1 00:00:00,510 --> 00:00:06,090 Welcome to the Oxford Psychiatry Podcast series, today's podcast will be a little bit different. 2 00:00:06,090 --> 00:00:11,790 I'm here with Dr. Daniel Ball to talk about his work in sustainability. 3 00:00:11,790 --> 00:00:17,700 He's taken two years out of his psychiatry training to think about sustainability. 4 00:00:17,700 --> 00:00:22,650 So, Daniel, could you tell me a little bit more about what you're doing at the moment? 5 00:00:22,650 --> 00:00:26,910 Thank you, Charlotte. Hopefully it will be different, but also interesting and different. 6 00:00:26,910 --> 00:00:30,510 Sustainability is something which is difficult to get your head around. 7 00:00:30,510 --> 00:00:37,920 But once you do, I think it's quite an interesting paradigm or interesting way of thinking about mental health services. 8 00:00:37,920 --> 00:00:46,800 So what am I doing at the Royal College of funded a two year post to think about sustainability of mental health? 9 00:00:46,800 --> 00:00:55,980 They've chosen a clinician because they realise the importance of thinking about sustainability from a clinical perspective. 10 00:00:55,980 --> 00:01:04,650 So the next two years will be about thinking through what a mental health service looks 11 00:01:04,650 --> 00:01:13,860 like when it is improving and sustainability when the practise is when the governance, 12 00:01:13,860 --> 00:01:23,700 when the interventions are thought about from a sustainable perspective and improvements are made that reduce the impacts, 13 00:01:23,700 --> 00:01:32,670 the broad impacts that services are having on society, the environment and economically as well. 14 00:01:32,670 --> 00:01:38,160 It sounds a very broad remit that you might be involved in lots of different things. 15 00:01:38,160 --> 00:01:42,330 But could you just give us a flavour of what exactly sustainability is? 16 00:01:42,330 --> 00:01:46,010 Sustainability is a very broad subject and it can be quite confusing. 17 00:01:46,010 --> 00:01:53,250 It rose out of the corporate out of corporate America when they were trying to understand what corporate responsibility should be, 18 00:01:53,250 --> 00:01:56,760 trying to understand the broader impacts of an organisation. 19 00:01:56,760 --> 00:02:02,940 And John Elkington came up with the triple bottom line as a framework for understanding sustainability. 20 00:02:02,940 --> 00:02:08,520 So an organisation has impacts in three broad areas. People profit and planet. 21 00:02:08,520 --> 00:02:12,390 So it has impacts on society, on communities, 22 00:02:12,390 --> 00:02:22,230 and has impacts on profit and the money that they're making or the money that they are using and has impacts on the environment. 23 00:02:22,230 --> 00:02:25,620 So when we think of our mental health services and sustainability, 24 00:02:25,620 --> 00:02:31,650 what we need to realise is that every everything that you do, every drug you prescribe, 25 00:02:31,650 --> 00:02:41,980 every intervention has a financial cost and environmental cost and the social cost or another way of thinking about this is about capitals. 26 00:02:41,980 --> 00:02:47,700 So if you think about the fact that we have financial, environmental and social capital, 27 00:02:47,700 --> 00:02:52,770 well, the first two, we need to make sure we reduce our impact on those capitals. 28 00:02:52,770 --> 00:02:57,600 And I think actually mental health services should be restoring social capital because 29 00:02:57,600 --> 00:03:04,140 mental health conditions can reduce social capital by reducing community contacts, 30 00:03:04,140 --> 00:03:08,010 reducing employment rates, things like that. 31 00:03:08,010 --> 00:03:14,430 So mental health services should be restoring social capital. So we think about it in those three areas. 32 00:03:14,430 --> 00:03:20,490 Right. Another way of thinking about sustainability is that analogy of a factory. 33 00:03:20,490 --> 00:03:25,980 We have a factory, say, in Europe somewhere that is producing the most wonderful teddybear, the cheapest price. 