a very concerted effort on working on the social determinants of health. Well mean that's quite a phenomenal figure. That's quite a phenomenal shift, and I think it's that level that we need because that's where the case is going to be made. Otherwise, I think it's just too easy for everyone to dismiss. Well, It was the right place, the right people, the right set of circumstances, and truthfully, that is the case. A lot of that when it works, hyper locally is down to serendipity. It's not a system wide piece, so I think if we're going to evaluate, we first need to have those really good targets set at government level, which are absent from a lot of policies I'm afraid. Or if they are there, they're unrealistic. So I feel like we need to have good targets at the national level that can be then rolled out locally, but we can draw on this extensive work, the Institute of Health Equity started to do around this, and around ways to measure it that are not overly onerous because those local authorities in those places that you are working in, Jacqui, will already be measuring. So you're asking people just to focus in on a different way, and then the VCS organisations can feed into that. Why not?

Jennifer Dixon: So Jacqui, how does Lambeth – you get multiple requests for funding across the wider determinants piece, say. Given the fact you can't measure the impact, the possible impact that these little groups that are coming to you for funding will have, how do you then adjudicate?

Jacqui Dyer: There is an example of one of the ways that we've created a pot of resource that enables smaller communal groups to access, and that aligns with what our borough plan, ambitions are, and that is a part around social value. So how are you contributing to the social value of our local population and not some big onerous way of assessing that, but something which is quite simple and accessible. That's one of the ways that we've been able to channel more resource into our community and voluntary sector. I would also add that we need to value more what our local communities, what our local populations identify as their indicators or their measures, as what constitutes wellbeing and find ways to honor that, so that then you have a combination of what measures are important to our communities and that helps to pick up some of the inequities and the diversity experience piece, as well as things that are on a more national and regional direction.

Jacqui Dyer: How many anchor institutions like Mental Health Trust, NHS Acute Trust, are using that social value mechanism in order to give back, in an almost corporate social responsibility way, back to our communities, because surely, part of the agenda here has to be, how do we move from a pipeline of people ending up in crisis? One which is more earlier intervention and prevention, and so that the resource flows end up coming back or build upon the resilience of our communities. How do we use our resource flows, our public purse, in a much more intentional way that benefits the health of our population, not just in crisis.

John Hume: I think we just need all of us to be a bit cautious about is, the concept that wellbeing could change and improve for people. I think you just mentioned that then Jacqui, and I think one of the dangers, and I know you'll know this, because you'll be working in this as well as we do, but one of the unintended consequences of some of our research was that wellbeing in some of the neighbourhoods we're working in has increased significantly. I mean, we're talking tens of percentage points increase compared to similar neighbourhoods experiencing similar levels of disadvantage. But actually, the health inequalities have widened. And there's a real danger there that, actually, what we need to do and what we need to create and how we need to balance these things out can't mask what is the fundamental problem, because people don't notice health inequalities widening when you're getting a change of 0.3 years of life. People don't notice that, but they do notice that they might feel better. Because there are more community groups it's more going on, you've got more of a collectivity going on, and it's a downside of this. Of the whole of that community development work that you could actually be starting to mask a problem.

Jennifer Dixon: What I've heard, and I will just come to you for a last comment on this, is it's some big messages here. So you've stressed, I think, the most important thing is to engage local people and trust their views as to what they are saying to improve health. The second is to have a wider group of people and assets, voluntary sector businesses, local government to act in consort on the wider determinants of health. The third to have a local vision or regional vision on health, what it takes to have a healthy life that people can buy into in order to act in consort, and fourthly, to have some longer-term effort, rather than piecemeal, every two years change. Is that the summary or is there anything that either of you would add that is coming out of this?

Jacqui Dyer: That's really helpful, and when I think of what you've just said, I think to myself, ‘Oh my goodness,’ and that's really what's embedded in, I call it Thrive London, and actually that's what's really embedded in our vision for public mental health across London. So yes, John?

John Hume: Yeah. I would say that my key thing is that we need to get this message out much stronger across to the public, so that people really understand, because that I think, in turn, will influence government that what health is about is not about big killers and the NHS. That's a sickness service. It's not the right thing. The only other things I'd add into that is that I think there needs to be much, much stronger across departmental government working, possibly with the implementation of something like health inequalities into the green book, like Nancy Hey, and the What Works Centre for Wellbeing did, which is a phenomenal piece of work and what difference that could make. There needs to be that policies piece linked to investment. We've got so many strategies. We don't really have any policies to implement them and certainly not much investment to implement some of them either. I think if you can link that to real life examples, housing and living wage, et cetera, that can actually work, I think there is an opportunity now, because I think, as you said Jennifer, the public's opinion is changing slightly on this and it's an opportunity to take and to run with, I think.

Jennifer Dixon: That's a great place to end. Thank you both very, very much. So that was really interesting. Thank you very much to Jacqui and John for great insights from their work with the communities they work with. All much appreciated. We've referred several publications in this podcast, for example, ‘A Matter of Life and Death’, which was published by us, of the work by the Frameworks Institute. You might want to take a look. In July, we'll be publishing a toolkit, which is a follow up, which will try to help people working with the public to frame discussions better on health, to unlock action on the wider determinants. We'll also put in the show notes links to our work on Anchor Institutions that was referred to by Jacqui and John in this podcast. Next month we'll return to health care, comparing the NHS to the German system. I'll be talking to the chief executives, managing two leading academic teaching hospitals, The Charité in Berlin, Germany's largest hospital, and Imperial College Healthcare NHS Trust. So that is going to be very interesting, given the extra resources that the Germans have in their system. There'll be fruity comparisons, no doubt. Anyway, all that's lined up. See you then, next month, and stay well until then.

Cost of living: Ban on buy-one-get-one-free junk food deals delayed for a year, as PM accused of playing politics with kids' health (2022) Sky News

Addressing the leading risk factors for ill health (2022) The Health Foundation

What Works Centre for Wellbeing

A matter of life and death: explaining the wider determinants of health in the UK (2022) FrameWorks Institute

The NHS as an anchor institution (2020) The Health Foundation