Dr Rupy: Nigel, thanks so much for taking time this morning. I know you're going to be on stage in literally minutes. Let's start with your role. You're a co-chair of the All-Parliamentary Group on Global Health. What does that mean exactly?
Lord Nigel Crisp: Well, what it is, is it's a group of peers and MPs who are interested in global health. And therefore we run a number of meetings in Parliament, we're trying to promote the ideas about global health and making people, helping people to think about the world when they're thinking about health, because the UK isn't isolated. We know that now. Three years ago, five years ago, ten years ago, we perhaps didn't understand that as much, but come a pandemic and of course we all understand how joined up we are. Not just joined up in the way that diseases will travel around the world, but actually think about PPE and the competition for ventilators and all the rest of it. And then the sort of issues of access to vaccines and of course, COVID revealed to us those great inequalities, didn't it? Inequalities in our own country, but also inequalities around the world. So that's the sort of broad set of focus that we in that group are interested in.
Dr Rupy: Where did your personal interest come to this? Because it's very topical now, but I imagine a few decades ago, it perhaps wasn't as…
Lord Nigel Crisp: Well, interesting, very interesting. When I was running the NHS, which was at the beginning of this century, feels like a long time ago, doesn't it? And I now normally say I'm now in recovery. But I met a lot of senior doctors, particularly doctors, but also nurses, who'd done a week or two in Africa or something like that. And they came back buzzing. They remembered why they were a doctor. I remember one particular radiologist who was dealing with a sick child and radiologists in a British hospital, they have their role, but it's not quite like that. And she had to go back to first principles and she remembered the passion, because one of the things I notice about doctors is you have that passion when you come into medicine. Sometimes the system knocks it a bit out of you. But actually, I find when I'm talking to these people, the passion came back. That was great for the NHS. And then I began to realise how much we could learn from that sort of experience, the growth of people, but actually from countries themselves.
Dr Rupy: You're going to, I'm assuming you've already spoken to a few people, but I feel that you're going to get the sense that a lot of medics currently in the system have lost or are losing that passion that they started the clinical career with. And there's something that's happened to me in my relatively short clinical career of almost 15 years. As I got ingrained and entrenched into the system, I've sort of lost my, the real spark that led me into the profession in the first place. What do you think we can do today to sort of reinvigorate people's passion?
Lord Nigel Crisp: I do absolutely recognise that. And actually, I fell into the NHS when in my mid-thirties, so I joined relatively late. And one of the first things a consultant orthopod said to me, and this is in the nineties, was, Nigel, today is the 25th anniversary of my Wednesday afternoon clinic. And he looked a bit depressed. That guy, I last saw him three years ago and he was medical director of a charity hospital in Lusaka in Zambia. And what you notice is that doctors in their careers tend to pick up some stuff that, and but it is important to reignite that passion. But then people get passion in different ways. But some of it actually is from teaching, teaching and research and so on. So I think we, what we desperately mustn't do is make you guys into technicians. And I think some of you feel, and probably rightly, that you're on a treadmill, that actually there's protocols telling you what to do, there's patients and there's targets and there's all this kind of stuff. So why did I get a medical training? Why am I a professional as opposed to being a technician? And I think that's really serious. And one of the things we're doing in the All-Party Parliamentary Group is we're looking at the future role of health workers, looking 20 years ahead. What is today's 25-year-old going to be doing when they're 45? And our argument out of all of that is, I better not give it all away today, had I? But actually, we need a wider set of education for people and we need to recognise that you've got a role as a clinician, but also as an agent of change. That actually, if you're a single-handed, and this take me back globally, if you're a single-handed consultant psychiatrist in Bihar, state in India, state in North India, well, you can see 20 patients a day or 30 patients a day or 50 patients a day, but actually you're not really going to make an impact on mental health in Bihar unless you're also working with the temple, working with the mosque if it's also a mosque in the area, working with the civil society organisations, working with other people, creating the conditions for people to handle mental health. So actually, our argument is that if we're really going to see you as the professionals you are, not technicians, we need you to be the agents of change and curators of knowledge. Because knowledge is now contested, isn't it? But who do I go to if I want to understand how I can find the latest stuff on health or whatever? Somebody like you. I hope.
