Poverty and Health Inequalities – What Can We Do?

Last week the Chief Medical Officer, Professor Chris Whitty, came up to Lancashire. He spent the morning in Blackpool and then came over to see us in Morecambe Bay for the afternoon. It was an absolute pleasure to meet him and to welcome him here. He came to listen – the mark a genuinely kind and caring leader. More importantly he came to listen to people who live in these Northern Coastal Communities, to really hear what life is like and to allow that to impact his thinking and he prepares to develop further strategy on tackling poverty and health inequalities. As an epidemiologist, he is grounded in data and understands the issues at hand. What I really valued was his humanity and humility as he listened to the stories of people who live and work here.

 

Last year, the Home Secretary, Pritti Patel also visited Morecambe Bay. She came to Barrow-in-Furness and spent some time at The Well, a CIC which works with people in recovery from addiction and of which I am a Director. In an interview afterwards, she was asked about the impact of Austerity and the reality of poverty in communities like ours (4 in 10 children in Barrow grow up in poverty). Her answer was that poverty is not the (sole) responsibility of government. I put sole in brackets, because she tried to insinuate that the role of central government in tackling poverty that exists in local areas is very minimal compared to the responsibility of local government (who have had their funding massively cut by central government in the last 10 years), local schools, local public services and local businesses. I’ve really wrestled with what she said since that time because she’s not altogether wrong! But nor is she right! Of course Central Government has a huge role to play in tackling poverty. It’s undeniable that national policy, economic strategy, including taxation, land ownership and business development all have massive implications. But poverty doesn’t only exist because of Central Government. Health Inequalities do not just exist because of Central Government. I am not for one minute, negating or diminishing their role, but we do have to all ask ourselves why we see and tolerate such inequality and what we can all do to change this narrative. Because as Michael Marmot reminds us so powerfully in his book ‘The Health Gap’ – none of this is inevitable and it certainly doesn’t have to continue. Marmot holds that “if you want to understand why health is distributed the way it is, you have to understand society.” So if we want to understand society, then as Prof Bev Skeggs (Professor of Sociology at Lancaster University) so eloquently says: “Society is shaped by our values and what we value“.

 

If we are serious about ‘levelling up’, ‘resetting’ and tackling age old health inequalities then we have to understand that this is both complex, but also entirely possible and need not take 100 years! As Marmot says in his amazing book ‘The Health Gap’ – essential reading for anyone who cares about this issue – we must do something and we must do it now! Marmot’s research proves that health inequalities are not a footnote to the health problems we face, they are the major health problem. We can actually make significant and measurable differences in a short space of time – so why aren’t we doing more? In the rest of this blog I hope to look at how we can make a real difference to poverty and health inequalities in our communities. We all have a part to play, no matter who we are. This is absolutely an issue for central and local government, but it is also an issue for society as a whole in all its facets.

 

Prof Imogen Tyler has written a phenomenal book called ‘Stigma: The Machinery of Inequality’. It is, in my opinion, the most important book published this year (I know that sounds like an overstatement, but it isn’t!). I believe this must be our starting point when we talk about poverty and health inequality. If we don’t understand how we have all subconsciously and/or overtly accepted a narrative that ‘the poor are feckless and lazy and could just pull themselves up by their boot straps if they wanted to, because we all have the same opportunities,’ then we are blind to the reality of the stigma that surrounds poverty and how it is weaponised to maintain the status quo. The thing is – it’s not just the government who have used this narrative – it’s part of British culture. So many of our comedy programmes ridicule and scapegoat the poorest in our society – The Harry Enfield Show (‘The Slobs’), and Little Britain (Vicky Pollard) to name just two. think of how many reality TV shows, like ‘Benefits Street’ have reinforced the stereotypes. Our national press continue to bombard us with very particular perspectives on ‘benefits scroungers‘ and ‘migrant swarms‘ and we read it, we drink it in, and whether we like it or not, it embeds itself as a way of thinking in our minds. That’s how propaganda works. It creates a corporate mindset by ‘othering’ our fellow human beings and pitting us against one another, rather than bringing us together to collaboratively find solutions in a way that works for everyone.  It takes significant and sustained effort to do our own internal work around stigma, racism, white privilege, sexism and toxic masculinity. But if we want to build a society shaped by our values and what we really value then whoever we are – this is where we must begin. Our first work is to demolish the strongholds in our minds, challenge our unconscious biases and undo our ‘go to’ narratives, replacing them with deeper and better truths about the innate value in every human life. We must be determined to create the kind of language which reflects this because language gives substance to our thoughts and beliefs. This important work needs to weave its way through every part of our education system. This will take effect in shifting the corporate mindset through the way we teach history in our schools, for example, with a more honest appraisal of the negative effects of colonialism, or indeed how the feudal system continues to dominate the price of land and the unaffordability of good quality housing. We need to equip the rising generation with the tools they will need to undo the damaging ideologies of stigma and find solutions to the issues they are facing around social justice and climate change.

