ollie: As many of you know, in Health Coaching and Beyond, we alternate conversations between Tim and I, chewing over hot topics and latest news and emerging ideas, but also bringing you conversations with thought leaders and people we admire in the field of health coaching and beyond. This week, I'm joined by local Sheffield Director of Public Health, Greg Fell, OBE. He's also president of the Association of Directors of Public Health, so he's a key national voice in the sphere of public health. With our practitioner two level, certificate being accredited as an Ofqual Level 3 qualification in health coaching by the Royal Society of Public Health, it felt really meaningful to talk public and population health with Greg and explore the balance between individual behaviour change alongside system level policy and the place of people's agency to influence both. We explore why obesity is the new tobacco. We explore commercial determinants of health. We talk about the fact that prevention's happening, perhaps and going unnoticed, and we even get onto the place of workplace and lifestyle medicine. So lots to get you thinking as always, and we hope you enjoy the conversation here in Greg's Views. Hello folks, welcome back again and I am absolutely delighted this week to be joined by Greg: this week to be joined. ollie: Greg Fell who is someone I've known for many years. He's the Director of Public Health here in Sheffield, a really crucial role, was absolutely seminal during Covid and in fact you're now Greg Fell OBE aren't you Greg? Greg: Yeah. Yeah. ollie: Yeah, yeah, which I think was on the result of a lot of the stuff you did during COVID and a sign Greg: Maybe. ollie: of your stature in the field. And of course, you're also now president of the associate of directors of public health. So you're quite a prominent figure, Greg. So it's great to have you on the podcast. Greg: Cheers, it's always a pleasure. A seminal was not a word I would use about myself, but there you go. Just Greg from Sheffield. ollie: Okay. Yeah, from Sheffield and brilliant. And you have such a crucial role in, and I think what we want to dive straight into is that, you know, I know that as director of public health, you're thinking about how a system can work that makes healthy choices easier, if you like. Greg: Yeah. ollie: And we've often debated on whether that's a system thing, how the system Greg: Yes. ollie: operates, or whether it's down to the personal individual roles that people take. And I think that's a really interesting place to start. I know you've written recently Greg: Cool. ollie: in your blogs about this book, It's On You. And I wondered if you just wanted to start there and sort of talk about some of the things you think about as a result of reading that and some of the blogs recently. Greg: Yeah, sure. So just a little bit history then. So I kind of first came into the thing that one of the constituent parts of what we call public health, which was then called health promotion in the early 90s. And when I did my first training in the space, we had this definition of health promotion is basically health education, which was largely around educating individuals so they behave, they eat less, they eat less fatty foods and drink less and all that kind of stuff. and healthy public policy. And there was a whole bunch of psychological theory underpinning that. I'm old enough to remember the first iteration of the stages of change model. I don't know if that's still a thing. I assume it is. That's the fella, ollie: Yeah, Pachasca and Di Clemente, yeah, still there. Greg: the health belief model, the health action model. It was a whole bunch of stuff. But we always neglected the healthy public policy bit because it's hard. It's hard to create an environment in which the healthy choice is the default choice. It requires more political agency, requires political shifts quite often. Therefore it's easier to default to individuals and that's just what we do. my starting point was then, but I guess I've never really left that. If you want to shift the behaviour of populations, if you want to shift the behaviour of individuals, work at individuals. If you want to shift the behaviour of populations, you've got to shift the system. So, Indy Johar and others do a fairly regular System Shift podcast, which I don't know if it's okay for one podcast to recommend other podcasts, but System Shift ollie: yeah, very fine, go for it. Greg: is a really, really good podcast. and if one of my jobs is around the prevention of non-communicable disease, cardiovascular disease, cancer, et cetera, if that's bluntly why people are poorly and why people die, you've got to quickly get into the business of, well, why is that? Lack of physical activity, as I frequently colloquialize it, people don't sweat enough and lift heavy stuff. Smoking, alcohol, access to poorly nutritious food. So I can stand outside Tesco's handing out Eat More Carrots leaflets, all I want. And I have done that in my past life. But it just doesn't make that much difference. It doesn't really shift the dial. So you get into sort of the iFrame stuff. interventions oriented and focused at individuals one by one and there's 572,000 of those individuals in Sheffield or you get into S-Frame stuff shifting the system. So I guess I've always been in that space but the thing that kind of crystallized or recrystallized it for me probably about six months ago was this book I read by Nick