Thomas More described an ideal world 500 years ago in a book whose title has now become synonymous with an unattainable state of perfect society: Utopia. It is an odd book, written by a Catholic but describing the renaissance debate about a rational society. Utopians have easy access to divorce and euthanasia, and the priesthood is open equally to men and women.
Utopia subsequently begat dystopia, which is a generic term for a collection of familiar works of fiction encompassing environmental apocalypse, police states, the rule of robots, societal breakdown and even (in the case of Huxley’s Brave New World) a state of such perfection as to be nihilistic.
What both genres have in common is that they obsess about a different future. But we live in an age when it is widely perceived that it has all gone horribly wrong already and we no longer have the luxury of speculating about the world of tomorrow. When people start talking about twelve years to save the planet from catastrophic climate change, potentially apocalyptic antibacterial resistance, air quality that is actually killing people, and expectations of life where the curve has dropped back rather than continuing to rise, the NHS and its partners have to start resolving the problems that we have now and not wait. Because all of these things have something in common: they are about our habits and the way we live and the priorities we set in response to public health crises.
Take for instance research published in May of this year – “Cardiovascular disease burden from ambient air pollution in Europe reassessed using novel hazard ratio functions” – which concludes that “the health impacts attributable to ambient air pollution in Europe are substantially higher than previously assumed”. Netflix aren’t going to make it into a series (although if they did they would probably call it Choking). Similarly the “Continuous Mortality Investigation (CMI) Mortality Projections Model, CMI_2018” (not yet starring Brad Pitt in a reprise of his Benjamin Button role) last month concluded that UK life expectancy growth has stalled and possibly even started going backwards. Lastly the Institute of Fiscal Studies has just published an evaluation of the Sure Start programme which concludes that it has been effective in some areas of policy (reducing hospital admissions) and not others (there is no evidence it has impacted on obesity or maternal mental health). Unsurprisingly Sure Start is deemed to have become less effective due to funding being reduced by approximately a third (from £1.8b to £1.2b nationally).
Personally I am an optimist; I believe we can address these and other challenges, but we must do it in partnership. Here in Surrey the County Council has declared a climate emergency, the cabinet member for environment pointing out that “Climate change is not just about the environment. It is about communities and jobs”. Public policy is now much more widely linked to health outcomes. There is a whole section on air pollution in the NHS plan and a commitment for the NHS to work on reducing this and the consequent burden of respiratory disease.
This is where Integrated Care Systems need to focus their efforts and help Integrated Care Partnerships and Primary Care Networks see the bigger picture. Large hospital Trusts can show leadership on carbon targets, as Jackie Daniels is doing as Chief Executive of Newcastle-upon-Tyne Hospitals NHS Foundation Trust with a pledge to be carbon neutral by 2040 (along with, it should be noted, city partners Newcastle City Council and Newcastle University who have recently made similar commitments).
If young people are genuinely galvanised into action by climate change we should capitalise on this energy to get them to change their behaviour and have an impact on areas such as the use of public transport and walking. They in turn can argue persuasively with their elders (who are often not their betters in this area) and have a still greater impact on behaviour of whole families and communities. If “place” means anything it means building community capacity , keeping the affordable greengrocer and lowering air pollution using traffic calming.
George Bernard Shaw called independence “the middle class blasphemy … We are all dependent on one another, every soul of us on earth”. We need to realise that when it comes to improving population health we are genuinely all in this together, whether it is parenting, air pollution, mental health, eating habits or alcohol use. This year may well be remembered as the one when we realised that there are no utopias or dystopias, only the here and now and the opportunity to make it better collectively.
Welcome to Thistopia. It isn’t great, but we can make it better.
Dr Claire Fuller
Senior Responsible Officer, Surrey Heartlands Integrated Care System