Well it’s great to be here.
It’s great to be back in Ireland.
And I just wondered, before I start,
well I will tell you the six things I’m going to say,
just in case this timer runs out on me
and then I won’t get cut off.
Just some reflections on what we have heard this morning
from what I thought were just some fantastic talks.
I will really make it in terms of what lessons we have learned,
both mistakes and some good things
that we have managed to pull off in England in this era.
The one first thing which is so good about HSE and EPA coming together,
is it’s not actually very difficult to do the future,
it’s just very difficult to do it together.
It is unbelievably difficult to do it together.
The idea that you tack on to the end of every sentence,
oh yeah, and we need to collaborate,
don’t belittle the role of collaboration.
We are innately highly competitive.
And collaboration often means compromising what you are trying to do.
So be very very careful.
I think it was Mike Depledge made the very important point about,
unless we have a shared vision, a truly shared vision
about what we are trying to do, together, it’s destined to fail.
Absolutely. And one thing about that vision,
it needs to be very very positive.
You know I can tell you two things that Martin Luther King did not say, OK.
One thing he did not say was, I have a nightmare, OK.
And the other thing he did not say is, I have a 12-point plan.
Now actually the second it’s quite useful to have plans.
Don’t belittle plans.
But that’s not where to start.
So it’s incredibly important, and one of the things
that we have done with some success in all parts of the health and care system in England
is to help people create a narrative for their own organisation,
whether they are a finance organisation, a regulatory organisation
or a states and facilities organisation,
or a scientific environmental organisation,
have a narrative which makes absolute sense to the people who fund you,
and the people you serve.
Because without that what we are saying in this room today,
is going to be completely fringe-like to most people.
It has got to be absolutely central to the narrative.
And that is a very careful crafting of words,
not just technical words, but words that make sense to people.
The second thing is that this is a people business.
It’s absolutely a people…it’s about engaging people.
By that I mean sustainable communities
in terms of what it means to live in a sustainable world.
And I think again Mike made the very important point
that you might have missed about we really
have to redefine what we mean by health and wellbeing.
Not in terms of absence of bio-physical illness,
but what does it mean to be well?
What does it mean to live a good life?
And this is very important in the sense of the role of communities
and what is a healthy community
in terms of how much inequality or social injustice is intolerable in communities.
And if you think to things like Syria,
the reason Syria kicked off big time is because people
who were disenfranchised in the country
with the longest drought the country had ever seen
came into the cities
and kicked off tensions that spiralled way out of control.
The reason people voted for Brexit or Trump
is because people get angry and feel disenfranchised and kick against the system.
So the second lesson I think is very important
is that it’s not what we do to the environment
or what the environment does to us,
it’s what we do to each other because of the environment.
The most dangerous species in the world is us.
And we don’t need many triggers to make it go horribly bad.
And the environment, as you have heard this morning,
is one of the big things that is going very bad,
climate change as the sort of very pinnacle of that environmental,
not climate change but climate chaos or climate disruption.
Climate change is very sanitised.
Global warming is very sanitised.
Be real about the science,
what the science is telling us,
and be proportionate about what the science is telling us.
One of the things that Jock told us this morning is about lessons from the past.
I mean we knew very well that tobacco is dangerous,
but we were very bad at framing how dangerous it was to each other, very bad.
You know, tobacco kills half the people who use it, period, end of story, fact, good science.
Get real about these things.
So the third thing I will talk about is about engaging people.
And engaging people is about listening to people,
not doing what I’m doing now which is preaching from a podium.
It’s listening to people. And one of the things I strongly recommend
is listening to young people.
I have never met a child, I have never met a young person
who doesn’t get this far better than we do.
Secondly, they are going to live with it longer than you or I are going to do this.
And thirdly, listen to young people,
and reframing what they say,
gives you a stronger mandate than any policy maker will ever give you.
Fourthly, the lesson I have learned is that this is not about efficiency.
In fact sometimes you know efficiency really gets in the way of this.
You know, the idea that we can do what we have been doing but a little bit better,
a little bit faster, a little bit cheaper, that is not going to happen.
We are going to have to do some radical changes
and we might as well try and make those radical changes smooth not horribly disruptive.
So I want to talk about some of the lessons that we have learned in England about doing this.
And finish off with some of the roles of leadership in this business,
not leadership necessarily at the top,
although I will show you some examples of leadership at the top,
but leadership at every level.
Some of the most profound examples of leading
a sustainable health and care system
which truly takes into account the physical environment,
the cultural environment, the fiscal environment,
have been taken at places not at the top.
Good leaders tend to understand what’s happening below them
and codify it and repeat it in better ways and embed it in better ways.
Good leaders at the top rarely have original ideas.
But they might have very good ears
and very good networks to sense what the future is all about.
Right. Oh I feel better now. Right, so have you all got that?
