How Does Change Happen?

How does change happen? This has become an incredibly important question to me over the last few years, and I am still on a big learning journey in discovering some answers. There is so much that needs to change – so much that is currently going on in our communities that simply doesn’t work for people. So I keep asking – how does change happen?

 

I recently read a book called ‘The Moral Imagination’ by the great peace-builder and activist, John Paul Lederach. In it, he talks about the concept of ‘critical yeast’. Yeast is itself changed in a new environment (surrounded by flour) and then begins to bring about phenomenal change around it. You don’t continue to see the yeast, but you surely get to see it’s effect!

 

For me, change begins with listening, and by that I mean deep, generative listening to those who we could think of as ‘critical yeast’. The kind of listening in which you can no longer continue to see things the way you did previously. As you listen in this way and find your self changed, you can longer continue with things as they are – you realise that things around you need to change also.

 

It’s one of the reasons why I am absolutely committed to putting myself into uncomfortable surroundings or situations which challenge my neatly held world views and beliefs. I try and make sure I take the lanyard off my neck, step out of the clinical settings I know and the board rooms I sit in and spend time in and with the communities we serve. I really believe it is vital for all leaders, especially those in senior positions to regularly take time away from the boardroom and really sit with the communities they are paid to serve. If you don’t have your finger on the pulse of the pain people are experiencing, then it’s all too easy to make decisions on behalf of them which utterly lack compassion or kindness.

 

So, together with my good friend, Yak Patel, who is the CEO of the Lancaster CVFS (Community Voluntary Faith Sector) and a man of real humility who holds our communities in his heart, we went to be with some people doing amazing things across our district. Yak is great at holding me to account and ensuring that I put my money where my mouth is!

 

We started on The Ridge, the largest council estate in Lancaster. There we spent time with Lisa, who we know through ‘the art of connecting communities’. She runs the community centre, and we wanted to listen to the experiences of people living on The Ridge and understand some of what they are facing. Simple things, like a cut on their bus service (as timetables massively favour the University) is leaving people isolated and cut-off, especially elderly citizens at weekends.

 

I asked Lisa what she thought about the growing rhetoric that the problems communities like ‘The Ridge’ are facing are not to do with ‘resources’ – she rolled her eyes and retorted – “easy for people to say that, but over the summer, I couldn’t pay myself a salary for 2 months, so that I could ensure that the youth provision needed through the holidays could actually run – the funding for those kind of activities has been cut so much, it’s a joke….” Lisa, like so many other big-hearted and socially-conscious community workers, had to work 80-90 hours a week, holding down a second job, simply to be able to pay her own bills – similar to what happened at Christmas, when she worked long hours to make sure that 75 children on the estate actually had something to eat and a present to open on Christmas Day. People of good heart are feeling overwhelmed, unsupported and burnt out. I asked Lisa what she would love to happen – she wants to bring the community together, to talk about what’s strong, not what’s wrong, ask the community what it is they actually want and need, rather than assuming the providers of public services somehow magically know (!) and focus on what The Ridge could become – for the community, by the community.

 

On The Marsh, we met Debz. Debz also came to ‘the art of connecting communities’ last year. You might describe Debz as a ‘salt of the earth’ person. Down to earth, she has seen it all. I asked her what the biggest problem is for her community…..”drugs…..the place is overrun with drugs – and people are on the ropes”. The food club was happening, thanks to fareshare, when we arrived (although huge trays of strawberries were already completely mouldy)….and there were queues down the street….she shared with us some of the complexities involved for young people and the situations they find themselves in – multi-generational trauma….but what she struggles with most is that those who are supposed to care, don’t seem to want to understand. She told us of difficult encounters with the local GPs, the local hospital, social services (one family had had over 24 social workers – what’s the point in that, she asks?), police, schools and city council….although she has noticed some attitudes begin to change (perhaps because of the poverty truth commission).

 

She feels that people on ‘The Marsh’ are judged, looked down on and it’s reputation is very hard to break. But she also knows that people who live there want things to change and they want to be part of the change. That can be really tough, with the threat of violence and the very real involvement of gangs from Liverpool and Manchester, bringing intimidation. “Why would people not do drugs and get involved in selling them? It pays better than any work available”, she shrugs.  She believes the community can find some more hopeful dreams and she talks about the difference a new church in the community centre are making (a conglomeration of a few different congregations working together)….She wants to bring the community together to talk about what they want to see change, but especially how they can be part of that change….however, she doesn’t think it can happen through some kind of new found motivation alone – it’s going to take real investment. She tells me that if we want to stop seeing men dying in their 20s, from drugs, violence and suicide – we need to think altogether differently about how we work together with communities. Yak nods in agreement – he used to have Debz’s job, before he became CEO of the CVS. He tells me how many funerals of young men he has been to from this community. I feel deeply sad.

