Who is responsible for our health and wellbeing? Helen McKenna talks with Professor Dame Sally Davies, as she prepares to move on from her role as Chief Medical Officer for England, about public health, her career, and the challenges of being a female clinical leader.
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- Shared responsibility for health: the cultural change we need
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- HM: Helen McKenna
- SD: Professor Dame Sally Davies
HM: Hello and welcome to The King's Fund podcast where we talk about the big issues and ideas in health and care. I'm Helen McKenna, a Senior Fellow here at the fund. Today I'm honoured to be joined by Professor Dame Sally Davies who is currently the Chief Medical Officer for England, but who will be leaving the role at the end of September this year to become the first female Master of Trinity College Cambridge. Sally, welcome to The King's Fund podcast.
SD: Thank you very much, it's I'm hoping a pleasure to be here.
HM: So we'll be talking more about your career journey and your current role as Chief Medical Officer for England later in the episode. But first, part of your role involves giving advice to the public about their health and wellbeing. Do you have any habits or guilty pleasures that you find you have to really keep in check?
SD: Well I like food, so I have ... and as you get older it's easier to get fatter so I have to be careful I don't overeat. I've always been clear I like good wine but as I have aged I've drunk less but higher quality. I'm lucky I've never smoked. I take plenty of exercise and I like a bit of chocolate. So, I'm quite lucky really.
HM: Yeah it sounds like you're quite balanced as well.
SD: Pretty well, yeah. I try. But I actively do try and live what I say yes, because I think otherwise it's very unfair to the public.
HM: Very good. So, you've held many fascinating roles in your career, can you tell us about your career journey and what led you to where you are now?
SD: So I did medicine at Manchester, but I was really interested in genes and DNA and all of that. But I loved patients. I did a couple of years and it's well-known because it's on record that I found the first couple of years very brutalising, sitting with people. I mean if I use one example of a patient with his feet tipped up in the air as he bled from his lungs to die of TB that night. Sitting with a young woman aged 21 whose kidneys had packed up post-pregnancy and we had rationing of dialysis and there was no space for her because they thought she wouldn't comply with the drug regime. So I found all of that rather brutalising. Then I married a diplomat and went and lived in Madrid for four years, did a couple of clinics a week voluntarily of paediatric cardiology and then I came back and got on with it and did paediatrics, haematology and became a specialist in sickle cell disease which I loved. And I did that out at Central Middlesex and I think it was very formative because working with the community in Brent, where actually, though I was a specialist, I looked after three generations of some families because it's an inherited disorder, so that was very special.
I think we had ... we quite likely still have some racial ... kind of institutional racism against the sickle cell patients. They were all in district generals like where I was and there was very little research money. They needed all sorts of services which they weren't getting. It has improved but I still think they don't get as good a deal as they should have. I enjoyed it but I got sucked into research, setting up my own small programme at the district general. Then sitting on the region's research committee, moving on to chairing it, becoming a regional director and eventually the director general of research. So I kind of slowly moved into running research and looking at it strategically and then from that I graduated to CMO as well and then CMO losing the research or giving it up and picking up a lot of global health work.
HM: So, I was really interested in what you said just then about institutional racism for sickle cell patients. Do you think that institutional racism goes beyond sickle cell?
SD: Well it probably does. We have lots of for instance genetic studies on diabetes but are we focusing on the South Indians? You have to go to the district generals again or the Royal London. But the main teaching hospitals which set a lot of the style of the NHS, at least the hospital medicine side, are less black, less Afro-Caribbean.
HM: Yeah, and that makes a difference in terms of what is chosen for research and what is understood?
SD: Absolutely. And the services that are provided, absolutely.
HM: So when you ended up working on sickle cell was it that sense of institutional injustice that led you to pick sickle cell or was there something else?
SD: It was both. It's the most fascinating disease and as I said I'm really into genetics and genetic diseases and all of that. But I've also always wanted to fight for the right thing and justice and I felt that I should put my effort into supporting that community, both in their services and in research.
HM: You talked about the brutalising aspect of the medical profession or your experiences when you started out, do you think that's changed for doctors starting now?
SD: I think it's changed dramatically but not always for the better. So, how do I explain this? I think that the episodes I had are no longer there and people get much more support, but the young doctors are terrifically intensely worked and that can be very stressful. They don't have the team system that we had or the firms, which gave me a lot of support, so I think they get a different form of brutalisation and yet they have to deal with the dying and the unwell and that intensity and lack of firm support.
I mean I hear from my children and their friends that consultants don't always know the names of doctors looking after their patients. Where's your support network then? You don't know who you're going to be on with next time you're at the hospital so how do you build the bonds between the different generations of doctors to help each other on getting the best outcome for patients, let alone on your own emotional support, which is terribly important.