Dr Rupy: Well, I think increasingly people are taking the initiative to look for other sources of information about their health whilst they wait to see someone like myself in clinic. There's obviously that issue as well. I just wanted to dive a little bit deeper in this into this concept of being an agent for change and the educational piece. How do we encourage the young clinicians or even the clinicians in the middle of their career to become those agents of change? Where do we look for inspiration?
Lord Nigel Crisp: Well, lots of things. Amongst those are role models. And you've seen it in your life, people who have actually sorted stuff out. And I meet a lot of younger GPs actually, who are not only seeing themselves as clinicians, of course, but also growing, there's a group doing growing health in Horley, which is not from, linking in with the organisations. Because one of the other big things I'm really interested in is the causes of health, not the causes of disease, the causes of health, creating health, salutogenesis, not pathogenesis. And I define that as being about creating the conditions for people to be healthy and then helping them to be so. And that it's what your parents did. It's what a good teacher does, what a good school does. They help you to become a robust, confident, competent doctor in your case, human being. And we need to get into all of that as well as into the pathogenesis, as it were, because we certainly need the clinical aspects. Nothing I'm saying takes any of that away, but it's a two-handed thing. We need creating health, which is not just prevention of disease, it's actually creating human flourishing. Great African saying, my book before the one we may be about to talk about, was called Health is Made at Home, Hospitals are for Repairs. Isn't that great? That's a wonderful guy called Francis Mwazwa, Professor Francis Mwazwa, who ran the Ugandan health service, ran at about the same time as I was running the English one. And he used to use that as his slogan. And he was, and his model was a traditional African village where everyone knew everybody else and children played with each other, you were part of a society, there were relations, there were belonging, all those sort of things that help create a more fulfilled human being.
Dr Rupy: That the concept of salutogenesis certainly resonates really well with me because I feel certainly when I was at medical school, there was an overt emphasis on pathogenesis. And it's very important, don't get me wrong, the knowledge around pathology, the knowledge around diagnosis, all those different aspects of what people typically think of when they think of as the doctor, the clinician, the investigator, that's very important. But creating the grounds or the environment such that health can flourish in and of itself, I think that's sort of lost at the moment. And it's conferences like where we are today that are really bringing…
Lord Nigel Crisp: This conference is important. Let me just have a touch on professional education because there's a, I was part of a group which 10 years ago, led by a man called Julio Frenk, who was a Mexican Minister of Health, and then Dean at Harvard, Dean of the School of Public Health from Harvard, and a man called Lincoln Chen, who was president of the China Medical Board, and then a group of us looking at professional education 100 years after it was radicalised by Flexner. You may or may not know your history on this, but the Flexner report, Abraham Flexner in 1910 introduced science into medicine. Kind of important. Germ theory, stuff like that. And it really changed medical education. So we were looking at it 100 years later. And they came up, and it was really them, not me, came up with this, there's three stages to medical education, or professional education, actually, we were talking about professional education, not just medical. There's the informative stage. This is where you become a specialist, where you understand that there are 52 bones in the foot and how they all work, etc. And the pathogenesis, if you like, the specialist bit. The second bit is the formative bit, where you add to that your behaviour and your values and how you handle patients and all that kind of stuff. And then there's the third bit, which is the transformative bit, which is when you become a leader. And going through those three stages and professional education needs to maybe handle those three stages differently. In fact, I think COVID has shown us that that first stage can be handled quite well online. The taking in of the science and the understanding. The second bit, of course, the formative bit and the behaviour and so on, you need to learn with other people and debate. But the transformative bit, you need to learn on the job, learning by doing. And therefore it's about role models, it's about getting traction with these ideas. So we see that professional education needs to change really quite radically to allow people to do that and to bring into it all the social determinants of health, all the health is made at home bit, education, housing, all these sort of stuff, so that you as professionals can be multi-competent and not just, it's a big just. Let me not undervalue, should I get cancer, I want the best specialist in the world. Of course I do. But I don't think I have cancer, if you see what I mean. But there's a big part of health that's not about that.
