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Yn y bennod hon, rydym yn archwilio atal yn ei ystyr ehangaf - ar draws systemau, cymunedau a bywyd bob dydd.

In this episode, we explore prevention in its widest sense - across systems, communities and everyday life.

Professor Jim McManus, National Director of Health and Wellbeing at Public Health Wales, explains why prevention remains one of the toughest challenges in health and care. He shares how poverty, place and inequality still shape life expectancy in Wales, and why we must shift prevention from a “side programme” to the organising principle of the whole system.

Jim argues that prevention isn’t just about saving lives — it’s about economic productivity, community resilience and human connection. As he puts it: “You can’t compete with China if you can’t get off the sofa.” He highlights what needs to change — from the way we educate children and design services, to how we empower voluntary organisations and digital tools to make healthy choices easier.

This conversation builds on our recent episode with Rachel Hope from NHS England, zooming out from digital prevention to the broader human and economic cycle that keeps people well. Prevention, Jim reminds us, is possible — but only if we design systems around people, not programmes.

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Transcript

Sam: 0:01

You can't compete with China if you can't get off the sofa. Public health and the economy are two sides of the same coin. When people are healthier, they're more productive. And when the economy thrives, we can invest more in keeping people well. But that cycle is breaking. In Wales, one in 11 people are expected to have type 2 diabetes by 2035. Incredibly, 90% of those cases are preventable.

Without change, that means more amputations, more sight loss, and more lives cut short. Across the UK, 40% of illness and early death is preventable. Yet our system still defaults to reaction. In this month's conversation, we're exploring what it would take to make prevention the way we work by design, not by exception.

Hello, this is Problems Worth Solving, the podcast where we meet people transforming health and care through human-centered design and digital innovation. I'm Sam Menter, founder and managing director at Healthia, the Collaborative Service Design Consultancy. If you enjoy listening, you can subscribe to this podcast and the accompanying newsletter at healthier.services. When I spoke with Rachel Hope from NHS England about digital prevention, one thing struck me. We still tend to treat prevention as something separate when it should be how the whole system works. So the conversation got me thinking about the bigger picture.

Today, we're zooming out, exploring prevention in its widest sense with Professor Jim McManus, National Director of Health and Wellbeing at Public Health Wales. He's tackling one of the toughest challenges in the UK: why people in Wales live shorter, less healthy lives than they should, with deep inequalities between communities. Jim is a chartered psychologist and one of the country's leading public health thinkers. He's shaped national policy on mental health, drugs, alcohol, and suicide prevention. Now his focus is on how prevention can move from a side program to the organizing principle of the whole system. Jim, thank you so much for joining me today. How would you describe the big problem you've been trying to solve?

‍Jim: 2:31

It's a compound problem that's taken decades to create of people across the UK who die too early and who don't have good enough health for long enough. And there's multiple parts to it. One of them is that we are too poor at doing prevention well, at preventing things before they start. And I'd probably reflect that my dad was a bus driver, my mother was a factory worker, and I grew up in a mining and farming village. And there was almost an assumption that you worked hard, you had bad health at an age, and you got particular diseases. And I'd kind of like to turn that around because it doesn't have to be the case.

Sam: 3:09

Wales has shorter, less healthy lives than it should, and big inequalities between communities. How much of a factor is that in the work that you're doing?

Jim: 3:18

I think it's a huge factor because if you look at the recent work on premature death that was published across the UK and the work published in Wales, and uh within the last couple of months, it looks at people who die under the age of 75. And in Wales, you know, the highest premature death rates are in areas like Blineau Gwent and Meth of Tidville, whereas Monmouthshire and Paris report marks lower rates. And there's a variety of things in that. One is poverty, one is jobs, one is education. Women fare worse than men. People in the 10% of local authorities with the highest early death rates are nearly twice as likely to die early compared to the people in the lowest 10% like months. So that's about socioeconomic factors, things like ethnicity, things like jobs, things like poverty, wealth account for quite a lot of that.

Sam: 4:11

If prevention was built into the way the whole system works and it wasn't just a program, but it was the default approach, what would people notice had changed about their everyday lives?

Jim: 4:20

I think you'd notice a lot. So when you look internationally, the UK actually lags behind peer nations as a whole, the whole of the UK. And you'd notice, I think, that you arrived at school with every child having the same vocabulary level as any other. So you wouldn't have some children much more ready for school than others. You'd arrive at school with every child being able to be resilient and ready to cope with life's knocks. Every child would have a full stomach, which some of our kids don't. You'd have uh every child would walk to school in an area with good air quality, you'd have really good dental care, and you wouldn't have early decay. And all of these, plus getting all of your vaccinations, they all set your health later in life. They they really do. And then when you leave school, you'll go into a good job with good work that has a good work-life balance, that doesn't predispose you to early musculoscolitial disease, for example. You'll manage to see a healthy weight. Physical activity will be the default for you in terms of daily physical activity. You'll have the ability to choose and you'll be able to afford good food. You'll have good healthcare services around you when you need them that will pick you up early, and you'll see life expectancy grow. But you'll also see people live what we call disability-free life expectancy. You'll see people's ability to live longer in better health with less disability and less preventable disease for much longer. So my dad got, I was a bus driver, he had a heart attack at the age of about 45, he died at the age of 69. You'd see people actually not having serious preventable disease until later on in their 50s, if we really got prevention right. I mean, things like cancer will always be with us, but we can reduce it. But if we go the way we're going now in Wales, by 2035, one in 11 people will have diabetes type 2, which is 90% preventable. And of that population, you know, that predisposes to amputations and to all sorts of things. So we'd shift that. You'd see older people happily and contributing to society in the way that older people can. I might I might sound like I'm painting a picture of utopia, but it's doable and some countries have managed it.

