Levelling the playing field in the health and wellness industry
This article is a prelude to my presentation at the National Sports Convention on 9 November 2020, in the category of Our Communities Future. It’s also in follow up to my previous article ‘Systems thinking critical to transforming the Australian Leisure industry post COVID-19’. Where I put forward the case that we can’t afford to restore the industry to what it was, it simply wasn’t working, with systems leadership part of the solution.
There have been long standing inequalities in society and the gap is widening. The evidence is clear, some groups find it harder to be active. Such as women and girls, people from culturally and linguistically diverse communities, people with disability and from low socio-economic areas. The latter is a focus for this article.
We all understand the health benefits of sport and activity but despite our best efforts we have failed to distribute these benefits fairly. Leaving those with the greatest health needs most excluded.
Given the COVID-19 pandemic, there are now more barriers in the way of people being physically active. On the 30th October 2020 Sports Australia released AusPlay Australia’s biggest sporting survey. It provides a first look at the early impact of COVID-19 on sports and physical activity participation. With the data concluding there are significantly more barriers to participate in organised sport than we have ever experienced.
Add to this the higher rate of unemployment resulting in less disposal income, and mental health issues also reported to be on the rise; for some the hurdles are insurmountable.
I see these increasing barriers as a call to action. To level the playing field so those that are more at risk of developing a chronic disease have as few barriers to physical activity as those that aren’t. To do so we must look outside our narrow perspectives and work collaboratively across the system. To achieve this, we will need to adopt a vastly different approach to our thinking, actions and leadership.
I propose three concepts that if combined are a road map to developing inclusive healthy communities, levelling the playing field. Where we all work to benefit, not only ourselves but each other.
1. Proportionate Universalism
2. Systems Thinking
3. Distributed Leadership
But first let me set the scene…
Even without COVID-19 we’re living in a time where there’s an increasing lack of physical, nutritional and mental well-being, which is leading to a rise in the number of people experiencing a chronic disease.
On an average day in our health system $467 million is spent on health ($19 per person). With over $10 billion spent on mental health annually.
Figure 1 illustrates the impact of chronic conditions on society and the economy.
Figure 1
Source: www.aihw.gov.au
In Australia 11.4 million people, almost 50 per cent, now have a lifestyle-related chronic disease such as cancer, cardiovascular disease, mental health condition, arthritis, back pain, chronic obstructive pulmonary disease (COPD), asthma, and diabetes. Nearly one in four (23%) Australians are estimated to have two or more of these conditions. The most concerning is the stats on health of people from disadvantaged groups.
The data tells us that generally, the higher a person’s socioeconomic position, the better their health. Compared with people in the highest socioeconomic group, people in the lowest group are:
2.1 times as likely to die of potentially avoidable causes
2.6 times as likely to have diabetes
The reality is the lower you are on the social hierarchy the more likely you are to die earlier.
The recent media release from the Australian Institute of Health and Welfare confirmed children from the lowest socio-economic areas are over twice as likely to be obese, compared with children from the highest socio-economic areas (AIHW media releases, 13 August 2020). From my personal and professional experience, I believe the main reasons are due to limited access to education, opportunities and services.
It is well documented that along with diet the golden thread to reduce chronic disease is physical activity. Bearing in mind the recommended physical activity guidelines, what does the data tell us.
The data shows that only 37.4% of Australian’s from the most disadvantaged communities meet the physical activity guidelines (ABS National Health Survey 2014-15). I think it’s safe to assume, due to COVID-19 the statistics have worsened.
Figure 2. Variation in physical activity by subgroups, ABS National Health Survey 2014–15
What’s not surprising is that the most advantaged regions are much more likely to meet the physical activity guidelines (60%).
If we overlay this data with the mortality rates (a solid barometer on the well-being of the nation), life expectancy in the lowest socio-economic areas has stalled. With an increasing difference in life expectancy of around 12 years between the most affluent and deprived areas. (www.abs.gov.au/AUSSTATS).
A recent study by the Australian Population studies published in May 2020 also showcased the widening inequalities in premature mortality in Australia, 2006-16.
