‘We must shift the dial on our society thinking about health policy’

Maddy Arden (MA): We're going to talk about how health psychology and public health might work better together. Let's start with your conception of public health, Greg, which I know is broader than some.

Greg Fell (GF): It's maybe broader than those people outside of public health think it is. I hate answering the question you get asked in the pub: 'So what do you do, then?' The purpose is health: I exist to improve health. The secondary purpose is to close the gap in health outcomes between the haves and have-nots. How long are we prepared to accept that the gap in life expectancy is 10-20 years between the best and the worst? 

We know what to do; some of the 'doing' is easier said than done, for all sorts of reasons. But if I if I had to define Public Health, I'd go straight back to the Faculty of Public Health definition, 'the science and art of promoting and protecting health by the organised efforts of society'. Each and every one of those words matters.

MA: OK, so let's focus in for now on 'the organised efforts of society'.

GF: It's not just what I do… most folk who deliver better public health don't have the term 'public health' in their job title, and I'm completely fine about that. It's a tricky thing, not being all imperialist about 'health is the only thing that matters'… people don't wake up in the morning thinking 'I want to have better health today'. They want to live the life they want to live, and health is quite important, but it isn't the end, it's a means to an end. Folk like me often forget that.

Then, the first broad domain is public health intelligence. So when someone asks 'what is life expectancy in Darnall?', some poor soul has to crunch the numbers. What is the healthy life expectancy in that part of town? What is smoking prevalence? What are good metrics for measuring mental health? So the first bit of the job is that intelligence on how healthy we are, and aren't.

The second bit is health protection, which covers all sorts of things including outbreaks of communicable disease. You may have noticed we were quite busy with one of those over the last couple of years. But there are also outbreaks of salmonella, E coli, hepatitis A… infectious disease goes in outbreaks, they're transmissible by their nature. My job in that is partly the medical detective work. 

You've got a bunch of people in hospital with E coli, where have they eaten, what's the common source that ties all of those people together? And there's a whole programme of food safety for the 5,000 or so restaurants and takeaways across our city. The law says, 'Thou shalt sell safe food', so someone's got to enforce that.

Then another part of health protection is vaccination and screening. Vaccines still save lives, and screening saves lives. My job is the orchestration of that… are we doing all we can to get coverage in different parts of town. The hard-won lesson of Covid was that if you want to get vaccination coverage in Darnall, don't give me a megaphone and tell me to stand outside the town hall, calling 'roll up roll up' as a middle-aged white bloke. Work with community and faith leaders. We learned that the hard way, and we forget it at our peril.

So that's health protection, and very occasionally there's stuff like my opposite number in Wiltshire dealt with – the novichok poisioning. What is this, how can it damage health, are other people at risk? We all dread that happening on our patch… it's just a nightmare scenario. But it could, at any moment, or another pandemic could break out tomorrow.

The third chunk is the responsibilities of the public health grant, a block of money – 33 and a bit million quid – that pays for sexual health services, family planning, drug and alcohol treatment, tobacco control, obesity and weight management, social prescribing – I hate the term, because it basically medicalises community development – and then 'Other', a vast array of all sorts of interesting stuff. For example, we're the main funder of Sheffield Citizens Advice Bureau. Why me? Well, poverty certainly matters for health.

The fourth is health improvements, which covers everything from fat, fags, eyes, not sweating enough, gambling, booze, right the way through housing, lack of access to green space, all of that. Some of those things I'm very much responsible for – tobacco for example. Some, I contribute to the party… for example, if you were really focusing your efforts on housing from a health perspective, where would you put your energy? Cold and damp in homes: I'd start with kids with existing asthma, for instance. My job is connecting medical and social together.

And finally, there's pulling it all together into a coherent strategy. We have the health and wellbeing strategy in Sheffield. The upside is it is a strategy; the downside is also that it is a strategy, it doesn't give you a detailed operating plan for what we're going to do on Smith Street in seven years' time. So the sum total of all of that is what's in public health… and that's why I hate answering the question in the pub.