 

Imogen draws on the work of The Poverty Truth Commission, here in Morecambe Bay and in other places to highlight ways in which we can break down stigma, build friendships and create a kinder society. The Poverty Truth Commission gives us a real insight not only into how we break down stigma, but how the building of friendships across the dividing walls in our society creates a new political space from which we can create ‘the good life’ together. Our political systems have become far too removed from every day life and we need a radical shift from disengagement to much wider participation in community life and decision making. There are so many voices calling for this from all sides of the political spectrum. We so badly need to break out of our entrenched twitter-siloed positions and learn to curate the space for a more collaborative and co-operative form of political and economic conversation and prioritisation. It is, in my view, impossible to think about breaking down health inequalities without involving those who experience them most severely to be a part of finding the solutions. For further reading on this: Radical Help by Hilary Cottam, Rekindling Democracy by Cormac Russell and Greed is Dead: Politics After Individualism by Paul Collier and John Kay are all vital texts. This requires a much more local, devolved, participatory kind of politics – the kind of thing made possible through initiatives like ‘The Art of Hosting’, ‘Citizens Jurys’ and ‘People’s Assemblies’ underpinned by principles of love and kindness. In this way we can create much more realistic ‘deals’ (like the one in Wigan) between public sector organisations and people in our communities. This might all sound a bit wishy washy, but as Marmot demonstrates, “the lower people are in the socio-economic hierarchy, the less control people have over their lives.’ He argues that “tackling disempowerment is crucial for improving health and improving health equity” This is where the circular arguments about absolute or relative poverty are missing the point. When Philip Hammond stated as Chancellor of the Exchequer that he ‘doesn’t see poverty in the UK‘ – he was talking about absolute poverty and implying it isn’t an issue in the UK. He’s profoundly wrong. Economist Amartya Sen helps us understand this: “Relative inequality with respect to income translates into absolute inequality in capabilities: your freedom to be and do. It is not only how much money you have that matters for your health, but what you can do with what you have; which in turn, will be influenced by where you are.” Marmot argues that this means people in this position cannot participate in society with dignity. It is this active participation in ones own life and the life of the community around you, coupled with a sense that you can be part of the change that needs to happen which underpins the strap line for the poverty truth commission. “Nothing about us, without us, is for us.” If we want to tackle poverty and health inequalities in our society we have to radically include those who are currently most marginalised to be part of the change with us. We’re not trying to fix them. Together, we are trying to untangle the injustice that allows this kind of staggering inequality to continue.

 

The NHS is currently exploring its own role in tackling poverty and health inequalities. As the biggest employer in the country it has the opportunity to make a massive difference as an Anchor Institution, setting a good example and creating a network, both locally and nationally for other partners to collaborate with. Along with other local employers it can make a vast difference through positive employment schemes for people from poorer communities, paying a living wage, procuring locally and developing apprenticeship schemes, to name just a few ideas. We have developed a charter in Lancashire and South Cumbria, which we hope will be nationally available soon. I’ve previously written on the role of Primary Care Networks (PCNs) and how taking a ‘radical help’ approach with our communities could make a real difference at a local level. PCNs have a particular role in Population Health Management. This approach that we are focusing on across Lancashire and South Cumbria uses the best in data science and enables health teams to focus in on the areas of greatest need, working with those communities to bring about change through co-creation. If the NHS is really serious about ‘levelling up’, however, one thing which must be explored is the national funding formula. If we’re serious about Population Health, we must be much more comfortable with allocating resources according to Indices of Multiple Deprivation. We must also change what we measure and ensure that Key Performance Indicators and clinical funding streams are much more aligned to this entire agenda. Incentives do change behaviour and we need to make sure that we’re getting them right, whilst permissioning PCNs, in particular, to have a change in focus. We need to make it more attractive to work in areas of higher complexity and create more sustainable models of care. It is my belief that without a Health Inequalities lead at the top table of NHS England and Improvement, the right level of accountability and prioritisation simply won’t be there. It won’t be enough just to have someone accountable in each system, vital though this is. Integrated Care Systems must take an evidence-based approach and recognise what a profound difference they can make in a short space of time. The drivers in the system must be wedded to this way of working. The NHS must stop spending such a colossal amount of money tinkering around the edges of helping people to live a bit longer and get deep into the game of tackling the vast and ongoing health inequalities in our society. It must use it’s powerful voice to continually challenge policies which make this worse and actively campaign to make society more equitable. Marmot and The King’s Fund have already detailed so much that the NHS can do. Olivia Butterworth and Sara Bordoley and their teams are doing some great things. We need more of it! It’s time to act!

