Duncan Selbie interview: "We've doubled healthcare spending in the past 20 years, yet the health gap has not closed"
Public Health England’s many responsibilities range from obesity to global pandemics, but public protection and promoting healthy life choices are at the heart of them all. Mark Leftly does the rounds with PHE’s chief executive, Duncan Selbie
In the corner of Duncan Selbie’s fifth floor office in Waterloo, a stone’s throw from The Old Vic, there is a small plaque bearing a quote from the founder of analytical psychology, Carl Jung: “Who looks outside, dreams; who looks inside, awakes.”
Selbie, who has been chief executive at Public Health England since this autonomous arm of the NHS was forged from 129 health agencies – including the National Treatment Agency for Substance Misuse and the Health Protection Agency – three years ago, looks embarrassed when asked about the quote.
The 53-year-old Scot mumbles that it was given to him by a communications executive. He is already blushing about a certificate from the Institute of Healthcare Management that hangs proudly on his wall, and he is clearly uncomfortable explaining why he received it.
“I’m very British, you see, so how can I say it’s for ‘Outstanding Contribution for Leadership’?” he smiles, awkwardly. “I’m not North American.”
Eventually, he matter-of-factly states what Jung’s quote means to him: “Public health is all about futures that don’t yet exist.”
PHE employs more than 5,000 staff in around 70 locations across the country and is responsible for tackling sexual health problems, obesity, smoking, drink and drug abuse and even screening for potential pandemics like Ebola. On top of this, it must avert chemical and radiation risks. Selbie, who has been at the organisation’s helm since 2013, says his twin duties are to protect and improve the health of “the people”.
The government dishes out money to local authorities to tackle these issues in conjunction with PHE, but, to the anger of councils, public health funding will be slashed by 3.9% a year in real terms to 2020. This is on top of a £200m cut for 2015/16 made after the Conservatives won last year’s general election.
Alongside the many health-sector voices which condemned the cuts, the Local Government Association’s senior vice-chairman Nick Forbes argued that taking money from services that could be used to prevent illness is “extremely counterproductive”. And it’s not as if the NHS is currently in rude health either: Chris Hopson, chief executive at trade association NHS Providers, recently issued a stark warning that hospitals “cannot provide the right quality of care and meet the performance standards on the money that is available”.
Selbie’s CV is impressive. He joined the health service in 1980, a teenager straight out of school, and worked his way up to become chief executive of South West London and St George’s Mental Health NHS Trust. He has served as director general of programmes and performance, and later commissioning, at the NHS, and – from 2007-2012 – chief executive of Brighton and Sussex University Hospitals NHS Trust. These days, thanks to the profile of a role that sees him regularly interrogated by the Health Select Committee, and given the financial constraints he now faces, the father-of-three’s current job is surely his toughest to date.
But Selbie is unusual among health service leaders in that he is “completely agnostic” about budgetary restraints. He says: “The government actually, of whatever ilk, is already making a huge contribution […] What I’m interested in is the £100bn that goes into the health service and the £100bn that goes into local government and the £100-plus billion that gets spent by the third sector in this country… If you said, ‘would you like another billion?’ Well, why would I say ‘no’ to that? But what I’m much more interested in is how is the billion that BEIS [the Department for Business, Energy and Industrial Strategy] is spending on fuel poverty is reaching the most vulnerable.”
Selbie argues that healthcare has been looked at far too narrowly. He believes PHE can use its expertise to help departments tackle issues that have a public health aspect – hence his concern BEIS better allocates money to those who can’t afford their gas and electricity bills.
In June, Selbie revealed to the Health Committee that he wanted his staff to work with Whitehall departments to deliver strategies and policies that had a public health element. He said that he had met 10 permanent secretaries in six months, talking to, for example, DCMS chief Sue Owen and head of the transport department Philip Rutnam, to help them make their respective sports strategy and air quality plans work.
This harks back to an idea that Selbie told MPs was in place “two reorganisations ago”, though given the constant tinkering with the NHS by successive governments, it was not clear how far back he meant. Selbie insists this system is in fact one he remembers from many years ago, certainly long before the reforms of controversial former health secretary Andrew Lansley, who was the brain behind the creation of PHE.
Selbie says PHE can act as a conduit between departments and local government officials: “We’ve got connections into every local authority in the country. Each of them has a director of public health and a public health team and they know more than we would ever know about where the most vulnerable people are. A Whitehall department, with the best will in the world, would never know at that level of detail.”
PHE staff, Selbie insists, would not be embedded in departments, but officials could phone a “named individual” quickly for advice or ask them to make presentations and take part in policy forums.
This drive seems to stem from Selbie’s belief that health policy is not a silo, but that economic, educational, and social factors are key to improving the lives of the poor. He constantly refers to the “health gap”, which he describes as the 20-year difference in healthy life between someone living in affluent Guildford and struggling Bradford.
“The gap between those in good health and poor health has remained stubbornly unaffected at least for the last 20 years and arguably for the last 40,” says Selbie, who pertinently has a copy of Peter Dreadman’s Live Well, Live Longer on his bookshelf, a work that explores Chinese teachings of a “nourishing life”.
He continues: “We have universal healthcare, we have doubled the spend on healthcare in the past 20 years and yet we’re not seeing a closing in that health gap.
“It’s an economic question, because long-term unemployment is a recurring theme with the people we’re talking about. It doesn’t really matter whether you’re looking at the problem through an economic lens or a health lens. They’re the same.”
As well as economics, Selbie believes that companionship is key to a healthier life. He’s aware that might sound a little new age, but points out that this can be as simple as an elderly person being comfortable in the knowledge they have someone to take them home after a hospital operation.
If changing economics is out of PHE’s reach, Selbie does have two immediate concerns: safe sex and alcohol. PHE made headlines last year for a study that showed e-cigarettes are 95% less harmful than ordinary tobacco, and he is also proud that a PHE smartphone app outlining Britain’s sugar consumption reached 1.3 million people.
However, sexually-transmitted infections remain high, with worrying increases in gonorrhea and syphilis. Next year PHE will launch a social media campaign highlighting the need to use condoms, though Selbie will leave this to his boffins – he confesses to barely being able to use email.
Selbie refuses to provide full details on how PHE will tackle the UK’s notorious alcohol consumption problem, but calorie labelling is clearly on the agenda. In essence, drinkers are far more worried about the impact on their waistlines than their livers.
“We’re doing an evidence review at the moment – it’s out to peer review,” Selbie says. “We’ll give our best advice to government about what might be done to reduce alcohol harm as a nation. For certain groups of people, knowing the calorie content of alcohol would make a difference, we believe that to be the case.”
In 1961, Bill Wilson wrote to Jung saying that his teachings were a pivotal inspiration for him in co-founding Alcoholics Anonymous. Selbie lacks the audacity of a North American like Wilson to link himself so closely with Jung.
But it’s clear the softly spoken Scot’s plaque means more to him than he lets on. Be it alcohol, tobacco or safe sex, Selbie believes that the country needs to take a good look at itself and its wider problems before it can fully resolve its health issues.
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