Black Swans and Poverty

Here is a copy of the speech I recently gave at Morecambe Food Bank when Heidi Allen MP and Frank Field MP came to be with us and to listen to the community here in Morecambe Bay about our experiences of poverty. There were some incredibly moving testimonies from community commissioners of the poverty truth commission. This was my contribution:

 

First of all I would like to start by saying thank you. Thank you to all of you for being here to talk about these really important issues. Thank you to my friends, Karen, Emily and Daniel for being brave enough to stand up today, to tell your stories and to allow yourselves to vulnerable and to be heard. Thank you to my friend Siobhan for being willing to speak out consistently about the realities that children in your school and this surrounding area are living with, and for doing so, despite unfair and untrue things being said about you in the public domain. Thank you to Annette and the team here at Morecambe Foodbank for your hospitality, generosity and welcome here today and for all the ways in which you provide for people in this community.

 

Thank you to Si Bellamy from the Eden Project – we’re so grateful for the hope that your partnership brings to this area and for the common values we share in wanting to uncover and deal with our deep systemic issues and injustices and co-create an economy and way of being as community that really works for humanity and the planet. Thank you to so many of our friends across the voluntary and public sectors for being here today and demonstrating our sense of unity in working together with our communities. And thank you Heidi Allen and Frank Field for choosing to work across your differences and to come and be with us today and to listen.

 

Today is not only about Morecambe. Morecambe is an amazing town full of wonderful people and there is a huge amount to be celebrated here. In fact, we could be having this same conversation, with similar but different and important communities across the water in Barrow, or over in Scarborough or down in Hastings because these same issues are found everywhere. Today is about coming together to really listen and to the reality of just how complex some of the issues we’re facing really are, like poverty, and the way it intertwines with many other aspects of our lives, for example our health and wellbeing.

 

Until 1791 people in England believed all swans were white. That was until a black swan arrived on these shores, brought here from Australia. Sometimes we can hold extremely fixed positions and ideas in our minds, until we are confronted by something which causes us to see the world differently. One of the truths about poverty is that it is an incredibly complex and wicked problem. And so it doesn’t help to entrench ourselves in our positions and throw stones at one another once those ideas are challenged.”

 

Robert Peston was right in his devastating analysis that we have become divided. So quickly we enter a blame game over poverty. “It’s your fault I’m poor”, “no, it’s your fault you’re poor”. But all this does is create more polarity, more distance between us as we become ever more entrenched in the certainty of our own arguments and perspectives. But that way of being is failing us, the 3 million children living in poverty and the hundreds and thousands of people who are now destitute. Trying to solve complex issues with overly simple questions is landing us in a mess! We want quick answers and we want to fix things but we do not appreciate the unintended violence of our policies and projects because we have not taken the time to listen, to understand or learn together. But when we do, we discover that not all swans are white and we begin to realise that we can longer continue to see the world that way.

 

The theologian, Samuel Wells, speaks of poverty as not being primarily about deficit, a concept that leads us into blame and heroism. Rather, he recognises that it is our dislocation, our isolation, our separation which is the real root cause of our issues. And so, here in Morecambe Bay, not only through the poverty truth commission, with the mantra that “nothing about me without me is for me”, but in many facets of our life together, including in the NHS, where I have the privilege of working both as a GP and as Director of Population Health that it is in togetherness, through relationship in which we are creating the space to build trust, to ask some really difficult questions and in the process we discover the reality of our pain and despair in one hand and in the other, as Barack Obama would say, we hold the audacity of hope, despite it all.

 

There are things to which together we are saying, “Enough now”. Enough now that some children in our communities cannot afford to eat, despite their parents being ‘back in work’ – and we are so grateful for the youth and community projects that open early to ensure kids get breakfast on the way to school and tea on the way home, despite a real struggle for resources. Enough now of the adverse childhood experiences or traumas through which many of our children our living, massively impacting their physical, mental and social health for years to come. Enough now of the reality that some children living in this Bay can expect to live at least 10 years less than children growing up just 6 miles down the road, with a far poorer quality of life along the way. And as we say enough now to those things and many more human and environmental injustices, we discover that the answers are not found in our current opposing political or economic models. Rather we are finding that together we can begin to create new possibilities of how we can re-imagine and build a future that works for every person and the planet.