Further, according to the suicide prevention and poverty researcher Gerry Georgatos, nearly two-thirds of all Australian suicides are socioeconomically narrated.
It’s clear there is a common theme here. The health and well-being of all Australians should be a top tier public priority.
Source: The Australian Prevention Partnership Centre ‘Getting Australia Active III
The role of Government in the health and wellness industry
There are many factors which influence the health and well-being of communities. All of which cannot be directly impacted by the businesses in the health and wellness industry alone. These are called the social determinants of health which are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.
However, to get the biggest bang for our buck and improve the health and well-being of all Australians, a strategic priority of Government must be supporting those that need it most. This means people from lower socio-economic areas.
The data tells us we are failing to reduce inequality, with chronic conditions increasing, particularly in low socio-economic areas. We need to work smarter across sectors with a common language of public health promoting the benefits of wellbeing.
We are at crisis point, and fundamentally government needs to invest in health now which will save on the health system down the track.
Proportionate Universalism
I am a strong advocate of proportionate universalism and I’m not alone; it feels like there is a growing movement. Proportionate universalism was born from the Marmot Review ‘Fair Society, Healthy Lives’ which looked at evidenced based strategies into health inequalities in England in 2010.
Marmot outlines that we need to improve everybody’s health but do more for those that need more help. He talks about the concept of a ‘universal service’ meaning it’s for everyone.
There is a misconception of proportionate universalism in that you only give help to those that need it most. This is not the essence of proportionate universalism.
An example of this in the health and wellness industry would be to provide free or subsidised access at certain times to leisure facilities for everyone. And, based on where you live or means tested, people are permitted different amounts of access; but everyone gets something dependent on need. The proportionate bit is scale, with everyone getting something proportionate to their need.
A fantastic example is the Be Active scheme in Birmingham and the collaboration between Birmingham City Council, three Birmingham Primary Care Trusts and The Active Wellbeing Society (TAWS). TAWS are a community benefit society working to develop healthy, happy communities living active and connected lives, who Collective Leisure has partnered with.
Be Active, is one of the UKs largest public health programs, increasing physical activity levels among Birmingham residents through providing free access to public leisure centres, proportionate to their need.
We must remove barriers and (as a sector) our bias towards meeting the needs of those most active or able to pay. The economics of exercise as prevention and medicine to reduce the social and economic burden of chronic conditions is compelling.
In a report to the Australian Government, KPMG assessed the value of community sport infrastructure in 2018. They estimated sport creates significant value with at least A$7 returned on every dollar expended in the sector.
Sports England commissioned a report by Sheffield Hallam University in 2018 measuring the social and economic value of community sport and physical activity in England. The findings of this report show that for every £1 spent on community sport and physical activity in England, an economic and social return on investment of £3.91 is generated.
With benefits such as crime reduction, subjective well-being, improved education achievement and social capital all a by-product of sport and physical activity, the evidence is undisputable.
This is not about equality, it’s not even about equity it’s about social justice as illustrated.
Some may consider this radical but considering the magnitude of the health issue being faced, which is only getting worse, we need to do something different to what we’ve always done. Spend now to save later. Economically it’s a no brainer if we are trying to reduce the $467 million daily spend on the health system; but just as important are the wider social impact benefits.
For some disadvantaged groups, attending a leisure facility is akin to attending the Australian Open tennis final for most of us. We need to rip down the fence as per the illustration, providing access for all socio-demographics.
In summary, as a health and wellness sector we must work collectively with Government to improve the well-being of everyone, giving a greater priority to those in greatest need.
Systems Thinking
The social challenges we face can only be solved when people and organisations work together; across sectors, boundaries, and cultures. Systems thinking is a way to make sense of a complex system, that gives attention to exploring relationships, boundaries and perspectives.
Greater Manchester Moving (GM Moving) in the UK is a fantastic demonstration of system wide collaboration. Working across ten local authority areas totalling 2.8 million residents.
GM Moving aims to improve physical activity levels and reduce physical inactivity, improve mental health and wellbeing, address health and social inequalities, embed physical activity across all sectors and communities, changing culture to make physical activity the norm.
