Around the world, cities are increasingly concerned with not only protecting, but also improving the health of their citizens. This is driven by many factors, the link between a healthy population and economic success being one of the most politically compelling. Closely linked to this, health inequalities/inequities are recognised as barriers to cities achieving their potential. This concept has gained traction with a broad range of politicians and policy makers, even if the breadth of factors and levers to achieve these goals are perhaps less well understood. What is clear is that the delivery of a healthy city requires the involvement of agencies beyond the traditional, narrow, understanding of those which deliver medical services. We all regularly hear and chant the mantra of needing to end silo working and the virtue of adopting holistic approaches.
Since 2012 City Health International has provided a space where a broad range of agencies and cities can showcase and discuss innovative projects. This has provided a rich environment to allow for consideration of the diverse issues facing our urban centres. Many participants have clearly valued the opportunity to hear views of those with differing specialisms and perspectives. Some have found it challenging to have the norms of their own disciplines or professional cultures questioned. On occasion there has been visible discomfort, but I strongly believe that this level of challenge is necessary if we are going to develop the ability to look at problems and their potential solutions in the round, to develop the horizontal, cross cutting approaches that are essential in maximising available assets and resources to deliver the best possible outcome for our cities.
Professional and philosophical silos are comfortable places to inhabit. They provide structure, certainty and security. This links to peer support, increasingly narrow specialism, hierarchy and career structure. Let me pause a moment and make clear that I am not criticizing specialists or experts- they are vital. Especially, for example, if I am going to be the beneficiary of their hard- won expertise. But all this can make it hard to look at broad, big picture issues. We don’t want to diminish expertise; we need to think of ways to mix it up, to potentiate it. Easier said than done when structures and funding often encourage silo-based approaches.
Yet there are many good examples of experts knocking holes in the walls of their silos, reaching out to collaborate and identifying new approaches that meet the needs of people and areas. An example of this kind has been produced by the Guy’s and St Thomas Charity which works closely with the hospital of that name in South London. I apologise for being London centric again but it’s where I work, and I think the example is applicable elsewhere.
Their recent report From one to many looks at the experience of people with multiple long-term conditions in two London boroughs (Lambeth and Southwark). It is, to the best of my knowledge, the first report of its kind. From the beginning it challenges common preconceptions, not least in that long-term conditions are not just an issue for older age. It raises the issue that a narrow focus on a specific condition or disease may not provide a good understanding of an individual’s experience. It provides further, in-depth evidence of the impact of social context, ethnicity and economic background. It is presented in a manner which combines expertise and accessibility (the interweaving of personal stories with population level data is very effective), sound research and impactful graphics.
A chart that illustrates the average age of diagnosis for a range of conditions highlights the importance of mental health issues and their interrelation with physical conditions. It highlights co-morbidity in a highly effective manner, placing diabetes very much at the centre of health concerns as regards long term conditions. It does a great job of corralling risk factors. 96 % of people with long-term conditions in Lambeth have more than one associated risk factor (e.g. hypertension, alcohol consumption, obesity, high cholesterol). Not that surprising, I grant you, but do we reflect this in how we commission and deliver services? The report highlights the amount of medication prescribed and the benefits of social action. It also raises the potential of learning more from examples of positive deviancy. What are the factors that allow certain groups and individuals to overcome challenging situations or thrive better than their peers?
The report ends with questions, it doesn’t pretend to provide a menu of answers. Those seem most likely to be found when we escape the comfort of our silos and engage with colleagues from other spheres in the communities we work with. It may not always be comfortable, but it is likely to be rewarding. City Health International provides a valuable forum to develop this thinking.
If you have examples of research or experience from other cities, please do send me links or an outline via City Health International.