Month: August 2013

Sustainability, Health and Cycling ‘on yer bike’

Sustainability, Health and Cycling.

 

Following the success of cycling at the London Olympics, which has propelled Chris Hoy and Victoria Pendleton into the limelight, and two successive Tour de France wins by British based Chris Froome and Bradley Wiggins, the Great British public are getting back on their bikes and not just to find work. At the mass cycling event ‘Ride 100’ held in London this summer,  even London Mayor Boris Johnson (17 stone) took part, commenting that he was no “chiselled whippet”. Boris is of course also known for the introduction of the Boris bike in the capital. He stated: “The truth is it’s not that hard, and I’m here to prove it. I am 17 stone, I’m by no means fit, and I got myself round that (100 mile) course in a perfectly respectable time. Not supersonic, but perfectly respectable…The message we’re trying to get over is this is for everybody”.

The Department of Transport has produced figures on walking and cycling by local area based on a survey in 2010/11. The key findings include 10% of adults cycle at least once per week but this varies a great deal by area (from over 50% to less than 5%), 11% of adults cycle for at least half an hour at least once per month but again with huge variations (35%-4%). Perhaps unsurprisingly, Cambridge  reports 52% cycling at least once per week and the highest rates are reported in cities and boroughs within cities. Why do we cycle? The survey suggests that 16% do so for utility purposes and 77% for recreation. The Cycling Touring Club (CTC) reports cycling is up by 20% in the last 12 years from 4 billion kms in 1998 to 5 billion kms in 2011.

So this is good news. For society, a shift from cars to cycling may bring about reduced air pollution, reduced greenhouse gas emissions and increased physical activity. For the individual there is an increase in exposure to air pollution and risk of road accidents. The health benefits of cycling are well understood. According to the NHS choices website these include helping you to lose weight, reducing stress and improving fitness. The example of calorie burning is given: someone weighing 80kgs (12st 9lbs) will burn more than 650 calories in an hour’s riding. As a keen road cyclist I can burn 1500 calories on a weekend ride. Of course there are concerns about death and injury on the roads, even Bradley Wiggins has been involved in a collision back in the UK after winning the Tour de France. Department of Transport figures for 2011 indicate that 107 cyclists were killed, but this figure is declining from 2004. However, combined figures for deaths and injuries show these steadily rising to 19,215 in 2011. What of course we really need to know is the relative risk of cycling compared to say horse riding, other forms of motor transport or any other activities. We need to know how many deaths per 100,000 kms of cycling and then to ask, whatever the number is, is cycling beneficial despite the risk?  Depending on who you ask, the health benefits of cycling do seem to outweigh the risks. Hartog et al in their study (2010) argue “on average the estimated health benefits of cycling were substantially larger relative to car driving for individuals shifting their mode of transport”.

Cycling is not just an individual issue, it is a social issue and perhaps a political issue as well. Both Denmark and the Netherlands have higher rates of cycling than the UK. This might be obvious given the geography, but the story is not as simple as the relative lack of hills, it is also down to political and urban planning decisions taken and active policy decisions by politicians over decades to make the countries cycle friendly, to get people back on their bikes.

In ’The Energy glut – the politics of fatness in an overheating world’ Roberts and Edwards (2010) argue that fossil fuels are making whole populations fat/obese. We have replaced food with fossil fuels as our main energy source while at the same time we are eating, if not less than we did, then certainly no more. We have become sedentary, replacing walking and cycling as active transport with mechanical modes of transport, mainly the motor car. Whole societies are using the energy oil has given us to replace physical labour. The upside is the construction of advanced civilizations and huge increases in food production, and the ability to buy stuff, the downside is that as countries develop and begin to increase their car use, whole populations get fat, and experience death and injury on the roads that make cycling injury statistics seem small. Did I mention the contribution to climate change?