34 00:03:25,980 --> 00:03:27,960 And you think, well, it's a fantastic factory, 35 00:03:27,960 --> 00:03:36,750 but actually you take a broader look and you realise that that that factory is working its workers to the bone so that they their morale is low, 36 00:03:36,750 --> 00:03:40,770 their relationships break down because they're spending all the time at the factory. 37 00:03:40,770 --> 00:03:48,480 The factory don't give pay them enough so they can't send their children to school and you find that they're polluting the river a lot. 38 00:03:48,480 --> 00:03:56,220 So what you find is that although it's a great product for small cost, the environmental and social impacts are really significant. 39 00:03:56,220 --> 00:03:58,470 And in a sense, the NHS is doing that. 40 00:03:58,470 --> 00:04:06,180 We are delivering really good interventions for small amounts of money, which is great, and I don't want to knock that. 41 00:04:06,180 --> 00:04:08,910 But actually, if you look at the environmental impact, it's huge. 42 00:04:08,910 --> 00:04:16,590 It's the equivalent of a few sub-Saharan Africa countries put together or a couple of Eastern European countries. 43 00:04:16,590 --> 00:04:18,790 And actually, if you look at some of the social impacts, 44 00:04:18,790 --> 00:04:26,040 the staff experienced patient experience or actually what the NHS is thinking about in terms of contributing to communities, 45 00:04:26,040 --> 00:04:30,240 to local communities and the impact that it could have, it's just not thinking in these ways. 46 00:04:30,240 --> 00:04:34,350 And just like that factory needs to wise up a bit. 47 00:04:34,350 --> 00:04:40,530 The NHS needs to wise up to the fact that it has a lot of potential to improve its practise and a 48 00:04:40,530 --> 00:04:51,420 lot of scope to really build build communities and be an inspiration really to other organisations. 49 00:04:51,420 --> 00:05:00,270 And as health care professionals, we should be leading the way in this regard. But I can see for a service such as, say. 50 00:05:00,270 --> 00:05:05,670 Renal dialysis, there might be a lot of savings that you can make that might have an impact on the individuals 51 00:05:05,670 --> 00:05:10,020 and communities and also on the environment and the planet thinking about water usage. 52 00:05:10,020 --> 00:05:18,270 For example, how would this exactly relate to mental health services where we might be using less resources to some degree? 53 00:05:18,270 --> 00:05:29,130 How can we make that move? It's a very good question. I think that it is easier for the technical specialities, like kidney care, like anaesthetics, 54 00:05:29,130 --> 00:05:37,170 where they're using a lot of materials to focus on what the environmental impact of that is. 55 00:05:37,170 --> 00:05:42,840 But a way that I think about it is we use the bio psychosocial framework, biological, 56 00:05:42,840 --> 00:05:47,880 psychological and social framework to keep a patient healthy when actually any health 57 00:05:47,880 --> 00:05:53,910 organisation needs to use the triple bottom line to keep the service healthy. 58 00:05:53,910 --> 00:05:57,830 So when we think about mental health services, actually medications. Right. 59 00:05:57,830 --> 00:06:05,670 So if you if you look at studies, about 50 percent of patients that we prescribe medication to actually take kids, 60 00:06:05,670 --> 00:06:13,080 if you look at the carbon footprint of medications, they are about 20 percent. 61 00:06:13,080 --> 00:06:21,610 So they're about 10 percent of the income for the NHS is produced by pharmaceuticals that aren't being used. 62 00:06:21,610 --> 00:06:27,210 OK, so what do you think about that? What about maximising adherence? 63 00:06:27,210 --> 00:06:39,870 Another thing is looking at things like how can we reduce clinic attendance by empowering patients to manage their own care so 64 00:06:39,870 --> 00:06:50,480 that there is a different relationship and a different less reliance on services so that empowering patients is about prevention. 65 00:06:50,480 --> 00:06:55,560 It's about the lead service analysis and it's about using technology. 