How Do We Build a City That Works For Everyone?

I recently hosted a couple of conversations for people in the city of Lancaster, UK, in which we explored this question together: “How Do We Build a City that Works for Everyone?” We framed the conversation (which we had using a ‘World Café’)from two current and important concepts. Firstly, the great work of Kate Raworth in ‘Doughnut Economics’ – how do we create a city that is socially just for the people who live here and that is environmentally sustainable for the future? In other words, how do we ensure we have an economy that is distributive and regenerative by design? Secondly, we drew on the important work of Sandro Galea (Professor of Epidemiology at Boston State) and his concept of the Goldfish bowl as a way of thinking about ‘Population Health’ or Epidemiology (see my last blog). Politics IS health, according to Galea.

 

One of my favourite quotes is from Einstein, when he said that “If I had 60 minutes to save the world, I would spend 55 minutes trying to find the right question and then I could solve the problem in 5 minutes.” It turns out that the question we used itself is problematic at a few levels! Here are some of the questions we found ourselves wrestling with: Do we need to build the city, when it is already here?! What do we really mean by ‘the city’ – is it people and communities or more than that? What do we mean by ‘works for’? That felt to some like we were settling for something that was just enough, maybe scraping by, rather than thriving! And who do we mean by everyone?! This didn’t stop us having a a great discussion, but highlights how powerful the perspectives and biases we bring into the room can be!

 

Despite not having a perfect question, (and hopefully, by the time we host 3 much bigger conversations across the city during 2019, we may have honed something more helpful!), some key themes emerged, through our generative conversation. 

 

  1. Relationships are vital! We want to live in a city which really does “work” for everyone. So, we want to give value to the currently unheard voices and we want to value diversity and inclusivity. Taking time to get to know neighbours and colleagues grows a richness of community. We want to live in a city that values love and kindness in how we treat ourselves and other people.
  2. We need to build on the amazing assets and skills that we already have in the city. If we made space and time to discover and share these skills with each other more, we would develop a richer life experience within our communities. This is an expression of ‘gift economy’ and ‘reciprocity’, which Charles Eisenstein writes powerfully about in his book ‘Sacred Economics’). It builds on voluntary power, and may require a reimagining of how we work and what we value in how we invest our time, energy and resources. We also have so many incredible physical assets in this area, which we don’t tap into enough or perhaps make fully accessible for all who live in the city.
  3. People want to be part of the change, not have change happen to them! This requires much better engagement and democratic discussion about how budgets are spent, for example or how land is developed. Somehow, there needs to be a better safeguarding against ‘invested interests’ and ‘dodgy deals’ with far more transparency about how decisions are made. Such a process, it is believed, would enable far better personal and corporate responsibility when it comes to caring for the fabric of the city and the people who live here, similar to what has been developed in Wigan. There was a recognition that when we talk about personal choice and responsibility that this is much more possible for some people and communities than others. However, it was felt that increasing self-esteem and a sense of belonging would enable more personal responsibility and choice.
  4. Housing really matters. The physical environment is actually causing fragmentation and silos. There were many more questions than answers here – but that’s ok – this is an iterative process, and we don’t have to solve everything in one go. So…how do we create really good social housing? How could we redesign the spaces of the city to encourage togetherness and community? How do protect green spaces in the process and take care of the city’s drainage (strong memories of the recent floods)? How could we ensure that everyone has a home to live in, and what might that mean for both the homeless and also for single people?
  5. We want an education system that really values the unique beauty of each child, treats each one with compassion, mindful of what traumas they may be experiencing and values creativity and activity in education just as much as academic outcomes. We care about who our children become, not just about what exams they pass. So we recognise that we have a measurement problem but we’re not quite sure yet what to do about it! 
  6. We need to invest in our children and young people by providing physical spaces in which our young people can feel safe and not bored! Many have been affected by the closure of children’s and youth centres. If we are to really invest in our children and young people, there was a sense that we also need to provide parenting classes across the board to pregnant couples and through ‘family centres’ and schools across the district.
  7. We want to create a greater sense of value for our older citizens. There were many people present who felt they have things to offer, but don’t have an obvious outlet. Involving those retired from paid work more in the life of the city would break isolation and feed the gift economy. 
  8. Business needs to thrive in a way that really values entrepreneurial gift and allows it to flourish, whilst holding it true to the ideas and principles of the doughnut and the goldfish! How could the business community serve the needs of the city and how can the city enable business to really thrive, creating jobs, whilst caring for the environment and the needs of the people who live here? Kate Raworth’s work could really help us!
  9. Transport systems need to be redesigned to encourage more cycling and walking or the use of green public transport alternatives. Transport routes also need to join up our communities more effectively to improve opportunities for those who live in areas that are currently more financially deprived. 
  10. If we are to really improve health and wellbeing and care for the environment, then we need to see this written into EVERY policy decision. If politics IS health, as per Sandro Galea, then we need to take this seriously and stop making policies which do not care for these things.
  11. We want to be part of city that does welfare well! We think there are many possible new ways of doing things more effectively, as described in Hilary Cottam’s book, ‘Radical Help – Reimagining the Welfare State’. One of the things felt to be important is increasing skills in money management (85% of people living in social housing in this district are in debt to the city council -though this is certainly not only due to poor money management , but an unjust system that isn’t working for the majority). Morecambe Bay Credit Union offers an alternative economy as a way of using micro finance in our local geography.
  12. We need better ways to communicate and connect people together. There is smart, digital technology that could help us here….perhaps a Lancaster portal, that connects us together more effectively and helps facilitate the sharing of our assets and gifts.