Sam: 6:48

That list that you reeled off there, it sounds incredible, doesn't it? And I was sitting there listening and thinking, well, does it not just sometimes feel completely overwhelming, just the scale of what you're trying to achieve there?

Jim: 6:58

Yeah, it it does. I mean, it's a marathon, not a sprint. But I didn't kind of enter public health not to be daunted. And I think what's the value of a public health professional is to look around and actually identify the things that can make a difference to our population and make them happier and healthier, but also more prosperous. You know, that health and economy are intimately linked, and the healthier we are, the more prosperous we will get because you can't compete with China if you can't get off the sofa. If you look at what happened, so from an Irish and Scottish background, over the course of about a hundred years, the life expectancy of the population I came from improved dramatically because the school system professionalized us and taught us how to get better jobs. Of course, it when that started going badwards from alcohol and smoking and everything else, but it just shows you what you can achieve if you put your mind to it and work at a system. And this is doable. I really truly believe that.

Sam: 7:55

The role that you're describing is moving away from health and into politics. It's kind of system change that you're talking about. Do you see your role as a political role or more as a health role?

Jim: 8:06

I think there's a level where public health is innately political with a small peer because it sooner or later gets into public policy. And it's so I I was in local government for many years of my life, and one of the best things about being in local government at senior level is you're politically restricted, which is a good thing. You know, you have to be publicly neutral, and it forces you to speak from the evidence and not from your own views. So I think there's a risk if in things like public health we get too political with a big P, then we stop serving all sections of the public. Our job is to enable policymakers and decision makers to make good policy by giving them the right information about what will work. So I kind of care that the information we give people is is understandable and actionable as much as I care that it's accurate, if you like. And there's something about the old ethos of public service that's in there. Um, I'm not a politician, I don't want to be, but I do want to be a servant of the public.

Sam: 9:09

So there must be a tension between your influencing policy, policy is influencing commerce. And so there might be things that are good for public health that aren't good for commerce.

Jim: 9:19

Yeah, I think you need a level of pragmatism. I tend to think that if something is good for health, it will be good for business if you if you get it in the right way. So selling people products that kill them with tobacco is now becoming bad business, as you can see from the reaction from industry. I think there is something around an ethical business. I mean, we want business to make profit, we want business to to generate wealth. Because that's actually an important determinant of health. Why wouldn't we? It's how you generate it in a way that that harms or helps people. And so things like the Welsh policy on local procurement and the Welsh policy on food standards, all of these things I think are aiming to get good business that builds net health in populations. And you'll see some of the big companies who actually passionately care about that. I don't think there has to be a conflict if you take a really enlightened approach to profit and wealth and business sustainability and keeping your market. Keeping your consumers healthy is in your interest because you get customers more loyal for longer. I think you have to be a little bit idealistic in this game, otherwise, why do it?

Sam: 10:35

Where do you think we should draw the line between partnering with industry to improve health and regulating industry to protect people? And who do you think should be making the decisions around where that line is?

Jim: 10:47

Do I think it's a decision for elected politicians because they are the servants of the public who are elected? I once had uh an argument with the Directorate of Public Health when in England when we were in the NHS before we came across to local government, and the the person said to me, I can't understand why elected members are not accountable to us. And I said, Oh, democracy is such an awful thing, isn't it? And I don't think she realised that I was being provocative or possibly a bit sarcastic. Maybe I shouldn't have been. And she's well, well, you know, this should be accountable as. I said, Well, that's easy, resign, get yourself elected as a councillor and get yourself made leader of the council, and they will be. There you go, job done. I think there's something around the science is a good thing, but actually in the public square, we have to remember that that if the world was run by scientists, no, it wouldn't be utopia. It would there would be just as many problems, and there's a level of humility, and I think there's a balancing act to be done. And my greatest contribution comes in helping politicians, or policymakers rather, make decisions. And there is a policy calculus that is, I think, different from a scientific calculus, and you have to you have to recognise that because that's that's human life, and and I don't have a right to tell people what to do. I think the good thing about Wales is that the policymakers I've worked with, I mean you cut them through the middle and the you'd read I love my community all the way through of any political persuasion that I have met. And I think that's a good thing. So there's a balance, there's a tension. Obviously, I would say as a public health professional that the controls on tobacco, because tobacco is lethal, have to be put in place because it has made a massive difference to the health of the population. The rates of cancer dropped, the rates of heart attacks dropped, all sorts of things, and that is a good thing. Most philosophies of public life would tell you that there is a point at which the state has to intervene to protect the health and well-being and safety of its citizens. And actually, that's really where public health in the UK came from. And the history of public health, you know, back to the word quarantine, it was an Italian word for unquarantino, meaning a period of 40 days, was state action to protect people. So but you have to be aware that there is a balance between the scientific evidence and the policy decision, and that properly has to be accountable to local people.

Sam: 13:09

Have you got examples where regulation has worked or voluntary codes have worked or failed that spring to mind?

Jim: 13:16

Yeah, I think reformulation has been a bit of a mixed bag in the UK and internationally. Reformulation of food has worked to some extent, but not to others.

Sam: 13:25

Can you tell me a bit more about that? I'm not familiar with reformulation.