Dr Rupy: I really agree with that. I mean, the overt focus, I think there's an underlying focus on specialism within the medical community of that's sort of the end goal. But having those two extra pieces, particularly the leadership piece, is really interesting. I want to turn to the concepts in your first and most recent book now, Turning the World Upside Down Again, that's the second book. And this whole concept about what more affluent countries can learn from developing nations. Let's talk a bit about it because you mentioned the temple and the mosque in Bihar as the sources of where you spread the sort of health messages to create a healthier community. What are the concepts underlying your book?
Lord Nigel Crisp: Well, let me give you two examples. And they're mostly about people. I mean, there's some technical stuff and we could talk about that. But actually, they're mostly about people. And let me, the theory here is that, or the experience I've had is that we can learn an awful lot from people who are just as smart as we are, don't have our resources, but they also don't have our baggage of history and of vested interests. So actually, in some ways, they can be freer to think. Now, they've got worse health problems than we have. Let's be clear. It's not a romantic notion. But let me give you two examples. One is Bangladesh. I'm going to stick in Southeast Asia for the moment. And an organisation called BRAC, which was actually founded not as a health organisation, it was founded when Bangladesh split from what used to be East Pakistan. And it was founded for the ultra-poor to give them support. But it now provides a lot of the health services in the country. And its starting point is to empower the women. So it actually runs empowerment classes for women in the villages. As a result of that, more of them are then actually doing some of the things you need to do with your baby. They managed to make child mortality crash by, because a lot of children still in parts of the world die because they've had diarrhoea and their mothers don't know how to rehydrate them. And in fact, actually at the BRAC University, they invented the, they patented the salt that you use. So they get into health and then they realise, of course, what health is connected to everything else. So these women need an income. So they set up a microfinance bank which would give them some money, only to women, by the way. We can talk about that if you want. But only to women. And then they realise, well, we better set up some shops, hadn't we? To sell the produce or whatever. And actually, their schools. And so, and what they've done is they're creating the sort of, they're creating a good society, if you like. They're creating the bits that you need to move from absolute poverty and destitution into self-realisation to some level of fulfilment. And these things are connected. Yet we separate schools over here, hospitals right over there, and employment over here, as it were. And we need to think about how we can bring some of that together. And that again is what a lot of the current thinking, I think, in the UK is coming on. But let me give you a practical example from the other side of the world of something that's happening here in the borough of Westminster. Both in Brazil and in Africa, they have what are called community health workers, which and lady health workers in Pakistan and Ashas they're called in India. And essentially, this is local women who know how to do 20 things, 10 curative and 10 preventative or whatever. Well, a GP, a UK GP who'd worked as a GP in Brazil and is now at Imperial College as a lecturer, brought over the concept and persuaded the primary care group in Westminster to use it. And as of the autumn, there were four community health workers working in Westminster, being mentored by the Brazilian community health workers. And what's really interesting about this group is most health workers react, you react to the patient coming to you and say, I've got a problem, help, doctor. And they often come late, of course. These people visit every household once a month. And they are the entrance way. They can advise people, they can talk to them about contraception or food or whatever. They can do those sort of messages stuff. They can encourage them to get the check-up. They can answer basic questions. They can do all of that. And they can pick up other issues as well. And they are essentially, again, creating health, creating the conditions for people to be healthy. And I understand that it was being so successful even in its first six months that they've spread it to other areas in Westminster. And there's a lot of interest. Now, I wouldn't be at all surprised if in a year's time, 18 months, two years’ time, you didn't see quite a lot of community health workers as part of the new approach to primary care. But a complete mindset change. Turning it upside down. Seeing things in a different way. And because people have come at this with, I mean, my friend Francis Mwazwa, whom I mentioned, has this, he says, Nigel, we don't have the resources, but these are our people. What can we do? So we use what we've got.
Dr Rupy: With my sceptical mindset on, the thought of having an army of community health workers go out into the borough of Westminster and actually being able to catch a number of people and actually deliver health messages sounds like a really ambitious target. But I guess if this is coming from Brazil, which is already a very densely populated country, and I'm assuming it was an urbanised environment.