I mean I work in the area like many of you do, in the area of sustainability.
So get sustainability clear in your head about what it is.
It’s about not knowingly screwing up the future.
It’s not about durability or doing the same thing,
it’s about not knowingly screwing up the future
either in time or actually elsewhere.
So if you ever want to go and talk to someone who knows about sustainability
go and talk to someone who lives in a very poor community
or a very poor country who are living on the edge.
They are living with it now. Climate change,
climate chaos is not a future issue.
It’s a current issue.
Look at the WHO statistics on climate change
related health and disease and deaths, it’s happening now.
It’s not a future issue.
The second issue I would just really remind us about is,
many of you will know about triple bottom line
or people planet profit or environment and
social and economic, that triple bottom line.
These are not equal, they are not equal circles.
They are not competitive circles.
These are nested interdependent things.
And it is the natural world on which all life depends
which as Mike said or quoted “makes life worth living”
on which everything else depends.
I was talking in a small chapel in North Cambridgeshire last Friday evening,
and a child in the front row.
We were having questions and a child put his hand up and said
“Excuse me. Could you tell me what the economy is for?”
So while you have got a free moment, just write that down,
and just answer it by the end of the afternoon.
I would be very keen, and I’m sure she would have been very keen
to know what your answer was.
So there’s no doubt that science is very important,
the techniques and how we address it is very important.
But I do want to concentrate on the communication engagement and political issue.
And this was brought home to me very very worryingly about 18 months ago,
when an IPCC report was published,
and a colleague of mine, a Guardian journalist,
Manchester Guardian journalist, who is a very eminent spokesperson on climate change
from the Guardian, phoned me up and said,
David I have just been to an IPCC press briefing,
and you know I realise, I know that climate change is an environmental issue,
but apparently it’s a health issue too.
Now that should strike you as really odd.
And it should strike you in a way
that should remind us all that the world
out there does not see the environment and health as synonymous.
We all do. We are totally brainwashed.
We are the prisoners of our experience.
But you have got to remember that the reason air quality
became a very big issue in the US
is because it was deliberately not framed as an environmental issue.
It was framed as a health issue. Air quality is a health issue.
Cut out the middle word.
You know, if you listen to Christina Figueres
talking about climate change, she will say,
talk about climate change as a health issue.
I know if you have got the word environment in your job title
it’s not great news to hear this.
But remember that this is a health issue.
Don’t give people an excuse to put semantic barriers
in between what’s happening and what matters and what we can do.
It’s very important. So there you go.
It isn’t just about the environment it’s a health problem. OK.
So just remember that the way you frame things
is incredibly important to the way you engage people.
And engagement means people vote and people speak up
and it becomes a social issue not a technical issue.
So we all know that climate change damages people.
There’s no doubt about that.
And someone made the great point this morning about,
don’t let’s over-medicalise this.
These sorts of things like malnutritional cataracts or dengue fever
or skin cancer are typical ways of bio-medicalising this issue about saying,
this disease will go up, we need more health professionals to do this.
This is easy to do. We know how to do this.
And in fact it’s a dangerous way to look at it,
because you are adopting traditional approaches of past models
and you are medicalising it, you are making it into a disease issue.
We know that actually it involves communities much more.
This is what we are bad at doing because addressing things like heat wave
and forest fires and floods and extreme events,
these require people to do things together, very very difficult, we know that.
And what human beings, what we cannot do is we cannot control systems.
We are totally useless at looking at things like
crop failure and droughts and economic collapses
and migration and civil disorder, issues like Easter Island,
which you all know well.
So that fifth slide about civil disorder is what we do to each other it creates things.
Think of Maslow’s Triangle, it’s very very important.
These are the things we are trying to avoid.
And we are not doing it very well.
OK, so the time is now. We know that.
And even if 60,000 people died in Europe in 2003,
I want you to tell me how much that changed policy in Europe.
What changed? OK. One at a time. Hardly anything, OK.
Somebody in France got sacked.
We started having a heat wave plan in England.
But you know 60,000 deaths, it’s not going to change,
60,000 deaths is a statistic not a tragedy or a disaster.
You know, you would be amazed how much doesn’t change,
even with data like this. So be very careful how you frame data, very important.
So I just want to say something about the global issue.
And some of you may know this.
This comes from the Lancet Report in 2009
about climate change being almost without doubt
the biggest single strategic health crisis of the 21st century.
In a sense, you know, history books, if there are any historians left to write history in 60 years,
will be remembering the era that we live in now,
today, this week, this month, this year, as the age of the climate crunch,
more than the credit crunch.
So this is who produces the greenhouse gases.
And I’m going to show you the next slide about who bears the brunt of it.
So watch very carefully, if you spot the difference between,
this is just a cartograph which exaggerates sizes in relation to the burden.
So that’s who bears the burden.
So I will just show you that again.