Jim: 13:28

So things like changing the calorific content or the formula or the manufacture of what goes into food. So, for example, if you look at palm oil and trans fats, in some places that's worked really well, in some places it's needed regulation. I think one of the areas where regulations worked has been minimum unit pricing, another for alcohol, another has been tobacco. The evidence for that shows it's worked. I think the regulation of sugar has been a mixed bag. Because you're not just dealing with this piece of regulation doing that, you're dealing with different economies. So Mexico's approach to regulating sugar has been different from other nations, for example. And I guess what that makes me think is that never dismiss a lever as ineffective in and of itself because voluntary work, voluntary self-regulation can be effective in some in some places, but there are other places where you do need it. But we remember we had regulations on bread in the UK in Victorian times because of the stuff that people were adulterating bread with. People may not remember history, but there was a time in the UK when bread production was so highly regulated by law because people were putting alum and all sorts of other harmful stuff in it.

Sam: 14:42

Why were they doing that? Why were they putting other ingredients in it?

Jim: 14:45

It was cheap. It was cheaper than flour. And you and it made it look better sometimes by, but it poisoned people. So you you would find that the same thing with lead and makeup in some countries. So a balance between regulation to protect the population and voluntary codes developed by civil society, maybe with industry, sometimes not with industry, has always been a bit of a balancing journey if you read history. It's never been purely one thing or the other.

Sam: 15:23

I feel like, Jim, you're someone whose career has been defined by your values and your background. And I wondered if you could tell me a bit about your early life and how that's informed your work and your your values that have driven your work.

Jim: 15:37

So I was brought up in a in a council house in a village in Scotland that was uh in the middle of Fife. My granddad was a minor, my uncle was a minor, then an engineer, my dad was an army man and a minor, then a bus driver. And I was brought up in a very, I suppose you could call it strict now, Catholic family, but it was a very outward-looking Catholic family where you know you you'd come home from school and then you'd go and do voluntary work. And actually at school, every w at high school, every Wednesday afternoon, we were kind of chopped out of school to do voluntary work. So that this kind of ethos of service was kind of drummed into you. And you were you were told to work hard, you were expected to do something that was of public benefit. So my sister became a nurse. Um, my mum and dad were kind of determined that we wouldn't have the life they had, so they they they they wanted us to get the best. I benefited from the fact in Scotland those were the days when you had a full grant. So I got a science course at college and then four years of funding for university because Scott's degrees are four years, and then came out and went straight into a job in public service. That's the summary version. But you know, the times I've gone wrong in my life when I've forgotten those values, and the times I've gone right in my life. And my mum and dad used to say to me, Look, this is a very Scottish thing to say, but you know, nobody's any better than you, but you know better than anybody else. And you know, my dad used to say a bit of hard work and never killed anybody and do your best. And we had we had nuns in our school. It was an ordinary Scottish comprehensive, but the teachers wandered around in gangs, which is a bit weird, and we're looking back at it, and but that's the Scottish education system for you, and it was a broad system, unlike the English system, where you did you did more stuff up to leaving level. But we had nuns who basically taught you values, and that stuck with me all my life, really. And when I'm at my best, I'm connected with those values. So I don't I do the job I do because I care about getting the results for people, which is actually one of the reasons I moved to Wales because Hartford's lovely. But I I think when my mum died, I I think she would think she would want me to have another go at serving the types of communities I grew up in.

Sam: 17:59

I think when you find yourself working with people with shared values, it stops the work feeling too much like work and just feels like, you know, the thing that you should be doing that you've been put here to do.

Jim: 18:09

I absolutely. And you begin to see things, you can see things as a gift or an opportunity, although sometimes I get too many gifts. But you know the whole kind of thing about stress is something is stressful if you perceive you haven't got the resources to meet it. But if you perceive you have got the resource to meet it, it doesn't become stressful. And if you can go through life with the attitude of gift and grace, and you're put here to build a better world and it's in the kin with your values, you see things very differently. And I think that gives you a with me, it tends to mean I stick with something and stick at something when sometimes other people might give up and go away. It's like you've got no perseverance, is a is a value. But also I think it I mean you see leadership differently. You see leadership as about creating the conditions for other people to be successful. Uh and also I think it means sometimes public health is about both art and science. And I keep saying one without the other, well, the art without the science will be dangerous because you're the art is about how you get stuff done. But science without the art just makes you feel better because you've got a publication and who cares. The point is the two have to come together.

Sam: 19:24

Was there something you experienced early on that made you steer towards prevention and think about a big picture?

Jim: 19:31

So I think I fell into public health because when I was at uni, I was I volunteered with a drugs project and in Glasgow, could where I went to uni, and loved it. And then went for jobs working in drugs and various other things, working in HIV, working in drugs, um, working in preventing older people having falls. And the more I thought about it and the more I read, the more I thought actually prevention needs to get above the individual level. And my first job in local government, the offer to pay for a master's in social research, which was lovely. But I ended up taking a postgraduate diploma in health psychology instead, which was great. And that got me thinking about you know, it's it's the a public health intervention is never one thing, it always has layers. And there's a famous chapter in the Oxford textbook of public health by uh Detroit and Company that talk about layers of public health. So from the biological, something like nicotine for smoking cessation, right up to the societal, which is legislation for smoking. And a good public health approach actually can't rely on any on any of those alone. You need to have multiple. And I think that my first job, my volunteer experience when I was what, about 25, 20, probably shaped my thinking on prevention being a multiple uh, you know, it's a both and approach.

Sam: 20:54

So we know that prevention improves health, saves money, and eases pressure on services. There's lots of evidence for this, but in reality, lots of systems still default to sort of reacting as problems arise. Why do you think that prevention struggles to become the way we work and what would we need to change to make it the default way of working?