 

The issue of land and the lack of affordable housing has a huge effect on people being locked in cycles of poverty and creates massive health inequalities. Central Government has a huge role in sorting this out, but increased devolution may make it become easier with increased public participation in the daily politics of life. Most of the way our land is distributed and inflated was designed in the 11th Century and through the Middle Ages. Alistair Parvin has written the most phenomenal piece on this issue and it deserves time to be read and digested. He makes a very tight case as to why we find ourselves in the situation we are in, but encouragingly he comes up with some really possible, pragmatic and solutions-focused ideas about how we can solve this, if we want to. Of course there are many vested interested and people in positions of significant power, who would resist such an approach, but we must not let that stop us having some grown-up conversations about this. Parvin accepts that it would take a government with extraordinary vision and bravery to do what is really needed and offers some really helpful pragmatic smaller steps that would get us in the right direction.

 

I am not going to copy and paste his paper here, but I hope this whet’s your appetite enough to seriously engage in the possibilities. We can’t keep passing this ball to future generations. We have a once in a lifetime opportunity to reset our economy and in this time of ‘jubilee‘ we need to grasp this nettle if we are serious about creating a society that truly works for everyone. Mariana Mazzucato, Kate Raworth, Katherine Trebeck and Carlota Perez are just some of the brilliant people creating the kind of economic and technological frameworks we need. It’s time to build an economy of hope, shaped by our values and focusing on what we value. We know that the UK population would like us to place health and wellbeing at the heart of the UK economy instead of GDP – this is a massive shift and one that we must hold onto. This priority along with the creation of more social co-operatives, new local/community banks and credit unions would all help us to create a fairer economy that really works for the people.

 

 

So, we all have a role to play. As individuals, in our communities, through our work and via a more engaged, participatory, devolved, democracy, we need to deal with stigma and ‘wicked issues’, be determined to be more  switched on, truly engaged and find together some pragmatic solutions fit for the 21st century.  Disengagement is not an option. Let us not miss this moment. We can and we must do something. As Michael Marmot says in the final sentence of ‘The Health Gap’: “Do something. Do it more. Do it better.”

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Time to Reimagine the Future!

So many voices are saying that we can’t go back to how it was. We don’t want to live at the same old exhausting pace anymore. We don’t want to continue to harm our environment nor accept such staggering inequality. This quote below is actually from Sonya Renee Taylor, not Brene Brown!

One of my favourite stories to read my kids when they were younger was ‘The Great Green Forest’ by Paul Geraghty . It talks about the destruction of the Amazon Rainforest and how one day, the man on the digger stops and listens to the forest and realises he can’t do his job any more. He can’t be part of this destructive way. So he gets off and walks home and never returns, whilst the forest envelops his old machine and regenerates. It used to choke me up and the kids would look at me and wonder why I had tears strolling down my cheeks! Our world does not have to be shaped by the idea that we are ‘homos economicus’ – the selfish, self-centred, self-made man of the neo-liberal era. That is OVER! And all neuroscience and developmental psychology points to a very different reality anyway – one that we have perhaps been blind to. The truth is, we’re actually wired for empathy and compassion, but the systems we have created have warped our behaviour. But through all the pain and difficulties of COVID-19, something in our corporate memory has been awoken of our interconnectedness to the family of humanity, other species we co-exist with and the biosphere we co-inhabit together. We simply cannot go back to how things were – everything has changed.