Charter, George Lowenstein called It's On You and I would say it's the best public policy book I've read in... in like a decade or more. the TLDR was the sort of the... We've basically got the policy focus, the needle of policy focus has been on individuals and personal agency and personal responsibility for drinking responsibly and gambling responsibly, yadda, dadda, dadda. And I'll come onto agency in a minute, it does matter. But that takes the shift of focus away from... And if you look at World Health Organisation, Best Buys to Prevent Non-Communicable Diseases, the interventions are price, marketing and advertising, and availability, and access to good quality treatment. in tobacco it's smoking cessation, in alcohol it's alcohol addiction treatment. So you can apply that to pretty much anything. But policy is focused on individuals. And that's somewhat problematic. And the book, It's on You, basically describes how that applies to a whole bunch of areas that I would call public health and other people would call public policy, the difference is probably moot, but it also applies, the book talks about retirement savings and economic inequality and plastic pollution and not necessarily a thing for this country, but gun violence is a massive issue in the States, significant ollie: Yeah. Yeah. Greg: cause of death and illness or morbidity, and there's that sort of the whole... guns don't kill people, people kill people. Well, that's the National Rifle Association's mantra. That keeps policy focused on irresponsible adults that haven't kept their guns in safe places rather than per capita gun ownership in the state. So, Issa Niu talks about the psychology that underpins that public health policy and it was a really, really, really interesting read. Probably not loads new to folk that work in my field. and kind of sets up that a focus of policy on agency and the focus of individual agency and a focus of policy on the structural conditions in which people live out their lives as in competition with each other which there's a little bit of zero sum game stuff in that but actually it depends on what your focus is if my jobs and my responsibilities focus is to help individuals many clinicians that is their job and they do a bloody good job at Maad too but my job is the responsibility for setting the conditions in which we can enable health which is a different job so there are different things that we should think about them differently rather than this indirect competition. ollie: Yeah, That's a brilliant framing. And I think that's why I'm so interested in this conversation, because I think with you coming in from a population point of view, and I guess myself being a GP and teaching people to use health coaching skills, Greg: Yeah. Yeah. Yeah. ollie: mostly on a one-to-one level, but increasingly on a sort of one-to-many and maybe a system level, it's fascinating to explore the interplay, because it's tempting sometimes to get very polarised and think, well, you know, it's all about the system. It doesn't matter what anybody does, because it makes no difference if the kind of policy and the... you the environment isn't right. And equally, you know, then you can kind of get the other way, can't you? And sort of say, well, you know, you can make the environment right, but people don't take responsibility for themselves. And, you know, there is a difference between how people respond in the same situation. Greg: Yeah. ollie: It doesn't matter. And you get people forming two camps. And I get the impression, Greg, you like to look at the middle ground as well as the broad picture. Greg: Well, I'm probably in the broad picture camp. If I had to be in a camp, I'd be in the broad picture camp because that's my job. That's the responsibility ollie: Yeah. Yeah. Greg: that I've got. But I fully recognize there are a number of camps and none of them are invalid camps and people can happily camp in either of the two, three or maybe even more camps as far as I know. But ollie: A lot of camping, yeah. Greg: there's a lot of camping going on. But say, know, pick... Pick obesity. Obesity is nearly the new tobacco. Everyone says that X is the new tobacco. Tobacco is still broadly the new tobacco. But as smoking prevalence comes down, I'll come onto that. Obesity bluntly we're not doing very well around obesity. Obesity causes cancer, causes cardiovascular disease that you as a GP will know all too much about, and causes early death and early illness. And that's a thing. Obesity is nearly the new tobacco, where smoking prevalence comes down. Weight management interventions, personal responsibility in that space does matter, but largely is outgunned by the environment in which we live our lives. People will say there's a sort of a mass loss of personal responsibility and that's why the prevalence of obesity has shot up. In our lifetimes, the prevalence of obesity has shot ollie: Yeah, yeah, yeah. Greg: up. When I was a kid and you were a kid, I'm... figuring you're about the same age as me, about 24, ollie: Yeah, I think we're roughly the same age. Greg: early 20s. Obesity wasn't really a thing, but it genuinely is a thing now, and that is causing illness, and one of the reasons why the long-term fall in cardiovascular mortality is leveling out is obesity is now playing into diabetes, which is playing into cardiovascular outcomes. So obesity is definitely a thing now. We haven't had a mass loss of personal responsibility in that