Men’s Health Strategy Is Not a Poster in a GP Surgery with Professor Paul Galdas

0:00Professor Paul Galdas:This episode is supported by Movember, the leading charity changing the face of men's health.

0:12Welcome to To Be A Boy podcast with me, Elliot Ray.

0:15Professor Paul Galdas:And me, Jodie Braley. Today we are talking about the health of men and boys. 75 % of suicides are men. Suicide remains the leading cause of death for men under 50. Men are more likely to die prematurely. They live around four years less than women. In the most deprived areas, men die up to 10 years earlier. Men are more likely to be homeless, be in jail, and addicted to drugs and alcohol. And to add to that, they are less likely to seek help, often suffering emotional and physical pain in silence. I acknowledge that's probably the most depressing start to the podcast. Sorry about that. But in a world where we recognise men's privilege, we have only recently started to have a mainstream and national conversation about their pain.

0:57And the good news is that this has resulted in the UK government publishing its first ever men's health strategy last November to try and address some of those poor outcomes. So today we are talking to Paul Gaudas, Professor of Men's Health at the University of York, Jolie's neck of the woods, and Chair of the Men's Health Academic Network. Paul was instrumental in developing the men's health strategy. This conversation will help us all understand what's going on with the health of boys and men, what the government is doing about it, and importantly, how parents can support their boys' health.

1:30Welcome, Paul. Thanks. Great to be here. Thanks, Elliot. Lovely to have you. So, Paul, talk to us about being a coronary nurse back in the day and treating men who had delayed seeking help for chest pain. That must have been so insightful and you must have had some really life-changing experiences. What was it like meeting and treating some of those men? Yeah, it was life-changing. It was formative, really, in terms of how it informed the rest of my career. Many people don't know that I started my career as a registered nurse. Well, I'm still a registered nurse now, although I wouldn't go anywhere near clinical practice.

2:05I don't think I'd be fit for practice right now. But I used to work as a coronary care nurse, as you say, looking after guys and women who'd experienced heart attacks and acute cardiac problems. And I was in my early 20s and looked after a lot of young guys that we saw come in, sort of in their early 40s to early 50s, sort of the age that I am now. I noticed that they were really uncomfortable in hospital really ill at ease with the whole system and as a young lad from a working class background I found I connected with with them a lot of the time and I almost made it not my clinical specialty but I kind of gravitated towards those guys because I feel like I could almost speak their language and I was really interested in listening to their their stories and what was really common was almost all of them had a story around putting off going to the hospital and going to the doctors when they were experiencing chest pain for as long as they possibly could it was really really a common story and when they looked back on the reasons why um it was that they were trying to carry on work or carry on with their responsibilities at home and they knew something wasn't right but often had wait until the last possible moment where they thought i can't cope with this any longer and i need to get help um and often it was their partners or close family members who ended up calling the ambulance or calling the doctor out and so really that that was what stimulated my original thinking around what's going on here like why are these guys feeling like they can't reach out why have they delayed and it really had an impact on you know their their prognosis and their health afterwards and so I ended up doing my PhD in that topic at the University of Leeds in early thousands looking at what are the decision making processes for men who experience cardiac chest pain and importantly my interest at that particular time and has been throughout as well how does masculinity influence those those decisions so yeah it's something that i still think about this was over 20 years ago now but we're still kind of grappling with some of the same sort of issues when we when we talk about it in terms of men's health yeah i met a guy a couple years ago and he was telling his story he'd had a lot of pain in his kind of lower belly area for a long while and he was urinating a lot in the night time and he basically ignored it over and over again for months until he woke up one night and plus blood in his urine and he wanted to ignore it but his wife was like literally go to a and e and he went to a and he had statistically cancer and he hadn't gone that day you know who knows but he had an operation and he's fine but I remember him saying even when he went to the doctors and he was in A &E he still didn't really want to tell his workplace about what happened because he had a team and his idea of masculinity was wrapped up in in work and being present and whatnot and I hear that so often I mean I used to be like that I've changed now I go to the doctors for anything they're sick of me I go all the time but recognize what you're saying why do you think it is that like so many men just ignore symptoms and they don't go to the doctors.