Jim: 21:14

I think there's multiple reasons. So I I did a piece of work earlier in 2025 for the with the Chartered Institute of Public Finance about reasons why preventive efforts fail. And I came up with about 17, and I think there's and there's a bit of a typology. One of them is the mindset. It's easier to react to somebody in need than it is to prevent it. Secondly, it's difficult to know what's the right thing to do sometimes, although actually there are a number of preventive things that are just no-brainers that we know. The third thing is how do you know it's got a difference? How do you prove you've prevented something if it hasn't happened? That can be really difficult. I I think the fourth thing is we've actually set up our systems not to be preventive in much of the world. We've set up our healthcare systems, maybe with the exception of France and Germany, where where primary care is much more preventive. But your average GP doesn't have time to think or turn around half the time. So getting them to be preventive when they've got so much need going on, I think is a real challenge. I think the other thing is a disintegration of community and things where people would look to other community actors or to each other. What we know about long-term conditions, for example, is that people who have better peer support do better in their disease journey than people who don't. And what do we do? Well, we chuck a self-management course at people. Well, great, but actually what you really need to do is create empowering communities where people can feel that they're cared for. So when I had cancer about 13-ish years ago now, I had a very serious, it was grade four blood cancer, but I was lucky because the cancer was really responsive to chemotherapy. But when I came out of hospital, I just kind of fell off a cliff. There was no peer support, there was no sort of how do you cope with all of these different symptoms. And you had to build your own journey. So I took up weightlifting. And the I was on a trial, they recruited me onto a trial. And I remember sitting one day, it was about a year after I'd finished treatment, and there was a guy who was in a room opposite me in the same ward, who was still walking with a stick. And I was back on a bike cycling at the gym. And the difference the doctors thought was that I'd had more peer support and he hadn't. And we struck up a conversation and got on like a house on fire. There are little basic things that we do that can gear the system to be preventive, that because we are so often overwhelmed with work, it is difficult to do. I think the other thing is um there's a there's 40 years of psychological research on the nature of patient professional interactions, and actually you can have a conversation with somebody in two minutes and motivate them to be able to do the right thing, or you can have a conversation with somebody in two minutes that frightens the living daylights out of them and disempowers them from taking the action that they need. And we do too much of the latter and not enough of the format. Not because we want to, but because we've configured the system to be like that.

Sam: 24:16

And that's not built into training to think about that communication.

Jim: 24:20

It's slowly being built into training. So health education and improvement whales are working on a kind of almost the psychological skills, I would call it for prevention, that's not the way they call it, of how you train people. But you've got so much to cram into clinical education and teacher education. So I'm on a advisory board for a university centre that is busy training teachers in how to deal with bereavement in a way that stops kids progressing to serious mental ill health. It's that kind of thing that you can't train everything, but you can train lots.

Sam: 24:55

It feels like there's more investment now than there has been in prevention. And the 10-year plan is prioritizing prevention. How do you think that's going to impact your work?

Jim: 25:05

So I'm hoping it will impact it really well. I would just say this: I think our Welsh policy framework is actually ahead of England. This nation really gets under your skin. I challenge anyone to work in Wales and not fall in love with Wales and not fall in love with Welsh people. It's just impossible. And that's a good thing. But I think what all nations and the benefit of being in the UK is you can look across all nations and look at them all doing it differently. We all face one challenge, which is how good our implementation is. So the 10-year plan will only be as good as the implementation and the effort and the skill we put into it. And I think we we need to get better at that across the UK. And for me, there are some golden rules about you know, just do the basics really, really well and thoroughly with every single person. Just do the basics.

Sam: 25:54

How would you summarize the basics?

Jim: 25:56

Well, things like if you really believe in systems theory, then you accept that most systems have emergent properties. And one of the best things to do in that system is interpersonal contact in that type of system. So how you greet someone, how you say hello, how you communicate with them. And the letters you send and the texts you send, can people understand them? Are appointments accessible? Do you give people basic information when they're diagnosed with something? Do you give people information in a way that enables them to be motivated to act on that rather than just chucking information at them? Can the systems you've got help them to and empower them to take control of their own health? Which I think is the flip side of the personal responsibility narrative. You know, we haven't got fatter as a world because we've lost willpower successively. We've gotten more obese as a world because actually the environment has made it more difficult for us to maintain an energy balance. That's not about personal responsibility, that's about configuring the environment in such a way that we can enable people to keep a healthy life. Some of that's about information, but only a very little bit of it. But some of it is actually about how we greet people, how we the options we give people, the things we can do.

Sam: 27:11

Can you give some examples, some tangible examples of how that might manifest?