MA: So what would you pick out from all that as a focus our readers might not be aware of?

We really, really try to focus our energy and attention on the structural determinants of health rather than whether or not individuals behave responsibly. I'll give you a practical example. Obesity is nearly the new tobacco: not quite, but it nearly is. I can and do provide weight management for those who are overweight and obese. It's moderately effective, at best. At the current level of investment and the current level of effectiveness of weight management services in Sheffield, it'll take me 250 years to 'solve obesity'. 

Meanwhile, we're in an environment which is saturated with fast food outlets, and advertising targeting your kids and my kids. I wonder why obesity isn't really under control? So we focus more of our energy on this stuff upstream rather than individual behaviour. The latter does matter, but the former also matters, we just need to get the balance right.

MA: I completely agree. I'm going to give you a definition from our Division of Health Psychology website. 'The goal of Health psychology is to study the psychological processes underlying health, illness and health care, and to apply these findings to the promotion and maintenance of health, the analysis and improvement of health and prevention of illness and disability'. That seems to be a tiny part of what you've just talked about, and I think I work well beyond that: what I do in the Centre is broader than that. 

But I agree with you on the structural thing. Health psychology 20 years ago was perhaps entirely focused on the individual: cognitions, intention, behaviour. I think it's shifted quite a lot. Susan Michie's had a really big role to play in that, because the Opportunity part of the COM-B model is part of the system, isn't it?

GF: Yes. 20 years ago, public health was in the same space – focused on what one would describe as a medical model, very focused on individuals at the expense of structures. It's structures that determine how we do and don't behave. They provide the incentives, and we all respond to incentives. Focus on structures is much more powerful. 

Of course, the sociologists will tell us it's both, and there's a really strong drag back to the downstream, to the more easily measurable, accountable stuff. There's a strong societal preference for identifiable individuals versus what's way upstream, like influencing policy and political processes.

MA: I've just come back from Tramlines Festival, and I know that you and your team have worked with Tramlines around the presence of vaping brands. It was remarkably different from last year, and that's a good illustration… you could have been there handing everybody an educational leaflet about vaping, but you've got to think about the structural and environmental things.

This is a problem, though, for health psychologists, and for academics generally, in how we do research. We have to apply for grants for research funding to do stuff that's under our control, which is basically only service delivery and communications. All the other policy categories, you can't do research on those in the same way.

GF: Agree. Same in public health. A huge amount of the research effort in gambling harm is about providing support to identifiable individuals. Lindsay Blank, a Research Fellow at the University of Sheffield's School of Health and Related Research, gave a seminar for us a few years ago with a systematic review of interventions. Brilliant job, but all of those interventions were about the identification of, the referral of, and the provision of treatments to individuals. 

Nothing about policy interventions, about banning gambling advertising, about systematically excluding gambling industry influence on the policy process. The whole enterprise of research in this space is oriented around service delivery and individuals. The research funders and councils need to get their head around that. I think that psychologists in your space, and folk like me on the public health side of the fence, are shifting that, but it is a long, slow process.

MA: It's one of those things… even looking at the National Institute for Health and Care Research funding, their public health scheme, for example, they want to do research into non-NHS funded interventions. But there's a massive crossover. So there's a call at the moment on smoking, but in Sheffield and most of Yorkshire and Humber you commission your services out to NHS suppliers don't you? So the research field just isn't set up for that.

GF: That's interesting. It'd be worth the chat with some of the tobacco leads on that one. I spend a million pounds on tobacco control in Sheffield. It's got its fingerprints on 20 per cent of all deaths, and 15 per cent of all illness, yet we've got 0.04% of the budget for tobacco. I'll let that thought hang for a minute. But of the million quid, half is spent on stop smoking services – a very bonafide, legit thing to do, spectacularly well valued, and has made a big impact. 