 

In actual fact, learning to live well together is really difficult. It takes humility, forgiveness, kindness, breaking down hostility and replacing it with love. It means taking a good hard look at ourselves rather than pointing a finger of judgement at others. It means letting go of mechanistic thinking to fix things and embracing the reality of complex living systems. It means recognising that change starting with us. For me that means dealing with my own ego, my wounds, my root needs, my genealogy, my white male privilege, our colonial history and discovering that it is in encountering the ‘other’, someone utterly different to me that I am changed and I encounter in that person, the very face of God.

 

And so not only are we saying “enough now” to things which must change, but won’t change with our current ‘go to’ solutions, we are also finding that “together we can”. Here in Morecambe Bay, through working together as communities, we are seeing many dozens of initiatives emerging, like our food poverty project, our mental health cafes, community choirs and new partnerships forming across the voluntary, faith and public sectors working on issues like addiction and early intervention in neighbourhoods.

 

We are finding that together we can break down walls of division and find kinder ways of building society. Together we can see different perspectives and change our opinions and views. Together we can discover models of business based on mutuality and sustainability. Together we can help each other take more personal and corporate responsibility, whilst recognising how much easier that is for some than others and so together we can create compassionate communities.

 

Together we can face up to the challenges we see in our NHS and social care with the eye-watering savings we are being asked to make. Together we can ensure every child has a great start in life, we can build an education system that works for every child and face up to the growing mental health crisis in our young people.

 

Together we can ensure that our elderly citizens are respected and cared for. Together we can live in streets that are clean and safe, with every person having a warm, dry home to sleep in. Together we can face up to the environmental disasters which lie ahead if we don’t change. Together we can build a social movement for change with a different kind of power and discover a politics and economics that works for every person and the sustainability of the planet, based on self-giving, others-empowering love, empathy and kindness. And as we are here together today, together, through policy and through partnership we can ensure that no child goes hungry and every life matters. So, I am looking forward to listening and to learning together, through our conversations here today. Thank you.”

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Four Circles of Population Health

In my previous blog in this series, I wrote about the ‘Pentagon Model’ which we have developed in Morecambe Bay to help us think about how we manage Population Health. The Pentagon approach actually forms one of four parts of some over-lapping circles, based on 4-Ps (Population Health Approach, Partnerships, Places, People Movement), which give a more holistic view of what is involved.

 

At the heart of the model we are working with, sits the people and communities who live in Morecambe Bay. Communities can be geographical, communities of interest (e.g. faith-based/workplaces etc), or transient (e.g. students). We are absolutely passionate that we do not do things TO people and communities, but rather, guided by the brilliant principle that ‘nothing about me, without me, is for me’, we do things with the people and communities we are trying to serve. We look to co-design, co-create and co-produce our services, because the services belong to the people. This takes culture change and some new thinking on our part and we are learning to work differently.

 

Our Venn-diagram gives us a framework with which to think about Population Health more clearly. The Population Health Approach Pentagon of prevent, detect, protect, manage, recover really forms one of the circles. Included within this, also, are a few other important factors. Firstly culture. If we don’t get culture right, then we don’t get care right. I’ve done three separate vlogs on the kind of culture we are trying to embed across the health and care system in Morecambe Bay – Joy, Kindness and Excellence. Secondly, we are redesigning work around various different health problems, for example, diabetes or respiratory problems WITH people who actually live with those conditions and use our services on a regular basis, building pathways for people that actually make sense and work for everybody. Thirdly, we are taking time to really understand the data available to us through many sources and using it to enable both the leadership team and our local teams to make informed decisions about where we need to focus our efforts to improve care.

 

More than ever before it means that we need to share resources with other organisations in order for us to be able to cope with current budget constraints. It also means that we have to think very carefully about where we align our resources. One of the issues for us in population health is that we have never really tackled the growing health inequalities in society. It is simply NOT OK that some people in this Bay die 15-20 years earlier than people who live 6 miles down the road. It is also NOT OK, that it is in these areas of higher deprivation, where we also see more complex medical and social problems, but do not allocate the money or the staffing to cope with the increased demand. And yes – it is true, that the problems are complex, and so money and resource is not the only answer, but it is definitely a part of the answer! If we’re ever going to make an inroad into changing the health of our population and tackling health inequality, we need to apply the triple value approach of Professor Sir Muir Grey – of how we prioritise our resources. (http://www.nhsconfed.org/blog/2015/05/the-triple-value-agenda-should-be-our-focus-for-this-century). Here is a short clip about it, if you’re interested! (https://vimeo.com/155569869).

