Durable Design: Constructing Practical, Enjoyable, and Sustainable Urban Environments

Air pollution, traffic congestion, litter, noise, and patchwork concrete – elements synonymous with the concept of a city and simultaneously at odds with the conception of what a city could be – green spaces, intuitive and efficient public transport, cycleways and walkways. Though form follows function, it seems most of our urban spaces are not optimised for pedestrians, business, social engagement, nor vehicular traffic, and instead constitute a fairly ‘unhappy middle’ for all. Part product of poor design, part product of inadequate foresight, and part product of necessity during development (from the Main streets of a horse-drawn cart era), the urban landscape is often seen to represent an inevitable inconvenience (or ‘necessary evil’) (1) as an evolved compromise between these competing requirements for different users. Though all urban design must balance such factors as local demography, local industry requirements, commuter demands, continually evolving technology, and population shifts, present conditions are of languorous and reactionary tendencies towards meeting the needs of urban dwellers and commuters, and the ever pressing need for climate action.

From another perspective it is important to consider the two-way influence the urban landscape of cities on inhabitants, and the manner in which decisions around city design can impact and influence populations in positive ways; leading the very direction in which cities develop, rather than simply reacting to the purported needs of users. As a case study, though ostensibly inseparable in the minds of many international jetsetters, Amsterdam and bicycle riding have not always experienced a loving relationship and given the turbulent politics and protests of the 1970s. Examining the forces at play during this period, it is apparent that for Amsterdam, the transition from an automobile-centric to active transport friendly city would perhaps not have eventuated without the combination of both strong grassroots activism and bold top-down leadership on cycling infrastructure (2), leading the city in a very different direction to the urban and social landscape we see today. In essence, though an impetus for change existed in the hearts of a vocal cycling population, Amsterdam represents a city that grew into a cycling utopia and not simply as the perpetuation of an inherent and established status quo.

Though construction of a cycling-centric CBD is not appropriate for a great many cities due to factors ranging from local topography to climatic demands, capitalising and building on sustainable modes of transportation that aim to increase social capital and make urban centres safer and more accessible places for work and leisure is the important underlying principle. No single rigid solution and no pre-specified set of rules exists to guide this kind of change and development; cities must engage with the structures already on the ground and actively work with and respect the existing complexities (27). Though what is the right fit for one city or neighbourhood will unlikely suit another, we can always learn from the successful examples already deployed around the globe. Practical and pragmatic approaches to this somewhat nebulous idealism of improved urban design might include upgraded cycling infrastructure (3), the ‘pedestrianization’ of main streets and central areas (4), careful and considered attention to improving the specific pathways and areas of natural people movement in cities (23), and realising the central role that well-designed public transport can play in increasing social capital – including among socially disadvantaged groups (5).

Unfortunately the present paradigm of suburb-living city-commuting with the concomitant protraction of commute time seems suboptimal for health and wellbeing (6), a situation likely exacerbated by the trend towards urban sprawl. Outside direct negative health impacts of the urban environment mediated through exposure to air pollution (7), infectious diseases (a risk especially true for developing and non-OECD nations (8, 9)), motor vehicle accident risk, and unhealthy diets (10), there are implications for the social and preventive health activities that necessarily come second to work commitments. With more time expended commuting, individuals have less time available to invest in their own health - with food preparation, physical activity, and sleep representing the most sacrificed domains (11, 12). Given both current and expected population growth in urban areas, current underdeveloped public transport systems represent a kind of kryptonite exacerbating traffic congestion and reliance on private transport (24).

Additionally, the environmental (13, 25), social, and negative health impacts of urban sprawl (12, 13, 14, 15) represent inextricably related challenges as a case study of Ontario illustrates, linking the urban sprawl land use with higher per-capita energy use, automobile dependence, emphasis on private realms over public space, increased servicing cost, and longer commutes (16). To further emphasise, it can be seen that although a distal factor, the design of urban and build environments represents a central common determinant of both human health and environmental impact, (the latter importantly being critically related to the former) (26).

 Though difficult to quantify and spread across a range of sectors certainly inclusive of human health and environmental sustainability, there can be many anticipated benefits in the adoption of a salutogenic approach to the design of the urban landscape that prioritises active commuting, efficient public transportation, social green spaces, and pedestrian activity. Chronic lifestyle diseases of obesity, type 2 diabetes, and hypertension are likely influenced by the walkability of urban environments (17) and even small increases in daily physical activity across a large proportion of the population are likely to yield health benefits (18). Promotion and support of active commuting where possible is also likely to bring population health benefits (19) and self-evident benefits for carbon emissions (20, 21). Furthermore, investment in efficient and inclusive public transport systems that both replace the need for private transport, permit urban intensification (22), and reduce the deleterious health and environmental effects of sprawl (13) represents a true cornerstone of improving urban design. 