5:23They ignore what's going on in their body. I think it's a complex problem and we kind of look for simple answers to this in many ways. But I think the important thing to emphasize that whilst stoicism and solving your own problems and some of the sort of common attributes around what it means to be a man in society today play into this, the challenge doesn't reside in individual men it's how the the health system and our structures around how men live work and play responsive to their needs and i'll give you an example of that um that kind of connects with what you just said there elliot that i need i need to make a gp appointment i may have called my gp yesterday um and they said oh um you know it's a bit late to get in before the time you need to, but the doctor can call you between 12 and 5 on Friday.

6:22So I was like, okay, well, that's fine for me because I sit here in my office and I can take a call. But if I was an electrician working on site, that's not going to work for me. Or if I was a school teacher, the system isn't as responsive as it can be. And we know that it's not just that. If we put in place services that are responsive to men's needs, then men do go and they won't ignore symptoms and they'll take early action. And one of the big problems that we do have in relation to men's health right across a range of conditions is supporting men to engage with services before crisis point.

7:01um and so the whole men's health strategy is around shifting the focus away from thinking about why are men not doing what we want them to do with going to the doctors earlier or taking actions in order to maintain their health to toe um why is that why the system not not reaching men and engaging them in a more appropriate way that reflects their needs preferences and one of the things that I say to kind of bring this to life and I love an analogy is that the health systems like the high street right and for a long time in relation to men's health we've thought why are men not rocking up at the high street why are they not showing up we need to tell them more about the high street and tell them why it's good to go there rather than thinking what is it about the high street that's not appealing to men maybe we need to change the opening hours, maybe we need to take some of the shops closer to where they are, maybe we need to add in some things within that high street that are genuinely appealing to them.

8:00And so it is about not just thinking about the deficits that men may have, but actually, how can we have a system that's more equitable, so that it works for everybody, including men, and particularly men who are facing the greatest disadvantage within society.

8:19Professor Paul Galdas:So, women... In my view, without reading the data, I think, you know, from my friends, we happily go to the doctor all the time. But I always think that's because we are forced to interact with the medical profession regularly from a really young age because we have periods and because we can get pregnant and because we have to go on the pill and we have to have like things shoved up as a lot to check that everything's all right up there. Yeah. So we just get much more used to going to the doctors than boys and men do. And often the first time perhaps a boy might or a man might go to the doctors is because there's something specific to them.

9:00Professor Paul Galdas:Whereas for girls, it's just a regular, you know, part of being a girl. Do you think then there's perhaps something you can do at a younger age to engage boys in the medical profession? Yeah, absolutely. And the evidence bears out what you've just said there, and is that women tend to have natural touch points across their life where they have to engage with health services, reproductive events being the kind of the main ones, whereas men tend not to have that. And if you look at the data, patterns of engagement between men and women diverge, you know, they're massively different in the working ages, only at the very beginning of life and the very end of the life are the same.

9:39And even if you take out female reproductive events, actually there's still a big gap between patterns of consultation so to expect a lot of guys to access a system that they have little familiarity with that they feel like they they don't they're not confident no don't know what to expect can be a real challenge part of the solution here as you've said is around normalizing that level of engagement from an early age but also making sure that the services feel welcoming and normal for boys and young men at an early age as well. A lot of the evidence points towards supporting men to understand health as an asset rather than as a deficit.

10:24I mean, we often frame health around the prevention of illness. You must do this, otherwise this might happen to you. But actually, if we frame health around staying well, staying strong, being able to be more active as a father, as a colleague, and as a friend. Those things tend to resonate better. It's seen as a strength and as an asset rather than as a deficit. So moving away from this sort of, I've never been to the doctors in my entire life as almost a badge of honor, to developing services so that guys see it as appealing and normal. And fatherhood actually is a key, and the men's health strategy touches on this life transition point where men can naturally start to engage with services and again but if systems are not shaped to value men's contributions as fathers in their own right and support them to take their child to the doctors to get their immunizations or you know workplaces are supportive to enable guys to say i've just had that call from nursery i need to go pick up my child because you know they've had three loose poos or whatever you know and i kind of need to send them to the doctors it it it won't again support that development of that familiarity um so yeah it's not just about telling telling guys to behave differently it's around how the systems and structures around them are creating norms for what it means to engage with health and health related behaviors and services