 

Partnerships are absolutely key in improving the health of the population. There is so much cross over between county and city/district councils, the police, the fire service, the NHS in it’s various guises (including mental health, GPs, acute hospital trusts and community services), the CVFS and indeed the business sector. The relationships at strategic-leadership level and within each locality are the oil that allow us to work effectively together. It is only through honest, transparent vulnerability that we learn to trust each other and to share the resources we have to serve the needs of the population. As social care continues to sit under the remit of the County Councils and Health remains under the NHS, increasingly devolved into the regional Integrated Care Systems, without a deeper and more shared accountability and effective working together we will not have the necessary leadership to enable local team to transform the future of care.

 

This is where Place becomes really important. It is harder to get culture right, and build relationships that really work well if we’re always talking about “working at pace and scale”. As services are reconfigured, it is important that team structure allows for small enough teams to enable good working relationships to happen and that the necessary work is done to get culture right! I was in conversation with Professor Sir Chris Ham, CEO of the King’s Fund, and he is adamant that it is at this local neighbourhood level where the real change takes place, because this is where we are able to work with people and our communities in a very real way. That’s why we are so passionate about our Integrated Care Communities (ICCs). This is where, in a very relational way, traditional barriers between organisations are broken down and new bonds are formed in working together for local communities across the public and community-voluntary-faith sector (CVFS). There is a real danger that we focus so much on the ‘super structures’ and put huge time and energy into reorganising the system and lose sight, in the process, of the very thing we are trying to do, which is to make care better! Our ICC teams must feel the full permission and receive the resource needed to do this transformational work.

 

The reality is, however, that unless we have a people movement for improved health and wellbeing, nothing will change. The issues we are facing health and care-wise are incredibly complex and multi-faceted. In Morecambe Bay, we currently spend £1.20 for every £1 we receive. We are doing our very best to try and reimagine how we deliver health and social care, working more efficiently in partnership and redistributing resource where we can – but when we are all in financial deficit (and in our local NHS we need to cut our cloth by £120 million over the next 3 years – 1/5th of our total budget) when we have already had some eye watering cuts to the county councils budgets, especially in the area of public health, there is only so much we can achieve! We understand the frustrations that people feel when it comes to health and care, but we cannot fix it from within the system alone. There is a need for us all to recognise that things we could provide a few years ago may no longer be available or not within the same time frame as previously. It would be wrong of us as health leaders to simply make changes without the communities having a say. But for example, if we are to improve our Children and Adolescents Mental Health Service in South Cumbria (which is desperately needed), we might, as an example, need to do less knee and hip replacements……we simply can’t afford it all, with our current allocations of resource and staff, and therefore we need local people to work with us on this, and help us work out where our priorities should be. We know, if we don’t involve our communities in these decisions, complaints will go through the roof, which drives down morale and is utterly exhausting for teams to deal with. However, we are going to have to be brave in some of our decision making.

 

As a society, we also need to all be more healthy and well, taking care of ourselves and each other.Some might argue this is all down to personal choice. Of course, there is some choice involved – however, when you read the National Audit Office report (https://www.bbc.co.uk/news/education-44468437) into the huge difficulties Universal Credit is causing, and the Joseph Rowntree Foundation Report into Destitution in the UK 2018  (https://www.jrf.org.uk/report/destitution-uk-2018) then you begin to realise that it is easier to make healthy choices in some communities far more than in others. These are inconvenient truths, and need to be reflected upon with due diligence. There is a danger that we choose to work with highly motivated communities to improve health and wellbeing and actually make health inequalities worse. However, if we really listen to what is going on with local communities and work together, we can do some great stuff . Work from the University of Birmingham shows that if we can see a change in just 3% of our population, then this will have an effect on 90%. As the work in Canterbury, New Zealand shows though, this takes time and relationship – the process is actually more important than the end product. And for an under-resourced, already exhausted community, supporting any social movement requires investment at many layers. The NHS 5-year forward view and the learning from the Institute for Health Innovation both recognise that social movements/people movements are key to transformational change. We must press on with this work, and base it on a foundation of love and collaboration if we are really to change things together. So, this is why we are so passionate about really working with our communities, here in Morecambe Bay and will continue to host  and hold space for community conversations. We are talking about many things, from economic development,  to childhood, education, loneliness and mental health. These spaces are vital for us to connect together, hear one another, meet people who are different from us because it is only together that can reimagine a future that is good for the planet and socially just for humanity.

 

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