time. fundamentally shifted is the food environment. So we can have all the agency we want and agency matters. Let's not pretend that agency doesn't matter and acting responsibly and doing the right thing. Of course it matters, but it's outgunned by the environment. And that's kind of where I am in my thinking in that space. ollie: Yeah, yeah, no, I get that. Greg: And if the advertising environment is saturated by, I'll be pejorative here, but. Turkey Twizzlers and McCain Oven Chips and other brands are available, I hasten to add. And then guess what? That drives consumption. That drives population consumption of calories, which drives obesity. So yeah, ollie: Yeah, yeah. Greg: you've got to help individuals, and individuals have to do the right thing. But one of my responsibilities is to try and set the environmental context as straight as is possible. But I know full well I'm up against exceptionally powerful multinational corporations, which makes my job hard and interesting at the same time. ollie: Yes, absolutely. And we're very grateful for what you do in fighting to help the environment work better because behaviour change works better, doesn't it, if the environment is more Greg: Yeah. Yes, quite. ollie: favourable. But let me be a bit provocative then, actually. You talked about Greg: Goop. ollie: smoking the ground we've made on smoking. Do think Greg: Yeah. ollie: the food industry has become like the new kind of tobacco industry? Yeah. Greg: Yes, Well, the update is well documented. In my trade, we call this space, it's called increasingly the commercial determinants of health. Our health isn't determined by the individual or aggregate of our choices, it's determined by the choices made by multinational corporations, usually headquartered in Geneva or Burnup, somewhere of that ilk. And we know full well. that those corporations, it's well documented and well evidenced that those corporations share exactly the same playbook in terms of their influencing and lobbying tactics on governments, the way in which they frame obesity as a matter of personal choice. That environment, that context and that narrative and discourse upon which policy is set is very, very well shaped and sculpted by PR. and advertising which sets and shapes norms in which our policymakers form their views and opinions and eventually their policy choices. All of that is very, very well documented. In my trade it's known as the playbook. The tobacco industry largely invented the playbook, but now it was put on turbocharged doses of steroids by the oil industry to sell us fossil fuels and all things that fall in that ship. And off note, climate is a significant public health hazard. And now it's well documented that many of the what I would call health harming industries use broadly the same methods and tactics to maximise their profits. I would, were it me, I'm responsible, if I'm in charge of Mondeley or Kraft Foods or whatever, and again other food brands are available, my responsibility is to my shareholders to maximise profit. That comes from maximising sales. So of course that's the way it works, but the consequence is obesity and all of the early death and illness that comes from that. So, but the playbook space is well trodden. ollie: Well, let's, I mean, I'm trying to sort of make sure we get some good positives out of this in terms of, so you've already, I know you've told me a lot in the past about how positive the story is around tobacco in a way, you know, and Greg: Yeah. ollie: as a clinician, I'm often used to sort of like, know, inducing sort of smoking cessation programs, having brief interventions and Greg: Yeah. Yeah. ollie: operate on a personal level, but there's also been some wide system change as well, some policy levels. So would you put that as a success of both things working in parallel? Greg: Yep. stellar success. stellar success. There are a fair few successes and I'll call it public health. accept other people will call it different things. That's just the nuance of language. ollie: Yeah, go on, on, share more, I'd to hear. Greg: But CDC published a top success stories of the last hundred years on their website. Presumably still up there. I don't know. I've not checked recently, but the long term story. on the near eradication of measles by basically vaccinating anything that moves was clearly a public health success story. Tobacco control is clearly a public health success story and there were 10 others, forget what they all are. Long-term reduction in motor vehicle collisions, killed and seriously injured on the road, Ditto, systematically applying the right interventions doggedly and well over a long period of time. That's what change looks like. When I came to Sheffield a decade and a little bit ago, smoking prevalence was from memory about 19%, one nine. Now it's about 12%, a little bit more, a little bit less depending on how you do the prevalence ollie: Yeah, that's amazing. Greg: surveys. That didn't happen by magic. It happened because people doggedly worked at it over a long period of time. Clinicians up and down the city. I've done brief interventions and made referrals to definitive stop smoking services over a long period of time. That in itself probably reduces prevalence by somewhere around 0.15 to 0.25, a quarter of a percentage point a year. Not much, but if you aggregate that over quite a few years, it adds up. At the same time, both locally, we've done a lot on policies, working with