Abstract
Lord Nigel Crisp has written a thought-provoking, highly relevant yet practical book on health and healthcare post-2020. From his vantage point, in the House of Lords and as a former head of the National Health Service (NHS) in England, Crisp provides a unique view of emerging health problems; what is working and what needs to be done to manage health demand after the pandemic of 2020. Taking a big picture view of health, he has examined how to create health in communities. The solution is broader than conventionally thought, encompassing more than the diagnosis and treatment industries.
As many have quipped, 2020 is providing the world, and particularly the health sector, with unprecedented clarity of vision of our systemic weaknesses. Lord Nigel Crisp argues that health services, including the NHS, cannot deal with many of today’s major health problems—obesity, loneliness, stress, poverty, and addiction. The health system was designed to deal with yesterday’s problems he states. Now “with our world disrupted by the pandemic, is the right time for us to act” to build health in the community. He argues we all have a role to play in health creation by learning from the health creators outlined in the first half of the book. Technology also has a significant role to play in effective health creation and improved health service delivery. He recommends governments partnering with health creators, social enterprises building community strength across the nation, and with researchers in disease prevention and effective health service delivery.
Accepting that the health of each city is only as resilient as their healthcare system, COVID-19 has highlighted the significance of Crisp’s approach by showing the converse is also true as “…our healthcare system is only as resilient as the city or community it serves.” The publisher Marc Sansom argues, COVID-19 “may finally bring about more joined-up, collaborative thinking across the public and private sectors and community” for health.
Crisp looks at health at the citizen level prior to people become patients. Crisp finds that healthy individuals depend on healthy communities. Crisp identified that where the informal community systems are strong, they take the strain off the formal health system, but where they are weak, the health system experiences unmanageable pressure. The pandemic has shown that health systems and communities are interdependent and only as strong as the weakest links. Austerity measures in the UK have shredded the social and health infrastructures. However, health is being created in unusual ways.
Crisp notes that health is created for individuals in the community. Conspicuous success has been achieved by groups addressing mental health, stress, and addictions in workers in London’s financial district through the City Mental Health Alliance and corporate training for Mental Health First Aid. The camaraderie built in grassroots organizations for food security, DADZ groups, and men’s sheds have addressed loneliness and isolation in disadvantaged communities. The health, economic, and social benefits of programs for disadvantaged children were found in innovative community-based actions. The Scottish daily Run-a-Mile program for junior schoolchildren and staff has lowered obesity and improved well-being and learning. The examples demonstrate that schools can be places for health creation providing lifelong benefits.
At the other end of the age spectrum, the negative concepts of aging (e.g., the societal burden of those over 65) are challenged by dynamic innovators organizing to live full lives while continuing to help others. Brilliant examples of cancer support through the Maggie’s Centres and community palliative care demonstrate the effectiveness of community-based partnerships with the formal system. However, an absence of health creation in disadvantaged communities has led to a 20-year earlier onset of major illnesses for ongoing management by the NHS. Crisp argues that the alternative of health creation models extended to at-risk groups can provide powerful benefits including reducing demand on hospitals.
Harnessing the power of design and the environment to improve health is revealed through movements like Horatio’s Garden. The approach is summarized as “First life, then spaces, then buildings—the other way round never works” quoting Jan Gehl. At a time, when the quality of the home and local environments for health has been of greater importance for people in lockdowns, Crisp finds that new government regulatory action to ensure a better standard of housing is required. The hospital costs of substandard housing are estimated to be £1.4 billion each year. Reflecting on the 19th-century exemplars like the Bourneville village and the later Garden City movement, he cites considerable evidence to link good housing, good design, and good health.
The need for a more sustainable future for health has also been made evident by the pandemic. Crisp considers the positive effects of improvements in housing and changes in service delivery and working environments. Technology enables more local digital manufacture and remote service delivery through telehealth, wearable sensors, artificial intelligence, genomics, and other advances. Local food supply initiatives have also supported healthier communities, including in highly urban environments. Successful social enterprises ranging from the internationally successful the Big issue to local Sewing rooms have achieved impressive results empowering people to positive mental health and physical health improvements.
Crisp’s experience underpins bold thinking to take health systems forward from the traditional “public charity” approach to health to systems that effectively support successful societies and economies. Crisp signals a sustainable health system as one that enables and empowers health at the individual and community level, displays the benefits of multiple examples, and foresees strong, supportive health-giving environments with “hospitals for repairs.” Through illuminating conversations, Crisp advocates practical approaches to sustainability which can take health to a new level. Importantly, he advocates addressing health at the citizen rather than the institutional or state level.
Taking an international view of approaches that improve health, Crisp describes European and African successes. Analyzing the superior health achievements of the Scandinavian countries, Crisp identifies that the approach to health is fundamentally different from the UK experience. Better life expectancy for Scandinavians has been achieved through research and deliberate consistent government policy aiming to improve health dating over 50 years. Recognizing health is created in local communities through individual interventions, Crisp cites numerous significant achievements in disease eradication, prevention, and community health building. Unleashing the power of nursing is key to successful health and bottom-up advocacy for health creation he argues. He builds a vision for a global center for creating and delivering health.
More effective care of health is neatly detailed in the penultimate chapter drawing on the big ideas unpacked in preceding chapters with 10 big achievable ideas. The actions to change the NHS from a top-down, resource-constrained, episodic illness based system are clearly and thoughtfully outlined in the final chapter. Crisp concludes that contemporary problems in healthcare require a less rigid, more flexible, devolved approach both to health creation and for the treatment of illnesses in hospitals.
Crisp offers a progressive and coherent set of options for change. His message and strategy are aligned with the substantial work of Sir Michael Marmot on the gaps in health services and the more clinically focused Darzi Review (Darzi et al., 2018; Marmot, 2015). His approach addresses the determinants of health and issues of inequality by calling for a radical change to the way health is conceptualized and delivered. He argues that health needs new measures of success rather than just recording the business of illness. Crisp shares conversations with leading figures who predict the pandemic will profoundly affect the outcomes governments seek and the ways that success is measured. Better societal outcomes, including enhanced health status, are expected to underpin economic recovery across the world. And Nigel Crisp has a plan.
The book concludes with the glimpses of the future-shaping healthcare responses and the potential for future healthcare to be freed from the limitations of the past. Crisp challenges us to consider the bigger picture to actively seek to improve health for our communities, particularly the most disadvantaged communities. The economic benefits of a healthy community have never been clearer than during the pandemic. He argues that our health and hospital systems of the future depend on our investment in our local communities and developing health strategies for people, not merely patching up the problems. At this critical moment, Crisp’s book addresses some of the key issues faced by many health systems and is well worth obtaining and reading.