HM: Do you think that the idea of providing emotional support and sort of mental health wellbeing support for health professionals seems to be pretty new in the medical profession despite what they've been dealing with, day in, day out? Do you think we're now at a kind of shift in terms of that kind of being taken on?
SD: I think it's getting better but you have to remember where we came from, a male hierarchical system where if you needed support or said you wanted help you were weak and that was a bad mark. So, it's as you break that sort of system down and we get more women in, you get a different sort of system. So I think it's changing, but the intensity as I say, the lack of firms, I deplore. I worry for our young doctors. They find it inhuman how they are looked after.
HM: Tell us a little bit about your role as Chief Medical Officer for England and in particular what other things you enjoy most about it?
SD: I've always held that there's a job description and a job you have to do and if you deliver that then you can do other things that that platform allows you. So the job description is about giving advice to the government which may be policy or ministers, not just in the Department of Health but actually across government, on all matters to do with health. The ones I have to major on are of course public health and it's not just how to improve health and the role of prevention and all of that, but I've developed a role around genomics, going back to my love of genes, the research I did and setting up Genomics England. There's a big element of advising and supporting during emergencies, so during my time we've have Ebola, we've had bad winter crises with flu, so that then strays over to me rather than a management issue. We've had Novichok.
Meanwhile of course there's the public advice and engagement and the ones that jump out are of course the low risk guidelines for drinking alcohol, the advice to the government on social media more recently. So there's that. Then, one of the fun things that I have to do is produce an annual report, it's a statutory requirement on the state of the nation's health. The first one I did was much more like previous ones had been, much more about data. But then once Public Health England got going I realised that wasn't needed, the data was there, so then I started using the advocacy part of the role and focusing on what I saw as interesting on Cinderella areas and that's been great fun. I have to represent us internationally on health, I sit on the WHO Executive Board but I've of course developed an international role on antimicrobial resistance and played out our UK health diplomacy and soft leadership around that role, because I passionately care about it as well.
HM: It's a really wide brief actually when you think about the number of different big issues you're kind of having to go in and out of and be on top of.
SD: That's what makes it fun, I'm always learning. One of the great things is everyone's happy to advise me, so I can call on the best and they help and I mean what fun. No-one could have a better job. Oh until I move to Trinity of course and then that'll be my fourth career.
HM: Even better.
SD: I'm sure it will be.
HM: So I know that you're committed to ensuring that scientific evidence and research are at the heart of government decisions about health and in a previous role you actually created the National Institute for Health Research, I just wondered about how you find it working with politicians because politics is often about ideology. So in some ways your role takes you right to the frontier between evidence and ideology, how do you manage that conflict as somebody who's so driven by evidence?
SD: So, yes, my USP is evidence, but I think I moved on many years ago from evidence based policy being my objective to evidence informed policy. I have a role, it's technocratic, it's providing advice. Ministers have a role, as democratically elected people, and so the iteration is very important to try and get to the best answer. But I've only once had to say, if you do that I would have to resign. In general ... well no, always they listen with respect and in general they will follow my advice and I'm pretty content with the way they end up.
HM: What was the issue where you said - ?
SD: Ah, that's shrouded in history.
HM: Oh really? Will it come out in your memoirs one day?
SD: We'll see.
HM: But I guess you're not just in your role seeking to provide advice and leave it there, you also want to persuade. What's your style of convincing ministers to do what you think is right?
SD: Well my family would say it's water on a stone of course. I would argue it's a bit more subtle. I'm quite careful to frame issues so that the person, the minister or the policymaker who listens, can understand the relevance to them and why I'm saying it. So that's one thing. Another is, you know, people don't like being bounced, so as I do my annual reports, I and the Chief Editor will go round to various people and say, you know, I've done a report on this and I'm thinking of saying this, what do you think, could you live with that? Sometimes they say well if you just change two words we'll come out and support it or we'll do it. Wow. Well then it's usually worth it. Not always but usually. Other times they don't like it. But it means that by the time it's published they're not shocked by it and being difficult, they're saying well yeah we knew she was going to say that, yeah. So it's about how you handle it and thinking through the handling very consciously of the various issues.
HM: Let's talk a little bit about public health. What keeps you awake at night in terms of the big public health challenges and what do you think is the biggest threat to people's health and wellbeing right now?
SD: So we know ... you know, I'm going to talk about antimicrobial resistance, so let's just put that one on the side and think about the other things. If you look at the work of Chris Murray from the Institute of Health Metrics and Evaluation you will see the big threats going forwards remain smoking, hypertension, obesity and I would now add pollution. So it's the lifestyle and behavioural issues.
HM: Yeah, and in your role you've done a lot around trying to make it easier for people to make healthier choices. Where do you think the balance lies between government, businesses and us as individuals when it comes to looking after our health?