Jim: 27:15

So when you diagnose people with type 2 diabetes, there's no point offering a factory worker a self-care course that's five days 95 that means you need to take a week off work. Actually, digital solutions can help people better. Is your point of diagnosis pack? Well, A, have you got one? B is it easy for them to understand? C, is it clear? Is it attractive? Does it use basic psychology to help people navigate through it? So when I was diagnosed with cancer, and I remember sitting there, scared out of my mind, with this chemotherapy nurse who came in and and and proceeded for an hour to tell me about the four cycles of chemo and everything else I was going to get them. And all I remember is we're gonna give you the Rolls Royce of anti-nosia drugs. Well, they didn't work on me. And it all went in one ear and out the other, and she left me with this ring binder that I was in no fit state to read. And she thought she did a great job. And the only thing I remember is what she said about nausea and the fact she cared, and the fact she said, You're gonna come through this. I didn't remember anything else of that 90 minutes she sat in a chair while I was in the bed in pain because they hadn't started chemo, and I was in real pain because of how rapid my tumors were growing. I don't remember any of that, and so I think there's something around meeting the person where they are and co-designing things, and I'm I'm really proud of the fact that we've got people with diabetes and whales who are going to help us design the point of diagnosis package. And my colleague David Taylor and our colleagues in Diabetes UK and Breakthrough Diabetes are working on that. I'm really proud of that fact because I think that's where we need to go. I'd give you another example of I think HIV is a shining example of empowering people to take charge, not exercise personal responsibility. I think that's the wrong one, to take charge of their health and actually understand the health and manage their health. So things like if you've got certain types of HIV drugs, then you that you should leave some time between those and taking a zinc supplement, for example, just one tidbit of information. The kind of self-empowerment and peer empowerment that's done around HIV is light years ahead of what we're doing in other conditions. So those for me are I think the lessons we need to learn. Now you can't get that into primary care, but why should we expect primary care to do all of that? Why can't we build voluntary sector networks to do that? Because they're better at it than we are. So I think you have to look at this complex system and actually look at where you might go to build interventions that improve people's lives. And I think our job with public health is about looking at those systems. And looking at those complex things and then building coalitions that can help them. That's a different style of public health than perhaps many of us were trained to practice.

Sam: 30:14

So that idea of building coalitions and working with the voluntary sector really connects with some research we've just been leading at Healthia. We've been exploring how charities and healthcare professionals can build more effective relationships. Because when those connections work, patients and carers benefit and pressure eases. The project brought together organizations like Diabetes UK, Breast Cancer Now, Macmillan, and Alzheimer's Society who've been sharing what actually works in practice. We'll be presenting the InSummit in an online session at the start of November. To join us, just sign up for the Problems Worth Solving newsletter at healthier.services and we'll be sharing full details. I'd like to talk a bit about education and health and where prevention really starts, because it can be seen as two separate areas. So we often talk about education and health as separate systems, but in reality, as you've described, they shape each other from very early years. Is it useful to ask where education stops and health starts? Or do you think we should be measuring things like health readiness in schools alongside academic attainment?

Jim: 31:28

Oh, yeah, definitely. Because actually, I mean there was a so it was Wendy Wills and colleagues at the University of Hertfordshire declaring interest, because I've had a long association with them, who did a review for Public Health England on the links between pupil attainment and health. And their conclusion is more or less like you can't have one without the other. Which should have been kind of obvious, but they did the research and did it. And you won't get good education if you don't have good health. And if you have good education, it's a good predisposer of better health because you get a better job, you get you can cope with life better. So it's I think the conversation we need to be having on many things in life now is not we're just one stop and the other end, but what are we both trying to achieve and whose job is it to do which bit of this change? I once read a book, the best book I've ever read on multi-agency partnerships is one written for the private sector and it's about 30 years old now. And it talks about private sector partnerships are built around value. Whether it's share of market or c or shareholder value is doesn't really matter, it's built around value. Public sector partnerships tend to be built around legislation and statute. But actually, what we should do is what's the value? So if you get a young person by the at the age of 18, what's the value to the education system? What's the value to Wales PLC? What's the value to health? And there is a value, and we've all got bits of it. And this might sound a bit cringe, but I look around, and the single biggest person I see as an advocate for the mental health of our young people in Wales is actually the Cabinet Secretary for Education, who passionately cares about the mental health of our young people, to the point where she will, if I'm in a meeting with her, she will say, What are you doing? She holds you to account, which is what you want. Um and so does the Senate, and I think that's great. And I think that's what you want. We should be accountable, in my experience. So I think it's about whose job is it to do what? And our education inspector in Wales, Eston, and our directors of education association are actually all really interested in children's health because they recognise that the whole school day can be health generating, but actually good health generates better attendance, generates better outcomes. And we know that actually mental health and attendance in children has been sliding for over a decade now across across the UK and internationally. And so I think they have to go hand in hand, and maybe what we need to do is is really build a new world of if we're having partnerships with the voluntary sector and health, the partnerships between education and health are every bit as important. And I think that message is being embedded in Wales. Dare I say at the risk of getting complaints a bit more so than in other some other nations.

Sam: 34:09

What do you think it would take for education, health and work to share a mission to be working together on one particular goal?

Jim: 34:16

What I find works is you set everybody down and you say, what's the value that we're after? And the value is a well-adjusted, secure, capable, healthy young person leaving education to go and make their mark on society. And when you begin to have that conversation, you can see things like, well, actually, it's really good for kids to have access to experiences other than just cognitive learning. It's sport and physical activity. We'll do all sorts of things around musculoskeletal health, but they'll also have cognitive benefits and educational benefits. The biggest problem in prevention is that as professionals we are too often very siloed and we think about our silo because we've compartmentalized and specialized things, which is a product of modernity, I think. So you don't speak to a physicist anymore, you speak to a physicist who specializes in one bit of physics. You don't speak to a biologist, you speak to a systems biologist or a cell biologist or whatever else. Actually, what we need to do is get back to the fact that we need to stop coming from our specialisms and start with the value to society that we want to create, and then we need to discern what our role is in that. And when we've had conversations like that, you get a very different type of implementation plan for a problem than you do when you start with, well, let's get a public health person and an endocrinologist in a room together and feed them coffee for an hour.