Just in case you didn’t get it.
There’s that and there’s that. So you now know that.
You can’t unforget that.
So I would just put to you that that’s completely unacceptable.
Completely. And every one of us in this room unwittingly
unknowingly unavoidably has our fingers on this.
So this is not just a technical issue, it’s not even an engagement issue,
it’s an ethical and moral issue of our time,
that we are knowingly doing this. It doesn’t make it easy.
We are all concerned. We wouldn’t be in this room otherwise.
But this is of today and it is very difficult at a system level,
at a country level, at a national, international, global level,
to get to grips with what am I supposed to do about this?
So I’m not saying this is easy, but I’m saying it’s important.
So one of the things we did in the UK
and Mike Depledge said it much more eloquently earlier today,
was you have to have good science.
So you have to start measuring things.
It is not the breakthrough issue it needs to be.
But without good science, without good data,
without good surveillance, all other cases for action rest on very flaky foundations.
So that’s where you sit.
I mean I won’t go into the detail of this,
but that’s where we need to be by 2050.
Now it is not one of those diagrams that says a miracle happens here.
We can probably do this, we have the technology to do this.
Whether we have the human ingenuity to collaborate to do this is another issue.
But let me tell you, this is not going to happen through efficiency.
This is going to happen through transformational changes
in what it means to organise a truly sustainable health and care system,
truly sustainable environmentally, socially and economically.
I will tell a few final stories really about why some healthcare organisations do.
So it’s important to recognise from the psychological and the organisational development point of view
why some people take this seriously.
And it will come to you as no surprise that the first is to save money.
The second is to comply with the law.
So I will show you an example of a law,
I mean we do have quite good laws in the UK about this,
but it’s interesting that the laws aren’t used as well as they could be.
And thirdly, really to have an ethical responsibly,
to take exemplary action in the face of scientific evidence,
not just to be worthy and pleading,
but to start with the data, start with the mandate.
Data, science, research is one of the most important ways
to gain a mandate for action,
to make the case for action, to write the narrative for action.
Why don’t we do more?
Well I always show this slide in a sense to give people an excuse to sort of say,
oh, see, I fit into one of these, this is why I don’t do more.
And the first thing is, we are incredibly busy.
I always say this when I am talking to my clinical colleagues,
but the truth is, that a lot of us in this room are paid to do this.
So we are not busy, this is our day job.
But many people who have to do things
in the health and care system have got other things to do.
There are other important things to do.
And as you know we are a bunch of crisis junkies really.
We love crises but actually it’s very difficult,
when you are very very busy to know even which bin to put the dirty sharp in sometimes.
So it’s tough out there.
Secondly, in terms of health systems,
and this is a point that one of the speakers made this morning
about distinguishing between a healthcare system
which is not really a healthcare system,
it’s a very glorified repair system in a sense,
built in times when the whole disease profile
and health profile was different.
We are very good at reacting to demand.
We are not so good at reacting to need, planning or preparing for tomorrow.
Health professionals do not do the future. OK.
Get used to it. We are people of the day of the hour of the minute.
So if you want to get health professionals involved in doing a future
you really have to incentivise the idea
of being strategic about this.
And we just don’t do strategy.
Just like we don’t do prevention actually,
prevention is not you know…
funny enough when I was at medical school
I don’t think I ever went to a lecture on what causes health.
I went to plenty of lectures on what causes multifocal leukoencephalopathy
but I did not go to any lectures on what causes health.
And understanding what really health is all about
is something that we really need to get to grips with.
And health and illness, health and disease are not the opposite ends of the spectrum.
if anything they are orthogonal in the sense that you can be healthy,
you can be very healthy and be living with many diseases.
Most of us in this room would probably consider ourselves reasonably healthy,
but probably most of us are living with multiple conditions.
Equally there are lots of people with very few illnesses
who are unhealthy, unhealthy people, unhealthy planet.
So please don’t see it that way.
This is a really dangerous one about, we are doing a lot for health already.
You know the number of clinical colleagues of mine who say,
David, look, I’m too busy saving patients to save the planet.
To which my response is nearly always,
well do you think they might be connected?
But you know we all run the risk of working in noble organisations
like universities or charities or faith groups or health services
that already are doing worthy things.
And I have to tell you that most worthy organisations
tend to treat their staff pretty poorly.
And that is an indication of what Moralov said
all noble organisations is all about.
But in the health care system we perpetuate systems
that are rewarded for activity.
The Secretary of State in the UK parliament
will get up and say, great success, we have done more operations,
to which my response is:
doing more operations is as much a sign of system failure
as a sign of system success.
It won’t happen in my lifetime, I guarantee you.
Why could we do more?
Well because….do you remember that cartoon this morning?
You know what happens if climate change is a hoax
and we create a better world for nothing?
Yeah, it’s real.