SD: Well, we all have roles to play but I'm not libertarian in the sense that it is everyone's responsibility to make sure they don't have too much weight because we have a society structured that makes taking the healthy option a difficult option. It makes taking the unhealthy option the easy option. So I do think that the government and business have a role and you can play it out in different ways, of changing the structures of our environments. So if business don't want to do it on their own, and they generally don't, for quite good reasons actually, what they generally want is a level playing field. If one of them starts then they may lose money. So when I talk to business they often say well yeah we have sympathy with that. We wouldn't mind doing it but we want the level playing field. Put in regulation and we'll comply. Put in a regulation and we'll innovate to do better.
I mean one of the examples that I quite enjoy is Nestle. They had done the basic science on how do we taste sweetness and we taste it as an immediate hit on our tongues and so you don't need a dense sugar molecule and they designed a new spherical one where the sugar was on the outside and nothing on the inside. They can make chocolates that taste really good and KitKats, though I to their surprise could tell the difference, but they were still very good. But they can make chocolate with half the calories.
HM: That's fascinating.
SD: So they can innovate round it you put in the regulations.
HM: If you put in the incentives for them to do that.
SD: Yeah and if you look at the sugary drinks levy, I mean they've reformulated most of them. So, I do think the government has a role in the structural environment that we all live and it's highly supported by the public but particularly to ensure that our children are protected.
HM: That's fascinating. I heard you say in an interview, we are not an island when it comes to health. It made me think about Brexit, not surprisingly at the minute, are you worried about the impact of Brexit on health and particularly public health and our ability to collaborate with others on public health issues?
SD: So I think everyone's worried about the impact of Brexit on our health service, the workforce, if we have a hard Brexit or fall out what that will do to drug supplies. We can't guarantee that everything will work as it should do and that there will be no deaths. On public health, at the moment we work very closely with the EU and it is the EU that brought in the regulations that give us clean beach standards and clean river standards and things. Because of the way we've gone about it we're going to transfer those directly into our own legislation but what will come later that we wish we had, but we may not happen.
I suppose that then takes you into trade wars, you know, do we want chlorine washed chicken when the EU doesn't have it and I think there are going to be all these debates and every time we have one the economy and trade will battle with other issues, whether it's chlorine is an animal welfare issue, but there will be other issues that could be human health. I'm sorry if we move into a much more adversarial system where health of ourselves and the planet are not given a high priority.
HM: I hadn't really thought about it like that, just in terms of those stark ... that stark conflict that may well arise now, between our interests in health versus our economy interests and how that's going to now potentially be fought on every single one of those.
HM: Okay, antimicrobial resistance, which I know you are a massive champion of. Where are we now in the fight against AMR?
SD: Well I'm very proud of where Britain is. We've reduced use in the community, we've stabilised use in the hospitals, despite increasing throughput and complexity and ageing, so that's pretty good. Though with our new antimicrobial strategy that came out in January, we're asking for more. But what your listeners probably don't know is we've been doing pretty well on animals too. You know a 71% reduction in antibiotic use in the poultry sector, with an 11% rise in protein production. We've reduced by I think it's 48% over the last four years, in the pork production. It's more difficult in beef and lamb but I mean we're doing really well.
HM: Yeah. It involves us being mindful around some of the decisions that we're making.
HM: So I want to talk a little bit about leadership. I was on a leadership course recently and we heard from some amazing leaders who came in to talk to us and they spoke about what drives them and one of them described their drive as, she used the words ‘the fire in my belly’. Another described it as the sort of what makes them angry. So I want to ask you what drives you and what makes you angry?
SD: I don't often get angry because if you get angry then you can't think so how am I going to sort it. I'm very cool and quite careful. But I feel passionately about doing what I would call the right thing. Whether it's the right thing by science, the right thing by the public and it's about telling the truth, it's about trying to protect people, even when they don't know they need protection, it's about moving science forwards. So it's about right and rights.
HM: You've had a lot of firsts in your career, you're the first female Chief Medical Officer for England and you're going to be the first female Master of Trinity College, what firsts would you like to see next for women in health and care, or wider science?
SD: I want it to be that it's truly a fair and equal society. I'm not really interested in quotas; I don't want equal numbers of women at the top. But I want women if they're as good to get there if they want to. I think that means we have to support women through child bearing, through being a mother and we have to support both sexes through caring for elders and disabled too. But people should be given a fair chance.
HM: Do you think as a woman that you face particular challenges in your career that maybe men wouldn't?
