In the final part of his blog, Felix relates his post-conference fire-side chat with Sir Michael Marmot, and his lasting impressions from his time in Singapore
On day 4 of my time in Singapore, I am busy updating the Coastal team via WhatsApp and shopping for souvenirs for them as a token gesture for being the lucky one to get invited. We have also established a busy WhatsApp group between visiting speakers in Singapore and have been dining together in the evenings (yes, the Merlion and the lights at Marina Bay Sands are impressive, if a little Disney). We practice what we preach and hugely benefit from the peer support, seeing the conference very much as a social prescription, and trying to find volunteers to host the next conference.
We await Sir Michael Marmot’s presence with anticipation, and he does not disappoint, while spending most of the day after his Q&A tucked away busying himself in a sound-proof box just behind a screen mounted behind the speaker platform (we are not sure and slightly paranoid whether he might have been listening in to the panel discussion, and my afternoon session on evaluation). He has a point in being slightly dismissive of social prescribing being ‘too individualist’. Having initiated embedded research projects in both children and adult social care, I agree that it takes a HEALTHY village to raise a child more than it needs social prescriptions, or another mindfulness null-trial. I acknowledge the importance of play as a fundamental right, as embodied by the wonderful Tanny Stobart, one of our many community partners and the work she does with Play Torbay. One only wishes Sir Michael would have engaged with the international panel which was so skilfully chaired by James Sanderson, to learn about the nuances and the potential of social prescribing as a force for change.
There is considerable banter about the missing fireside for the chat, and to a very select audience of around 40 senior SingHealth staff, policy makers and academics. Sir Michael makes a very convincing argument for Singapore being an ideal place to become another Marmot Community. He mentions the idea of ‘proportionate universalism’ all along the social gradient, as opposed to targeted support, and explores the Marmot Principles as policy objectives at length – by carefully scripted prompts:
1. giving every child the best start in life
2. enabling all children, young people and adults to maximize their capabilities and have control over their lives
3. creating fair employment and good work for all
4. ensuring a healthy standard of living for all
5. creating and developing sustainable places and communities
6. strengthening the role and impact of ill-health prevention.
He is full of engaging anecdotes and is at his most entertaining when he goes to, likely well-practiced, George Bernhard Shaw’s Pygmalion, gleefully enacting the full exchange of Prof Henry Higgins and Doolittle (“I am one of the undeserving poor”). He talks empathically of his successes with high-level activism through chairing various WHO commissions in countries across the region (going through the doors open to him and where invited only), and acknowledges the WHO delegation from the Manila office present and their implementation efforts. I am left a little depleted as I sometimes feel I don’t have a choice but to bang my head against closed doors trying to make local change both within academia and services. He is surprisingly humble, jokes about the narcissistic nature of communities using the Marmot label, calls himself an impostor, and tells me in the Taxi on the way to the closing Gala Dinner about Maggie Rae at Bristol just having signed a contract to roll-out Marmot Principles across the Southwest. There is hope.
I have not heeded my Borneo mate’s advice of not trying to be too clever in my workshop. I am not sure how well the prop of socially inscribing and passing around a freshly minted, uncirculated £2 proof coin goes down. The inscription on its rim ‘standing on the shoulder of giants’ and the tenuous link to the scientific revolution since Newton, and Aristotle’s Eudaimonia (Human Flourishing) was meant to be a segway to the ontological underpinning of social prescribing and the paradigm shift required for its evaluation…anyway, CEO Margaret Lee graciously accepts the coin in-lending until we meet again (officials are not allowed to accept gifts), as a reminder of the social prescription it represents, the importance of virtues, and that money can only buy so much. They love the massive amounts of data I present, and everyone is tired at this stage. I am delighted Kate Mulligan finds the energy to tweet on my behalf, emphasising that simply counting goals and process data might just be a more powerful and easier outcome to collect (as opposed to impossible, traditional trial designs): https://twitter.com/KateMMulligan/status/1597486151673450496?s=20&t=4nTPPUCfOhGjf0lAlwAQtw
The day ends with dinner in one of the finest Shanghainese diners in Singapore – incredible food simple strong flavours and with the swivel table making this interactive surrounded by the SingHealth Community Hospital Senior Leadership Team (COO, Deputy CEO, Chief Nurse, Director Allied Health). I encourage the COO, who is an Occupational Medic and gets it, to do some ethnography and observing the changes if at first clinical encounter he were to inquire about his patient’s family and work. When saying good-bye, I tell the lovely chief nurse that the Torbay CEO is a nurse, and that she should keep the doctors in check – we all laugh. Saying see-you-again-soon to CEO Margaret Lee and her chairman, I am inclined to hug her but bow and smile a lot instead (wondering what they talked about with Sir Michael at the next table over…). I am double handed (using two hands is a sign of respect) offered my final business card of the visit by the chairman (there is quite a collection of them, with hopeful future opportunity – I should have paid to have some printed myself).