11:51Professor Paul Galdas:because the system is actually actively hostile towards fathers from my experience like when you're pregnant and the father comes with you I know that my partner felt very excluded and ignored and not consulted with whatsoever and then when we had our first son we had some significant problems in his first few weeks of life and my partner took my son to the hospital and they said to him where's the where's the mother why is she not here and they never said to me where's the father when I took him on my own and he was like you know on the back foot felt really sort of awkward and embarrassed about it yeah and i think that that's a common story that i've heard and is reflected in some of the research evidence is that i would frame it is that that services and systems are not father inclusive or family centered that you know we talk a lot about about family centered approaches about father inclusive services but the reality is still at the moment they aren't set up to reflect father's roles as parents in their own right Often, I think father's roles are framed around support for mum, support for kids, but not actually, you know, the role of the father.

13:05I mean, these are deeply ingrained norms as well that reflected in systems like maternity services, like parental support services. We've been talking a lot recently around about family hubs and making sure that they're family centric and father inclusive as well. And we need to move beyond rhetoric around that, you know, just saying we welcome fathers or a poster up there or painting something blue, you know, it's not going to wash that. I think it kind of needs to be co-designed with dads. You know, dads need to be and families need to be part of the design of services. And again, this is something that I talk about when we talk about what does system change mean?

13:42Like what are we talking about? And I think father is a really good example in that, you know, we kind of put, we can put together a fatherhood program where you can get dads together. But really what will affect sustainable change and realtor change is around changing policy so that, you know, dads are welcomed, dads are included. And we don't kind of talk about them as almost like a side issue that we can do in a particular separate program. Yeah, I remember going to my eldest, she used to have really bad allergies. and so you should get these annual checkups and I took her many years ago maybe four or five years ago to one of the checkups and I'd had her on my own for a couple of days I went to the appointment and the nurse was asking me what did she eat yesterday so I told the nurse and she wouldn't believe me she was like I need to call mum mum will know I was like no no like mum was at work yesterday this is what she ate and she wouldn't have it and she got my wife's number from the file and called her up it was like what did your daughter eat yesterday my wife was like I don't know ask her dad it's crazy in regards like offering services that are inclusive to men in parenting out loud we've worked hard over the years to to learn the lessons from the medical profession in terms of language in terms of activities in terms of framing it around performance making it clear what we're going to discuss and how they're going to benefit from it but it can still be a struggle to get men along we can have events at a football stadium and there's football players there and they get a stadium tour and a free lunch and still some men will be like i'm not sure so that the barrier is real but i wanted to ask you about parents and what do you think parents can do parents of boys to encourage them to seek help when they need it from a young age what would your advice be for parents listening well i think um i think the first thing is what not to do and what not to do is is um telling them off saying that they're bad or that they're behaving badly.

15:35I think that rarely works in most parenting contexts when we're talking about modelling positive behaviour, when we're trying to encourage positive behaviours. And that modelling is probably the most important thing, I think, is that boys learn norms around what it means to be a man through various different messages that exist, not just within the family, but also in the communities and systems around them, school, media and so forth. But respond a lot to what they see, not just what they told and so you know i think having a having father on my role model who models those positive behaviors around around proactive engagement with a health service and not just health services when we're poorly but um being able to demonstrate vulnerability being able to to say this that these are these are concerns and it is a great strength and shows self-respect in order to kind of look after your own health.

16:33I think that is really how parents can best affect how boys can grow up thinking about what does it mean to be a man and look after your health. In the same way around physical activities as well. You know, you can see this in families, you know, that if your parents are kind of into doing running, sport, hockey, football or whatever, the kids are kind of more likely to go into that. if you have families with loads of musical instruments around or books then the kid then the kids naturally kind of engage in those things so it is a sort of a normalization of patterns of role modeling and connection and i think that's the thing as well is that keeping the door open even if boys are not willing to talk about some of their health fears or health challenges maintaining that that connection and keeping that door open um is is massively important and as a as a research scientist and as a as an academic i tend to just focus mostly on the evidence and don't talk about my own personal experience but i will talk about my personal experience because i've got an 11 year old i've got an 11 year old son so i kind of live in these challenges you know and we got him so we got a we've got i've got an older daughter as well 16 year old daughter and when she was going through puberty we kind of got her a book you know and said this is the book how my body's changing and so forth and she was evidently reading it and at the questions coming.