Lord Nigel Crisp: No, no, no, it was more rural actually. Oh, really? Okay, fine. So that's slightly… It's a mix because Brazil is actually huge and it's got a huge rural country, but it's São Paulo and it's the favelas as well as everywhere. No, but it's not just health messages, it's actually supporting people because we can all see adverts, we can all get messages, but it's actually how do people internalise that? And you as a doctor listen to doctors. We listen to the people who are like us. And if this is my neighbour but ten along, they're the people who influence you about stuff like vaccines, aren't they? People like us, your mates, not even your family necessarily. And so it taps into some much deeper things. Now, it's being researched. I mean, actually in this book, I've got their job description and I've described this story so you can see it's a bit more than just that, but it is that support sort of set of mechanisms. It's to some extent what, perhaps in previous existences, other people in villages may have done in the UK. And maybe a role that the church has played or indeed mosques or synagogues or temples or whatever, supporting people. But it is this concept that we've got to remember that health care is distinct. And actually, if health is about ultimately human flourishing, which it really is, being all you can be, I mean, you know that feeling good about yourself is actually pretty good basis for moving on. And you know that food is kind of good for you and making food and all these sort of things. And actually, if you're also encouraging people to cook or whatever or use fresh vegetables or teaching them how to use some of the stuff that's in season or whatever, making all these sort of links, then you're starting to create a completely different environment.
Dr Rupy: I love that idea of the spread of information and misinformation. There's actually a lot we can learn from the spread of misinformation during COVID, actually. Because you're right, you're more likely and inclined to listen to people that you identify with, who are your peers, and who are in your network. And actually, if you can tap into that storytelling with a positive slant, a nudge, if you like, that's something that could be very powerful when it comes to spreading messages of improving one's locus of control over their own health, whether that be moving more, eating better, sleeping better, etc.
Lord Nigel Crisp: Exactly. It's all those things. We know the evidence of exercise and food. We've heard that for years, but there's now a terrific genuine medical exercise, sorry, medical evidence. I mean, proper stuff that you cynical, sceptical, appropriately so, clinicians will understand about how relationships count. And that actually having meaning and purpose in life. And if you've got a, if you're not social, if you're, if you've got a good social circle and supportive relationships, you recover much quicker from illnesses on average, not always and not all illnesses. And you are more resilient in the face of attack, as it were, on your body. So there's now hard evidence around that. There's hard evidence around meaning and purpose in life being important.
Dr Rupy: I'm a firm believer in that, by the way. And you know, the tenets of health for me, whilst it's easier to look at nutritional medicine and the objective studies that we have and the observational work and all the rest of it, I think sense of purpose, happiness, those perhaps less tangible measures of wellbeing are just as important. And to go back a little bit, actually, looking at the examples that you mentioned in Southeast Asia or Asia, it seems like the distribution of wealth is an important factor when wanting to elevate the health of an area or the nation or a community. This is something that we're struggling with at the moment in the UK and other Westernised nations as well. The inequality in distribution of wealth and the cost of living crisis and inflation, how that's harder hitting on poverty. From a more sort of objective standpoint, if we're looking to improve health on one side, would it stand to reason that we should really be looking at ways in which to redistribute wealth or even create like a blanket system, something like universal basic income, something that's been experimented with in a few different countries?
Lord Nigel Crisp: I think there is a case for universal income. I read two studies yesterday which changed my mind a bit about this. All of yesterday evening, which was actually saying that the biggest correlation between health and money was not actually income, though that was important, it was debt. And it was whether you were in personal debt. Now, if you think about that, the anxiety that comes with that, the inability to do things and all the rest of it, there's a logic to that, isn't there? You can understand that. But if you think about that, you then have to think about, well, actually, what are the policies I would try and introduce to tackle inequalities in health? And it was something like the income affected inequalities by health by a factor of two, and the debt by a factor of four. Oh, wow. Two together by a factor of six. So, you know, this is significant. But actually, you know, there's something to be said for focusing on debt. And in fact, I'm going to be raising this in the House of Lords now that I've read this paper, you know, because I think actually, if we're going, we are in a cost of living crisis and so on, I mean, debt is going to be something that is going to be causing enormous stress and distress and which will therefore also be completely affecting the health service and the health system.