But of the remainder, about £250,000 is spent in trading standards… basically kicking doors down in the east of Sheffield, confiscating enormous quantities of illegal tobacco and illegal vapes, which we know are on sale to kids. Is it any surprise that five kids a day start smoking? And illegal tobacco is linked to organised crime: drugs trade, sex trade, people trade. So that work makes a difference, and it's a socially useful thing to do. But no-one's doing research into that space, what intervention is doing.

MA: There's quite a lot of research we're doing at the moment, which doesn't really fit into a definition of health psychology. It's about how people are engaging with services, which is an important behaviour. There are voluntary sector services, social prescribing, family hubs… but unless the people who most need them are accessing those services, they're missing the mark. That's an important space for health psychology, because we're talking about a clear behaviour there. What is it about that service that means that people aren't accessing it?

We did some research around the groups that weren't accessing the stop smoking services. One of the reasons was that it was promoted as a stop smoking service, and people didn't want to stop smoking! They're using it as a stress management method. The switch to vape, for example, is much more attractive. So there's things like that, but I think health psychologists can do a lot more.

GF: I agree. We know remarkably little about those that don't access the various services. That's just not okay. It's fairly virgin territory, so go for your life.

Just on smoking for stress management… that's an invention of the tobacco industry. Smoking as good for managing stress is a very durable myth of about 50 years now. I'm always keen to correct that one. Again, doing some research into some of those myths would be an interesting thing to do.

MA: I think what people were talking about is the experience of nicotine withdrawal, which feels like stress, so it just reinforces that cycle… that it is reducing my stress, and I need more of it.

I've really engaged in this idea we're not finding out enough about the people that most need the services. We get participants to take part in research, but are they the people that most need interventions or policies? In the behaviour change wheel – how you decide on an intervention or policies – I don't think we're doing nearly enough on equity. How do we make sure that we're not making things unequal? The 'nudge' stuff, for example, is low hanging fruit… you can shift people from 'Yeah, I might do it, I might not' into doing something. But is that actually tackling the real challenges?

GF: It hard wires inequity into the machine. I'm sure there are millions of examples in health psychology – there definitely are in public health practice – where we've actually done that. We need to reflect deeply on whether that's OK. We can shift the population mean, but if that's done at the expense of those who have least to start with, that's an ethical problem.

MA: What are your thoughts on the 'nanny state'?

GF: There's this ideology there, that it isn't the role of the state to interfere in people's lives. Well, we wear seatbelts because the law tells us to, and a surgeon once told me he could remember when orthopaedic wards started to fill up with people with broken bones who otherwise would have died in road traffic accidents. 

So the state interferes in our lives all the time. Then that narrative is also driven by commerce… multinational corporations want to keep the policy dial away from regulation of industries that sell products that harm us.

I get accused, moderately frequently, of being the 'nanny in chief'. I'll pick on gambling, because it's in my inbox at the moment. The gambling industry spends trillions of pounds on advertising every year. The purpose of that advertising is to shape consumer behaviour to encourage more people to gamble, and spend more of their money with multinational corporations that are largely offshore. And the same companies spend probably tens of millions on PR and lobbying to shape the policy debate, and a narrative that keeps the focus away from regulating an industry.

Both of those things work, massively. Who's the 'nanny', in that context?

So there is something about levelling the playing field. But there's also the purpose of my types of interventions, which is actually to give people more choice, not less. Choice in a way that's pro-health, pro a level playing field, pro an environment that is free from your kids, or my kids, being saturated with gambling adverts or fast food adverts on their mobile phones day in day out. 

Someone's got to be the architect of the world, and it really all boils down to what their intentions are. The fast food industry wants to sell us fast food. If that was all consequence free, I'd be absolutely fine about it… go for your life, guys. But it's not.