 

Change doesn’t just happen because we want it to – that’s a good start, but vision alone is not enough! I’ve been spending a bit more time in my garden of late. I love gardening. For me it is the place of my best personal development and growth. Last year, I let the whole garden be fallow – I just left it. This year, when I came to plan what I wanted to grow, I found that I have a lot of clearing to do. There are things I need to “uproot and tear down, destroy and overthrow”, before I can “build and plant”. It’s particularly amazing to me how florid certain weeds, like creeping buttercup, can be! The networks of roots in the soil, take quite a bit of digging out. For me it’s a great metaphor for our mindsets, fixed beliefs, thought patterns and subsequent behaviours. If we’re going to make space for a kinder and more empathic, life-giving way of thinking and being in the world together, then we have to be willing to root out our old ways to make room for that which we want to plant and sow.

 

To take this garden metaphor further, once the ground is clear, my seeds aren’t going to grow on their own and I’m not going to cultivate a harvest overnight. I am going to have to work the land (thankfully some of this has been done by previous garndeners and I am grateful for what they have sown). I am going to need to build frames to enable good growth and ensure the soil remains cared for and the plants watered. I’m going to have to protect the seedlings from birds, rabbits, slugs, flies and all kinds of other pests, whilst recognising there is providence for them too! There is a tenderness and a ferocity to gardening that helps us to think about how we co-create and labour for the kind of world we want to be good ancestors of.

 

And so let us do the work together. Let us clear the ground, begin building the frameworks we need to co-create the world our hearts are longing for. In Morecambe Bay, we’ve been thinking about the areas of politics, economics, society and ecology. There are many others, but here are some things we might want to consider and build towards (there is further reading/material to engage with if you feel like going a bit deeper In the hyperlinks):

 

Reimagining Politics

 

Patrick Chalmers is currently writing a series in The Correspondent which helps us face up to our own political illiteracy. He invites us to explore together what we mean about politics and how we engage with political ideas, like democracy. Many people have been writing for a number of years about the broken nature of our political system. Well, now we have a chance to reimagine it, let’s grab this bull by both horns and engage with it fully.

 

Here in Morecambe Bay, we’ve been exploring what it might mean to develop a politics of love and kindness. We agree that the basis of a politics of love is friendship, deep listening and the embrace of the ‘other’. It means loving our enemies, doing good to those who may seem to want to harm us and choosing the way of peace. It involves seven key principles:

 

  • prioritising the poor
  • protecting and promoting the wellbeing of children
  • instating women to ensure full equality in everything
  • caring for the sick
  • restorative justice for those in prison
  • welcoming strangers – particularly refugees and asylum seekers
  • caring for the environment in which we live (locally and globally) by being responsible in how we steward the earth’s resources

 

What does that mean in practice? It means holding spaces for communities to come together and talk about the issues that really affect them. We’ve found the Art of Hosting really helpful in creating a framework to do this. It means deliberately building relationships with ‘the other’ through initiatives like ‘The Poverty Truth Commission’. It means creating trauma-informed practice and building a culture of hope. Do we dare to do the work required to reimagine, reinvent and reinvigorate this space? Can we throw off our apathy and cynicism and engage with the stuff that shapes how we do life together? We must embrace a politics that is much more local, participatory and engaging.

 

Reimagining Economics

 

In Morecambe Bay, we believe that an economy of wellbeing is what we need to build together. This means doing away with stigma and the idealisation of growth at any cost and replacing it with a much kinder way of stewarding the earth’s resources to create sustainability and justice. The New Internationalist is clear – We cannot grow our way out of poverty.

 

Here is a framework created together by 170 academics In The Netherlands and helpfully summarised by the brilliant Jason Hickel, which provides a hopeful alternative:

 

  1. Shift from an economy focused on aggregate GDP growth to differentiate among sectors that can grow and need investment (critical public sectors), and sectors that need to radically degrow (oil, gas, mining, advertising, etc.)
  2. Build an economic framework focused on redistribution, which: establishes a universal basic income, a universal social policy system, a strong progressive taxation of income, profits and wealth, reduced working hours and job sharing, and recognises care work.
  3. Transform farming towards regenerative agriculture based on biodiversity conservation, sustainable and mostly local and vegetarian food production, as well as fair agricultural employment conditions and wages.
  4. Reduce consumption and travel, with a drastic shift from luxury and wasteful consumption and travel to basic, necessary, sustainable and satisfying consumption and travel.
  5. Debt cancellation, especially for worker and small business owners and for countries in the global south (both from richer countries and international financial institutions).

