This week: Dame Sally Davies
Why she matters: Chief medical officer between 2011 and 2019, Dame Sally remains the UK special envoy on antimicrobial resistance and is a non-executive director of Genomics England. Last year, she became the 39th person, and first woman, to be made master of Trinity College Cambridge.
HSJ interviews Dame Sally the day before the publication of Sir Michael Marmot’s “10 years on” report, which accuses Conservative-led governments of the last 10 years of reducing life expectancy by pursuing austerity policies.
As her time as chief medical officer encompassed that period, does she feel some responsibility for this record?
“We have ended a period of austerity in a place that is worrying for the health of the public,” says Dame Sally. “Are they interrelated? I feel they may be, but the proof isn’t there.”
While she admits the last decade marked a “period of stagnation” in efforts to improve public health, she wonders if the performance of the economy will prove to have been a bigger factor than any specific government policy.
In fact, the former CMO reveals she made a conscious choice not to challenge the governments she served over austerity.
“Marmot was making a lot of noise and not getting anywhere. I didn’t think that I would get anywhere, so I didn’t go there,” she states with typical bluntness.
“There is something terribly frustrating about the Marmot approach. Poverty is at the root of it all or poor education [he claims]. Yes, so what are we going to do about that? I’m from the Department of Health. There is not much we can do about it.”
Dame Sally’s strategy was, instead, to use whatever influence she had to focus on areas where progress was possible — such as the fight against antimicrobial resistance, reducing alcohol consumption and measures to discourage smoking.
“I think we didn’t do too badly,” she claims.
Dame Sally says few realise how achieving national policy change is a lengthy, painstaking and often thankless process.
“You don’t get politicians to move until they get the problem [and] they know they won’t lose votes. Tobacco is the classic [example] — 50 years from knowing it kills you to getting the ban in public places.”
In this context, she is pleased with the increased speed with which politicians and the public are beginning to understand the threats posed by a range of public health issues.
“If you think about obesity, David Cameron got there after a couple of years, Theresa May got there after a couple of years. I’m hoping Boris will get there after a couple of years.”
Driving change also means having to learn to work with industry, she notes.
“I would argue that the sugar levy has been very interesting because it’s driven innovation and different ways of making drinks with far fewer calories. The smoking ban and standardised packaging has probably helped drive vaping. I’m not particularly supportive of vaping — I would treat it like tobacco — [but it] is much safer than cigarettes. On air pollution, if the government’s strong, it’ll drive innovation and much more electric cars and electric transport, [as well as] car-sharing and better public transport. Innovations that’ll benefit not only the public’s health but will actually benefit those companies because if they innovate and become greener and there’ll be able to sell abroad as well as to us.
“You shouldn’t be fighting industry; you should be taking them with you because you’re trying to push them to innovate, to be first movers in the global market.”
This willingness to work with industry more closely than many in the public sphere appear comfortable with what was developed during Dame Sally’s time as the DH’s research director.
“I’m not someone who thinks pharma is dirty. I think they can do dirty things and behave badly, but we wouldn’t have aspirin or anticoagulants without pharma. They do a service for society. And we as a society set them up to make a profit. I came in [to government] believing that as a society we’ve chosen capitalism and [that] in many ways it works.”
How to influence politicians
Over her time in government, Dame Sally says she learned to become less dogmatic and to appreciate the contribution of politicians.
“I have shifted from wanting evidence-based policy to evidence-informed policy. I think it is our duty to make sure ministers know the evidence, but they bring a different social construct and different views [to an issue] and they have that democratic right [to express it].”
Dame Sally says the politicians she really enjoys working alongside are those “I’ve had arguments with”.
The former CMO remembers one occasion when she argued against the introduction of point of entry screening during the West African Ebola outbreak.
“I went into the meeting saying, ‘This is going to cost a lot, it’s going to take a lot of people and there’s no scientific evidence it’ll work.’ [The politicians pushed back saying] ‘We want to be able to show the public we’ve done everything possible to protect them.’ At which point I said, ‘That’s a different justification. If you’re prepared to pay for it, I can support you.’”
Asked why the public health and medical lobby have had only limited impact on government policy in recent years, Dame Sally identifies both arrogance and naivety as the causes.
“I saw a lot of academics coming in and lecturing ministers about what should be done. That’s not the way to take people with you. You’ve got to think ‘where are they coming from’ and frame the issues so it has salience for them. You want to start with an elevator pitch and see if you can entice the people to listen and have a discussion.
“Of course, you talk about the disease burden, but you [also bring] some case studies, patient stories [as the politicians] call them. You’d [suggest] simple things that they might like to start with to see how it plays. Some public polling is always helpful. The [scientific] evidence should be almost taken as read. It’s about how you tell your story.”
Another good way to win support for an idea is to combine a strong track record of delivery with flexibility of delivery. “I would listen to what they wanted and then say, ‘I think the outcome you’re after is this and I can help you get there.’”
Dame Sally adds it is also important to remember it is often the politicians who will have to communicate a policy and persuade people that it is justified and that this is sometimes “not an easy job”.
Given they are in the firing line, it is only fair they should also sometimes “take the credit” when things work out. “Some of the things I’ve done, well, you will never know I did,” she says, “[and] that’s absolutely as it should be [if you] get the result.”
Dame Sally is unabashed in her belief that the current tide of populism should be harnessed for the benefit of the public’s health. She cites the recent push on childhood obesity, which was based on sound evidence, but also made use of emotive messaging which stressed how children struggle to escape exposure to unhealthy food and drink.
Return public health to the NHS
Dame Sally says she was initially in favour of moving public health out of the NHS and into local government and praises the contracting rigour councils have bought to the procuring of services. But she has since changed her mind about the move following disinvestment in tobacco cessation and other services.
Agreeing with HSJ’s suggestion that not having Sir Simon Stevens to defend its funding has hurt public health, she adds: “Why would he put effort and money into public health when he wasn’t going to get the credit for it?”
If public health was returned to the NHS, Dame Sally believes it would be much easier to persuade NHS England to make the “trade-offs” needed to shift a higher proportion of health funding towards prevention.
“We would do better to nest a lot of the public health back into the NHS. I would leave some things with local authorities, but drug treatment services, women’s contraception, sexual health they definitely [belong in the NHS].”
The mother of the nation
Dame Sally famously gave the BBC’s Nick Robinson a right telling off when he described her as “the nation’s nanny” and her ire has not yet totally receded.
“Let me start by saying why I really object to nanny. Most of the population think ‘nanny, rich family, they don’t care’. The rest had nannies and on occasions hated them, but most of them, because they were mother substitutes a lot of the time, loved them. It’s just too emotive.
“Now, if you said to me, ‘Are you, on health issues, the mother of the nation?’ I would’ve said, ‘Probably.’ We all know that mothers set the framework for developing your life, [and need] to be strict, to be kind and help you develop your habits, your behaviours etc.”
Dame Sally was the first CMO who had a rival for the title of ‘Britain’s top doctor’ for the whole of her tenure. She claims working alongside NHS England medical director Sir Bruce Keogh and his successor Steve Powis did not constrain her and she always “reserved the right to trample all over the NHS if I chose to”. This never happened, though she admits she was “fairly pushy at times of emergencies”.
She says the UK is making steady progress in its efforts to combat antimicrobial resistance, but that much work remains to be done. “We’re not hitting our targets on bloodstream infections and resistance,” she says, adding that in areas like the correct use of blood cultures in diagnostic testing, “there’s a heck of a lot of just basic stuff to be done”.
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