 Clever design of the urban environment holds the potential to concurrently and synergistically improve human health and promote environmental sustainability but at present most of our cities and towns lack the requisite infrastructure and investment. As demonstrated by the Amsterdam case study, a combination of persistent grassroots pressure and bold top-down leadership is likely required to effect change in such a space, but the intersectoral payoff from such a paradigm shift constitutes an undisputably worthwhile cause.

T Michniewicz, 09/09/19

Reference

1. World Health Organization (2019) ‘Urbanization trends’[online]. Regional office for South East Asia. Available from: <http://www.searo.who.int/entity/health_situation_trends/data/chi/unbanization-trends/en/> [Accessed: 09/09/2019].

2. Van Der Zee, R (2015) ‘How Amsterdam became the bicycle capital of the world’. The Guardian. Available from: <https://www.theguardian.com/cities/2015/may/05/amsterdam-bicycle-capital-world-transport-cycling-kindermoord> [Accessed: 09/09/2019].

3. Kirschbaum, E (2019) ‘Copenhagen has taken bicycle commuting to a whole new level’. Los Angeles Times. Available from: <https://www.latimes.com/world-nation/story/2019-08-07/copenhagen-has-taken-bicycle-commuting-to-a-new-level> [Accessed: 09/09/2019].

4. Global Designing Cities Initiative (2019) ‘Pedestrian only streets: case study Stroget, Copenhagen’ [website]. Available from: <https://globaldesigningcities.org/publication/global-street-design-guide/streets/pedestrian-priority-spaces/pedestrian-only-streets/pedestrian-streets-case-study-stroget-copenhagen/> [Accessed: 09/09/2019].

5. Currie, G and Stanley, J (2006) ‘Investigating links between social capital and public transport’. Transport Reviews. 28(4): 529-547. DOI: 10.1080/01441640701817197. Available from: <https://www.tandfonline.com/doi/abs/10.1080/01441640701817197> [Accessed: 09/09/2019].

6. Hansson, E, Mattisson, K, Bjork, J, Ostergren, P and Jakobsson, K (2011) ‘Relationship between commuting and health outcomes in a cross-sectional population survey in southern Sweden’. BMC Public Health. 11:834. DOI: Available from: <https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-11-834> [Accessed: 09/09/2019].

7. Black, C (2019) ‘Air pollution’ [website]. World Health Organization. Available from: <https://www.who.int/sustainable-development/cities/health-risks/air-pollution/en/> [Accessed: 09/09/2019].

8. Neiderud, C (2015) ‘How urbanization affects the epidemiology of emerging infectious diseases’. Infection Ecology & Epidemiology. 5(1). DOI: 10.3402/iee.v5.27060. Available from: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4481042/> [Accessed: 09/09/2019].

9. Berg, N (2016) ‘As cities grow more crammed and connected, how will we discourage the spread of disease?’ [website]. Ensia.com. Available from: <https://ensia.com/features/as-cities-grow-diseases-spread-faster-and-urban-design-key/> [Accessed: 09/09/2019].

10. World Health Organization (2019) ‘Nutrition insecutiry and unhealthy diets’ [website]. Available from: <https://www.who.int/sustainable-development/cities/health-risks/nutrition-insecurity/en/> [Accessed: 09/09/2019].

11. Christian, T (2012) ‘Trade-offs between commuting time and health-related activities’. Journal of Urban Health. 89(5): 746-757. DOI: 10.1007/s11524-012-9678-6. Available from: <https://link.springer.com/article/10.1007/s11524-012-9678-6> [Accessed: 09/09/2019].

12. Taylor, A (2019) ‘Why Sydney’s urban sprawl is harmful to your health’. The Sydney Morning Herald. Available from: <https://www.smh.com.au/national/nsw/why-sydney-s-urban-sprawl-is-harmful-to-your-health-20190906-p52os0.html> [Accessed: 09/09/2019].

13. Gallagher, P (2001) ‘The environmental, social, and cultural impacts of sprawl’. Natural Resources & Environment. 15(4): 219-223. Available from: <http://www.jstor.org/stable/40924406> [Accessed: 09/09/2019].