66 00:06:55,560 --> 00:07:03,000 I'm quite excited about the potential for using technology, for educating patients, 67 00:07:03,000 --> 00:07:07,350 for using online cognitive behavioural therapy techniques that have good, 68 00:07:07,350 --> 00:07:17,040 good evidence that first actually peer to peer support networks for patients actually to have access to the electronic notes 69 00:07:17,040 --> 00:07:25,350 and be able to write on them and monitor their symptoms using texting from their smartphones onto a Web based platform. 70 00:07:25,350 --> 00:07:28,470 There's lots of different areas that we can really empower patients, 71 00:07:28,470 --> 00:07:34,260 really educate patients to manage their own conditions more and therefore reduce reliance on services. 72 00:07:34,260 --> 00:07:40,410 And we know that reduce reliance on services actually is less costly financially. 73 00:07:40,410 --> 00:07:50,280 It's less costly for the environment actually, and hopefully will restore them back to an independent functional state in that community. 74 00:07:50,280 --> 00:07:53,550 Therefore, restoring social capital. Wow. 75 00:07:53,550 --> 00:08:00,200 I mean, it sounds like the sustainability agenda then could really improve things on so many different levels. 76 00:08:00,200 --> 00:08:06,620 Actually, when you look at the constraints of the health services at the moment, they're really significant. 77 00:08:06,620 --> 00:08:10,990 So the Climate Change Act says we need to reduce emissions by 80 percent by 2050. 78 00:08:10,990 --> 00:08:19,860 And that's not necessarily legally binding. We're not going to be thrown in prison if we don't meet them, but the NHS is committed to meet them. 79 00:08:19,860 --> 00:08:26,040 If you look at the funding, we're unlikely to get any real time funding increase for the next 10 years for 80 00:08:26,040 --> 00:08:31,740 activity in mental health services increases about four or five percent per year. 81 00:08:31,740 --> 00:08:37,590 How do you think that increase in activity, if you look at the population growth with the fastest population. 82 00:08:37,590 --> 00:08:41,880 We've got the fastest rate of population growth in Europe. How are we going to deal with that? 83 00:08:41,880 --> 00:08:46,250 Mental health services, actually, if you look at society as well. 84 00:08:46,250 --> 00:08:54,420 It changes all the time using social networking sites. Urbanisation, sustainability is something which not only deals with the constraints, 85 00:08:54,420 --> 00:09:02,520 but also moves with the times and gets you thinking about how to engage with society in a preventative way, 86 00:09:02,520 --> 00:09:11,880 not in a not necessarily an individual illness focus, but establishing a community health focussed, preventative and empowering. 87 00:09:11,880 --> 00:09:19,260 I say that as more of a sustainable way of looking at mental health services from a systems point of view. 88 00:09:19,260 --> 00:09:23,640 It sounds like this all makes sense and it's all a really good idea. 89 00:09:23,640 --> 00:09:29,590 But why should psychiatrists or other clinicians actually be interested in this? 90 00:09:29,590 --> 00:09:33,960 What's in it for them? Yes, that's a big question. 91 00:09:33,960 --> 00:09:43,590 It's very difficult to when you speak to clinicians who are overly stressed with their day to day work, 92 00:09:43,590 --> 00:09:48,930 with their day to day clinical burden to get them to think big. 93 00:09:48,930 --> 00:09:59,710 I think patients need to be interested because actually this is a Win-Win if they can begin to see new ways of practise. 94 00:09:59,710 --> 00:10:05,590 To say, which I mean, I've got some ideas I don't have out of it by any means, you know, we we need to work together. 95 00:10:05,590 --> 00:10:10,210 That's part of the network that I'm creating, a sustainability representative network. 96 00:10:10,210 --> 00:10:18,760 We're trying to build up a body of all bank of case studies and experience of what sustainability looks like on the ground. 97 00:10:18,760 --> 00:10:30,790 And we find what you find is, is that there are some things we can do which make life easier for ourselves by, as I've said before, 98 00:10:30,790 --> 00:10:39,010 reducing burden on services, but also working together and having a greater responsibility for your service in general. 