Angela Raffle is a founder member of Transition Bristol and a public health worker in the city. She was one of the people that produced the Bristol Peak Oil Report. But her experience was that because the government says that fossil fuel depletion isn’t a concern, the NHS finds it very hard to act on the issue. Since 2010 her focus has been on finding ways to bring the public health message and Transition together in issues as diverse as transport and food, with varying results. As part of our month on ‘Transition and Health’, we wanted to hear her thoughts on the challenges, and the opportunities, of seeing Transition as public health.
Where are the largest areas where energy consumption can be reduced within the NHS do you think? Where are the places where it could make the biggest impact quickest?
Procurement is the big one, and a big chunk of that is pharmaceuticals. That’s the entire pharmaceutical industry, in terms of the drugs, the packaging, the whole advertising schamoozle that goes behind it, flying people all over the world to conferences. It’s a very difficult one. Some of the pharmaceutical companies are taking it seriously, but we’re in this situation with the NHS that it’s a very politicised institution, it’s bound by government policy, and economic growth and jobs in the pharmaceutical industry are more important to the government than human health in a way.
Per capita the carbon footprint of the NHS is probably about half a tonne per head per year. If you gave people the choice "would you like to fly less or give up your entire entitlement to the NHS?" they’d say actually "I’ll fly less". The NHS can reduce its carbon footprint a lot.
How do you characterise the pressures that the NHS finds itself under at the moment?
I see health as wider than the NHS. Health is an outcome really, and everything that the Transition movement is doing is good for health because it’s about clean water, clean air, good food, safety, security, connection with nature and towns that are liveable.
The NHS is a delivery mechanism for a huge and complex range of different forms of care. At the moment it’s a very difficult environment to work in because it’s going through enormous structural changes and the 2011 Health and Social Care Act which led to the 2012 Health and Social Care Bill has really fragmented the NHS a lot. It’s become a really heartbreaking field to work in, to try and get unified change.
In theory we’re looking at discussions around public health which seem to open up the potential for local food, the idea that hospitals could become more like market gardens or looking at things like where food comes from. Local food as strategies for public health seems to open up some interesting avenues that weren’t there before, do they?
Yes, it’s a really fruitful area of work. The big North Bristol NHS Trust which is Southmead Hospital is the first hospital in England to get Silver in the Soil Association’s Food for Life catering award. That flowed really from quite some years back when Prince Charles ran some May Day events. The Chief Executive of that large organisation was at one of his events and came back saying to her catering managers "how do we do this?"
They’ve worked really hard at it. They’ve built a new hospital and put kitchens in. Nottingham Trust is also similarly done really well, though I think that there’s been recent changes to their catering contract so some of that work has taken a step backwards. It’s about having enough people in the right places within the NHS organisation who see that even though it might cost a few pence more per head per meal, that price is worth it because it’s better for health, it’s better for the environment and better for local businesses.
Public health was recently moved out of the NHS and into councils. Why was that and what difference does that make to what you’re doing?
In some ways it made no difference to what I’m doing because I was already working with local government on transport, food, planning, built environment, that kind of thing. It hasn’t only moved public health into local government. It’s also created new organisations, NHS England and Public Health England, so at the moment public health people are saying, where is everybody? Half our colleagues are in organisations and we don’t quite know where they are, everybody’s in new jobs.
It’s my 13th restructure in my career in public health. It’s immensely diverting because of the amount of paperwork. It’s like getting a divorce, knocking your house down and rebuilding it all in the same go. The links in local government are good but the funding cuts in local government create challenges.
Clinical Commissioning Groups, on paper at least, could potentially have a role if you had the right people in those, of really driving the process of local procurement and investing in on-site renewables and so on and so on. Can they do that, or is it a rather naïve interpretation of them?
They are very stretched, short of skills, criticised daily by politicians, and under threat of judicial review for any decision from people who quite understandably want to throw a spanner in the works with the current reorganisation which they see as simply selling the NHS to the private sector. The Health and Social Care Act had clauses and phrases within it which changed what’s at the heart of the NHS. When the NHS was established, its system aim was to deliver care fairly, free at the point of delivery universally to everyone no matter who they were.