14. Frumkin, H (2002) ‘Urban sprawl and public health’. Public Health Reports. 117(1): 201-217. Available from: <https://pdfs.semanticscholar.org/8e5f/c4b34a20cfea33061313de1c9568342f4855.pdf> [Accessed: 09/09/2019].

15. Garden, F and Jalaludin, B (2008) ‘Impact of urban sprawl on overweight, obesity, and physical activity in Sydney, Australia’. Journal of Urban Health. 86(1): 19-30. Available from: <https://link.springer.com/article/10.1007/s11524-008-9332-5> [Accessed: 09/09/2019].

16. Environmental Commissioner of Ontario (2019) ‘Urban sprawl: the road to gridlock’ chapter in 2019 Energy Conservation Progress Report. Office of the Auditor General of Ontario. Available from: <https://docs.assets.eco.on.ca/reports/energy/2019/why-energy-conservation-04.pdf> [Accessed: 09/09/2019].

17. Chandrabose, M, Rachele, J, Kavanagh, A, Owen, N, Turrell, G, Giles-Corti, B and Sugiyama, T (2019) ‘Built environment and cardio-metabolic health: systematic review and meta-analysis of longitudinal studies. Obesity Reviews. 20(1):41-54. DOI: 10.1111/obr.12759. Available from: <https://www.ncbi.nlm.nih.gov/pubmed/30253075> [Accessed: 09/09/2019].

18. Department of Health and Social Care, Welsh Government, Department of Health, Scottish Government (2019) ‘UK chief medical officers’ physical activity guidelines’. UK Government. Available from: <https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/829841/uk-chief-medical-officers-physical-activity-guidelines.pdf> [Accessed: 09/09/2019].

19. Shephard, R (2012) ‘Is active commuting the answer to population health?’. Sports Medicine. 38(9):751-758. DOI: 10.2165/00007256-200838090-00004. Available from: <https://link.springer.com/article/10.2165/00007256-200838090-00004> [Accessed: 09/09/2019].

20. Maibach, E, Steg, L and Anabele, J (2009) ‘Promoting physical activity and reducing climate change: opportunities to replace short car trips with active transportation’. Preventive Medicine. 49(4):326-327. DOI: 10.1016/j.ypmed.2009.06.028. Available from: <https://www.sciencedirect.com/science/article/pii/S0091743509003326> [Accessed: 09/09/2019].

21. Bourne, G, Steffen, W and Stock, P (2018) ‘Waiting for the green light: transport solutions to climate change’. Climate Council, Australia. Available from: <https://www.climatecouncil.org.au/resources/transport-climate-change/> [Accessed: 09/09/2019].

22. Duffhues, J and Bertolini, L (2015) ‘From integrated aims to fragmented outcomes: urban intensification and transportation planning in the Netherlands’. The Journal of Transport and Land Use. 9(3): 15-34. DOI: 10.5198/jtlu.2016.571. Available from: <https://www.jtlu.org/index.php/jtlu/article/download/571/811> [Accessed: 09/09/2019].

23. Dalton, R (2019) ‘Making cities more walkable by understanding how other people influence our journeys’. The Conversation. Available from: < https://theconversation.com/making-cities-more-walkable-by-understanding-how-other-people-influence-our-journeys-111767> [Accessed: 09/09/2019].

24. Robson, K, Gharehbaghi, K and Scott-Young, C (2018) ‘Planning effective and efficient public transport systems’. International Journal of Real Estate and Land Planning. Vol. 1.

25. Brody, S (2013) ‘The characteristics, causes, and consequences of sprawling development patterns in the United States’[online]. Nature Education Knowledge. 4(5):2. Available from: <https://www.nature.com/scitable/knowledge/library/the-characteristics-causes-and-consequences-of-sprawling-103014747/> [Accessed: 09/09/2019].

26. Bambrick, H, Capon, A, Barnett, B, Beaty, M and Burton, A (2011) ‘Climate change and health in the urban environment: adaptation opportunities in Australian cities’. Asia Pacific Journal of Public Health. 23(2). DOI: 10.1177/1010539510391774. Available from: <https://journals.sagepub.com/doi/abs/10.1177/1010539510391774> [Accessed: 09/09/2019].

27. Greenspan, E (2016) ‘Top-down, bottom-up urban design’. The New Yorker. Available from: <https://newyorker.com/business/currency/top-down-bottom-up-urban-design> [Accessed: 09/09/2019].