 

Wowsers! Not bad for 2 conversations of 90 minutes each! Just imagine what a phenomenal city Lancaster might become over the next 10-20 years, if we set out on a journey together to build this kind of city! What is stopping us, I wonder?! #enoughnow #togetherwecan

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Who is Responsible for Your Health?

Who should take responsibility for you health? Sounds like a straightforward question, doesn’t it? But I get so frustrated when complex issues get squashed into simplified, silo-thinking, ready for twitter or media sound bites, or the under-girding of political ideologies.

So….just as the economy is not just made up of the interplay between business and the household, but is in fact far more rich and complex, so too the interplay of responsibility for our own health.

Kate Raworth, really helpfully uses the following diagram to help us rethink the components of the economy. I would like to suggest that we use it to think about health, also.

So…who is responsible for your health and wellbeing?

  1. Your Family/Household
  2. Society/The Commons
  3. The Market
  4. The State
  5. You

In some ways, I feel like all of these are obvious, in their own way, but I will just unpack each one a little bit more.

 

Your Family/Household

We all have needs. We need to know we are provided for (water, food, clothes etc), safe, loved, welcome, encouraged, disciplined and given place to dream and live those dream out. It is the role of our families or the household to which we belong to ensure those things happen as we grow. So much of our ill-health, our brokenness and our long term physical and psychological pain is because these basic needs were never met and left us without a sense of wholeness. The lack of met need, has a huge impact on the development of our personality and character. When we speak of ‘personality disorders’, each type has it’s roots in early life when needs were unmet and therefore parts of the personality remained undeveloped. Let’s face it – no family is perfect! And so, I would argue, that all of us have ‘disordered personalities’, and until we confront the shadow parts of ourselves that are trying to overcome this sense of loss or inadequacy, we continue to project an ego version of ourselves to those around us. We do so to cover over this pain, but facing it head on and allowing ourselves to fess up to our deepest needs, would actually lead to us being a great deal more healthy.

When I work with head teachers and ask them what the biggest need they have in their school, the answer is almost always ‘parenting classes’. However, there are very few providers of this available (due to cuts at a county council level) and the classes available are often very ‘middle class’ in their approach. We need to completely rethink parenting classes in the context of the poverty-truth commission and think about less twee ways to really engage with communities about how we raise happy and healthy kids. The truth that Adverse Childhood Experiences are our greatest public health crisis is not going away. Grasping this nettle is going to be painful but really necessary if we are to breathe health and wellbeing into our society.

 

Society/The Commons

Just as we get our needs met by those in our immediate household, the same is true of society. The way we treat children, the things we expose them to, the way we love them and educate them has a massive impact on their current future health and wellbeing. It’s becoming clear that social media is causing significant harm to our mental health as a nation, particularly our young people, and yet we don’t know how to curb our enthusiasm for all our technology…let alone the rise of the robots…

The commons is fast disappearing, too easily privatized and made available to those who can afford it. How do we safeguard the commons and use it for the benefit of all? What would the Diggers say to us now? The breakdown of our communities, with increasing isolation and loneliness is having a detrimental effect on our wellbeing. What can we do to recover the spaces that belong to us all and help us rediscover the joy of connecting and being together?

