Social Movements and the Future of Healthcare


As the crisis in the Western World deepens, and the growing reality sets in that business as usual simply can no longer continue nor solve our problems, our systems must change the way they view, deal with and hold onto power. The NHS is no exception. If we want a health and social care system that is of the highest quality, safe, sustainable and economically viable for the future, we need to understand the power of social movements, both within our systems and through the wider society. This is something we are really committed to in Morecambe Bay and so it was with great delight that I listened to the excellent Helen Bevan, talk about just how vital social movements are for the NHS and healthcare, worldwide at the recent IHI conference in London, Quality 2017. This blog will be an amalgamation of what Helen shared and my own thoughts about our early experiences with social movements.

 

 

A social movement in health and social care involves us all learning to connect, collaborate, cooperate, cocreate and coproduce at a level we have never done so, until now. But our circumstances are forcing us to reconsider the ways in which we work. We need the creative substance that is within our teams to be heard and harnessed so that we cut our waste and work more effectively together. The issues we face, need facing by us all, together; not by some board in an isolated room, making decisions based on diktats from on high, on behalf of us all.  But even this will not be enough. Those of us stuck in the system have become too homogenized in our thinking for us to do this exclusively from within. We need our citizens to help us re-imagine what it means for us to be healthy and well. We must stop designing things for our communities or doing things to them, instead we must design and do things with them. We must analyse, create and enact together and to do this, we must learn to solve the issues of power.

 

Helen Bevan, with her background in social science, demonstrates the great debate about the interplay between our organisational structures (rules) and agency (freedom) when it comes to effecting change. Where does the “permission” come from to enact the change we need to see? Is it externally generated by those in positions of power, or is it internally generated by a personal motivation? Our experience in Carnforth and Morecambe in community conversations has been a bit of both. There are many people of incredible heart and goodness, waiting to do something new and good that will positively affect the health and wellbeing of society, but are perhaps waiting for that sense of community backing, support, encouragement or indeed permission. With a bit of coaching or spurring on, we have seen some amazing initiatives begin that are bringing transformational work into our area and causing us all think differently. We need both individual agency AND corporate agency. Helen describes individual agency as being when people get more power and control in their lives – we see this in patient activation, shared-decision making and self-care – a greater sense of autonomy and responsibility. Collective agency, on the other hand, is where we see people act together, united by a common cause, harnessing the power and influence of the group whilst building mutual trust.

 

 

We have seen this used powerfully, in just one example by our maternity liaison service committee, who together have challenged our system to think more carefully about how we communicate to women, especially at key or stressful moments of their obstetric care. These stories are now a compulsory part of training for all who work in our maternity service and have significantly improved both our skill mix and ability to provide excellent care.
What is absolutely vital to understand is that we do not become transformed alone. We are transformed when we are in relationship with others (Hahrie Han). The problem is that we don’t really encounter the “other” enough to be changed. However,  when we let go of the kind of power that is held by the few, pushes others down, uses command and control, that is closed and transactional, and instead embrace a power that is held by the many, shared, open and relational, then we can begin to see the change we need (Hirschman and Ganz).

David Holzmer says that we are witnessing the collapse of expertise and the rise of collaborative sense-making. I would suggest that this has been going on for some time, but our systems have been incredibly slow at catching onto the change around us.

 

Now, what is hugely encouraging is this: research by Kollectif shows that you only need 3% of people in an organisation/society to drive the conversations with 90% of other people. In other words, you don’t have to get everyone on board from the word go. You find your passionate people with a sense of agency, infect them with the virus and watch it spread. These people need to be a mixture of ‘lone wolves’, mobilisers and organisers. Lone wolves are people who have been trying to help change happen for a long time but can sometimes feel like an annoyance to the system, so they are given tokenistic positions, patted on the head and patronised into exhaustion. Mobilisers build power by calling large numbers of people to contribute, engage in change and take action. Organisers build power by growing leaders in a distributed network, building a community and protecting its strength. We need all of them, though mobilisers and organisers will be the most effective in creating agency and bringing about lasting change  (Hahrie Han).

Joe Simpson says that ” great social movements get their energy by growing a distributed leadership.” The cult of celebrity can be powerful, but is not effective. The beautiful thing about a social movement is that is depends not on money, materials and technology but on relationships, commitment and community, and as the movement grows, these resources increase, rather than diminish. The problem, as Don Berwick puts it, is that leaders in position of strategic influence, are simply not seeing the resources available to the biggest problems we are facing.

 

Jason Leitch and Derek Feeley have powerfully shown that performance management (keeping the power), based on targets, sanctions and inspections can only get us so far. Quality improvement (sharing the power) gets us a little further, but mobilising social action, or co-production (ceding power) has a far greater potential to bring lasting change and far better outcomes for all.

 

So, how do we catalyze a social movement and how would we know if the movement was being “successful”? Well, our experience in Morecambe Bay is that you start with the 3%. You start with those who are drawn to the conversation, who recognise the need for change and who want to be part of it. You start with transparency, with openness, honesty and vulnerability about the mess we find ourselves in and the truth that we no longer have what it takes to solve the problem. And you start with really good questions and then deeply listen to the conversation which is emerging so that we ourselves are changed and can therefore be part of the emergence of something new, which operates on an entirely different kind of power.