So I usually take the whole nanny state thing head on. I just don't buy it. There's a bit of ideology in there, and we're all entitled to ideology, but there are an awful lot of hidden commercial interests too. Get that out on the table, and let's talk about it openly. People don't like being manipulated for profit, but that's what's happening. Sorry. You got me on my soapbox!

MA: My take on it is that if you start talking about the nanny state, it assumes it's a neutral environment to begin with. It's not. The bad guys of behavioural science are trying to get you to spend them your money on stuff that's not good for you, and we need some good guys to come and do the opposite!

GF: They've got a load more money to spend, they outgun us, they will do it every day. So there's a point about being smart, bringing the public with us in that whole nanny state debate. They'll realise being manipulated for the profit of multinational corporations is not generally a good thing. I take my kids to McDonald's, I'm happy to admit I'm fine with that. 

But I'm not OK with my kids' mobile phones being saturated with junk food adverts every second of the day. A friend of mine characterises this as a sort of a David versus Goliath type of battle, but David won that battle with a few very carefully aimed shots.

MA: Do you think that plays out in other areas? For example, you mentioned vaccination and getting that out into communities. There are reports now of mumps, measles making a comeback, and there's clearly an anti-vax movement on social media. How do we manage that?

GF: There's always been an anti-vax movement on social media, and it even predates that. There's always been fear and mistrust of things that you put in your body. It did go on steroids during the pandemic, and social media amplified it. That had consequences.

Vaccination saves lives, period. The clinical evidence on that is so overwhelming. And there's a really good mechanism for ensuring the risk benefit profile for vaccines that we use in this country. The Medicines and Healthcare products Regulatory Agency (MHRA) has served us very well over decades. Let's be clear with people, vaccines come with side effects. All medicines do. Let's be open and honest and give the data in as human a way as possible. I always argued against vaccine mandates, and I think I still do. Vaccinations are medical intervention and the process of informed consent is absolutely fundamental. My personal fear is that vaccine mandates ride roughshod over that, and feed the mistrust a little.

MA: What would you say to someone point blank refusing vaccination?

GF: An eminent public health leader once told me, don't go toe to toe with outright anti-vaxxers. Because it's about belief. I can't tell people what to believe. It will just create an awful lot of noise, heat on social media, and then more people get confused in the crossfire. So I try to spend most of my time making sure that our systems don't leave people behind. 

Vaccine coverage in Sheffield might vary from 92 per cent in some areas, to more like 50 per cent. That's where the outbreak is going to happen. So are we doing all we can in those areas, and making sure that primary care is doing what it can? Are we working with and through community leaders and our clinicians?

MA: That rings true. During the pandemic, we did some research for Public Health Wales, and one of the Welsh medical boards. It was originally about getting front-facing NHS workers to uptake the flu vaccine, but it turned into flu and Covid. In that group, there were very few 'anti-vaxxers'. But there were lots of people with concerns. As soon as you sort of start mandating things, people lose the opportunity to have conversations.

One of the areas where health psychology can really contribute is how to have those conversations. At the beginning you mentioned the 'art and science' of public health: I think the art of health psychology is about the way in which you have conversations. Reassuring people about their concerns, but not with a 'you've got that wrong' waggy finger… really listening and hearing people, and then offering the evidence base.

GF: Do you get accused of being finger-wagging? People outside of my field characterise me as 'finger wagger in chief', even though it's a long, long time since I've done any finger-wagging. Do you get the same in health psychology?

MA: I do think that practising psychologists are often using the principles of motivational interviewing and person-centred approaches, doing lots of training with lots of groups, and perhaps we're always quite surprised that actually, it is a bit telling people what to do. It's a function of problem-solving professions… they really want to jump in and sort of solve a problem. From the other side, that can feel a bit finger wagging.

We've been doing some work around active travel in Doncaster. Trainers' first instinct was to tell people how brilliant cycling is – 'why on earth wouldn't you be cycling?', etc. But that's not going to persuade your average person to jump on a bike. You need to understand where they're coming from, what their concerns are, and do lots of listening before you can offer that advice.