 

Hickel is clear. “We have a word for what’s happening right now: recession. Recessions happen when growth-dependent economies stop growing. It’s really important also that we don’t confuse economic de-growth with economic contraction. One is pressing the brakes to avoid a collision. The other is a compete and utter car wreck. When a tree or human or any natural organism reaches full adult size and stops growing we call it “maturity”. We would never call it “stagnation”. That we routinely use the latter term to describe the economy shows that we have no plan, no end in mind… just perpetual expansion. What we need is to build a different kind of economy altogether: an economy organized around human well-being rather than around perpetual growth.” Kate Raworth’s work on the Doughnut Economy is another way we can think about the future. It’s so exciting to see the City of Amsterdam adopting this as their model for the future.

 

Reimagining Society

 

Society is built and shaped by our values and what we value. In Morecambe Bay we’ve been reimagining what society might be like if we reassess those values starting with love, kindness and empathy.

 

To reimagine society we need to reimagine what we mean by the welfare state, or social security. It is broken, but it can be reimagined and indeed has been by my wonderful friend Hilary Cottam in her book Radical Help. Here is Hilary in a brilliant conversation with the world-class Economist Mariana Mazzucato and Tom Loosemore about the reimagining of welfare for the future.

 

We need a welfare system that is primarily shaped by relationship. Hilary Cottam’s six foundational insights on how to do this are so much food for thought. 

In this one page Hilary exposes everything that is wrong with our current system and gives us the permission and the flexibility we need to reimagine and implement an altogether kinder and more practical solution to the issues we face in the 21st century.

 

Two of the core pillars of the welfare state (and btw the concept of state needs to be fully reimagined also, if we are to create a just and fair world in which we live in peace together) are education and health. Both need reimagining and there isn’t space in this blog to go into all of this now, but here are some thoughts on where education and health need to move towards, but Hilary’s principles can be applied to these and many other sectors also.

 

Reimagining Ecology

 

There are so many incredible voices speaking into this right now and the earth is literally groaning for us to listen to what it is saying to us. Can we listen to the narrative of The Great Green Forest? Will we allow ourselves to be forever changed, to repent of our abusive and unkind domination of the ecology, and turn instead to the gentle stewardship of the land and all living creatures to which we are called? There are so many prophetic figures calling us back to this original purpose of humanity. One of my favourites is Alastair McIntosh. This is well worth a listen, if you’ve not heard him already.

 

The tectonic plates are shifting. We are moving from a patriarchal, toxic-type of masculine and dominant-sovereign understanding of how we shape the world towards a much more feminine, inclusive, collaborative and empathic one. Embrace it. Nurture it in yourself. Let this fresh wind blow fully in your face and shake off the dust of the past season that clings to you or the cobwebs which pull you back. The future is calling us. Can you hear it? Listen. Take a breath. Open your eyes. See what lies ahead. Link arms in hope and determination. Let’s go there together.

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How Does Change Happen? Part 2

Tweet This question has become extremely important to me, in my work around how we tackle health inequalities and social injustice. It’s all too easy to take sides, point fingers and play the blame game. But if our political system teachers us anything, it is that this kind of didactic, oppositional approach to life, brings [Continue Reading …]

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Love Society – Part 2 – Triads, Weaving a Web and Panel

Tweet Bev Skeggs gave us so much to think and talk about with each other. If you haven’t had a chance to watch her amazing talk yet, then please do so! You can find it in Part 1 of this blog series. She left us with a question – “How can we build value with [Continue Reading …]

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Love Society – Part 1 – Prof Bev Skeggs

Tweet   Here in Morecambe Bay, a very eclectic group of us are having some conversations about how we might reimagine life together based on love and kindness towards people and the planet. In April, we were together around the theme ‘Love People’ and in May, this became ‘Love Society’.   To help us and [Continue Reading …]

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