A Coalface Canary

One of the saddest aspects of healthcare is when the failings of a system are presented as the failings of an individual

It’s 2am and the emergency department is snowed under. Despite your best efforts to work through your meal break, the arrivals continue to mount, the wait times continue to climb. Ambulance trolleys now line any available corridors and the incessant alarming of bedside monitors rises above the background chatter to create a seemingly perpetual atmosphere of tension and anxiety. Steeling yourself before picking up the next case you glance left at a colleague, hoping to catch a sentiment of solidarity, some kind of acknowledgement to know you’re not alone in this moment but it never comes - they’re 15 minutes deep into a heated phone conversation with the medical registrar who is not having an ounce of Beryl’s abdominal pain admitted under them. On scrutinising the waiting list there is medical acuity at every level, and no smart way to sequence the languishing chaos of patients - a 90 year old gentleman with small bowel obstruction, 20 year old female with loss of her first pregnancy, 16 year old boy post attempted suicide awaiting medical review. Any system of triage or prioritisation seems heartless but idealism must play second fiddle to pragmatism, and now is not the time for philosophising. Even the indulgence of budget granulated instant coffee feels like an affront to the dozen nil-by-mouth patients anxiously waiting for CT scans and ultrasounds, and it would seem to require either transcendent zen mastery or sociopathic tendencies to take a meal break at a time like this. By nature, the emergency department represents the frontline and a kind of bottleneck for patient suffering, the weight of which is not one easily expunged from the forefront of the mind.

At a systems level, the interface of an ever-fluctuating patient load and fixed-staffed department without the inbuilt liquidity (if you will) to adapt, and meet increasing demand with increased throughput - and a ‘learned’ over-reliance of such strain being taken up by individuals working longer and harder. Such pressure on scarce healthcare resources, more specifically in an ED environment, seem manifested in protracted wait times and the very real human experiences of pain, anxiety, uncertainty, and additional time until definitive care - an omnipresent reality felt by all frontline healthcare staff. Equally concerning is the observed and expected workforce shortfalls both nationally (5) and internationally (6, 7, 8, 9) working synergistically with increasing hospital presentations (10) to create a perfect storm for medical error, clinician burnout, and poor patient outcomes; the emotional toll of which is not likely amenable to extra yoga sessions (11). Although as described much of this increased demand may well be taken up by staff working harder and faster, this is not without consequence, with a demonstrated association between increased time or production pressure poorer quality care, and rates of medical error (12, 13, 14, 15) especially true for emergency departments (16). It is therefore further regrettable that the fallout from adverse outcomes occurring in such a system, almost as a rule, rest with the unfortunate treating medic frequently without consideration of the situation in which she or he was operating (17). We can see many of these points highlighted in a recent British Medical Association report (18), which succinctly and unambiguously describes the signs, symptoms, and outcomes of a health system under pressure: burnout, longer ED wait times, poorer quality of care, and repercussions for patient safety (8, 18).

It is easy to feel helpless and disempowered when confronted with such a reality, and it is probable that without significant restructuring of resource redistribution and financial bolstering of the health system from a higher policy level that hospital access block, patient safety, and healthcare worker wellbeing will remain a regrettable reality (19). But several under-utilised and viable strategies exist for health networks and hospital administrators to address some of the immediate challenges that hospitals and emergency departments face. To begin, an immediate recommendation must be that more flexibility be built into the emergency department to better manage anticipated and unanticipated fluctuations in patient presentations; achievable from both a resource and staffing flexibility point of view (20) and through use of modern solutions such as statistical modelling and the practical application of queueing theory (21, 22, 23). Furthermore, the fundamental importance of adequate staffing, matching staff to accommodate peak patient periods, and having a critical mass of senior medical officers available in the department is mandatory to ensure high quality care can be provided (24). If we cannot first get the basics right and provide the current gold standard of medical care to every patient every time due to workforce and healthcare systems shortcomings, then we must collectively realise that in cutting edge frontier research and development into expensive and novel biomedical intricacies we are unlikely to find salvation.

I have always felt the existence of an especially hazy line between the issues attributable to shortcomings of a healthcare system and those I attribute to myself as personal inadequacies; rarely more so pronounced than whilst working in the emergency department. This is a dichotomy well elucidated by Reason (2000)(ref. 4), highlighting the conditions which make individual blame the dominant ideology in medicine when we think about medical errors. This is a mental dichotomy I propose exists also in the daily battles of healthcare, in procedural wait lists, in ED corridors, and in the race to always do more, and to do it faster.