The 2012 Act changes the duty of the Secretary of State to make sure that happens, so that healthcare becomes a commodity now. It won’t happen overnight but I’m just trying to be really honest with you because it’s only a matter of time before the NHS is just a brand and behind it are a lot of large multi-national organisations. So clinical commissioning groups, many of them are doing wonderful things, and people within the NHS have a strong culture of caring about not just personal health but community, the health of the whole community, the health of the whole ecosystem.
They are doing what they can and the NHS Sustainable Development Unit headed up by David Penchon [who we will be interviewing here next week] is helping them as much as they can, but there are also these other forces. It’s familiar territory to you – to us – in the Transition movement because in a way what the Transition movement is doing is setting up new prototypes that work at a local level irrespective of what’s going on in the big multinational corporations. In a way health will start doing that. We’ll start seeing community-owned companies saying "this is really fragmented, we’re going to set up to take over community care for old folk" or whatever.
There are already big links. There are GP practices in Bristol which allow people to grow fruit and vegetables in the land around the practice. There are all sorts of visionaries. All I’m cautious about is any massive top-down led approach saying resource depletion and the environment mean we should all do this.
What would be the best way for community groups, Transition groups listening to this, to support their local health institutions in this kind of shift? What would this kind of shift look like if it was working in the kind of way that you’d like to see it working?
One of the strongest things is people who work in the health sector participating actively in Transition and those who don’t work in the health sector and who are aware of some of the issues we face extend a hand of friendship to people in the health sector and recognise the constraints that health sector workers are under.
This is the same across so many spheres. Every time I hear someone criticise the NHS my heart sinks because I take it personally, and I have to tell myself "no I mustn’t take it personally". The NHS is very large and everything you say about it is probably true somewhere. So just forming those connections at a local level and seeing where it leads.
If you were to be able to wave a magic wand, if you became a Health Secretary of State tomorrow, what would be the three key things that would need to be changed in order to make the NHS more resilient, playing its part in terms of climate change and peak oil and so on?
I would want to see an honest appraisal of resource depletion and its impact on the health sector. I would commission that straight away. Because without that, it doesn’t matter how many people in the health sector are saying "the way we’re evolving our new models of care are less and less resilient and more and more resource intensive". It doesn’t matter how many people say that at a local level. The driver from the top becomes you can’t talk about that, there is no problem with energy and resources. So number one I’d commission a review from people who are independent of government and could look at the evidence and say what they felt they needed to say.
Number two, I’d reverse the key clauses in the 2012 Health and Social Care Act so we would still have a nationwide system committed to delivering care fairly and according to need.
Number three, I would put into the requirement for every health sector organisation clear measures that are about their transport footprint, their food procurement. Probably those two. The NHS has been good on energy use in buildings, but they haven’t really had any legitimate emphasis on their impact on transport and their impact on food.
I’d also want to invent what India are doing which would probably be quite hard legally, which is to have our own pharmaceutical industry that looks at using the simplest medicines and the most important medicines instead of this endless pursuit of more and more drugs that do less and less good.
So would I be correct to summarise that if the inspiration was to spark within the NHS there is quite a lot the NHS can do but the difficulties come with the procurement rules and the restrictions from the top down as to the degree of freedom that individual hospitals have?
I think you’ve really hit the nail on the head there. Once a year everyone in the South West gets together and we have a really brilliant residential school at Dartington, and we ran a session on contentious issues and used the example of fracking. Everybody at the workshop tables were asked to say if they were producing a health report on the impacts of extreme energy extraction what it would look like, and if they woke up in the future and the public health movement had done everything they could wish for what would it be like. Everybody came to the conclusion that big picture wise, from the public health perspective we shouldn’t even be thinking of extreme energy extraction for very many sound reasons.
In contrast, Public Health England were given a brief to say, in effect, we are going to do extreme energy extraction, please see if there is any evidence that this will cause direct damage to human health. Of course the answer to that is there isn’t much direct evidence yet. But that’s not the question we want to ask, so when you say the freedoms people have within the system, to take those big picture questions the freedoms aren’t really there. It doesn’t mean people can’t do a lot, we can do a lot but we have to be a bit creative about how we do it. And as you say, you have to join health and sustainability. They’re like twins and you do it on that double argument.