Sam: 35:44

If you could change something in the school system to improve lifelong health, if there was one thing you were going to change now, what would that be?

Jim: 35:51

Make teachers feel by the way we configure the school day that we passionately care about the importance of what they do, and make children feel through the way we configure the whole school day that we passionately care about their health. And the day starts with a smile and starts with some breathing space. And for some children, starts with breakfast if they've gone in and starts with a sense that people care about you. And I hated my secondary school and bits. I loved primary school, it was great fun. I hated bits of my secondary school. I I loved other bits. But when I look back, the one thing I got when I left school and went to what we called in Scotland a College of Technology, what I got from my lecturers was a sense that they really cared. So I was quite confident making all sorts of mistakes, particularly in the chemistry lab, I would have to say, where on several occasions I forgot to turn the fume cupboard on. But I think that would be the thing I could change, which is this psychosocial environment.

Sam: 36:50

It's really interesting that you I was expecting you to jump to something like everyone should be doing a round of the school field three times a day or something physical, and you've gone to the mental health side of things. I did an interview with Dr. Leah Ali a few months ago on here, and she was talking about the biopsychosocial approach. She described the system as carrying Cartesian split, which is this legacy of thinking of the mind and body as separate. And so mental health is treated as a specialist add-on rather than woven into the design of everything we do. And then I was thinking if if we took this biopsychosocial approach, recognising that biological, psychological, and social factors constantly interact, are there ways we should be integrating mental health into the whole system more and moving away from prioritizing physical health when in reality they're deeply intertwined and interdependent?

Jim: 37:38

And your answer is yes. And you I mean, you know, you I think the biopsychosocial model works. I think there's other bits you need to add to it. But if you've got flu, you feel grotty and you don't really feel very social, do you? And if you live in long-term pain, then it affects your psychological health. And you know that that long-term conditions can predispose you to depression and vice versa. So a bit of a shout out to Andy Bell from the Centre for Mental Health, who Oh, you could we just bottle him and clone him, please. But he's happy as our idea. Uh and he can he can be very eloquent on this. And he's very eloquent on the fact that there is no health without mental health. And so I think good mental health, a good sense of who you are, feeling loved and secure. Katie Cooper, the guy who is the occup famous occupational psychologist who wrote the book with Ivan Robertson called The Psychological Contract, got this right when he said the most important thing any leader can do in an organization is create a positive psychosocial environment. Because that in and of itself is so powerful against stress, it's so powerful around building loyalty, it's so powerful around reinforcing good behaviours. Um, so mental health and the conditions for that do need to be the foundation, I think, of everything else we do. Offering people counselling for workplace bullying is a band-aid for organizational change when the problem is the organization is allowing bullying. If you think about it like that, we too often jump to little solutions rather than actually let's lay the foundation for good mental and physical health and good resilience. And I think that's where the science is inviting us to go. So, how do you build that into everything you do? Now, physical activity has massive psychological benefits, really. I mean, there's some evidence that it can be as good as other therapies for, you know, moderate to mild um depression or anxiety. So we need to normalize the fact that how we feel psychologically and emotionally about the world is a bit of a substrate. There's a bit of a digression here about modernity, which is we've become we assume that the way of knowing is our mind is almost disembodied from our body and we leave our feelings outside the room, but actually we too often compartmentalize the human. If you think about how you know something, you don't know that the bus is going to be there by the simple scientific knowing. You know a variety of ways, and you learn to know through practice, and you know emotionally, there are emotional ways of knowing. People that philosophers who write about epistemology will tell you about this. There are spiritual ways of knowing, and they are ways of knowing. And if you think about it, what's at the basis of that is emotion and mind, it's not body. So why wouldn't you put good psychological health at the basis of everything you do? It makes philosophical and scientific sense, and you get better outcomes. And all the research on stress, I think, and culture, organizational culture backs that up.

Sam: 40:43

Is there an example of a mental health intervention that you know can deliver a good return on investment?

Jim: 40:50

Oh loads. So the contact clubs for people who are isolated, just getting them in a room and working around an activity. Going to museum. So in Wales, the National Museum for Wales actually has a mental well-being program, and we're looking at arts and mental health on prescription. So you will get mental well-being activities in some of our museums, particularly a wonderful museum called St. Fagan's, which is just awesome, where they've they've basically recreated Welsh towns and villages and buildings, and you can walk through, you can actually walk past a herd of sheep, you can buy bread in the bakery. It's a fab day out. It's awesome. So these things, and talk therapy, uh actually connecting you with a body who's had the same mental health challenge you have. You know, all of these things is basic things, actually changing the style of leadership in an organization, giving people some time off. There there are several hundred things you can do that will improve mental health and give you better productivity. Even things like one of the things from the four-day working week that was at South Cambridgeshire Council piloted, that had mental health benefits for staff. And actually, productivity went up. And one thing that I was very fond of in a previous job was doing exam stress packages for teachers because teachers get as stressed as pupils around exams. So creating an exam stress package for teachers and relieving their stress, reduced absenteeism among teaching staff because they weren't going off sick with stress. So there's loads of stuff you could do, and it's costing us money not doing these things, and they don't cost money to do a lot of them.

Sam: 42:36

And who can make those things happen?