In one hand an individual narrative - I can always envisage myself as working harder, better, faster, stronger; and taking lengthening wait-times as a personal failing, indicative of the very real human pain and anxiety ongoing prior to definitive care. If only I didn’t take the coffee break, if only I had read up on this presentation last night, if only I wasn’t so slow at taking blood, if only I could touchtype better. This mentally destructive thoughtline runs like a common thread through healthcare, peddled and perpetuated by the training atmosphere and culture of medicine so historically ingrained as to seem inextricable the profession, and an almost universal to those working in health - with stories such as Yumiko Kadota’s a fairly saddening indictment of the current climate (1).

In the other hand a health systems narrative - a statistically unpredictable and fluctuating patient load intersecting with a fixed-staffed department, interwoven with bottlenecks of imaging and diagnostic services, coupled with the exponentially increasing documentation requirements (2) and medicolegal ramifications that pervade the modern healthcare climate mean that the system itself is fundamentally incapable of accommodating the idealistic throughput so avidly sought by administration. Such turnover not possible without due counterbalance of briefer and riskier consultations, run with the kind of heuristic, seat-of-your-pants, system 1 thinking required for high turnover - this risk becoming entirely inherited by the individual practitioner, as evidenced in the Bawa Garba saga (3).

And there seems no way to truly reconcile these two competing storylines, not least any satisfactory armistice with which I am familiar. For myself, and I am sure for many others, this cognitive tug-of-war will continue without reprieve, each day and each shift, undulating between a sense of guilt from personal shortcomings, and helplessness as a cog in the wheel. I don’t know that there is ever going to be any clearer of a line between the two, and I don’t know that a happy middle ground or goldilocks zone truly exists somewhere between crippling self-doubt or jaded cynicism at each extreme. What I do know is that I am unconditionally grateful to all who can compose themselves to work and thrive each day in such an environment - let such steadfast dedication not be undervalued.

NB: All situations and patient cases described above are for illustrative purposes only and do not relate to any specific persons. The health situation detailed above is fictional and does not reflect any scenario occurring in any specific hospital, health network, or district, at any time. All patient case details are fictional and for illustrative purposes only, and as such, any association to real cases, health networks, hospitals, or situational similarities are therefore entirely coincidental and unintentional.

T Michniewicz, August 2019

Reference

1. Kadota, Y (2019) ‘Physically alive but spiritually broken: why I had to resign as a junior doctor’. The Guardian [online]. Available from: <https://www.theguardian.com/commentisfree/2019/feb/08/physically-alive-but-spiritually-broken-why-i-had-to-resign-as-a-junior-doctor> [Accessed 02/08/2019].

2. Xu, R (2018) ‘A major medical crisis: doctor burnout’. The Atlantic [online]. Available from: <https://www.theatlantic.com/health/archive/2018/05/the-burnout-crisis-in-health-care/559880/> [Accessed 07/08/2019].

3. Ketchell, M (2018) ‘What happened in the Bawa-Garba case and why was reinstating her the right decision?’. The Conversation [online]. Available from: <http://theconversation.com/what-happened-in-the-bawa-garba-case-and-why-was-reinstating-her-the-right-decision-101606> [Accessed 02/08/2019].

4. Reason, J (2000) ‘Human error: models and management’. BMJ. 320(7237): 768-770. Available from: <https://www.jstor.org/stable/25187420> [Accessed: 09/08/2019].

5. Calderwood, K and Miskelly, G (2018) ‘NSW needs nurses as ‘catastrophic’ shortage predicted to affect patient care’. ABC News. Available from: <https://www.abc.net.au/news/2018-01-12/nsw-set-for-major-shortage-of-nurses-and-midwives/9321464> [Accessed: 09/08/2019].

6. Campbell, D (2018) ‘NHS ‘could be short of 350,000 staff by 2030’. The Guardian. Available from: <https://www.theguardian.com/society/2018/nov/15/nhs-could-be-short-of-350000-staff-by-2030> [Accessed: 08/08/2019].

7. The Economist (2019) ‘A shortage of staff is the biggest problem facing the NHS’. Available from: <https://www.economist.com/britain/2019/03/23/a-shortage-of-staff-is-the-biggest-problem-facing-the-nhs> [Accessed: 08/08/2019].

8. Johnson, S (2018) ‘Patient safety hit by lack of staff, warn 80% of NHS hospital workers’. The Guardian. Available from: <https://www.theguardian.com/society/2018/mar/18/hospitals-staff-shortage-nursing-nhs-rcn-patient-care-sarah-johnson-survey> [Accessed: 08/08/2019].