99 00:10:39,010 --> 00:10:44,080 And I believe in is a sense of community amongst staff members. 100 00:10:44,080 --> 00:10:52,610 So whilst you might be stressed out by himself, by working together on these things, you can really foster a positive spirit. 101 00:10:52,610 --> 00:11:02,750 And also, I think there needs to be a broader responsibility for amongst clinicians, for the health of their service. 102 00:11:02,750 --> 00:11:07,090 We're in a situation where the NHS isn't guaranteed for the next 50 years. 103 00:11:07,090 --> 00:11:17,530 And we need to really be an advocates for showing politicians and commissioners that we can produce high quality services that are fit for the future. 104 00:11:17,530 --> 00:11:19,360 And we need to think actively about that. 105 00:11:19,360 --> 00:11:27,250 So I think our responsibility does lie in broad, broader terms than necessarily just the patient sitting in front of us. 106 00:11:27,250 --> 00:11:33,340 And clinicians have a history of forward thinking. And I think sustainability is that. 107 00:11:33,340 --> 00:11:38,440 Can you give me a snapshot of what a sustainable mental health service would look 108 00:11:38,440 --> 00:11:44,410 like or perhaps any specific examples about what you're doing locally in Oxford? 109 00:11:44,410 --> 00:11:52,720 Right. Okay, so I think one particular area, when you mentioned kidney care is being an easy way to think about sustainability. 110 00:11:52,720 --> 00:11:58,660 If somebody needs dialysis, they just need dialysis. Well, or they need a new kidney. 111 00:11:58,660 --> 00:12:02,920 But if somebody has a mental health condition, yes, they need all the management. 112 00:12:02,920 --> 00:12:09,490 They need the medication and psychotherapy, the support the mental health services can bring. 113 00:12:09,490 --> 00:12:13,210 But there is also a lot of work that they can do to help themselves. 114 00:12:13,210 --> 00:12:25,690 So I would say there's something about a sustainable mental health services that has recovery as a priority at every step along the patient journey. 115 00:12:25,690 --> 00:12:35,210 It also is one that's developed structures within the community that can maintain mental health. 116 00:12:35,210 --> 00:12:42,130 So an interesting thought is that for people with chronic health conditions for 117 00:12:42,130 --> 00:12:51,220 hours spent in front of a clinician compared to the 4800 hours spent at home, 118 00:12:51,220 --> 00:12:55,060 clinicians tend to focus on the four hours they see the patient was actually we should 119 00:12:55,060 --> 00:13:01,150 really be enabling the patient to deal with those 4800 hours away to improve that. 120 00:13:01,150 --> 00:13:13,870 One way that we think about that in Oxford, as you've asked, is, is the true colours intervention, which is something run by Professor Geddes here, 121 00:13:13,870 --> 00:13:22,960 which is a mood monitoring service and now is more than mood monitoring any kind of mental health symptoms where you texted it on your smartphone, 122 00:13:22,960 --> 00:13:27,790 it goes to a Web based platform. You can see how your your symptoms are doing. 123 00:13:27,790 --> 00:13:32,110 Say you've been drinking a lot. The symptoms aren't so good. You stop drinking, your symptoms improve. 124 00:13:32,110 --> 00:13:35,130 You think, oh, I should maybe not drink as much as I do. 125 00:13:35,130 --> 00:13:42,880 It teaches patients, enables patient, empowers patients to manage their own condition a bit more as one example that we've got. 126 00:13:42,880 --> 00:13:48,080 OK, and are you taken two years out for the Sustainability Fellowship? 127 00:13:48,080 --> 00:13:56,980 What kinds of things are you doing during this fellowship? Well, I'm trying to understand how to measure sustainability. 128 00:13:56,980 --> 00:14:05,440 That's looking at the bottom line framework. People profit think not trying to think not just how much the service costs financially, 129 00:14:05,440 --> 00:14:10,990 but what the environmental impacts, one of the social impacts of an intervention. 