Jim: 42:38

So if you're in a school, the head teacher, if you're in so I'm a trustee of a hospice, which is a massive hospice, and our HR director led a program to improve mental health in our hospice staff, didn't cost us anything, reduced sickness abstinence, did a great job, just did work on started with smiles and behaviors that embody our values. Bosses can do it, gym gyms can do it, GPs in the way that they greet you and can refer to you, can do things. So my Jeep, I don't think I've ever seen the same GP twice in the last five years. But one thing I do get from my GP is I get a smile and uh you'll do well. And that makes all the difference. So anybody can do it, but just actually asking people how they feel can say hello. You know, the the Spanish mystic Theresa Vaverly once said, you'll never know the good that a smile can do. And I was brought up to say hello and thank you to the bus driver.

Sam: 43:36

Is that not a normal behaviour?

Jim: 43:38

I think it is in Cardiff, I've noticed. It's not in London.

Sam: 43:42

Right. Um it's cultural.

Jim: 43:44

It yeah, it's cultural, and it is it it is still in Glasgow and Edinburgh, and it is still where I when I go back to Scotland, but it's not universal. But you know, saying thank you to the bus driver, thank you to the taxi driver, um, you know just being nice. Yeah, being nice. And when was the last time you went for a cup of coffee in the shop? And the person said to you, Hello, how are you? And it brings you up and say, I'm well, thanks. And then you go, How how you? And you strike up a conversation. And just that kind of connection that someone notices you can help. And we talk about the five ways to well-being that are evidence-based, you know, take notice, stop and look at the flowers. They can all be really good things as well. So there are lots of things you can do that are evidence-based. It doesn't have to be a complex intervention.

Sam: 44:36

There's lots of talk at the moment about moving care closer to home. And that means shifting resources and skills and trust out of hospitals and into communities. Do you see this impacting the role of public health? And have you been thinking about how we equip primary care and community organizations and frontline staff to lead that change?

Jim: 44:59

Yeah, and to be honest with you, we've been talking about that in the UK for 30 years. So I remember when I was in the NHS in East London, we were talking about Kaplan's commissioning a patient-led NHS in 2005, and we talked about shifting to primary care. The acid test is whether we shift resources. So, where I was in East London, we actually moved outpatient appointments for cardiac follow-up into a community heart team, and we moved some community heart failure into a community heart team. Nobody died, but what we did was we actually had the consultants in the hospital leading it and training up the GPs. So if you're going to do this kind of stuff, first of all, you need a resource shift and a policy shift. Most nations have now got that. Secondly, you need the expertise shift and you need to free up the bandwidth in primary care to do it. You can't just lump extra things on primary care. You need different skill mixes and different people, you know, what can be done by nurses and what can be done by other people. You then need to build peer support voluntary sector around it. So if you look at the CARIS practice in Edgebaston in Birmingham, they've done a lot of this. They've actually invested in doing this and shifting into primary care and care closer to home. So it can be done. And in fact, the hospice I'm a trustee of we have more people being cared for in their own homes now than we have in inpatients in the hospital, which means that that our inpatient care does a different job than it used to do. But you have to, you have to have the right attitude, the right skills. You have to think about this carefully as a system, you have to fund it well, you have to invest in the right skills, and you also have to actually invest in empowering patients who are the crucial people. So it can be done. I think it's the right thing to do. Where it works well, it can really work well, like diabetes care, uh closer to home. There's all sorts of things that that when I first joined public health, people say you could never do, like point-of-care testing when you walk into primary care and get your buds done, that you can now do. And a bit of a story is many years ago when I lived in Brighton, I got some kind of growth on my hand that kept bleeding, and I didn't know what it was. And the GP said, Oh, he said that's whatever it was. Yeah, fine. And he said, I don't think it's malignant, but it'll take a biopsy. He said, Well, we can cut it out. I went, Great. And he said, So hospital? He said, Well, you can put you on the referral list to hospital, and it will and you'll get seen in about six months. So we could do it minor surgery here in the surgery. I mean, okay, well, let's go for minor surgery because we'll need any. When could you say, How about Tuesday? I thought, okay. And he did it there and then, he cauterized the wound. My my chest was his operating table and my chest and a bit of sterile paper. And the surgery was half a mile from where I lived in Brighton, and I was in and out in half an hour. Okay, it was a bit sore for a few days, but he gave me, he said, just take high bootprofen, and it worked, didn't have a hospital admission or anything else, and it really, really worked. And so I think we can do it if we put our mind to it.

Sam: 48:00

Was that a one-off because he was particularly good with a blade? Or is that the way that GPs could be operating?

Jim: 48:06

So that practice did blood tests. So in the last place I lived, if you wanted a blood test, you had to go into the hospital. When I lived in Brighton, the blood test, you walked in and the practice nurse did it. He had minor surgery every Tuesday afternoon. You had diabetic patients titrated for insulin in the practice. So it could be done, but you need to invest in primary care. Really, you need to shift money to primary care, is the most important bit of the system, and and change the model. And I think that's if you like the holy grail in healthcare policy. Everyone wants to do it. We're all making steps towards it, but it takes an awful lot of time. And we've got this massive population of people who are ill, who need hospital, but actually are the systems configured. So even down to things like have you got enough internet access for the GP to log on and get somebody's test results quickly? Have you got good pathology? It's a whole industry, but it can be done. Germany's done it, but it's if Italy and Spain have done it.

Sam: 49:10

I want to go on to talk about digital a bit because digital tools are often held up and seen as the answer to prevention, you know, from apps to AI-driven risk scores and things like that. In practice, they can either knit the system together, or I've seen instances where they're adding more complexity and having the opposite of their intended effect. Where do you see digital having the biggest real-world impact on prevention? And what are the pitfalls do you think that we need to avoid to make sure it builds trust rather than erodes it?