You might call this a re-humanisation of our systems based on love, trust and the hope of a positive peace for all. But this social movement is not aiming for some kind of hippy experience in which we are all sat round camp fires, singing kum-ba-yah! This social movement is looking to cause our communities to flourish with a sense of health and wellbeing, to have a health and social care movement that is safe, sustainable, socially just and truly excellent, serving the needs of the wider community to grow stronger with individuals learning, growing and developing in their capacity to live well. That is what we must measure!
And so we need disruptive co-creation, which breaks through the top-town/bottom-up approach and causes us to see and hear like we have never done before. It is hugely exciting and enables managers to stop feeling like they have to extract as much performance as possible from the system, flogging the workforce, blocking change and innovation and inadvertently driving down the quality of care in the process.

The invitation is instead to become part of the change that we all long for. If we’re going to have an NHS in the future, we have to give it back to the people and work with them. In order to do this, we have to deal with and change our relationship with the very notion of power – something I will turn my attention to on the next blog!

 

 

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Solutions Focused Thinking in Population Health

My last blog focused on how we can think about solutions instead of problems in the NHS. Well the same is true in thinking about the health of our whole population. Yes there are some problems! We have growing health concerns with obesity and diabetes. We imageshave huge health inequalities. There are major issues with housing, economic policies that are not working for huge swathes of our population, with more people having to use food banks, struggling with fuel poverty, living in damp houses and unable to make ends meet. Yes, our kids are spending more time on screens and less time in activity. Yes, the sugar lobby, alcohol lobby and advertising giants have far too much power. Supermarkets are designed deliberately so that we buy things that are bad for us. And sometimes, we just make poor choices (if you can call them choices, which for some people, they aren’t always) – we do not all live as healthily as we could – we eat the wrong stuff, work highly stressful jobs, and exercise less than we are recommended to. Mental health issues are on the rise, especially for teenagers, due to crazy targets and league tables, with all the pressures they face. We are less happy and more separated than we ever used to be, despite the rise in social media…..(or maybe because of it……)…..Man, I can paint a negative picture – it’s like storm clouds and darkness everywhere……..

 

imagesBut what if it wasn’t that way? What if we got a bit angry about it, but instead of finding someone to blame and pointing the finger; instead of getting all tribal and throwing stones at others, we chose to use our energies creatively to find solutions, to work together and make positive changes?! Let’s put away our pointing fingers and our ranting tongues and let’s work together for a better future for everyone! Doesn’t that sound good?! It’s what we’re trying here in Morecambe Bay, and I’m hoping it spreads like wild fire so that we can become a place where health abounds and beauty surrounds (that’s the motto of this place!). That doesn’t mean we stop speaking truth to power, but we also let our actions (and maybe our votes) speak louder than ever before.

 

imgresWe’re talking together, taking time to dream about what it would be like if we were the healthiest area in the UK. We’re training up many people to host conversations, so that we break down walls and learn to collaborate for the sake of everyone. We’re not just dreaming about physical health, but mental, social and systemic health as well. We’re encouraging those who want to rise up and take some leadership, to be pioneers in the stuff they are passionate about. Even in my little town, we now have a mental health cafe that is literally saving people’s lives, because a lady called Jane wanted to make a difference. We have a cafe for all the people who have circulation problems because one of our nurses wanted to break people’s isolation and improve their healing rates at the same time. imagesWe’ve got a carers cafe, a dementia cafe and will soon have a breathing cafe for those who have severe COPD, sharing ideas and diminishing anxiety. We’ve got exercise classes to help with pain, a community choir, dog poo wardens to help us take more pride when we walk down the street and food banks to help those who can no longer afford to eat.

 

image[1]We have 2000 kids aged 4-11 running a mile a day at school with staggering results for our children here in terms of physical, mental and educational health. We’re hoping over time, this becomes the Morecambe Bay Mile, part of a cultural shift towards being more active. We are working with local chefs and supermarkets to enable people with pre-diabetes or weight struggles to eat more healthily.  We’re choosing to lead by example in the NHS to work well and flourish in our work places. We’ve made a commitment to see the 5 ways to wellbeing in every NHS organisation and we’re hoping many other systems and businesses will follow us in this. We’re finding radical ways to help people who are struggling with alcohol and drug addiction, get free and stay free with amazing results. We’re helping people live well with and beyond cancer.015c74b06779fe8d8496d585fb9865ea We’re changing the way consultations happen in the NHS to enable people to make more informed and better choices about their own health and conditions, so they feel empowered to make changes that work for them rather than beaten up when they go for an appointment! We’re launching the Morecambe Bay Poverty Truth challenge, learning from those who are lived NAWIFUexperts in poverty to help us work together and care better for those most struggling in our society. We’re having difficult conversations about death to help people be prepared for every eventuality.

 

All of this has started in the last year! What else might be possible? What other dreamsimages will be awakened? What other partnerships, collaborations and relationships might be formed? Being all tribal and accusatory of others saps our energy and stops us being creative. Mud slinging and blame will achieve little. We have to work from where we are. We have to build bridges and work together. We have to build a future of positive peace and that means binary thinking is over! The future doesn’t have to be full of doom and gloom. It is alive with hope! What resources might  we find? What talents might we discover? What might we see develop over the next 12 months/years/decades as we look for solutions together for a better future for everybody? Don’t you feel just a little bit excited?

 

 

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Embracing Weakness

Tweet Last weekend, I spent the weekend with my wife and a bunch of close friends, immersing ourselves in the enneagram. It’s something I’ve done a bit of before and highly recommend it! The enneagram is an ancient way of understanding the human personality, our instincts, gifts, struggles and strengths. There are several different perspectives [Continue Reading …]