17:58So we've done the same for my son, who's kind of going into that tweenagery thing. Well, he hadn't looked at it. He hadn't looked at it. He doesn't want to talk about it. He doesn't want to touch the book. Really? Oh, so we're like, what do we do then about this? So anyway, we just kept the book sort of somewhere with the thinking, well, keep the door open and maybe talk about it at some point when he has to. But rather than, you know, I think berate him and say, well this is something that you really need to learn and understand it is about that maintaining connection and yeah so I guess the thing that I can say there really is I don't know myself either really yeah we're all learning we're all learning you know I've got a 10 year old daughter and we need to get her a book um ASAP but on the on the role model thing I definitely relate to that so we've got a builder um shout out Kenny and he's maybe in his 60s but this guy is in shape like sometimes in the summer he takes his top off and walks around the house i'm like okay kenny cool this is what you're doing um but he's in shape and he's always he's always says to me like i go to the doctors all the time and he said it to me about four years ago and i think that has seeped into my psyche because i looked at him i was like if i can be like that at 65 i need to start getting my checkups um so yeah great advice there role modeling let's talk about um premature death and some of the risks so we know from the strategy it highlights that men are more likely than women to die as young adults and particularly from external causes like accidents violence overdoses and suicide i want to ask your your opinion on why you think that is why do young men have this elevated risk of passing away from these external causes yeah again it's complex and rarely is the The one factor that's contributed to us is kind of an accumulation of risk across societal norms and risk-taking, substance abuse, alcohol and drugs that tend to be more common amongst younger men, distress and emotional inexpressiveness and socioeconomic disadvantage that kind of all comes together to what we say in public health is a compounding of risk.

20:19So each of those different factors elevates risk and that's why we see patterns of poorer outcomes across some of those key issues. And the same goes for men as well. And as they go into the older ages, when we look at patterns of suicide and death by suicide, It's, again, multifactorial, associated with socioeconomic deprivation, financial problems, relationship breakdown, and stress, and a range of different factors, as well as substance abuse as well. So, you know, the solution then has to be around tackling some of those issues earlier and providing support, again, trusted, accessible support for a range of those issues early so that we're not just responding when crisis happens, when those problems start to manifest.

21:12And so, you know, we need to be working with boys and young men to learn what it is that they need, what is trusted support, what does that look like? And it might look very differently to what we think they might need. I mean, we just talked about, you know, books and giving your young child a book. That's me saying that as somebody who reads books, you know, they might just want something digital. They might want something that, yeah, somebody from a peer group who's not a health professional or, you know, who's from their community, who they know that they can say things to that's not going to get back to either school or their workplace or their parents.

21:55Those things tend to be reflected in the evidence around various different issues about how we design services so that they reach and engage boys and young men earlier. About meeting them where they're at so that they get the support that they need early. And again, I said right at the beginning, Elliot, it's the challenge that we face with a lot of boys and men's health is around shifting support away from crisis response to proactive early engagement. so what would you say are the main things from the men's health strategy that are kind of aiming to address particularly like overdoses and suicide is there particular interventions that you see in the strategy that would help yeah i mean the the main take-home i think from the strategy is that isn't it shouldn't really be viewed as a sort of a collection of interventions but more around a call for systems change and there's some headline things in the strategy that are important that will help sort of build momentum around change.

22:57So, you know, partnership with Premier League around suicide prevention and investment in community-based programs, for example. But really the success of the strategy will be around how local health systems respond to the plan and its framework. So, when I say local health systems, I mean, what are local authorities do differently? What are integrated care systems that oversee NHS services within each region? How can they respond? So it's not necessarily about straight away doing new things, but more around, I've been going out and speaking with local authorities, I would say, you will have existing smoking cessation services, gambling and addiction services.

