Interview with David Pencheon
David Pencheon is the Director of the NHS Sustainable Development Unit, which aims to make the NHS a leading sustainable and low carbon healthcare service. Previously, he was Director of the NHS Eastern Region Public Health Observatory and worked with the NHS R&D programme, in China with Save the Children Fund (UK) and as a clinician in secondary care.
The Sustainable Development Unit is due to announce a programme of work to support the NHS to engage with patients later this year. Can you give us an idea of what the objectives are for this engagement?
“Well, it’s quite clear that if you’re trying to meaningfully shape policy within the NHS, you can’t get anywhere unless there is some evidence that patient outcomes will be improved at the end of the process. That is quite right, of course. Having said that, it’s quite surprising sometimes that the health service - like many other key services - takes its key clients into consideration as little as it does. Although for the first two of three years of our work at the Sustainable Development Unit, we have not really looked at the patient perspective, it’s become increasingly apparent that we must at least start that journey of engaging, talking with and listening to how patients interpret the issue of sustainability in healthcare. The importance of engaging was brought home to us partly because one of our most respected colleagues on our advisory systems said rather forcefully and rightly that if we don’t get the patients involved meaningfully at some stage, large-scale change in the healthcare system is just not going to happen.”
Can you give us any clues on what this programme might include?
“I don’t have a lot of precise detail because we’re still very much in learning mode. So far, we’ve been very much influenced by two workshops we’ve held. One was a day-long process with 12 members of the public, some of them within the formal healthcare system and some not. In the other, we spent some time listening to ‘proxy’ patients, such as organisations, often with single issue medical causes. Often, these are people who are much better at engaging patients than we are. We’re learning a lot. For example, the way in which we articulate the benefits and trade-offs will very much affect how people engage patients. We’ve also realised that for most people when it comes to healthcare, especially in emergencies, nothing is more important than the care you receive. In this kind of environment, there’s not a lot of room for trade-offs and considering pros and cons, it’s a question of whatever is needed, is needed now. In particular, considerations about the future just don’t come into it. This poses a real challenge in patient engagement in sustainability issues.
“However, what we have learnt is that when you do show people that there are better ways of delivering healthcare which happen to work for patients now and, also, are fortuitously more environmentally sensitive, that’s a very important win-win which they are enthusiastic about and which we can begin to work with.”
There are already a lot of patient engagement initiatives within the NHS. How, if at all, will it differ from these?
“It’s interesting you say that the NHS does a lot of patient engagement, because I’m not sure that we do. I think we try and we may do a lot in terms of quantity, but whether we do it in terms of quality is another matter. I’d love to be proved wrong. But despite the fact that the NHS, as a public service, sees a million people every 36 hours, I’m not sure that we are brilliant at strategically engaging the people we are trying to serve.
“I think one area where our engagement will be different from most health engagement is that what we will do is try to bring the medium and long-term future into account. Most patient engagement is around the quality of service that we provide now for you and your family, and how we can make it better, whether that’s focused on processes, outcomes, respect for diversity, etc. And all these things are really important. I think the thing that makes it slightly different and slightly more difficult for us is that not only are we interested in how to provide better healthcare now, but also how to provide that healthcare in a way that doesn’t endanger our ability to provide it to a similar high standard in the future. And most people in health are not that interested in the future. Healthcare is a very here-and-now phenomenon, both for the people who give it and those who get it.”
So, trying to take the future into account in a service which is so focused on the here and now will be a challenge. What other challenges are you expecting?
“I think the other attitude which we will be up against is a real focus on problems. In healthcare, the focus is on people who are ill, who are distressed, who are in pain. Now, if you start talking about sustainability, people immediately think of climate change: it’s a problem. Of course they’re right that it is a problem, but if you just focus on it as a problem it will grind you down. We’ve got to be slightly more positive and look at the silver linings – that, actually, tackling climate change also helps us explore other issues such as increasing public expectations, a very rapidly changing dynamic between the individual and the state, an ageing population, those who are not economically active, etc. Rather than getting a sinking heart about all these so-called problems, most health professionals will return to their comfort zone, and that’s helping patients who need help now.
“In healthcare, we like crises and problems and we like to fix them. And then we like to move on. We like a bit of drama. The long slog over a painful journey over 20-30 years is not quite as glamorous.”
Your engagement is focused both on healthcare professionals and on patients. How will these two interact?
Well one aspect that I feel particularly strongly about is that you can’t start engaging with the public unless you’re also engaging with health professionals. I’m influenced a lot by my experience working in the area of tobacco consumption. We knew that there was no point in berating individuals to cut down their tobacco consumption unless the health service and the health professionals were clearly of one mind and one voice that this was a bad idea. But, for a long time, doctors were quite heavy smokers, so we concentrated a lot of the time until we were sure that the level of doctors smoking was really very low. The same is true now I think. I do lie sleepless thinking why is it that health professionals are not as engaged in this issue as much as they might be. If you look at the scientific evidence then, much as we’d love not to believe it, you’ve got to take environmental sustainability seriously. And yet there is a disconnect between strength of the evidence and professional engagement. One of the key problems is the phenomena of moral offsetting. It’s easy for doctors and other health professionals to feel that we do enough good things, thank you very much! We’ll leave the other challenges to somebody else. I’ve seen a similar attitude among other NGOs and humanitarian organisations. After all, there’s only so much you can do in a day. Or, rather more pessimistically, some people might think ‘I recycle a few plastic bags every now and again, that allows me to drive my four by four’ which is just completely out of proportion.
“If we’re going to engage the public meaningfully in sustainable healthcare, we have to overcome this with healthcare professionals.”
One of the recognised dangers of public engagement has been the ‘deficit model,’ which sees public reluctance to accept or respond to new science as a failure in understanding. A lot of public engagement is accused of falling into this trap; rather than listening to the public, it’s really a public education exercise in disguise. How will the Route Map public engagement exercise avoid this model?
“That’s a very good point, and certainly something we’ll be aware of as we move forward. It’s right, of course, that if you start making big changes for environmental reasons, people do get slightly suspicious. Because all change, especially when it’s mandated from Government, implies that there are winners and losers, people suspect it’s being done to save money and, therefore, there must be a cost somewhere to somebody. So if there isn’t a dialogue and if we’re not completely open then it won’t be successful. This must be true for a lot of areas, but particularly so for the environmental agenda because I suspect a lot of the public still see doing things for environmental reasons as quite threatening – the idea that it will take away your foreign holiday or your car. So I think there’s a very big communication issue but, as you say, we don’t need to be in broadcast mode, but in listening mode.”