The hangover – So what?
I am buzzing and digesting on my 29-hour journey back and looking forward to seeing the family again. I seem to have missed the best week of swells this winter, and acclimatise back to the UK hitting the surf that first day back, 4C air- and 12C water temperature, balmy loving embrace of mother nature. These are the takeaways for me:
1. The virtues of embedded research and social prescribing: To be impactful in anything you do as an action researcher, you need to practice what you preach. If significant amounts of implementation research evidence suggests that traditional research products do not get implemented directly, that tool-kits by themselves don’t work and that academics should be more embedded, hands-on, and immersing themselves in the local contexts of a permacrisis of public services in the UK, then it is our moral obligation as public servants to fulfil the anchoring role of Universities in partnership with local public services. After all, the experience of the conference itself and the authenticity which all speakers displayed is that this is about all of us and the whole population, as those who give/care and receive – it is fundamentally about belonging.
2. The methodology: the blog above shows that everything is data, any change be it at service level, organisational, or societal is about reaching hearts and minds – i.e. combining storytelling with numbers. Implementation and Impact are inextricably co-dependent, there is such value in researching the process as value beyond traditional impact assessments prioritising numbers and Randomised Control Trials, and to build on and using existing system data and naturalistic designs instead (watch this space for our recently started work on linked data sets and Population Health Management programmes in Devon). I am delighted and excited that the recently started NIHR Study by Paul Wilson seems to do exactly that, watch this space for a paradigm shift. We also discussed the potential of Social Return on Investment analysis (SROIs), and my bet is on Kate Mulligan to have a go as we need these desperately to make the wider point around systems intervention while also pandering to the existing paradigm. The conference has also shown that you can have two different types of wellbeing coordinators of the same label in different parts of the world, with some core active ingredients that are similar, while allowing for local variation and adaptation. As Trisha Greenhalgh put it, we need to stop saying generalisability and talk about transferability instead.
3. Earth-People-Systems view: I was struck by the nuanced discussion with Sir Michael Marmot who pointed out that health and health care are often conflated (and that we are myopic towards hospitals and GDP). I was heartened to learn that Sir Michael was approached by Legal&General, managing £1.3 trillion in assets. It slightly dwarfs ambitions for immortality (that can be explained by Terror Management Theory, or the pickled shark: ‘The Physical Impossibility of Death in the Mind of Someone Living’; Damian Hirst, 1991) by the likes of Elon Musk around effective altruism, solutionism, long-terminism, and pro-natalism. I firmly believe that true legacy comes from the people we really touch during our life-course and who will remember, and not from how much we are cited or how much grant-funding we brought in as academics. I see an opportunity that human flourishing in its widest sense, the wider social determinants, and Equality Diversity and Inclusion can all unite under the social prescribing umbrella. I look with hope and anticipation towards a future where these complexities can be measured in interaction with our environment through neuroscience, looking towards models like ‘body budgeting’ (Lisa Feldman Barrett), power and social behaviour (Sukhvinder Obhi), and attachment (Louis Cozolino). We owe it to our children to get our heads around this planet as one self-regulating system (Gaia, James Lovelock, RIP).
Visit the PenARC Researchers-in-Residence page for more information on our work to develop a theory about how whole-system changes can support the creation of improved experience and better care for people living with long-term conditions.