9. World Health Organization (2013) ‘Global health workforce shortage to reach 12.9 million in coming decades’ [online]. Available from: <https://www.who.int/mediacentre/news/releases/2013/health-workforce-shortage/en/> [Accessed: 08/08/2019].

10. Australian Institute of Health and Welfare (2018) ‘Emergency department care 2017–18: Australian hospital statistics’. Health services series no. 89. Cat. no. HSE 216. Canberra: AIHW. Available from: <https://www.aihw.gov.au/getmedia/9ca4c770-3c3b-42fe-b071-3d758711c23a/aihw-hse-216.pdf.aspx?inline=true> [Accessed: 09/08/2019].

11. Girgis, L (2018) ‘Meditation, yoga, and mindfulness aren’t going to solve physician burnout’. Kevin MD [website]. Available from: <https://www.kevinmd.com/blog/2018/10/meditation-yoga-and-mindfulness-arent-going-to-solve-physician-burnout.html> [Accessed: 10/08/2019].

12. Zavala, A, Day, G, Plummer, D, Bamford-Wade, A (2018) ‘Decision-making under pressure: medical errors in uncertain and dynamic environments’. Australian Health Review. 42(4):395-402. doi:10.1071/AH16088. Available from: <https://www.ncbi.nlm.nih.gov/pubmed/28578757> [Accessed: 10/08/2019].

13. AlQahtani, D, Rotgans, J, Mamede, S, Mahzari, M, AlGhamdi, G, Schmidt, H (2018) ‘Factors underlying suboptimal diagnostic performance in physicians under time pressure’. Medical Education. 52(1): 1288–1298. doi:10.1111/medu.13686. Available from: <https://onlinelibrary.wiley.com/doi/pdf/10.1111/medu.13686> [Accessed: 10/08/2019].

14. Tsiga, E, Panagopoulou, E, Sevdalis, N, Montgomery, A, Benos, A (2013) ‘The influence of time pressure on adherence to guidelines in primary care: an experimental study’. BMJ Open. 3(4): e002700. doi:10.1136/bmjopen-2013-002700. Available from: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3641486/> [Accessed: 10/09/2019].

15. Carayon, P (2007) ‘Production pressures’. Patient Safety Network [website]. Available from: <https://psnet.ahrq.gov/webmm/case/150/> [Accessed: 10/09/2019].

16. Adams, J and Bohan, S (2000) ‘System contributions to error’. Academic Emergency Medicine. 7(11):1189-1193. Available from: <https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1553-2712.2000.tb00463.x> [Accessed: 10/09/2019].

17. Ketchell, M (2016) ‘Blaming individual doctors for medical errors doesn’t help anyone’. The Conversation [website]. Available from: <https://theconversation.com/blaming-individual-doctors-for-medical-errors-doesnt-help-anyone-28212> [Accessed:10/09/2019].

18. British Medical Association (2018) ‘Working in a system that is under pressure’. Available from: <https://www.bma.org.uk/collective-voice/influence/key-negotiations/nhs-pressures/working-in-a-system-under-pressure> [Accessed: 09/08/2019].

19. Cameron, P (2006) ‘Hospital overcrowding: a threat to patient safety?’. MJA. 184(5):203-204. Available from: <https://www.mja.com.au/system/files/issues/184_05_060306/cam11160_fm.pdf> [Accessed: 10/08/2019].

20. Ward, M, Ferrand, Y, Laker, L, Froehle, C, Vogus, T, Dittus, R, Kripalani, S and Pines, J (2015) ‘The Nature and necessity of operational flexibility in the emergency department’. Annals of Emergency Medicine. 65(2):156-161. doi:10.1016/j.annemergmed.2014.08.014. Available from: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4302065/> [Accessed: 10/08/2019].

21. Alavi-Moghaddam, M, Forouzanfar, R, Alamdari, S, Shahrami, A, Kariman, H, Amini, A, Pourbabaee, S and Shirvani, A (2012) ‘Application of queuing analytic theory to decrease waiting times in emergency department: does it make sense?’. Archives of Trauma Research. doi:10.5812/atr.7177. Available from: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3876544/> [Accessed: 10/08/2019].

22. Chowdhury, N, Riddles, L, Mackenzie, R (2018) ‘Using queuing theory to reduce wait, stay in emergency department’. American Association for Physician Leadership [website]. Available from: <https://www.physicianleaders.org/news/queuing-theory-reducing-wait-stay> [Accessed: 10/08/2019].