23:41Do you know who's showing up to those? and importantly, which guys are not showing up to them, who's been missed, where are the guys who are falling through the gaps, and then thinking about, well, what do you need to do in order to change those services and systems so that they are reaching those guys. And really, that's the focus. It's around the men in society who the system is missing. And so that'll be different across different regions, but fundamentally the general principle that this is not just about individual men and their behavior, but it's about reshaping our health system, our high street, as I said, so that it's equitable for everybody and particularly those who have got that accumulation of risk, the greatest disadvantage.

24:31You know, reading a strategy, there was one bit that kind of really made me sad, to be honest, and it was that 6 % around one in 10 men in England say they are often or always lonely and it also said there is some evidence to suggest that young men may be more likely to say loneliness is something to be embarrassed about and I read that I just had to pause and think about that deeply in regards to just my own life and whether I have been lonely and really interrogate that but also to think about would I be embarrassed to say I was and I probably would be if I'm honest I would probably be quite embarrassed I wouldn't admit that I was lonely I would see that as a deficit on my part and I would feel judged by it so what do you think about I guess big question but why are so many men lonely and also do you have insights into how loneliness impacts wider health outcomes as well yeah I mean it's a big it's a big issue it's a big public health issue for both men and women, actually, in patterns of loneliness, rates of loneliness are increasing.

25:35But you're right in what you say in terms of the reluctance to admit or accept feelings of loneliness. We did some research a year or so ago here at the university around men's experiences of loneliness. And we used a number of different scales to assess the perceptions of their loneliness. And what we found was that men were reluctant to respond to a direct question around are you lonely or not they were more likely to say no but then when you look to the responses to the other questions that that related to to being lonely it was clear that they were around lack of social connection feelings of isolation so there's a clear disconnect between what was actually happening and how they were willing to respond around it and in many ways maybe even asking that question around loneliness might not be helpful it's in the same way that using diagnostic labels for mental health depression or anxiety can sometimes be unhelpful for men but what we found in terms of loneliness in men was that it wasn't necessarily about isolation it was around so it was around social connection and belonging and meaning and what mattered most for a lot of guys was feeling like they were part of something and you know we there could be a look there could be alone there's a difference between being alone and being lonely but really what what was key was feeling that connection that they were they had belonging meaning and attachment to something that was important to them that could be through work could be through um you know hobbies or through community and i think you know as we're kind of just beginning to unpack really what are the reasons why we're seeing these increases, male friendships and decreasing, for example, and feelings of disconnect.

27:22And I think there's been a big shift since the pandemic as well. But we know that improving those social connections can be a health intervention of itself for men. It has strong protective factors across a range of different issues, particularly around mental health and suicide. And so again, that's an example of how when we're thinking about how the system's working within our communities are they affording opportunities for men to build those social connections particularly guys who were you know like i say were at the greatest risk so we know that being lonely is the equivalent of smoking 15 cigarettes a day in terms of your health like it's really bad it is very very bad for your health and well-being so yeah after i meet with my friends i just feel so much better and it's the sort of thing you do and you're like we should have met up like months ago why did we delay this because you just get a feeling that you feel like grounded in yourself again and sometimes when we do our parenting out loud events one of the main things that come out we hear from men and dads is they don't allocate time for themselves so they feel stressed out with everything that's going on they put a lot of pressure on themselves to be strong for everyone else to do this to work these are very involved dads you know they're doing all the stuff and the main conversation comes back to I have no time to to do anything for myself yeah and so we always get into a conversation of like what can you do can you find 15 minutes in a day can you find that club you go to every other week like how do you speak with your partner about making time for each other join the football club whatever it is and that tends to be 99 % of the time like the thing that that helps men so much yeah and we took that approach actually in a mental health program that we developed we developed and tested in um nhs frontline workers men who were working as men who was working as paramedics doctors nurses physios and maintenance workers and things it's called behavioral activation so it was it's a well-established program a little bit like cbt but it focuses on behaviors and how they connect to how you feel rather than thinking about patterns of cognition necessarily and a key part of that is around helping guys identify what are the things that they are doing that help them feel well and what are the things that they are doing in order to don't make them feel great with understanding that when things happen in life work pressures becoming a busy parent illness those things we can sometimes cope by stopping doing the things that that help us stay well because you know an example being i'm just knackered when i get home from work So I'm not going to go to the quiz night tonight.