schools, on smoke-free environments, working with universities. hospitals and other big public service environments on smoke-free environments, that's shifted norms. And one of the early things that we did in my time here was implement smoke-free playgrounds so that kids wouldn't see their parents smoking in a playground because that shapes kids' norms and norms influence their ongoing behavior. We've done a lot on investing in trading standards teams to basically confiscate illegal and illicit tobacco. that was on sale in shops across the city in ones and twos at really, really cheap prices. Well, guess what? That's why five kids a day start smoking. So we basically used smart investment in trading standards to kick doors down and confiscate large quantities of illegal tobacco and now illegal vapes. And of note, which is often linked to organized crime, which is clearly a very important side benefit. And then nationally, relentless pressure on price, relentless pressure on advertising, marketing. So the collective effort of all of that has shifted smoking prevalence from, as I say, 17, 18, maybe 19 % down to about 11, 12%. You can't see the benefit of that because it's like the success in prevention is bad stuff doesn't happen. You ollie: Yes. Greg: can't count that. because it doesn't happen. But countless people who may otherwise have had a diagnosis of lung cancer or had a stroke or whatever as a consequence of smoking will not have that. So that's kind of a good thing. So that's our success. Sadly, as I say, we're not doing quite so well in obesity and in ditto, we're not doing quite so well in alcohol. But policy makes a difference is the broad story ollie: Yeah, completely. Greg: and broadly we know what to do. And it's a collective of One-to-one interventions for those who are responsible for one-to-one interventions and system shifts type of interventions for those who are responsible for that. Collectively, that's the thing that makes the difference. ollie: That's brilliant. I mean, I hear a pick up point. I'd love to come back to prevention a bit later on, but maybe, Greg: Yes, sir. ollie: you you've said that kind of obesity is almost like where smoking was and we've learned a lot from smoking of that combined effort. if you were looking at how we go forward with obesity, obviously we've got these GLP-1 drugs, which have been prescribed on mass or being used kind of privately on mass levels. Greg: I have seen. Yes. ollie: You know, we've got some one-to-one behavior change interventions and maybe there's a big space for... policy change as well. How would you see the ideal world playing out then to tackle the obesity crisis in a joint way? Greg: So on national level there's something around getting the right ecosystem and underpinning discourse and narrative to enable shift of policy away from things that only focus individuals towards structural system shift in the food system, particularly the food system. I'll come on to physical activity in a minute. So in terms of the specific policy bucket list, it's been well described by lots of people. Most recently, Nesta, who are quite active in this space, who are a national think tank, have written, this is our policy bucket list to have obesity in. 20 or 30 year time horizon, think. And let's be clear, it will take that kind of time horizon to do that. So I often point people towards Nesta. And I think Nesta perhaps overplayed the importance of GOP1 agonists a little bit in that, but broadly I think Nesta have done a decent job. There's something around the food environment in particular, and I frequently come back to Henry Dimbleby's Food Strategy, was published. So an independent commission for the previous government was published three or four years ago. It was brilliant, absolutely brilliant. It didn't get implemented as intercepted and intended, but we may come back to that. sort of broadly at national level, I'm in that kind of space. And then at local level, it's the sort of the, you know, I'm well documented as being pretty pushy about are we implementing, are we giving planning permission to new fast food, hot food takeaways within certain perimeters of schools and the council plan. Council now has a planning policy that's currently going through the inspection process. may come out of that. But that policy has been used to say no to hot food takeaways. We need to be in the space of school food, which matters. We need to be in the space of ensuring there is access to sustainable and nutritious food, which is partly a national food system, partly a local food system. For me, most of that comes together in that the city does have a food strategy. and most of the food strategy bits that I'm cited on are largely focused on access to sustainable and nutritious food and some of that is about price, some of that is about availability, which is a sort of food system thing. Of notes, the council has a policy on advertising and sponsorship. It will really come into effect when we novate the commercial contracts for the JC Deco and Clear Channel billboards and the like, but we're ollie: Yeah. Yeah. Greg: basically trying to out... Al Sadiq, the Mayor of London, who said no junk food adds on transport estate, well we've said on any estate that the council owns. What I can't do is if one of the two football clubs take a sponsorship, you know it's not my responsibility, but we're trying to set the right norms and the right context in that space and be