The program is being evaluated by Substance (a partner of Collective Leisure) and Sheffield Hallam University.
In an Australian context, it’s exciting, that the Australian Preventative Partnership Centre have developed an incredible document - Getting Australia Active III – ‘A systems approach to physical activity for policy makers’. The document isn’t just written for policy makers but anyone that is part of the health and wellness system and I encourage everyone in our sector to read it.
To tackle complex public health problems such as chronic conditions, we must work together across public health, government, leisure, health, sport, peak bodies, education, disability, and the social economy to name just a few. To improve my practise as a systems leader, challenge my assumptions, share knowledge and connect the dots, I host a weekly conversation called Part of the System hosted on YouTube.
Distributed Leadership
Everything rises and falls on good leadership. To see any of the changes I talk about in this article, we all need to examine the way we lead and how effective our organisations are. There are many leadership methodologies that are effective such as values based, servant, collaborative and transformational leadership. In the context of organisations maximising resources to deliver effective services, I passionately believe distributed leadership is a powerful approach to building self-sufficient and successful teams.
The practise expands human potential, giving people greater responsibilities and opportunities to grow and develop. To face the challenges we will see coming out of COVID-19, organisations must move away from old structures that involve top-down leadership in favour of a flatter structure, more trusting and with a shared values approach.
Distributed leadership cultivates decision making at all levels of an organisation. Encouraging initiative, problem solving, collaboration and inclusion. Clear communication and respect between team members are essential for distributed leadership to work well. A caring environment is key where there is a culture that if people fail or fall over in developing competency of skills, its supported with team members and senior leaders providing emotional and psychological support.
An example of distributed leadership in action is the ‘Refugees breaking down cultural barriers’. An employment project I developed at Auburn Ruth Everuss Aquatic Centre for Belgravia Leisure which was featured on SBS World News and won the Parks and Leisure 2019 NSW Community based initiative of the year.
What made this program so successful was empowering young leaders with the responsibility of continuing to cultivate a caring and supportive culture for the refugees. As well as, demonstrating how much I trusted the refugees by giving them responsibility and opportunities to flourish.
Final note
I appreciate this is aspirational, but I believe no one should be left behind. We have a health crisis and as a result we need more investment and action from Government aligned with companies mandated to deliver on social return on investment.
Models such as social enterprises can help build an alternative future. If we embrace the concepts of proportionate universalism, systems thinking and distributed leadership with organisations demonstrating collaborative leadership between each other. We must change our competitive culture and be willing to let go of power to create a new future, levelling the playing field.
If we invest upfront subsidising services supporting a health and wellness service, this will not only improve the health of the nation but would also decrease the cost of the health burden over time.
As a social enterprise, Collective Leisure’s contribution is to intentionally trade to tackle chronic disease, build resilient communities and provide access to employment and training for people from marginalised communities.
References
Australian Bureau of Statistics www.abs.gov.au/AUSSTATS
Australian Institute of Health and Welfare www.aihw.gov.au
Australian suicides are socioeconomically narrated www.independentaustralia.net
Fifty-percent-of-australians-have-chronic-disease-health www.abc.net.au/news/
Global Strategy on Diet, Physical Activity and Health www.who.int
Social determinants of health www.who.int/social_determinants/en/
Measuring the Social and Economic Impact of Sport in England https://sportengland-production-files.s3.eu-west-2.amazonaws.com/s3fs-public/2020 m09/Social%20and%20economic%20value%20of%20sport%20and%20physical%20activity%20-%20summary.pdf?Ifr7FqnmAz.8U3LLQu14rb1yIKL4SUJ7
The Australian Prevention Partnership Centre ‘Getting Australia Active III’ www.preventioncentre.org.au/our-work/research-projects/employing-physical-activity-to-prevent-chronic-disease/
The widening inequalities in premature mortality in Australia, 2006-16 www.australianpopulationstudies.org/index.php/aps
The value of community sport infrastructure in Australia https://home.kpmg/au/en/home/insights/2018/08/value-community-sport-infrastructure-australia.html
Acknowledgements
I would like to thank Martyn Allison for his support and inspiration.