 

Then we’re on to Poulton (which has the worst health outcomes in North Lancashire), to meet our friend Joanne, who runs Home Start for Lancaster and Morecambe. What an amazing lady! And such a great charity! We sit with Joanne and one of her trustees, Sheila (who used to work in children’s services at Lancashire County Council, before she saw the decimation of her team and the unacceptable levels of stress she and her team were having to work under, which she deemed to be totally unsafe). The work they are doing for young families is extraordinary. Most of their referrals come from Health Visitors, but they are now full, and simply can’t take any more referrals unless more volunteers arrive. What I love about Joanne and her team is the collaborative-coaching approach they take. As they have worked alongside families, and discovered what they want and need, they have seen co-produced groups around issues like Domestic Violence and Autism support. What Joanne is most proud of is that they have created a culture in which you can walk into a room and no one knows who is a ‘client’, who is a volunteer and who is a member of staff – brilliant! “A community of mutuality” – she beams! Humility is the order of the day and it leads to real relationships that bring real change. As services have been cut and fragmented, increasing pressure has fallen onto the charity sector to hold things together – but resources have not followed. Despite great connections across the sector, the pressures are mounting, the cracks are showing and the risks are increasing.

 

I have no idea how much money Lisa, Debz and Joanne must be saving the public services every year, in terms of health and social care….but I do believe we could be making some far better and wiser investments with the ‘public purse’. We should be putting a whole lot more faith in community centres and workers, like them. If we do so, we will find it much easier to tackle deep-seated health and social ineqaulities right in the heart of our communities, taking an asset-based approach, being brave enough to redesign around relationships rather than transactions (as my good friend Hilary Cottam says in Radical Help) and find that communities really do want to be a part of transforming their own futures. Just like in Wigan, there needs to be a New Deal between communities and the public services to ensure that there is mutual vision and accountability for the resources that are available. What are we brave enough to stop doing, so that we can learn to do what is altogether better? Are we able to change? Not if we remain in our silos and ivory towers and continue to tell ourselves the same old stories. But might we dare to step outside the fortresses of what we know and learn to deeply listen? If we can do so, we cannot help but be changed….and as we begin to change….well…..then change begins to happen!

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A Vision for Population Health and Wellbeing – All Together We Can

If you haven’t yet had the chance to read the Kings Fund’s vision for population health (and it’s the kind of thing that interests you) then I would heartily recommend that you do so. (https://www.kingsfund.org.uk/publications/vision-population-health). It is a real ‘Tour de Force’ and deserves some significant consideration. I like it because it doesn’t hold back from bringing some hard-hitting challenge, but also creates hope of what is possible. 

 

Last week, whilst I was in Hull, I unpacked some of my (many) thoughts about population health, drawing on the wisdom of this report, the significant challenges we face and the opportunity we have to reimagine the future, together with our communities. I was hoping to offer it as a podcast, but it didn’t record well! This is quite a long read, but I hope encapsulates the key issues and gives us plenty to wrestle with and discuss, reflecting on the great piece of work from the Kingsfund. 

 

When it comes to population health, we have to remember, especially when we look at a global stage, that the UK has had some of the best public health in the world. We have so much to be grateful for and have had some incredible breakthroughs in our health and wellbeing over the last 200 years. Consider how our life expectancy has increased, initially through the great improvements in clean water, sanitation and immunisations and then the emergence of the NHS, with free healthcare for all, no matter of ability to pay, and subsequent lifesaving interventions in the areas like hypertension and diabetes – we’ve come a long way, though there is still plenty of work to do! 