really really pushy and certainly be pushy on food that is supplied by the public pound should be nutritious and sometimes it is sometimes it isn't so ollie: Yeah, yeah. Greg: and and on Wayne management interventions etc and I am the responsible commissioner for a chunk of those and we were proud to do that and will continue to do that and it does make a difference for some but it probably isn't going to shift the dial of population but again white smoking cessation you've just got to keep going in that space. It's just a hard dogged work of prevention over a long period of time. However, just on the sort of the population impact of weight management interventions, I did once calculate this in a sort of a of a back of a fag packet way. But at the current level of investment and the current level of effectiveness of those interventions. Now this is average, it's kind of about average and some places will have much better outcomes than others, that's just the law of averages. It'd take 250 years to solve obesity by that stretch and there's one of my staff then said at the time, kind of like emptying an ocean with a teaspoon, which is true, but that's the difference between population level perspectives and individual level perspectives because at individual level perspectives those kinds of services make an enormous difference for some, so let's be clear on that. And then on GOP1s, do make a difference, significant difference for some. For a period, we don't know what happens in the long period. there's lots of worries about side effect profiles. There's lots of worries about people having significant side effects and coming off them. They work for as long as you take them. And they're kind of like statins. They work for as long as you take them. And of note, I'm increasingly worried about things like pancreatitis, because I'm looking at the... admission rate for acute pancreatitis is going up pretty steeply. I wonder why that might be happening. ollie: Yeah. Greg: But they will make a difference for some. And we can all see stories of folk, and I know folk who are on them, that have lost tons of weight. Fantastic. Do we want to get into the business of medicating 60 % of the population? I'm not sure. And at the current cost, we simply can't afford. to medicate 60 % of the population. I'm not convinced mass prescription of GOP1s is the answer that everyone thinks it is. I'm happy to be proven wrong. ollie: Yeah, that's interesting. it's sort of a multiple, mean, because this is a podcast around health coaching, I want to circle back to the agency factor. Because I suppose, from my perspective, we're often talking about kind of, you know, the very baseline of health coaching is building people's agency across a whole load of things. So, you do they Greg: Yeah. ollie: have a sense of self-worth, self-control for Greg: Yeah, yeah, yeah. ollie: themselves? But then perhaps also, I know some people have been writing about whether agency then can play into the public policy arena where, you know, sort of democracy in democratic places, people talking about wanting stuff more vocally and behaving in a certain Greg: Yeah, yeah, yeah. ollie: way will influence the policymakers. So I am interested in what you think of that kind of approach to try and build people's agency generally, you whether that's for obesity, smoking, the environment, you know, Greg: Yep. Yep. ollie: just how we operate with each other through social care, you know, where do you think that sits in the whole picture then? Greg: All four is a massively important thing. That's one of the things, again, you and I may use slightly different language to describe the same thing, but when I talk about community development, that's exactly the purpose of community development, is to shift power from state and institution to individuals and communities. Easy to say, it's hard to do for a million and one reasons, I know full well we under-resourced a whole bunch of that stuff. And I know full well that we have to get the environment and the context in which people live right to enable some of that agency. That's a policy versus individual thing again. But it's a fundamental part of my view and thinking and practice and all those can judge how well we actually do that. But agency matters. It matters enormously. It's one of the fundamental tenets of civil life and one of the fundamental tenets of democracy is people's ability. to affect social change. That's called democracy. That's broadly a good thing. So you can and will and should apply agency in a health coaching context, but it equally applies in lots and lots of other contexts as well. And the foundation building blocks are probably the same. So it matters and it matters enormously. It also matters to make sure the context in which people live their lives is as empowering as our efforts to try and help individuals. ollie: Well thanks, it's nice to hear you say that and I like the way you balance the two up. And so I'm going to circle back to prevention as well because Greg: Yeah, sure. ollie: you talked about how hard it is to recognise when prevention has had an impact because when things don't happen, nobody notices Greg: Yes. ollie: it, whereas bad things happen, we immediately cluster around it. But how are we going to, you know, there's this big articulation, at a government level isn't there, to move from reactive care to preventative care, it's one of the big three shifts. I Greg: Yep. ollie: know