23. Vass, H and Szabo, Z (2015) ‘Application of queuing model to patient flow in emergency department. case study’. Procedia Economics and Finance. 32(1):479-487. Available from: <https://www.sciencedirect.com/science/article/pii/S2212567115014215> [Accessed: 10/08/2019].

24. Northern Rivers University Department of Rural Health (2009) ‘Literature review of emergency department staffing redesign frameworks’. The University of Sydney and Southern Cross University, Australia. Available from: <https://www.health.nsw.gov.au/workforce/Documents/literature-review-emergency-department-staffing.pdf> [Accessed: 10/08/2019].

Health: Upstream Interventions, Social Determinants, and Looking Back in Time

Health investment must adopt a more intensive upstream approach towards proven high-value interventions, and step away from its sci-fi fascination with the new, the expensive, and the unnecessary.

It’s a sunny Tuesday and i’m sitting in with a general practitioner who has just been handed a dozen-page scientific report by her patient. “You can see here, it’s tested all the important genes and tells you what diseases I am at risk of, and which medications are going to work for me and which ones aren’t.” The report from a private genomic testing service professes to examine the patient’s entire genetic profile and create percentage-point accurate estimations of everything from the risk of cardiovascular disease through to how the patient is likely to respond to individual medications ranging from warfarin to metoprolol. This specific report states that the patient is likely to require a higher dose of the anticoagulant warfarin than others, predicted due to her unique genetic composition. “I’m not really sure what to do with this right now” replied the GP, and in a perfect sentiment, had summed up what I imagine to be the entire profession’s response to the promise of personalised medicine that has been so prematurely laid fourth to anxious and cashed-up health consumers by the medico-industrial complex (1). Health is complex, but in our hastened rush towards reductionist, biochemistry-centric, science fiction-esque devices and technologies we have forgotten the basic building blocks of holistic and preventive care; the high-value upstream interventions that are the bedrock of population health (2). Although clearly attractive to some, personalised-dose rosuvastatin based on genome profiling should not be on the same playing field as such sensible evidence-based recommendations as to walk more and avoid processed foods.

Our patient here is far too well to be seeking out pills and potions for ailments she is yet to even experience, but this privileged position of the worried well is not universal. Often in healthcare patients that are seen are at points of deterioration of chronic illnesses, complications of grumbling poor health and lifestyles accumulating to a breaking point. These situations are regrettably common; the geriatric patient with orthostatic hypotension and falls, alcoholic now with liver failure, brittle asthmatic with another ICU admission, and diabetic with recurrent lower limb ulcers, are archetypal. There are certainly enough conditions for which their preventable, or at least manageable nature pushes any clinician to speculate what could have been done to prevent this at some stage earlier in the cascade. Such times are a necessary moment of sadness but from these examples we must look outwards to those patients yet to develop complications, at every stage of health, and consider how the pillars of primary, secondary, and tertiary prevention might best be leveraged. Health must be seen for every patient as more than a snapshot in time, but always as an opportunity to affect the trajectory of future wellbeing.

So we arrive at a model of health which considers that time opportunity for maximum value and maximum benefit for an intervention for any given our health issue. Such a model naturally illustrates how such upstream determinants of health represent both a common risk factor for many adverse health outcomes as well as an opportunity for cost-effective action with the potential to improve health trajectories over a lifetime (3). For the chronic non-communicable diseases over-represented in western society, almost any example can be traced in such a manner; from the adverse socioeconomic conditions, poor diet, and sedentary lifestyle through to the third cardiac stent in an atherosclerosis-laden coronary artery.

We need to increase our focus and funding of those traditionally soft enterprises of managing the social circumstances, proven community services that keep patients out of hospitals and manage health at early opportunities in a holistic and patient centred manner - funding longer GP consultations that focus on preventive care (4), linking patients to social workers, occupational therapists, population-wide access to dentists for early preventative care (5), early childhood services, safe emergency shelter and social housing, and youth employment services (7, 8). This isn’t especially revolutionary or idealistic utopian daydreaming, and social housing programmes have already demonstrated both real-world viability and tangible, immediate cost-savings, in the region of $13,273 saved for every $6,462 spent per person year(6). The more distal and intangible health benefits that accrue over a lifetime for individuals who receive such early preventive care are far more challenging to quantify, and even for well researched single-item health interventions, mortality benefit estimates vary considerably (7). Attaching a numeric figure to the benefit of a preventive care activity such as increased access to social workers is unlikely to be accurate or reliable, but this uncertainty betrays how worthwhile such investment is likely to be (8).