 

However, there is a lesson in humility that we need to take from the All Blacks (consistently the greatest sports team in the world). After successive world cups, which they should have won, they had to take a good, long and hard look at themselves and face up to this uncomfortable truth – they were losing! (and I imagine after the mighty victory of the Irish against them recently, they may be having the same conversation again). We have to face up to the fact that right now, in terms of population health, especially around health inequalities, we are losing and we’re losing BIG. 1 in 200 of us is currently homeless. Childhood poverty is increasing year on year and many of our children go hungry on a daily basis. According to the Food Foundation, our poorest 5th of households would have to spend 43% of their entire income to eat the government’s recommended ‘healthy diet’. Much of our housing stock is unfit to live in. Our healthy life expectancy gap between the rich and the poor is nearly 20 years, with a shocking difference between the North and the South. We have a mental health crisis in our young people, with suicide the leading cause of death by some mile in Males under 45. And to top it all, we have a severe shortage of staff in the NHS and our public services which make it actually impossible to continue the level of service required by the heavy target-driven culture of Whitehall. 

 

To continue trying to deliver the same services in the same way, when these issues are so starkly in front of us, is beyond insanity. We simply cannot continue to continue with business as usual and think that we will achieve anything different or new. This is why I like the 4 interlocking pillars the Kingsfund recommend when thinking about population health and I will unpack some thoughts about each one. 

 

The Wider Determinants of Health

 

Before I start on this section, it is really important for me to state that despite what others have at times accused me of, I am not actually a member of any political party and so when I write things which challenge current government policy or praxis I am not trying to score political points. In fact, I believe it is one of the key purposes of (health) leadership to call out when decision making processes are harming the health and wellbeing of the population (whether intentionally or not). Indeed, the same would apply, whoever was in (seeming) power. 

 

When it comes to tackling the issues of population health, dealing with health inequalities and ensuring that the health and wellbeing of all people and the planet is taken into account in every government policy, the current administration is found sorely wanting. No matter what is peddled out about the “successes” of Universal Credit (which I do actually believe was introduced with some good intentions), it is failing and will continue to fail as necessary safeguards are not being put in place. Since the introduction of UC, we have seen a staggering rise in the use of food banks. Families, especially children are going hungry and the financially poorest in our society are not having their basic nutritional needs met. Since 2010, we have seen childhood poverty rise and the health inequalities gap widen. Much of this is owing to the burden of austerity being carried primarily by our poorest communities. In this same time period, we have seen the loss of overall goals for population health and no clear directives or measures to encourage change. In fact, many of the more project and target driven approaches to population health are often the very things that cause a worsening of health inequalities, like child obesity initiatives, because they do not focus on the wider determinants of health like poverty, housing and planning. 

 

On one level, we should applaud Matt Hancock, Secretary of State for Health and Social Care for encouraging the NHS to get into the game of prevention. However, a mirror then needs holding back up to the government to examine what this really means. It is clear that the current ‘rise’ in funding for the NHS, won’t even enable business to continue as usual (and one might argue that’s a good thing, because we need to change business as usual – except for the fact that there is no letting up on the drivers and targets from the Department of Health that continue to maintain the current modus operandi). The £3.4 billion per year increase won’t even touch the hole in our acute hospital trusts, let alone account for the whopping >49% of total cuts from local government (more than £18 billion in total, with more to follow), who are absolutely instrumental in tackling the wider determinants of health and wellbeing. Public Health, which has always been so vital to the work of prevention has been decimated within local governments, who are struggling to keep their statuary services up and running. So, no, it’s not actually that straightforward for the NHS just to now take on the responsibility of prevention, as the social determinants and wider economic issues, including funding aspects, are an absolutely vital component of getting population health right and asking the NHS to do so, simply piles more pressure on an already stretched and burned out workforce. An ending of austerity and an appropriate level of funding is vital if we are to achieve population health, uncomfortable truth for the government, though this may be.

 

Our Choices, Behaviours and Lifestyles

 

There is a worrying rhetoric finding voice that ‘people should just make better choices and take more responsibility for themselves’, but this is simply far less possible for so many of our communities than others, as a direct result of policy decisions and economic models over which they have no power or control. 

 

One one level, no one would argue that each of us has at least some level of responsibility to make positive lifestyle choices, make good decisions about what we put into our bodies and how much exercise we do or don’t take. But we must remember that this is so much easier for vast swathes of our population than others. 

 

There is plenty of evidence though that helps the NHS think about where to focus when it comes to population health management – where we can make the most difference. These areas include: smoking, alcohol, high sugar intake, high blood pressure, atrial fibrillation, high cholesterol (currently hotly debated!), healthy weight and positive mental health. Remember though, Sandro Galea’s work on ubiquitous factors! It is possible to focus in on projects like these and make health inequalities worse! These things cannot be done in isolation, but must be part of a wider vision. The temptation will be for governments to focus on these narrow interventions and claim great statistical significance whilst still not dealing the root issues. 