Dr Rupy: Talk us through some other concepts that you've talked about in your book, because I love the idea of community health advocates. I think primary…
Lord Nigel Crisp: Community health workers, actually. Not just advocates. Yes, yeah.
Dr Rupy: I totally agree that primary health care is going to change from one of a top-down approach that people traditionally think of. I go to the doctor when I have a cough or a cold or I'm worried or whatever, to one where it's more about creating environments where health can flourish. This conference is all about that. Dr Michael Dixon has done a lot of work in this in this field. What are the other things that you think we should be really looking at when it comes to creating a salutogenic environment?
Lord Nigel Crisp: Well, the there were four big issues that sort of fell out of it. One was this point about joining up health, education, employment, the big determinants, housing. And again, housing is a huge one. A second one was actually training people for the job and not just for the profession. And there is quite a mismatch. There's something that tends to get called task sharing, where in Africa, for example, people who jobs that doctors might do, nurses might do. So, for example, cataract surgery. Most cataract surgeons in Africa are actually not even nurses, they're clinical officers. But I do remember sitting in a meeting in Addis, Addis Ababa, capital of Ethiopia, with a bunch of people discussing the human resources crisis in Africa. This is about 10 years ago, actually. And there were a bunch of white Americans and Brits and, and there were a few Africans in the room. And one of the young Americans, because you know, one of the sad things, and I go into this in the book, is you get these young people going and telling people what to do. Whereas they, people know what they need doing. They want some help to do it. But anyway, this was an example of that. It was these people saying, you know what you need to do is task shifting. And then, you know, the Africans are terribly polite, but eventually there was a rumbling in the room and they said, look, you send us some doctors and nurses and we'll task shift some tasks to them. You know, think about where you are, mate. We've been doing this stuff for years because actually, if we haven't got doctors and nurses, professionals face up to what they can possibly do. You know? So there's a bit here, and in Africa you get that. In Mozambique, you have a an approach to, well, a young man then, Pascoal Mocumbi, became Minister of Health just after the revolution when they'd thrown the Portuguese out. Same time as BRAC was founded, actually, interestingly. And he found himself, he'd actually trained as a doctor and a nurse when he was in exile in Europe fighting the cause, as it were. And he came back and he was about 30, he became Minister of Health in Mozambique. Funny, he hadn't got any doctors because they were all Portuguese and they'd all gone home. And what was he going to do in particularly rural areas? For the biggest issue he saw, which was helping women deliver safely. Maternal mortality was huge. So he actually started with the help of the Canadians, actually, he started to train nurses as in obstetric operations. Technicos de cirurgia, forgive me anyone who's listening who speaks Portuguese, but technical surgical technicians. And studies published in the British Journal of Obs and Gynae show that over 20 years, they do them as well as clinicians, as physicians in the same environment, third of the cost, and the nurses stay, whereas some doctors are more likely to emigrate. And this still goes on. So this is from 19, what did I say? 1974, wasn't it? Yeah, to now, this process, the surgical technicians are still doing obstetric procedures. A discrete number of obstetric procedures. But you know as a doctor that you've got a panoply of skills. People can learn bits of them. It's you as doctors who've got the whole lot.
Dr Rupy: Yeah, yeah, yeah. And I think there is some sort of, there's definitely something to be learned from specialisation in certain tasks. I have a colleague who's an orthopaedic surgeon, he was burnt out by being in London and going through the whole sort of specialist ladder. I'm sure you're very aware, you know, you have to do a certain number of audits and publications and you have clinics on Wednesdays and all that kind of stuff. And he took some time out and spent some time in Durban, South Africa and Malawi. And when he came back, he was a changed person. It really ignited the passion for medicine that had sort of been beaten out of him by working in an environment where it's very algorithmic and guideline driven. And I wonder if there is something in creating like an exchange programme for NHS experienced doctors going to developing nations, providing support and education training. And it's certainly an exchange, it's not like a charity, you're going to be learning from all the different things that you talk about in your book.