The value of public health domain preventative activities such as vaccination and smoking cessation programmes are almost universally recognised as economically worthwhile health investments, both examples further enhanced in the public mind by their underpinning mechanistic biomedical narrative; ‘exposure to a an attenuated pathogen primes the immune system to fight a burlier version later on’. The ongoing push to decrease smoking and increase vaccination rates is a noble enterprise but we should not be limited to consider only hard science approaches to primary prevention. Although mental health has garnered increasing attention in recent years as an undervalued and underfunded aspect in any holistic picture of health (9, 10), potential health and societal benefits from primary and secondary prevention in mental health represents a domain for which we seem to have only scratched the surface. From a clinical perspective, poor mental health often appears as a lurking factor in the relationship between poor health and poor medical care, preventing individuals from taking charge of their health. It’s hard to schedule a dentist checkup or book that blood test when you can’t find the motivation to get out of bed, or knowing you’ll experience a panic attack in a GP’s noisy waiting room. And the effects of poor mental health are seen down the line, as the progression of the trivial into the life-changing due to loss to follow up; and the occurrences of the entirely preventable disease due to self-neglect. Again, mental health is the underlying, but organic medical ailments are the symptom.

To realise the capacity for change in the entire trajectory of patient health at a population level will require concurrent investment in both the traditional, tangible, biomedical alongside the overlooked, softer, social welfare and mental health domains. Science fiction technology will never substitute the basic building blocks of health; equitable access to primary care, social supports, safe housing and food supplies…; and it is a truth that health systems seem painfully reluctant to concede.

T Michniewicz, August 2019

Reference

1. Maughan, T (2017) ‘The promise and the hype of ‘personalised medicine’"‘. The New Bioethics. 23(1): 13-20. doi:10.1080/20502877.2017.1314886.

2. Masters, R, Anwar, E, Collins, B, Cookson, R, Capewell, S (2017) ‘Return on investment of public health interventions: a systematic review’. Journal of Epidemiology and Community Health. 71(1): 827-834. doi:10.1136/jech-2016-208141.

3. Gehlert, S, Sohmer, D, Sacks, T, Mininger, C, McClintock, M, Olopade, O (2008) ‘Targeting health disparities: a model linking upstream determinants to downstream interventions’. Health Affairs. 27(2):339-349. doi:10.1377/hlthaff.27.2.339.

4. Sim, M and Khong, E (2006) ‘Prevention - building on routine clinical practice’. Australian Family Physician. 35(1): 12-15. Available from: <https://www.racgp.org.au/afpbackissues/2006/200601/200601sim.pdf> [Accessed: 03/08/2019].

5. Mouradian, W, Wehr, E, Crall, J (2000) ‘Disparities in children’s oral health and access to dental care’. JAMA. 284(20):2625-2631. doi:10.1001/jama.284.20.2625.

6. Wood, L, Flatau, P, Zaretzky, K, Foster, S, Vallesi, S, Miscenko, D (2016) ‘What are the health, social and economic benefits of providing public housing and support to formerly homeless people?’. Australian Housing and Urban Research Institute. Melbourne, Australia. doi:10.18408/ahuri-8202801. Available from: <https://www.csi.edu.au/media/uploads/AHURI_Final_Report_No265_What-are-the-health-social-and-economic-benefi..._2edQIWr.pdf> [Accessed: 03/08/2019].

7. Ewald, B, Mar, C and Hoffmann, T (2018) ‘QUantifying the benefits and harms of various preventive health activities’. Australian Journal of General Practice. 47(12). Available from: <https://www1.racgp.org.au/ajgp/2018/december/quantifying-the-benefits-of-preventive-health> [Accessed: 03/08/2019].

8. Shrank, W, Keyser, D and Lovelace, J (2018) ‘Redistributing investment in health and social services - the evolving role of managed care’. JAMA. 320(21):2197-2198. doi:10.1001/jama.2018.1498.

9. Australian Institute of Health and Welfare (2019) ‘Mental health services in Australia’ [online]. Available from: <https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/expenditure-on-mental-health-related-services> [Accessed: 04/08/2019].

10. Sparrow, A (2018) ‘Mental health services get £2bn funding boost in budget’. The Guardian. Available from: <https://www.theguardian.com/uk-news/2018/oct/28/mental-health-services-to-get-2bn-funding-boost-in-budget> [Accessed: 04/08/2019].