The commons is also about our corporate voice. It is only really vast people movements, speaking with one voice that can really cause governments to sit up, listen and take heed of the needs of the people. It is only together, that we will make enough noise to change the health and wellbeing of all of us for the better. How might we speak and act together in a way that will take corporate responsibility for all our health and wellbeing?

 

The Market

Oh the benevolent hand of the market! If only…. But the Market plays an absolutely key (though currently over played) part in our economy and our health and wellbeing. We know for a fact that advertising is deliberately trying to misinform us so that we make irrational decisions. A key component is to make people feel worse about themselves so that they buy things they simply do not need. Supermarkets are being challenged for the ways they deliberately place products and arrange their stores to cause people to buy more unhealthy things and food chains are constantly trying to ‘up-sell’ their unhealthy products and downgrade our health in the process. They evangelize the masses with the idea that we are all free to make our own choices, but if this were so, they would not spend the billions of pounds involved in socially engineering our choices, so that we ‘freely’ choose that which harms us! Oh for a market that might redefine it’s moral code! The market could do SO much good, but unharnessed and left without true accountability or consequences, it serves to damage our health – something it is truly responsible for.

 

The State

The state has a vital role and responsibility in caring for all of our health and when it washes it’s hands of that responsibility or tries to pass it over, we see a massive rise in health inequalities and overall worse-health for all. The NHS in the UK is one of the great triumphs of the state. Providing brilliant healthcare for those who need it whenever they are unwell is truly amazing. Imagine not being able to afford this because it depended on keeping up with insurance bills. It is not uncommon for us to see people in General Practice, who literally cannot afford to feed their families any more and are having to make some incredibly difficult choices (made far worse by long school holidays). Easy to point the finger and start creating a narrative about how it’s “all their fault”, but far harder to hear the truth of what it is really like to be a lived-expert in poverty and the trap it creates and harder still to look to alternative solutions, rather than believe the austerity narrative. There is clear evidence that the more unequal a society becomes, the worse the health outcomes – both physical and mental. When the market is allowed to behave exactly as it wants, we also see the health of people suffer. It is only through the right kind of government that the market can be tamed. It is only with the right kind of legislation that the economy can be skewed towards redistribution and regeneration of the resources needed – this would need to include a radically feminist approach that works on behalf of women, in particular, for equal opportunity, pay and recognition of just how much the ‘household economy’ contributes to the overall wellbeing of the nation. It is only the right kind of leadership that will tackle the inequalities we see and refuse to be wined and dined into maintaining the status quo. It is only brave leadership that will take the ecological issues, like plastic in the oceans, massive over antibiotic use in animals, and ongoing air and river pollution that will give us a healthy planet and human population in the future.

 

You

And where possible, and for some given various health issues, this is more possible for some than others – we do not all have an equal starting place or a level playing field – where we can  – we do have a responsibility to ourselves and to the wider society to care for our own health and wellbeing, so that when the health and social services are needed, they are available for all. It also means using the health and social care services in a way that creates sustainability, being grateful for them and ensuring they and the people who work in them are not abused.

 

It’s complex, but it’s vital that too much emphasis is not put on any one area. We must not play the blame game, especially not towards individuals when we haven’t taken the time to hear their story, nor understood the wider context of the role of the other vital players on the field. Each aspect of the economy plays a massive role in the health and wellbeing of the nation, and it is high time that each plays it’s relevant part to its fullest ability.

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Building Healthy Towns and Regions

Tweet The other week, I was phoned by a BBC producer to ask if I would take part in a discussion on the Victoria Derbyshire show about how we can build healthy towns. It’s partly due to the work we’re doing here in Morecambe Bay with our communities around being more healthy and well, especially [Continue Reading …]

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We Have a Power Problem!

Tweet NHS – we have a problem! This blog forms a hiatus in the middle of a 4 blog mini-series about what I call the four rings of leadership (in the context of healthcare). I have been musing on some statements made at the IHI conference in London, Quality 2017, and before I go any [Continue Reading …]

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Reconnecting Clinicians to Healing

Tweet In the USA, doctors have the highest rate of suicide of any profession. In the UK, a similar picture unfolds. Why is it, that 69% of all physicians suffer with depression at least one time in their career? It could be because of the high workload, high stress, high demand, an increased sense of professional [Continue Reading …]

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UK, You’ve Had a Heart Attack – How Are You Now?

Tweet You might want a cup of tea whilst you read this! I often see patients a week or two after they have been discharged from hospital with a Myocardial Infarction (what we often refer to as a heart attack). In this part of my home county, once someone is diagnosed with having a MI, [Continue Reading …]

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