Upsetting the apple cart

David Ogilvie and Phil Hanlon

August 2005

Image (c) Stephen Mcwilliam / Fotolia

© Stephen Mcwilliam / Fotolia

In another article we argued that technical and environmental fixes are not going to be enough to address the emerging obesity epidemic. We suggested that in order to address the real causes of obesity, we will need to stop ignoring the contradictions in our individual and collective choices and bring about more fundamental changes in society. A similar argument could be advanced for some other contemporary public health problems.

We previously contributed to The Fifth Wave, a report of the Scottish Council Foundation's Healthy Public Policy Network which argued that although much has been achieved in public health, some of our established ways of doing things in and through public sector organisations may have largely run their course and now offer diminishing returns. Further advances in population health may depend less on technocratic or bureaucratic activity, and more on releasing authentic personal action and change — which can sometimes be constrained or prevented by our current organisational structures and processes.

We wondered how a new way of working might begin to take shape in a public health department...

At last, thought Dr Sisyphus as she struggled through the door of her office with the usual clutch of briefcases. Ten minutes' peace before the next meeting.

She put on the kettle and sat down at her desk. The trouble with being a director of public health, she thought, is that the paper just keeps on piling up; she couldn't remember the last time she'd seen the surface of her desk. She flicked through the new arrivals in her in-tray: new performance targets on healthy eating, feedback from the recent obesity strategy workshop... oh blast, she thought, that trainee still hasn't given me his chapter on obesity for the annual report, and we're supposed to go to press next week.

She got up to make some coffee. How has it come to this? she wondered. A quick caffeine fix and bolting down a pastry, when we're spending millions on a helpline to tell people how to eat properly. And it's not as if I'm losing weight with all this rushing around. Dragging my spare tyre up to the department every day is wearing me out, but I suppose I should set the right example since we put up all those stair-climbing posters next to the lifts.

There was a knock at the door. It was Ernest, the trainee. He was brandishing an evidence summary published by one of those national agencies — what was its name this month? "It says here," he explained, "that systematic reviews have found no good evidence that any population-level intervention to prevent obesity has been effective. Do you think we should mention this in the annual report after those figures showing the rise in mean body mass index in the local population?"

As if anyone takes any notice of what we say, thought Dr Sisyphus. "Ernest," she said, "is this the best we can do? Churn out the same old depressing data and hope they might eventually prod the rest of the world into taking the issue seriously? I've been chipping away at the Intersectoral Healthy Weight Strategic Implementation Management Advisory Group for the last three years, but all we've got to show for it is a new executive bike rack outside the council headquarters. Not much good for the performance assessment, is it? Where's Jamie Oliver when we need him?"

"You think we need celebrity endorsement?" said Ernest.

"People took notice of him, didn't they? Who on earth reads the DPH annual report?"

"Fair point," said Ernest. "But it wasn't just because he was famous. He touched a nerve... and when you saw him with the kids, you could tell he felt strongly about what was going on. And some people seem to make things happen without being famous. Look at the McCartney sisters. They got to meet George Bush, and who had ever heard of them? They decided what needed to be done and then just went for it."

"Is that what you think we should be doing, Ernest?" asked Dr Sisyphus. "Didn't they teach you anything about building coalitions and multi-agency working on that MPH course we paid for you to go to?"

"Well, yes," said Ernest, "of course they did. But they also taught us about John Snow. He wasn't afraid to go for the jugular and take the handle off the pump, was he?"

Funny, thought Dr Sisyphus, I thought that was a great story when I was a trainee, too, but I don't see the Intersectoral Group biting any bullets like that. Not when everything has to be approved by the senior management of all fifteen partner organisations.

"Anyway," she said, "I must run. Joint community planning group this afternoon... and I don't seem to have the papers. Where's Doris? Oh, I remember, she wanted a half day off today for some reason. Oh well, too bad."