30:04I'm not going to go to my run club or whatever. I'm just going to go to bed early. Now that can work as a short-term coping strategy, but as long-term, it can lead to avoidance and withdrawal. And so what our program attempts to do is support guys to just schedule those things and do it, even if you do not feel like doing it. So it's taking action. Don't wait to feel better before you take action. Take action and then you will feel better eventually. And that works for a number of reasons. And it's, again, well established in the psychological literature. But for a lot of guys, it was about providing them with the tools to make the decisions and goals and actions themselves.

30:44And that's a big thing that we miss around men and mental health is that men will engage. They do care about their mental health and well-being. But often just need to be given the tools to be able to take those actions themselves and look after their mental health and well-being. rather than feeling like I've got to hand over all of my problems and vulnerabilities to somebody else, and that can be a bit too much. So it's a really neat way of thinking about how to stay well is just look across your week, rate it one to five, how things are making you feel, and can you put some more four or fives in there, even if it's 15 minutes, even if it's 30 minutes, because if your week's just full of ones and twos, then that can lead to downward spirals.

31:26So yeah, I really like the acting before you feel better rather than waiting to feel better to act.

31:32Professor Paul Galdas:I love that, ones and twos, fours and fives. I'm going to do that. It must start early though as well because, I mean, I've got a real bee in my bonnet at the moment about the lack of youth clubs. There's no youth clubs around here and there's kids running feral and they've just got nothing to do. And we know that boys can gravitate towards computer games and staying in the bedrooms and just being completely isolated playing computer games. Is there anything in the men's health strategy around boys and how we make sure that we reduce loneliness for them? And are youth clubs in the men's health strategy, I suppose?

32:09Professor Paul Galdas:Yeah, well, I don't know where the youth clubs are specifically. Screen time is though. Screen time and the detrimental or potential detrimental impacts of screen time is going to be a key focus of the work of the academic network that I chair at the moment and the future programmes of intervention that will come out of the strategy. But again, it does speak towards how the structures and systems play into some of the health risks and challenges and that it's not, you know, it's good. It's okay saying to the young lads, you know, get off your computer and go out and go do something. But if there's nothing to do...

32:47Professor Paul Galdas:Exactly, that's it. without choice like my my boy is 12 and you get to the point of holiday clubs as well there's nothing for them to do in holidays they're cut off at 12 so there's nowhere for him to go yeah and so either i have to take time off work and entertain them or i'm kick him out and there's gangs around here where he doesn't want to go out and mix with that or he sits in the house and plays on screens and literally that's it that's your only option is screens so it feels to me we talk a lot about screens but actually the problem isn't the screen so much as the lack of opportunity to do anything else yeah yeah it is and i think diversity of activities is important is that demonizing screens and online connection is not the answer here i don't think and there's evidence shows that um boys can get and young men and older men can get a lot of value from from connection via online.

33:43But if that's the only thing, then that's when it becomes problematic. And we know that, you know, that getting out and just the physical aspects as well of being able to be outside in your communities, feeling safe and engaged and connected has a lot of benefits. And so we really need to take the same type of approach to supporting change, behaviour change in that regard as we do with other public health issues. like for example cycling if you want more people to cycle in our communities the evidence clearly shows that you don't just tell people to cycle you actually build infrastructure that helps them feel safe cycling you know more cycle paths and more green space and that that then gets people more people cycling just telling them to do it doesn't work because it doesn't overcome the barriers that they feel like safety and risk and it's the same thing when we're thinking about how can we affect change within our communities around different behaviors like getting boys to connect more in safe spaces and in activities that helps them feel connected.