Cycling as active transport is a positive sustainability issue, but it is also complicated in that in achieving positive health gains and reducing carbon emissions on the one hand, we have to also consider the carbon footprint of cycling. This includes the manufacture of cycles and  their transporting around the world. Raleigh manufactures in the Far East and my own Bike, a ‘Merida’, was shipped to the UK from overseas. Then of course there are the clothes and accessories and the taking part in weekend ‘sportives’ which may involve driving to events across the country. I have not calculated the carbon footprint of my own cycling interests nor have I calculated yet how many car miles I have not done as a result of cycling. I have to confess that I am one of the 77% who cycle for recreation, having not yet bitten the bullet on commuting. My only excuse is a 20 mile round trip to work on an A road in West Cornwall at , yes even in Cornwall, ‘rush hour’ where far too many drivers seem not have yet woken up and speed by far too closely.

My value system approves of cycling, I believe it has health benefits as well as risk but the risks could be far better managed if UK policy makers went even further in their plans for cycling. Am I about to sell the car though….?

 

 

 

How to save the NHS?

How to save the NHS?

 

 

In the context of rising demand, and an increasing gap in the budget to meet that demand starting with the £20 billion Nicholson Challenge, the NHS requires some radical changes. One report from the parliamentary Public Accounts Committee, suggested that 1 in 5  NHS Trusts were in financial trouble and bankruptcy was a real option, this despite the NHS having an overall surplus of £2.1 billion in 2012-13. This current surplus may not last, and the seemingly disorganised, costly management and inspection schemes alongside the disintegration of the providers into an ‘any willing provider’ mix of public and private do not bode well for the financial future of the service. The Private Finance Initiative (PFI) schemes have also locked some NHS organisations into costly long term contractual agreements.

 

So, what is the answer? Roy Lilley puts foward some radical solutions but it amounts to his oft quoted phrase “fund the front line, protect it fiercely, make it fun to work there”  and the problems go away.

 

Roy’s answer for Trust Boards:

 

  1. Cull the boards – too many people staffing Trust boards are locked into organisational thinking and theory that has got the NHS where it is. That is to say that although shared or distributed leadership is often discussed in the NHS Leadership Framework, it is often not practiced. Leadership should not be restricted to those who hold designated management roles – success comes from leadership based on shared responsibility recognising that anyone in an organisation can contribute. In Roy’s words, “staff always know best”.
  2. Get staff re positioned as co-owners and partners and have then on key committees and boards.
  3. Get as many women into management as possible.
  4. Change the organisational culture so that pointing out error is fine.

I would add:

  1. Focus on patient safety.
  2. Ensure minumum staffing levels.
  3. Ensure teams work in such a way that every voice matters.

For the NHS as a whole Roy suggests:

  1. Get rid of Monitor totally, it is expensive and has failed.
  2. Get rid of the CQC, it is expensive and it has failed.
  3. Stop financing any NHS initiative that is not front line, that includes things such as the NHS Leadership Academy, even if they are doing a good job.
  4. Scrap the market: health does not pay and the private sector knows it. This means repeal of the Health and Social Care Act 2012.
  5. Consolidate PFI debt, spread it across the NHS.
  6. Insist on a year on year 5% cut in all supplies and pharmaceuticals.
  7. A blanket pay freeze for 12 months.
  8. Scrap the CCGs.
  9. Give capitated population based budgets to Foundation Trustss and vertically integrate primary, community and social care. Let FT’s configure boards of their own choosing.
  10. Invest in doubling the bandwidth and make everything you can web based.

 

Some of these are radical changes, some Trusts are making progress through focusing on staffing levels, listening to front line staff and relentlessly focusing on patient safety. Salford NHS trust engaged staff very early on in their ‘Safely Reducing Costs’ programme. As a result staff came up with the ‘Smart health = Smart savings’ scheme. This involved on a monthly basis ideas being considered, with the best selected for development. Salford also has a ‘Quality Improvement Strategy’ aimed at patient safety. Staff initiated tests of change and senior leaders engaged in weekly ‘safety walkarounds’ . Salford also addressed staffing levels with the BBC reporting the ‘one nurse to 8 patients’ ratio, a level that under no circumstances should staffing levels fall (Safe and Sound – the safe staffing alliance).

 

The question for others in the NHS, seems to be around a lack of leadership at the right levels and ossified organisational cultures and thinking based on ideological commitments to competitive markets in health care provision. Leadership and management too divorced from the real issues front line staff face and a political leadership hide bound to political dogma and the private sector lobby who will benefit from cherry picking health contracts.

 

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