So yes, we have to be wary of wanting to help and to get to the solution before we've actually understood the problem. People come and say, 'right, we want to develop an app'. Do we know if we want an app? Do people look at apps? Lots of the work we do is 'hold on, stop. Let's go and work out what the problem is, first, what the barriers are, and then it might be an app that works, but it may well be something completely different'. We need to go backwards first.

Greg, you've talked about what you term 'fags, booze, pies, lack of sweat'… what else do you worry about?

GF: Maybe it surprises people when I list four things. Firstly, I say neoliberal economic thinking and ideology – privatised profits, socialised risk and concentrated wealth and power, that creates inequality in health and access to life chances. That takes me into a really difficult space, but that hole is the principal risk to health. 

Secondly, for me, is the commercial actors influence in determining health policy. I'll pick on gambling again: our policy is determined by actors with a vested interest in maintaining that status quo.

Thirdly, the state of finance itself. The local state is 50 per cent smaller than it was a decade ago. We spend less on housing improvement, we spend less on active travel, and we spend less on interventions to get people into parks and green space… which we do pretty well in Sheffield, but we do spend less on it. That determines health. And that's one of the reasons why life expectancy is now flatlining.

Fourth, what sociologists call the hegemony of medicine. Back to the individualisation and the medicalisation of health. Health isn't the NHS – it's the sum total of what happens in society. But our health policy nationally is hardwired to think that health equals the NHS. The NHS is brilliant, really valuable. It fixes people when they break. But it ain't going to be the answer to better health. The answer to better health is still way upstream of the NHS.

So that's my take on the big risks, and that influences how I do my day-to-day practice.

MA: Do you think the new integrated care boards will have any impact?

GF: Unknown, too soon to tell. I'm on my 9th significant reorganisation of the planning footprint to the NHS. It may or may not lead to more effective and efficient planning of the NHS. But to be really impactful, it's got to address the burning platform that is primary care. The health care system has neglected the massive epidemiological shifts over the last four decades or so, from single illness to multiple illnesses all at the same time: co-morbidity. 

The NHS hasn't kept up with that. We've invested our money and our workforce in acute and single specialty. So the acid test is a meaningful impact on primary care, because if that falls, the rest of the NHS falls in 15 minutes. It's like the heat sink on your computer… you might not really know about it until it's blown, but then you're going to know about it really quickly, and you're going to be on the phone to IT. I don't know who IT is in this context, but we do need to make sure that doesn't break.

MA: So to finish off, what would be your ask of health psychologists?

GF: Continue down the trajectory that you and other leading psychologists have set in terms of the shift in where we put our energy and emphasis. Focusing on that Opportunities bit of COM-B. Have we engineered our academic research and intellectual firepower, of which there's plenty, towards the opportunity that enables the right behaviour.

There's also something about who we are trying to influence in all of this. Yes, it all boils down to individuals, but also those responsible for the leverage points and the big structural shifts. We must shift the dial on our society thinking about health policy. The more we refocus our energy on individuals, governments are less likely to propose system-type solutions, and individuals are less likely to try and hold governments responsible for systems solution. Shifting that dial will give a massive leverage point and I know that health psychology is pushing pretty hard in that space.

MA: Yes, I completely agree. As we've said, the structures do somewhat limit that…

GF: So influence the structures as well. Work with the funders, the research councils, our universities, to get them to think in different ways. Donella Meadows wrote about leverage points in complex adaptive systems. The least impactful was willful interventions to focus on individuals. The most impactful was changing the way that people think. 

One of our jobs – yours and mine, but with slightly different spins and spheres – is changing the way that people think. And it's this sort of control. Controlling the narrative – the framing of our problems and our solutions – is a really important thing. It takes you into some difficult space, the policy and political space, but that's where the business end of change probably needs to be.

Photo of Greg Fell: E. Taylor