 

It is in this that again, we need to see the government come up trumps. Targeted and smart taxation can have a massive impact on the choices we make – we know this through the massive breakthrough we’ve seen in smoking in recent years. The same now needs to be applied to the highly influential, powerful and dangerous sugar industry. A best next step, according to Professor Susan Jebb, from Oxford University, would be to put a substantial tax on biscuits and cakes. Like it or not, along with our carb obsession, these are our biggest downfall and if the government are actually serious about tackling our ‘obesity epidemic’ then they need to break any cosy ties with this industry and stop the nonsense about being too much of a nanny state. Public opinion, which apparently hates the nanny state, thinks the smoking intervention was fantastic and the benefit is clear. The role of government is to see what damages our health and work with us to help modify that behaviour. 

 

An Integrated Health and Care System

 

There are plenty of places around the country where we can now begin to see the potential and power of working together differently. In the UK, Wigan, with great leadership from the likes of Kate Ardern, tells a powerful story of how incredible things can happen when population health is owned by everyone and a social movement is born. Manchester, with its devolved budget, political stability and holistically embedded view of population health championed by the Mayor of the City, Andy Burnham is a fine example of how working together differently can really offer some exciting possibilities. He recently said this:

“As Secretary of State for Health, you can have a vision for health services. As Mayor of Greater Manchester, you can have a vision for people’s health. There is a world of difference between the two!”

 

In Morecambe Bay, as an integrated care partnership within the wider Lancashire and South Cumbria ICS, we have already found some huge benefits in working more closely together. It gives us an opportunity to find solutions to the wicked issues we face through collaboration and combined wisdom, rather than through competition and suspicion. 

 

The integration is important at the macro level (where decision making and budgeting occurs), as well as in the micro level in our neighbourhoods. Our Integrated Care Communities in Morecambe Bay are without doubt one the instrumental building blocks we have to reimagining how we can deliver care more effectively for our communities. In each of our 9 areas around the Bay we have teams involving GPs, the hospital trust, social workers, allied health professionals (physios, OTs), police, fire service, community nursing, community and voluntary teams, faith organisations, and councillors working together for the good of our local neighbourhoods. 

 

The Places and Communities we Live in and With

 

Place is hugely important and so is community. Isolation literally kills us. We have certainly found in Morecambe Bay, that choosing to work differently WITH our communities, rather than doing things to them is fundamental in being holistic when it comes to Population Health and Wellbeing. It has meant learning to take our lanyards from around our necks, getting out of our board rooms (where traditionally we take decisions on behalf of people) and embracing humility as we learn to listen to and partner with our communities. One book I have found really helpful, personally has been ‘The Nazareth Manifesto’ by Samuel Wells. He is considered by some to be the ‘greatest living theologian’, and I consider it to be of vital importance for us to think and engage with these issues of heath and wellbeing as widely as possible, including theology, philosophy, sociology and economics, to help challenge and inform the necessary mindset shifts which are needed. Wells writes that for him, the entire Christian story is encapsulated in these 4 words: “God is with us”. Whatever, you happen to believe about God, there is certainly a majority view that if there is a God, he tends to be quite aloof, distant, hierarchical, dominating, controlling and power-crazy, if not seriously vengeful at times – and interestingly, we often refer to some leader-types as having a ‘God complex’! But if God is not like that, but is primarily about being WITH people, not over them, working WITH them rather than doing things to them, that has huge implications on much of western thought and how we set up leadership and governmental institutions! 

 

Hilary Cottam’s book, Radical Help and Jeremy Heiman’s and Henry Timms’ insights in New Power are both vital reading in really engaging with this whole concept. We need to radically embrace the fundamental truth of relationship as an agent for good and change in our society. Our public services have become devoid of real and genuine relationships with our communities. 

 

Over the last 3 years as we have had many conversations around Morecambe Bay, being honest about the financial predicament we find ourselves in (needing to save £120m over the next 5 years, 1/5th of our total budget, whilst still meeting all our targets!) and listening to each other as we try and work out how we can be more healthy and well together, so many beautiful and amazing things have started. These include: mental health cafes, community choirs, the Morecambe Bay poverty truth commission, walking groups, the daily mile in our local schools, new ways of working between the police, council and local communities, the voluntary sector working differently together, dementia befriending, mental health courses in our schools, a new focus on adverse childhood experiences and many many more. 