Jim: 49:38

This is a point where I need to channel my colleague Ian Bell, who is just talking about this. I think where it connects the system together and helps people empower themselves. So things like the My Desmond app, or then there's another app, and I've forgotten My Way Diabetes, they're really good at connecting that up. Where you can order repeat prescriptions up on the app, on your any on the NHS app rather than bothering your GP, for example. Or things that just make it easier and make it easier for people to do what they need to do and do the quick check. And that's about how navigable the app is and how easy it is to negotiate and various other things. Where it goes wrong is where you try and design a system in isolation from all the other stuff. Or you try to do so much that you end up building in such complexity you can't deliver it, or you put in so many firewalls and barriers. Uh and a good example was when I was in Birmingham, I was I led our telecare program. And I think one of the best things we did was actually putting movement sensors in rather than great big dirty pizza boxes into people's homes to check whether they'd moved and linked that to a control system. So thinking about how you simplify the ease of access, the ease of use, and the ease of information. If you think about really good apps that we use on our phones every day, the ones that we use most are the ones that are easiest to use, the ones that give us the thing we want, that direct us. You know, so some of the proprietary bookshop apps are not very easy to use, which is why I like prefer walking into a bookshop than using an app and digital solutions. It's the same with health. And what we tend to do is we create yet another app. So if you've got three long-term conditions, you've got an app for each condition rather than one app that helps you manage your health. So I think those are the problems with digital. I think the other thing is we're still not harnessing outcome data enough across the UK to really monitor and drill down into where people are most at risk, enabling us to do early intervention. There's a there's a wealth of data there where we could have digital solutions that can pinpoint people who could have an intervention that stops them going into hospital. We still talk too much about digital uh and still don't get the right solutions, I think.

Sam: 51:57

If you were to zoom out, we've covered lots of areas here, we've talked about lots of different topics. If you were to zoom out and say, okay, we we're going to track just one metric to show that prevention in Wales is working, this is probably something you've thought about a lot. Who would need to be around the table across sort of government, health, business, and communities to track that metric? And what would that metric be?

Jim: 52:18

So I think the metric would be I'm tempted to pick hypertension, but I'm not going to. The reason I'm tempted to pick hypertension is because 70,000 people in Wales have got uncontrolled hypertension, uncontrolled high blood pressure, and that's a net generator of hospital admissions and strokes and heart attacks and everything else. But I'm going to pick one that I think will be much harder to them, which is people feeling confident in caring for themselves and accessing care. And the reasons I will pick that because it buys into agency and it can also tell you about people's ecology of services and their access to services and everything else. I don't think we measure it in the way that the anywhere in the UK, in the way that the evidence suggests we ought to. But I think you would need a bunch of good research methodologists, a bunch of expert data people, a bunch of data systems people, primary care people, someone who could design a really good app or put the module into an app that people can answer. And I think it would be good to get employers who are signed up to our health program to get round the table and all of us collectively realize that if people are answering yes to some of the I mean there are other questions you could use, there are proxy questions, but if people can answer yes to that, there is evidence I think that they'll stay in work longer, they'll be more in control, they'll manage their health better, they'll take steps better, and that they understand that that would probably be the type of area I'd zoom in on on the metric to ask people. And I probably have about another dozen, one of which would be, you know, information and access to information and access to services. But that I think predicts stuff.

Sam: 54:00

What are you most optimistic about in the future, Jim?

Jim: 54:03

That there is an unstoppable movement of public will to improve the health of our population, certainly in Wales, and that people care and people get it, I think. And uh that is built on a sense of pride and a sense of understanding people have a right to get the best possible care for them.

Sam: 54:24

And if you could wave a magic wand and change one thing about the way the health system is working in Wales right now, what would you change?

Jim: 54:32

That every professional had time to breathe and had time to give good clinical care the care that they wanted. And that we turned the tide on the huge amount of complications and uh and ill health that we got, and that we and it became a a service that was focused on prevention. Those would be the things. If I could wave the magic wander, do all of that.

Sam: 54:54

Jim, a final question that I like to end these podcasts on. Is there something that you know to be true that others might not agree with? And this doesn't have to be related to health and care. So previous guests have talked about everything from non-human intelligence in US Congress to better ways to build culture in big organizations.

Jim: 55:13

Oh, I think there's lots of things that I believe to be true that lots of people would disagree with. And I think it starts from the fact that we are on this earth to do as much good as we can for as many people as we can for as long as we can, and that you truly find yourself in serving others. Now that's an insight from my faith. And we're put here. There's a Franciscan friar who once said to me, He said, you know, we're put here to squeeze every possible drop of enjoyment out of life that we possibly can. And I thought, yeah, I think that's true. Uh and I and when you do that, you you are happier and I think better and and see it better. Now I know lots of people won't believe that, but as human beings, we are here to we transcend ourselves. Otherwise, why the huge interest in meditation and mindfulness and all sorts of other stuff? And I think people are looking for that meaning and purpose. And it's when you find meaning and purpose, whether that meaning is in at one end of religious faith or at the other in your golf club, well hang on, that is also religious faith, isn't it? Or with some football club. Well, you know, with with these five football clubs, let's be honest, it's an act of religious faith believing in them when I was a kid. But um, or Scottish rugby for many years, finding meaning in something, in relationships and in people, is perhaps the most powerful thing for us as humans because we're social animals. Aristotle said that. We're social animals.

Sam: 56:36

That's brilliant, Jim. I'm going to stop there. So thank you so much for taking the time to talk to me today. It's been really interesting talking to you.

Jim: 56:43

That's been an awful lot of fun.

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