34:46I think we finally recognize that when it comes to men's health it's not just a men's issue we need to fix the infrastructure around it and I think that's a you know we've been doing this work for a while that's a new kind of national conversation it's great to hear that. Let's talk about the kind of class within this you know that men in the most deprived areas are likely to die over 10 years earlier on average and have on average nearly 19 fewer years of healthy life expectancy so I've started to go to a nice gym over the last few years which you know Jodie and Katie have heard about this many times but it's only going to this nice gym that I realized how much class has an impact on health because we're going there as a family we're going like the kids are playing tennis they're in the soft play we're eating healthy food there's a crash the parents are going to the gym they're playing paddle which is the new thing and i'm like wow i didn't realize when you have money and access you can work out as a family and when you don't like it's very hard to do that i didn't make that connection but now i'm firmly middle class i've gone over the fence from working class to middle class definitely if you're playing paddle exactly i'm there i'm not denying it i'm sitting in my middle class now it's fine i've acknowledged it i've come at peace with it but it's massive and i think most people don't know because maybe they don't go from either side so you don't know what the other person's experience is like so in the strategy and it's in your opinion as well how do we like help the people that need it most in regards to like the men that are really struggling what can we do to actually zoning on those people well that's the main story of the men's health strategy it's a health inequalities issue right um and it's deprivation is the key factor that shapes everything in terms of patterns of health outcome.

36:37Because as you've outlined there, the differences between different groups of men far outweigh and outstrip the differences between men and women. And really the success of the strategy, the men's health strategy, will come down to the ability to address the challenges that men who were facing the greatest disadvantage in our society experience. You've outlined there the difference in life expectancy and healthy life expectancy. And those things are reflected right across other conditions, cardiovascular disease, respiratory conditions, liver disease, diabetes. These are the major contributors to premature death in men and tend to be clustered around preventable risk factors such as overweight, obesity, diet, physical activity, alcohol consumption, access to health services, amongst other things.

37:29And so we really need to be thinking about those things and how we can support and engage men earlier in health promoting behaviours to ensure that they have got every possible chance of living longer, healthier lives. And so when we think about, for example, stopping smoking services around gambling and addiction services around weight management and physical activity services that are available, we should expect that those services that exist within our communities reflect the needs and preferences of the men who are experiencing the greatest challenges. And so the strategy is not necessarily about just well here's x amount of money to do this particular pilot or parallel system it should be baked in to our public health systems such that they tackle that level of inequality that exists within our country in the same way that we address other inequalities but it's just taking a men's health lens to it and i've said for a number of years that this is not about creating a parallel system or service for men it's about integrating it into into business as usual for the guys who can't afford to have the time for to to go to the gym or for the guys who can't necessarily afford um a balanced healthy diet um or perhaps don't know or you know so supporting supporting those things early is really the key here to getting sustainable change and improving the lives yeah yeah so important i grew up in wembley north west london and when I go back to get my hair cut I walk down the high street and it's just chicken shops and betting shops you're like what there's chewing gum on the floor there's spit on the floor like is the buses are quite dirty don't get me wrong I love Wembley anyone listening from Wembley I love Wembley I grew up there but you can see the difference in the environment to other areas and then around and I think it's it's it's a real challenge to get through to people who on a day-to-day basis are just thinking about surviving their health unfortunately is not on their priority list when you haven't got money um and when you're looking for a new job and you're just struggling with getting your kids into a good school and all those sort of things so yeah it's a massive a massive thing to address can we talk about fatherhood we've spoken a little bit about being a dad and and how we need to um make our systems more fatherhood inclusive we know that five to ten five to fifteen of fathers experience anxiety during the perinatal period and five to ten of fathers experience depression.

40:01But currently, in most NHS trusts, dad's mental health isn't routinely checked. And obviously that impacts their health, which impacts the health of their child and their child's outcomes. So, you know, me and Jolie, we always talk about paternity leave. We couldn't have this conversation and not talk about paternity leave. That's impossible. I didn't see paternity leave mentioned in the strategy in regards to it being an intervention. Obviously, there's the parental leave review. So it may have been that, you know, the Department for Health decided to leave it to DBT. But what would you think about how at least six weeks of paternity leave would impact the health of dads and the health of families if the government was to introduce that in the parental leave review next year?

40:43Yeah, it's massively important and important on so many different levels. I think fundamentally we can't have the conversation around the importance of fathers as key contributors to the well-being of families if policies and structures don't reflect that, you know, having a minimal amount of paternity leave. It's not just an employment rights issue, it's what messages that's sending in terms of the value and contribution of fathers. And so I think we're going in the right direction there. There's definitely more to do and we need to think beyond just, you know, that magical figure, which I think is important, but it is around a recognition that, as you've said, I mean, we've done some research here.