130 00:14:10,990 --> 00:14:19,390 We're scoping out potential review of the complex needs service here in Oxford is a potentially sustainable service. 131 00:14:19,390 --> 00:14:29,050 We are building a network which you can join if you go to the Centre for Sustainable Health Care's website and click on the Mental Health Network. 132 00:14:29,050 --> 00:14:32,860 On the left hand side, you can join a mental health sustainability network. 133 00:14:32,860 --> 00:14:42,340 We've got an increasing number of members, currently around 70, which is grown since since in the past month or so, 134 00:14:42,340 --> 00:14:51,160 as I've been beginning to advertise that that's really a sharing of ideas and opportunities for improving sustainability. 135 00:14:51,160 --> 00:14:56,560 And I'm also developing a college record for sustainability. 136 00:14:56,560 --> 00:15:00,100 And really, it's about. 137 00:15:00,100 --> 00:15:10,530 Creating a context for change, not only telling clinicians about how to think sustainably, but also giving them the tools to do that as well. 138 00:15:10,530 --> 00:15:17,380 OK, what are the challenges that you're facing when you're trying to do this work? 139 00:15:17,380 --> 00:15:20,860 Yeah, I think the challenges are a number of levels. Sustainability is very broad. 140 00:15:20,860 --> 00:15:31,750 It's difficult to get get your teeth into. So I think for providing case studies and practical examples are the key to that. 141 00:15:31,750 --> 00:15:41,680 Another key challenge is prevention, because as we squeeze as clinicians, 142 00:15:41,680 --> 00:15:47,080 it's very easy to become squeezed in your clinical practise to just fight fires. 143 00:15:47,080 --> 00:16:01,690 And sustainability is about forward thinking. It's about planning future opportunities or future relapse risk with your patients. 144 00:16:01,690 --> 00:16:07,270 It's really about prevention. And that could be a struggle when there's so much of a squeeze. 145 00:16:07,270 --> 00:16:17,020 There's also the challenge of working with teams, because you might find that as an individual, it really is tricky for sustainability. 146 00:16:17,020 --> 00:16:21,710 But getting the team empowered to change practise can be quite difficult as well. 147 00:16:21,710 --> 00:16:26,140 And I think sustainability is only going to become more important. 148 00:16:26,140 --> 00:16:36,610 We only have a finite amount of resources that we realise at a very high level of David Nicholson and Malcolm Grant. 149 00:16:36,610 --> 00:16:44,230 Malcolm, across the chair of NHS England since just resigned as the CEO of NHS England. 150 00:16:44,230 --> 00:16:48,520 And they've got sustainability. We they realise the importance of the agenda. 151 00:16:48,520 --> 00:16:53,710 And I think it's only going to get more important. But it's about realising the clinician. 152 00:16:53,710 --> 00:16:58,960 It's a it's a clinicians agenda today. 153 00:16:58,960 --> 00:17:03,970 It's not an agenda of tomorrow. That's not going to be a challenge. All right. 154 00:17:03,970 --> 00:17:12,880 Well, thank you very much. That was a really good introduction to sustainability and the benefits it can have on people on the planet and on profits. 155 00:17:12,880 --> 00:17:20,980 And it really does sound like it's going to be something that we all need to take on and think about in our day to day practise. 156 00:17:20,980 --> 00:17:26,410 You mentioned it once briefly, but could you just reiterate, if other people are interested in getting involved in this, 157 00:17:26,410 --> 00:17:33,460 how can they contact you and how can they get involved in this? Yes, if you're interested, please do get in touch with me. 158 00:17:33,460 --> 00:17:39,550 If you the best way to find me is on the Centre for Sustainable Health Care website, 159 00:17:39,550 --> 00:17:49,720 or you can go to my blog on RCF site, dot org, UK Forward Slash Sustainability or you can tweet me at sustainable site. 160 00:17:49,720 --> 00:17:55,840 So thank you, Sean. We'll certainly look forward to hearing about how you get on and hearing about how your plans develop. 161 00:17:55,840 --> 00:17:58,282 Thank you very much. Thanks.