it's something you've worked on all your career. Greg: Yeah ollie: How are we actually gonna get upstream towards prevention? Greg: Well, one we are, when someone says, there's nothing going on in topic area X or policy, there's always something going on. It's just that person doesn't know about that stuff. So I once had a very important, I won't name that person, but a very important and influential clinician say to me in Sheffield, say to me, there's nothing going on about tobacco. After I'd picked my jaw up from the floor, I educated ollie: You Greg: that person. I didn't know about any of that was the response. So often there is a whole bunch of stuff around prevention going on. And there's a job of kind of accelerating it. And of course, we all want to invest more in prevention. Usually the urgency and the immediacy of the acute in your face right now drowns out bandwidth and drowns out resources as well. Let me be clear on that one. life. I saw that to my cost in the pandemic where I basically stopped doing anything that wasn't managing a COVID pandemic and a whole bunch of stuff that is my day job that is prevention stopped. even I get the immediate versus the long-term important conundrum and you see this play out in health but you also see it play out in say crime and criminal justice. Well, the prisons are full because we haven't attended as well as we might wanted to of the long-term determinants of crime and criminal behavior, hope, poverty, good housing, good employment. So guess what? We don't get that right. Prisons get full. And then you can draw the logic model between the two things fairly readily. So it applies in health. It applies in lots and lots of other spaces as well. So that will always be a thing. But when I say we're going to shift from the treatment to prevention or cure to prevention. I've said there's plenty of prevention going on, you just need to know about it. And it's kind of long term, very slowly shift the dial. We can't suddenly turn off treatments. That would be wrong. Imagine if in the car accident, the ambulance didn't turn up because they've invested all that money in those public health people. Well, there'd be an outcry. Understandably, I get that. So ollie: Of course. Greg: long term, there's a bit of doggedly doing what... folk do over a long, long period of time. And I'll pick on cardiovascular disease here, so I forget my exact numbers now, but somewhere around a thousand people have a stroke, a thousand people have a heart attack in any given year in Sheffield. and that, that, massively impactful on people's lives. That number has come down and down and down and down over the decades. for a bunch of reasons and you know, I don't think we're quite in that space now, but I vividly remember conversations about closing cardiology wars because cardiovascular mortality, cardiovascular morbidity was coming down. So that happened largely because of access to good quality treatments, statins, funders of secondary prevention fundamentally shifted that massively speaking and long-term approaches to tobacco and smoking prevalence. Both of those things had a massive downward push on cardiovascular mortality, morbidity. That's prevention in action over a long, long period of time. Vaccination, we've not quite, but nearly eliminated some things that we used to have enormous outbreaks of over a long period, in the dim and distant history. There are plenty of things that we still worry about around vaccination, but fact, vaccines are probably second only to clean water in terms of the impact public health wise. We've got a well-trod system for delivering vaccination, largely but not exclusively through primary care. It largely works well. There are some things I think we need to attend to in that space, but it largely works pretty well. So that's prevention. But we can't ollie: Yeah, yeah. Greg: suddenly turn off treatment to shift more into prevention because I'll always fail. ollie: Fair enough. Greg: to some extent. ollie: Yeah. Greg: So it's a sort of a balancing of the two. The only other thing I say is one of the reasons, this is a healthcare specific thing, one of the reasons why the hospitalisation rates go up and up and up is that despite the long term narrative of shifting from acute to community, currently called hospital to community prior to that it was called the left shift prior to that it was called something else and ollie: Yeah. Yeah. Yeah. Greg: prior to that it called something else. That's been a long term policy objective for the UK and pretty much every country in the world for as long as either of us two can remember but we've done the opposite. The investment has gone down in primary community care. So if we want to get into prevention in a macro context people say what's the answer Greg? It's invest in primary community care. is primary community care where you manage long-term conditions that largely turn into one long-term condition turned into two and three and a multi-morbidity of the people have more than one thing wrong with them at any given time. Most of that is preventable and most of the hard work in that space in the healthcare context is done in primary community care. kind of investing in primary community care in a macro sense is prevention. ollie: Yeah, no, no, we could have another whole podcast about how we manage to shift that dial. But there's a couple of other places I wanted to go with you, Greg, and you can choose whichever you