SD: I would argue that in my forties ... I had my children in the forties, when they were young I let my career not develop, I was just doing a really good, steady career and I've often said to other women that many of us who have children come through at a later age because we come ... not that I left the workforce, but you come back when you've got the space in your life, with more energy and a maturity too. So we mustn't be ageist, particularly with women. We've got to let the women blossom at the stage that it is right for them.
HM: Yeah and if you could go back in time to when you were first starting out in your career and give yourself one piece of advice, what would that be?
SD: Well one thing is I'd be totally shocked with where I am. This is not ... I didn't have a plan and I didn't expect to end up here, so it's wonderful. What I would say to that, because it's something I've had to learn but I think it matters, is take the opportunities, hold your nose and jump.
HM: Don't be afraid, just go for it.
SD: No, go for it. I even now do things and think oh am I going to be all right. But I have never not been all right.
HM: You really do worry still about -
SD: Yes, I was doing a BBC pre-record yesterday and I said to the interviewer, I'm feeling nervous and she said what, you're nervous, but you're terribly good. I said, yeah it's like doing a viva every time you interview me. But of course that makes the adrenaline run so then I probably do better than I would do if I didn't get nervous. No, I worry at what I'm doing; I want to do a really good job.
HM: Yeah, that's good advice.
SD: Harness the fear to be a driver.
HM: To be even better.
HM: Just coming back to the sort of being a woman and a leader, I remember ... I think it was only last month actually, hearing the Today programme interview on Radio 4 when Nick Robinson described you as Chief Nanny and I thought you dealt with it brilliantly. But I also had my head in my hands as he said it. Talk me through a little bit around how that moment felt.
SD: He didn't actually say I was the Chief Nanny and he ended up with his head in his hands actually.
HM: He said other people.
HM: Other people described you as Chief Nanny.
SD: To be fair to him. But why I reacted very strongly and in the moment was because I'm quite used to that, once I've done the content, got the message over, at the end. Because after all they want some good radio and how do you have a go at me, well I've usually learnt my facts up, I'm passionate and caring, so you have a go at the nanny bit. But he started with it and I thought that was unfair, so I responded in the moment.
HM: Challenged it back. Tell me, who or what has been the greatest influence on your career; that could be a role model or a mentor?
SD: So I'm very lucky. I have had lots of mentors. I was talking yesterday with someone about Professor Sir David Weatherall, for whom I never worked, he was in Oxford but gave me such support and advice and told me to go for it, after I became a Regional Director of R&D. I clearly wasn't doing very well, I kept getting into kind of arguments with my colleagues, so I persuaded my then boss, Ron Kerr, who's fantastic and been really supportive to me all the way through, to send me on a management course and I went off to Fontainebleau to the European Business School on an emotional intelligence course and that was life changing, let alone career changing.
I've had a wonderful executive coach for something like 13, 14 years who would challenge me and say, you've been here before. Surely you can do better this time, and all sorts of things. So I've had lots of support in many ways. Of course the support of my husband who believes in me. On the way up to Trinity in the autumn for an interview by all the Fellows, I said oh why am I putting myself through this. He said, because you want it and I want you to get it. So you have to, you know, but there wasn't any, oh don't worry type of thing, it was just very straightforward support.
HM: There was a lot of excitement here at The King's Fund when people found out that you were going to be coming to be on the podcast, especially female colleagues, but everyone here was excited. I guess that's in part because women think of you as a role model. Is that something that you're comfortable with? Do you see yourself in those terms?
SD: I know I am for some but I'm perpetually surprised actually by the impact I have and by how many people see it as inspiring and everything, so I am perpetually surprised by it. But it's rather nice.
HM: Yeah, absolutely. So the final question to you. You'll be leaving your role as Chief Medical Officer in the autumn and you've done huge amounts in it, what advice would you give to your successor?
SD: I think you have to be in this role, to be successful, evidence based, able to speak your mind but to know when to back off and not over-react or react too quickly. Most problems are best slept on. Most problems are best shared with other senior colleagues. Most problems are best solved by teams, both within the department or the health system or across government. I work quite closely, you know, with the police, all sorts of people. But working as equals. I bring something to the table but they're expert at other things and they should lead on that. How can I help them?
HM: So recognising the strengths of others, not being a lone wolf.
SD: Yeah. I walk in to meetings and I say, I am your CMO, I'm here to help.
HM: Well thank you so much Professor Dame Sally Davies for joining us on the podcast today.
SD: Thank you, Helen.
HM: Well that's it from us; you can find the show notes for this episode and all our previous episodes at www.kingsfund.org.uk/kfpodcast. Thanks for listening. I'm Helen McKenna and thanks as always to our podcast team and our producers Ian Ford and Sarah Murphy. If you enjoyed this episode please subscribe, rate and review us on our iTunes or get in touch either on Twitter at The King's Fund, or my account @helenamacarena. We hope you can join us next time.