You know, don’t get too…
if you start talking to people about what will happen in 20 years
you have lost it already. Most of them are asleep.
It’s about immediate gains in health and money and resources.
So I’m just going to talk about three quick examples of this:
what we eat, how we move and what we breathe.
Most people will identify with that.
So you know that one, you know,
it costs the NHS in England £9bn to treat type 2 diabetes.
You know that one, that’s simple good framing.
That’s communication.This is about saving money.
You know, what is the money saved from an active travel scenario?
A lot. Do the research.
If we had 40,000 early deaths in England due to bad water there would be revolution.
But we tolerate it with bad air.
Isn’t that weird? Isn’t that really weird?
And interestingly one of the reasons that people claim this is
the case is because we can’t see it. It’s invisible.
But how is it that radioactivity when it’s invisible is scary?
But poor air quality when it’s visible it’s not scary.
I don’t know. So some really big issues.
That’s 8 month loss of life.
So when I say to my patients, if you smoke – you can smoke,
it’s your decision to smoke, but
it’s also your decision to see your daughter get married too,
in that last 8 months.
And this is happening, people having no control over this at all.
So when we were talking about citizen science this morning,
when you get apps where young mothers wheeling their children to school,
get alerted by their app and pass that information on
and you start crowd sourcing data through social media,
you will not just get social activism you will be political activism,
which interestingly enough is what politicians react to.
So that virtuous circle for health is about more investment.
It’s about more sustainable housing, less road trauma,
lower levels of multiple preventable conditions,
more life to years not just years to life as Jock said,
less dependence on a formal health and care system.
This is based on Anna Coote.
In 2002, this was 15 years ago Anna did this work.
This is not new.
We have 200 years of health professionals speaking out on many things.
But we are not speaking out on this.
Why is it we are not speaking out on this?
Our approach in England is very simple.
Reduce harm, why?
Improve people’s control over their health and resilience.
And embed it, not just embed it in every contact,
but embed it in every contract as well.
We have to normalise and formalise these things
into normal ways of doing business.
So those are the things we are going to do.
And most of those we have done.
We have got an Act which requires people to do this.
This is a requirement. When people say, do I have to do this?
I say, well look, you don’t have to obey the law,
but you know you will get prosecuted if you don’t.
It’s up to you. Survival is not compulsory.
Embed it into quality, so sustainability in quality.
Embed it into training, so the faculty of public health
it’s embedded into, it’s a requirement.
So interestingly, suddenly a whole cohort of health professionals
become interested in this. Sadly, because it’s kickstarted by this.
So I want to finish by three examples in leadership.
Who is this? Margaret Chan, well done.
That’s very good, yes. “…climate change is the defining issue for the 21st century”.
So you need people like Margaret to stand up and speak up and say,
it’s not going to change the world but it’s absolutely required of leaders.
All leaders have got to say it.
It doesn’t mean to say we know what to do.
But you need to say this is an issue. So who else?
This is Andrew Dillon, who is the Chief Executive of NICE,
getting him to say this is really important.
There’s Sally Davis, Chief Medical Officer in the UK,
getting her to put this on her list of five big things.
But I will finish with this last person.
Does anybody know who this is? OK.
This is Eric Chivian. He’s a physician.
He won a Nobel prize.
He won a Nobel prize for forming an organisation
called International Physicians for the Prevention of Nuclear War.
Got the Soviet Premier and the US President to talk about strategic arms limitation talks.
It was motivated by a group of many thousands of physicians
around the world who were worried that the health effects
of nuclear war were not being properly framed.
But actually he said to me, listen, that was easy, that was easy.
He said, climate change is wicked. It’s super wicked.
And he told this story.
I don’t know, do you know this story?
This is about nature. This is a cone snail.
He said this cone snail is very interesting.
About 200 species of cone snails,
each of them producing about 200 toxins,
very small peptides, very toxic because they kill their prey.
Now we have investigated 0.1% of all these toxins
and already we have found two drugs, naturally occurring.
One treats intractable temporal lobe epilepsy
and the other one is a drug called Ziconotide
which is a thousand times more powerful than morphine
and is completely non-addictive.
How about that? Is that good?
That is what pharmaceutical companies
have been spending millions of pounds trying to develop.
It’s sitting in a cone snail. It is a wonderful, wonderful finding.
That’s the good news.
The bad news, in 20 years these cone snails will be entirely extinct
at the rate of coral degradation,
because they all live on the coral.
And we are trashing the coral,
we are bleaching it, we are acidifying the oceans.
This is happening on your watch and mine
and it will be your legacy and mine.
So be mindful that this is happening here and it’s happening now,
and you and I are a part of it.
So it does need leadership at every level.
But not just from the Margaret Chans of this world,
but from all of us. Thank you.
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David Pencheon, Sustainable Development Unit, NHS England / Public Health England
Delivering Well-being in the NHS