like, really. Greg: hell. ollie: I'm interested in sort of like how you go beyond the health in terms of, you know, the wider determinants of health. And in particular, we've got quite interested in workplaces and the role that kind of the Greg: Yeah. ollie: employment sector can play in building health. And I know you think about those wider determinants of health a lot, you know, no policy without health policy. But then also there's been a rise of lifestyle medicine within healthcare itself as well. And I'm Greg: Yeah. ollie: interested whether you want to go on either of those two, whether you think lifestyle medicine is again sort of perhaps barking up the wrong tree or is it something that's really useful from where you sit? Where would you like to go on either of those two? Greg: I'll go on both if you want. workplace ollie: I thought you might do, Greg: health, firstly work matters to health. know, employment, good quality employment matters to health. Bad quality or no employment also matters to health. kind of, you know, basic employment policy, basic economic policy is arguably the most important determinant of health. So, but more specifically within that, work. matters to health, gives sense of purpose, gives income with which you can buy stuff and buying stuff kind of matters, gives you ability to afford to pay rent or pay mortgage or... So the income from work matters, the sense of purpose that comes from work matters, but equally we can get it wrong on the other side of the fence by bad quality work or no work. So work matters, clearly matters to UK PLC at the moment. There was... I'll back and do some of these references for show notes if you want. was the DWP in 2024, maybe five published their estimate of the cost of illness in working age people to UK PLC. It was a quarter of a trillion pounds. That's a lot. I don't know how many North there are after a quarter of a trillion pounds, but a lot of Norths. The vast majority of which was benefit system cost. and lost productivity. The relatively small sum of money was NHS cost. Benefit cost lost productivity. That made the Treasury sit up very, very, very straight in the chest. That's a big number by anyone's stretch of the imagination. And ditto, there was an Office of Budget Responsibility report, I think it was September 2024, long-term fiscal risks for the UK, at the long-term, the clues in the title, long-term fiscal risks. the costs and consequences of climate change were very, very, very sobering, as were the costs and consequences of long-term trends in population health. Treasury read OBR stuff, Treasury commissioned OBR stuff. So it matters in that context to UK PLC. The, led to fairly significant investment from Treasury on... What became known as accelerators and trailblazers, there's two versions, one of which is an NHSO owned entity, one of which is a South Yorkshire American-bound authority owned entity, we brought together in the same governance. But basically, systematic delivery of health care and other interventions to enable people who are close to but not in the labour market to be well enough to work, to get people well, get people able to work and to get them back in the labour market, because one is good for the economy, two is good for individuals. That's a health intervention. It's also an economic intervention for a million and one reasons, but it's certainly a health intervention. And Sheffield and South Yorkshire are doing quite well in that respect. So work sort of matters in that context. And last thought on the work and health agenda, there's a sort of a, there's an approach by many employers that the answer is an employee assistance program, a bike shed to encourage people to cycle to work and a bowl of bananas in the staff canteen. Sorted, healthy working environment sorted. But if we don't sort out things like toxic bullying, unsustainable workloads, well those things are causing mental illnesses so there's a sort of a you need to be in that space as well ollie: we're definitely interested in that space. And I think, you know, the skill set of health coaching within that, which tends to be Greg: I agree. ollie: a bit more upstream in terms of keeping people well, keeping Greg: Yes, I agree. ollie: them developing habits that keep them well, whether they're health habits or workplace patterns of behaviour, bosses to juniors, peers to peers. Yeah, Greg: Yeah. Yeah. great. ollie: so I think there's the scope there. So the lifestyle bit, do you want to say anything about lifestyle medicine and how you see that playing its part in the picture? Greg: So I'm not terribly sighted on the sort of the how the field has developed over the years. I think it's broadly a good thing. think it's a sort of a systemic and considered effort to try and demedicalise where appropriate the delivery of healthcare, which is an entirely good thing because there are plenty of things that absolutely require a medical and medicalised model approach. But there are plenty, as you and I both know, that don't. the thing that's become called lifestyle medicine is a fairly systemic effort to try and address a lot of that overdiagnosis, over treatment, which in itself causes harm. We know it's hard to document that harm, but we know it's there. The thing I see Most visibly in the lifestyle medicine pursuit is, there two things. One is the overdiagnosis over treatment agenda. And there's a fairly healthy body of people that pushing quite hard in