Public health, like any other field, has seen its fair share of trends and fashions. Over the past two decades, we’ve witnessed a variety of approaches come centre stage, each promising to be the silver bullet for improving health and wellbeing. Yet again and again we are beguiled by the shiny and new over what we know in our hearts is needed to improve health and wellbeing. Having worked long enough in this field, I get it. The shiny and new offers us hope, optimism and re-energises our batteries that are ever depleted by social ills and wicked problems. Plus innovations draw in charismatic leaders and investment and we can’t help but be enticed in.

One driver of trends is the need for innovation from funders and policy makers – it is much more difficult to find investment to sustain good work than it is to do something new. Some innovations are more thought through than others. Examples from my experience working in Scotland include social marketing for behaviour change, health checks, exercise referral, social prescribing, licenced training on mental health from other countries, and in the last ten years the focus on childhood trauma. What these ideas invariably have in common is they arise from asking what is the problem, and how can this problem be fixed?

Working in a deficits paradigm elicits a spectrum of responses. Initially it can be exciting and motivating that the work is worthwhile and will make a difference; part way through there may be a realisation that the outcome measures chosen to measure effectiveness are wrong or even too complex to measure (and there is no baseline); then towards the end of discrete projects there can be a sad dawning realisation that all the time and energy invested has been a waste of time and the project will leave no lasting impact on health outcomes. Whilst as health improvers we know and understand these pitfalls, the deficits-based system we work in lures us again and again. A prime example from my practice in the past 10 years was a national health check scheme for the over 40s in Scotland called Keep Well which despite significant investment, delivered no enduring legacy either in terms of embedded changes in service delivery or sustained health improvements.

One of the dangers in these trends is believing that there is an answer to complex health issues and thinking if we look hard enough, we will find the solution. The reality is reducing inequalities, improving health outcomes and preventing disease requires not just a multifaceted approach, rather, it would take a seismic shift of not only political thinking and social justice but also the collective attitudes and values of all of society.

History has proven that solving one problem often results in unintended consequences and new problems appear. Infectious diseases of the past have largely been eradicated, firstly from sanitation and then from an understanding of microbiology and vaccination; but then we had to contend with non-communicable diseases attributed to “lifestyle”. The 1990s saw us tackle certain diseases in very defined secondary and tertiary preventative ways, for example, by identifying people at risk of these conditions and developing guidelines and treatment pathways. However, new epidemics rise up and replace the ones we think we have mastered. Type 2 diabetes didn’t feature in the disease specific public health approach of the 90s and now costs us 10% of all NHS spending each year.

I suspect the current excitement around Marmot Places is symptomatic of thinking we have found the answer and wonder if this may be our latest trend? What has originated in England is now gaining traction throughout the UK with many policy frameworks badged as Marmot approaches.

Before I go any further a qualifier is required – I love Michael Marmot – having read his Whitehall studies in the 2000s at a formative time in my career, I have been hugely influenced by his research. This seminal work tipped on its head the premise that high powered managers were risking their health due to the burden of stress and gave currency to power, status and income being protective of health and wellbeing. A career devoted to studying protectors and risk factors for health means his name is now synonymous with aspirations for a more equal society.

There are many advantages of naming healthy equity approaches with Marmot’s name and working in this co-ordinated way, not least in generating new enthusiasm and commitment to this important agenda. However, learning from the past, we must be aware of the investment that would be required to see measurable improvements and the complexity of whole systems having to mobilise and collaborate around common goals.

It is important to understand the principles behind Marmot Places are in no way new. The focus on inequalities and the social determinants of health has been the cornerstone of public health for decades. What Marmot Places brings to the table is a renewed emphasis and a structured framework for action but please let us not be distracted by the shiny and new again and think we now have “the answer.”

A Call to Action

So, how can Marmot Places help us? First, we need to embrace the complexity of public health challenges. This means adopting a holistic approach to the social, economic, commercial and environmental factors influencing health. We must distance ourselves from quick fixes and invest in long-term solutions that promote health equity and sustainability beyond this generation; perhaps looking to our Scandinavian neighbours as role models. Even better, let’s think how we can create cross party consensus to move away from the boundaries of parliamentary terms of government.

Second, we can reframe from being the doers to being the enablers. Yes, we require a commitment to evidence-informed practices but let’s be brave and advocate for a shifting of power and responsibility for health and wellbeing back to communities, for this is where the potential for good lives is greatest. People going about their lives in their communities are the ones with the biggest stake in these places being strong and vibrant and our work should nurture these indigenous aspirations.

Finally, we must learn from the past. The fads and fashions of public health have taught us that there are no easy answers. By acknowledging where we may have gone wrong and building on our successes, we can work with communities to aspire for a fairer and more equal society for all.