 

So Where from Here?

 

I believe we find ourselves in an intersectional moment in which we can unlock a very different kind of future than the one we appear to be currently heading for. It is time for deeper listening and a reimagining of how we really might live in a way together that cedes health and wellbeing of humanity and the planet through everything we do. This means we can honour previous ways of doing things, recognising where some of them have been detrimental and contradictory to true population health, letting go of our insanity in the process and find a new, more healthy way forward. It is vital that we consider these four interactive pillars of population health and embed them into every facet of our life together in society. This means ownership and resulting policy change by the government with funding that actually works for the kind of integrated, living and flexible systems we need to co-create. We need communities to find new ways of being well together, take responsibility for our own lifestyles and behaviours, with compassion and kindness for whom this is less than easy.

 

From my perspective this would mean a reimagining of politics – a rediscovery of how we live well together – away from binary competition and white male privilege and towards collaborative inclusivity and equality, based on love, kindness and compassion aka “kenarchy” in which we renegotiate our relationship with power. It would mean a reimagining of economics – a recalibration away from transaction and a ‘use and abuse biopower’ towards a ‘doughnut economics’ in which we learn to live in the sweet spot of environmental sustainability and human justice and mercy. 

 

There are so many things that we have accepted and reports we have ignored. It is time for us to collectively say “enough now” to that which is dividing and killing us and hold together the reality of despair and hope in our communities, as we allow the reality to sink in that together WITH each other, we really can begin to find an altogether better future for us all and the planet. It won’t be easy and means there are many of our own personal ego structures, deep wounds and problematic behaviours that will need healing and changing along the way, but let’s open our eyes and allow new eye light to help us see the future which in our hearts we are longing for. 

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Changing the Future of Adverse Childhood Experiences

Tweet Applying a Population Health Approach to Adverse Childhood Experiences   Adverse Childhood Experiences are one of our most important Population Health issues due to their long lasting impact on the physical, mental and emotional health and wellbeing of a person and indeed the wider community. It is therefore really important that we apply a [Continue Reading …]

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Health Spending in The North vs The South

Tweet A few months ago, I wrote a couple of blogs exploring the social justice issue that is the vast difference between the health spend in the North, compared to the South.   This week a graph was produced by HM Treasury to show how overall spending has changed across England since 2012. Here is [Continue Reading …]

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Just to be Clear – This is a Social Justice Issue

Tweet Following on from my blog earlier this week, I want to be really clear in what I am saying! The funding formula used in health and social care is weighted towards the wealthy and the well…therefore the north is worse off compared to the south… We are already at a major deficit in terms of health outcomes, [Continue Reading …]

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What Every Northerner Should Know About the North/South Health Gap

Tweet Everybody knows about the Gender Pay Gap – it’s well publicised and very much in the public domain for discussion – and too right! – How is this even still an issue? It it is quite simply wrong that women should earn less than men, any time, any place, end of discussion.   Well the [Continue Reading …]

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Why Are We So Inactive in the North West?

Tweet So, I was interviewed on BBC News 24 on Monday evening (sorry for the poor visual quality), to talk about why it is that we are so inactive in the North West (worst in the country, apparently at 47% being inactive). We have also pretty much the worst health outcomes, with high rates of [Continue Reading …]

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The Morecambe Bay Mile A Day!

Tweet Every day in Morecambe Bay 2000 children aged 4-11 run a mile a day (how fantastic is that?!). Inspired initially by the story from Stirling, the word  is spreading and we now have another 3000 children starting across Lancashire. Our early data shows that there has been a dramatic improvement in the children’s health, [Continue Reading …]

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Changing Health and Wellbeing Through ‘Self-Care’

Tweet Better Care Together is the way in which health services are now being redesigned and reorganised around Morecambe Bay, so that we can provide the best care we can for the people who live here in a way that is safe, sustainable and accessible. It is an on-going process and involves the breaking down [Continue Reading …]

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5 Ways to Wellbeing 2) BE ACTIVE (Changing the culture of the NHS)

Tweet In my last vlog, I started looking at how we might use the 5 Ways to Well-being  to help build resilience and promote health, particularly for those who work within the NHS (though it can apply to anyone). This second vlog takes a look at the being active and how it can improve health [Continue Reading …]

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