some of that. And of note set against that is the sort of med tech industry that will happily flog us with as many pharmaceuticals and medical devices as we want. And they got better PR than those on the opposite side of that. ollie: Yes, David and Goliath again. Greg: That's a thing. I've known David won the David and Goliath battle. So he did it in the end with ollie: he did, exactly, let's remember that, David won, Greg: a few carefully aimed shots. So yeah, that's a thing. And then the second space I see the lifestyle medicine advocates in is the whole exercise as medicine thing. Wide open goal, go for it. Because I think we grossly underuse exercise as a modality of treating people's illnesses, but also obviously importantly preventing people's illnesses. Healthcare is a high volume pursuit where healthcare professionals see very, very, very high volumes of people. Even marginal shifts in that volume of people can achieve a not insignificant goal in terms of improving the health of population. And I've seen plenty of progress in that space. I always want to see more. ollie: Yeah, that's great. Well, we've both been involved in the Move More Sheffield programme for many years, haven't we? Well, maybe that's a clue for you for your last question there then. Is the one thing people can do for themselves and the city to advocate for more physical activity? Greg: Move more. Yeah, go on. Well, it'd be a nice easy thing for me to say. Off, off. Yeah, I know. Well. ollie: A really nice, well, I don't want to let you off the hook. What would you say? What would be your final rounding point then of what people could do? Greg: On physical activity and the move more strategy per se, think we're now on our third iteration of the move more strategy. I think we are. ollie: Yeah. Yeah. Greg: But broadly, we've taken a sort of a. whole city, whole system, multiple systems all interacting together, know, speak to places, environments, parks and green space, leisure facilities, healthcare, you know, all of that in a mix, all at once. And the proof is in the pudding, Sheffield does quite well. Sheffield is quite a sweaty city, all things considered. I think to continue my sporting analogy, I think we're somewhere at the bottom end of the premiership in terms of how we rank. Given our socio-demographic profile, that's no mean feat. And again, hasn't happened ollie: It is. Greg: by magic. It's happened because a lot of people have worked very, very, very hard on it over long period of time. We can do better. Yeah. I don't follow football, to be fair. I ollie: Maybe better than our football teams. Maybe better than our professional football teams. Greg: cycle. I'm a moderate cyclist. We can do better so as to get to the top of the premiership. But we do okay in that sense. And that's testament. to the broad strategy that we've adopted and way in we've enacted over many years. you know, the one thing, physical activity does matter enormously. So, I might talk the question because I suppose the big idea, people always want, people ask me frequently about what's the one big thing or the three big things. I don't know, I think the big idea is that there isn't a single big idea. So it's the aggregate of a whole bunch of ideas that makes the difference in doing that doggedly. Can I tell a story on what we're doing with regards to the main risks, to lifestyle risks, and I loathe the term lifestyle for a bunch of reasons, but the main lifestyle risks to health, tobacco, physical activity, food, alcohol. Yeah, I can. In some of those spaces we're doing really well, in some less well. Can I tell a story of what the city's doing around the illnesses that those things cause or lead to the increased risk of, cardiovascular disease, cancer, et cetera? Yeah, broadly. And again, some of those things we do well, some of those things we do less well. Can I go upstream and tell a story about what folk call the determinants of health, but what I will call transport policy, poverty, income maximization policy? Yes, again. But I'm loathe to pick the one thing. because it's kind of like picking your favourite children. It's a very, very, very dangerous pastime. ollie: Fair enough. I'll let you off on that one then, Greg. I Greg: Alright, thanks. ollie: think maybe that's a good point to finish it, actually. There's a little bit of everything. actually, you know, I've got a key principle for health coaching is based around what matters most to you. So maybe it's use the Greg: Yes, indeed. ollie: thing that you enjoy the most and you've got most energy for and start there and know it has some effect. But Greg, the time has flown. Thank you so much for your time. you know, hopefully that's given people to think about where your personal agency matters, the individual bit. perhaps it's been slightly overplayed and we should be pressurising alongside that for system approaches, but ultimately it's going to be a mixture of both. And we're very grateful for you leading us as a city and a country really from a public health perspective on this, Greg. So thanks so much for all your conversation today and your efforts globally. Greg: It's pleasure, it's been fun. I haven't quite got to global yet, I don't think I ever will but... I'm not sure... I'm not sure about that. Anyway, it's fun. Thank you. ollie: Well, in a global sense, mean, you you'll get there, Greg. I'm sure no doubt you'll be influencing the Donald at some point. Thanks so much, Greg. Cheers.