Lord Nigel Crisp: People are doing that actually. But so he was probably working with Chris Lavy. Chris Lavy in in in because that Malawi programme is quite an interesting one because they they invented orthopaedic technicians, not totally unlike the obstetric technicians and doing manipulations and so on and and you know, dealing with club foot with manipulation rather than surgery and some really interesting stuff. So it's a great story. But and people are doing that. And as when I was chief of the NHS, I started to encourage that. And there's an organisation called THET, Tropical Health Education Trust, which organises partnerships. So the nearest hospital here is St Thomas's and they've got links with a number of other hospitals where they send people each way and they learn together. But we need more of it. This is a global world. If you are a GP in East London, the world will walk in your surgery, won't they? So actually, I remember meeting a guy in Ethiopia who's an anaesthetist who said, in Nottingham, we had four cases of TB last year. So I thought I'd come to somewhere where they know about TB because it's obviously on the increase.
Dr Rupy: And you came to East London, did he?
Lord Nigel Crisp: No, he went to Addis, actually. But however, you could do now, couldn't you?
Dr Rupy: Yeah, absolutely. Listen, this has been fascinating. I want to be respectful of your time because I know you're going to be on stage very soon. But I think your book's brilliant and thank you just so much for sharing your knowledge and your wisdom around this. It's going to be very interesting to see what future clinicians are going to be talking about in the next 10, 15 years. And hopefully that stems from medical education as well. Are you privy to some of the sort of the new ways in which we could be looking at training medics from an early stage to appreciate some of these concepts?
Lord Nigel Crisp: Well, I am, but I don't know if I'm talking, you and I are talking about the same ones. I mean, I am quite engaged. This group that I talked about earlier who who were doing, who produced the Lancet Commission for Professional Education for the 21st Century, published in 2010. I'm doing a 10-year update. So I am, but I get a better understanding of it globally than necessarily, I certainly don't know the English politics, as it were, of what's happening. But I know what, I know where some, some of the leading edge stuff globally is. And there's some big and significant changes, including the really important one about getting the right, recruiting from the whole community. And again, some, I talk about some of the people who do that, the Latin American medical school, which deliberately goes out of its way to recruit people from indigenous areas because they work back in indigenous areas and from poor communities and so on. And we need to be thinking about some of that in our country too. So that there is a reflection of the, so that people understand some of the cultural aspects, because we haven't talked about culture, there's big cultural aspects. I don't need to tell you, but you know, there's big cultural aspects in all of this.
Dr Rupy: Just one last thing, actually, on that note before I let you go to the conference. We have a large audience of a mixture of people. We have medics, medical students, nurses, as well as people who don't come from a medical or scientific background, but are really passionate about health and wellbeing. What sort of things should they be looking out for and be potentially getting involved in as well as we move into sort of a healthier living environment and some of the things you're talking about?
Lord Nigel Crisp: Yeah, a healthy society one. Two quick answers to that. One is, it's become even clearer to me than it should have been clearer earlier that the health of an individual is intimately connected with the health of the community, with the health of wider society and with the health of the planet. So actually, it's at any of those levels that people may want to get involved. But my second point is we can't prescribe this top down. The issue here is that if you are living in a particular community or you're aware of a particular set of issues, get stuck into those issues. Don't pick one from my guidelines or my toolkit or whatever. You go and get stuck in and learn by doing. Because these people who are doing this stuff, there isn't a model. There isn't, it's not like medical education, which I know is this very structured set of processes. Actually, these are messy problems in messy in a different sense, as it were, you know, they're wicked problems. So actually, and and and respect the community. There's a great saying from a health visitor in this country, which is, you know, communities know how to cure themselves. And you could apply it in an African village. They know what the issues are. Actually, but maybe they need your expertise, you know, Mr Nurse or Miss Doctor or whoever you are, you know, to help them do it. This is about turning your world upside down again. And it's not just you setting out to heal the world. Actually, you heal the world by helping the world heal itself.
Dr Rupy: Well, you've certainly helped us think a little bit more laterally. So, yeah, thank you very much for that. I appreciate it, Nigel.
Lord Nigel Crisp: Good. Enjoyed the conversation, Rupy.
Dr Rupy: That was great. That was wonderful.