Later — much later — Dr Sisyphus got home. Wound up and worn out as usual, she collapsed onto the sofa in front of the TV news. I could just do with a curry, she thought. Where's the cordless phone? Digging in her handbag for the takeaway menu, she came across her gym membership card. Special rates for NHS staff! One of these days, she thought, I might actually go back there. Maybe in the new year.

She saw a familiar face on the TV. Oh, she thought, that's the chief constable. What's he up to this time? It seemed he'd become so angry about all the new bars opening in the town centre that he'd decided to turn up in person to oppose the licensing applications. Blimey, thought Dr Sisyphus, he must feel strongly about that if he's bothering to go himself.

The next news item was something about planning permission for a new fast food restaurant. She saw the usual clutch of sixties throwbacks waving placards and shouting something about globalisation. Ah, she thought, the naivety of youth. Then, suddenly, she saw someone else she recognised. Who was that in the front row? Surely not! It was Doris, her secretary.

Dr Sisyphus was used to appearing on TV, of course; she was the authoritative talking head wheeled out whenever there was a screening scandal or yet more MRSA at the local hospital.

Before she knew it, the programme cut to a vox pop with "Doris, local resident". "This planning decision is a disgrace," said Doris, "not just because we don't need another fast food restaurant, but because it's going to replace the historic market! Where will people be able to buy their cheap fruit and veg now? And where will the local farmers sell their produce?"

"But Doris," said the reporter, "aren't you pleased about the planning deal that will see a new superstore opened out on the ring road instead?"

"You have got to be joking," said Doris. "They fly in their apples from the other side of the world, even during the British apple season. Have you ever compared their prices with the market stalls? And more than half the people who live in the town centre don't even have a car. No, I'm sorry, there's something far wrong with our priorities in this town."

My goodness, thought Dr Sisyphus. This is really important to her. I never knew she had it in her. But she can't be allowed to behave like this.

Early next morning, back in her office and fortified by a breakfast bap from the drive-through — one of the benefits of the relocation of the public health department to the motorway business park — Dr Sisyphus rummaged through her filing cabinet to find the disciplinary code. Just as I thought, she sighed. Talking to the media without permission is a ground for dismissal. Human resources will be on the phone by nine o'clock. We're going to have to sack her. It's just as well she didn't say where she worked — our planning partners would be furious.

Just then, the phone rang. Here we go, thought Dr Sisyphus. The inquisition is about to begin.

"Hello, Dr Sisyphus," said an unexpected voice. "Joe Commoner here."

Joe Commoner? she thought. The council leader? "What can I do for you, Councillor?" she replied.

"I thought I recognised that woman on the telly last night," he said. "She works in your place, doesn't she? I've seen her bringing in the papers for meetings."

Bad news travels fast, thought Dr Sisyphus. "Yes," she admitted, "but let me make clear that our department had nothing to..."

"What a breath of fresh air," said Councillor Commoner. "I've been thinking the planning regulations were no good for years, but I couldn't find a way to get anyone to take any notice. But what Doris said... it made me realise. This stuff really does matter. When can we meet to put the case together?"

Dr Sisyphus reached for her coffee. Here I am reading about gross misconduct, when Doris is the one who's actually broken through and got someone to take notice at last. What on earth am I going to do with her now? And after that, what am I going to say in my annual report?

There was a knock at the door.

"Ah, Doris," said Dr Sisyphus. "Come in. I might as well dictate this to you now."

Introduction to the annual report

Our public health intelligence unit has continued to provide detailed analysis of local health problems and our progress in addressing them. These analyses form the essential foundation and direction for our action to improve health in this town.

We have also continued to work closely with our partner organisations, ensuring that the links between health and other sectors are recognised and that the decisions made take account of the health needs of local people.

These themes have provided the main content of previous annual reports. This year, however, things are changing in the public health department...

How do you think Dr Sisyphus should continue? Contribute here.

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Text © David Ogilvie and Phil Hanlon (2005) and licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 2.5 Licence.

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