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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How Does Change Happen? Part 2

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 about little change, if any.

 

Over the last few years in Morecambe Bay, we’ve been exploring the power of Social Movements and how we can best work with our communities to effect real and lasting change. As, I said in part one of this series, we’ve been very affected by the need for personal change and the need for deep listening. Change begins with us and this requires genuine humility and deep listening, putting ourselves into uncomfortable situations and surroundings. How can we possibly make decisions for communities with whom we have never spent any time? It’s important that we do our own work and reflect on what we hear and be willing to change our way of working as a result. Series 3 of The Crown, highlights this beautifully with the inauguration of Prince Charles as The Prince of Wales. His relationship with his Welsh tutor utterly transforms the way he sees the plight of the welsh people and indeed his understanding of power, but it only comes from being immersed in Wales and having some significant challenge brought to his world-view.

 

Personal change does not just happen through encounters. The encounter with ‘the other’ invites us into a deeper journey of change. It’s why I have personally also found The Enneagram to be such a helpful tool when it comes to dealing with my own internal issues and mechanisms. For me, as a type 7, it has helped me to understand why I run away from pain and needlessly distract myself from the present in search for ever more stimulation. I have had to face this head on, in order to learn to become more fully human and the best gift I can be (nowhere near there yet!)….

 

I believe we will not see societal change if we are not, ourselves, willing to be changed. Personal transformation, however, is not enough, vital though it is. In thinking about wider social change, I have been really influenced by the philosopher, Valerie Fournier. She talks about three key components which are necessary to drive change within communities. Firstly, she says we must cultivate anger. Initially this seems like quite a strong statement, but what she is referring to is the need to stir a corporate sense of passion around injustice. I have certainly found this to be an important aspect of enabling change in our communities. If we’re not careful, we can spend much of our waking life asleep. If we are to be truly woke to the issues we’re facing across our communities then we must create a space in which people can become stirred to care enough about the reality of the status quo. We have found that people across Morecambe Bay really care about the fact that people living only a few miles apart can have a 15 year difference in life expectancy and an even bigger gap when it comes to years lived in good health. Our experience is that if we give no voice to the discontent within the communities, especially for those at the receiving end of systemic injustice, then we can end up going round in circles, unable to move forward. We definitely don’t want to remain in the place of anger, but it can be harnessed as an incredible energy for good. 

 

The expression of anger is an important part of The Poverty Truth Commission process. Those who are subject to poverty and at the receiving end of the coldness of ‘the system’ need to be given voice to express what that means for them and how it impacts their sense of wellbeing. I think in Britain, we’re not particularly good at ‘anger’. It’s uncomfortable for us. It doesn’t feel polite. We would much rather keep things under wraps and hide away that which makes us feel ashamed. However, when we choose to be present enough to suspend what we think we know about poverty and the experience of it, and really listen to the harrowing reality of it, in another human being and then go on to build relationship and even friendship with that person….then we too are invited into that same anger, not to rage against the machine, but to use the power of our ‘fileo’ (friendship) love to become an agent of radical change. 

 

Anger harnessed in this way leads to Fournier’s second step in social change: ‘Challenge inevitability’ – challenge the inevitability that things must always be this way. When we think about issues like poverty, health inequality, social injustice, adverse childhood experiences – things which feel ‘too hard to change’, it’s easy to resign ourselves to the notion that things will always be this way – therefore we should just ‘keep calm and carry on’, and just do what we can to ‘help those less fortunate than ourselves’….but all this does is reinforce the same old story. Social change requires that we challenge the inevitability of the status quo and that means challenging the world views we hold and the stories we tell ourselves. It doesn’t mean that we must therefore create a greater division between rich and poor or make enemies of ‘the elite’. It’s about taking ideologies that we hold to be ‘true’ and asking probing questions of them. In fact, it’s about giving them a really good shake and uprooting those that are deeply damaging and throwing them on the fire. There are great examples of this kind of work in economics – Kate Raworth in her book ‘Doughnut Economics’, or Katherine Trebeck in her book ‘The Economics of Arrival’ – both challenging economic theory built on GDP and obsessed with growth. We see it in Hilary Cottam’s tour de force ‘Radical Help’ in her challenge to the transactional basis of the welfare state. Bev Skeggs and Imogen Tyler, sociologists both challenging the way society is set up. Rob Barratt, challenging the way we think about education. 

 

At the same time as challenging inevitability we just also incept our thinking with possibility of an alternative future, asking ourselves some powerful ‘what if?’ questions. I wonder what an economy might be like if it held wellbeing of people and the planet as it’s core principles? – a question they are asking in Scotland, New Zealand and Iceland. What if we had a society in which women (change women for any other subjugated group) were treated as true equals? I wonder what education might be like if it were truly future orientated and took climate change seriously? If we challenge what is, it allows us to reimagine what might be.

 

New ideas though, are not enough. The undermining of our current realities opens up the possibility for Fournier’s third aspect of social change, which is to ‘Create moral alternative economies’. We must move from anger and challenge, into experiment. Appreciative Enquiry is a great approach to help us move into this space. It allows communities to focus on what is strong, rather than what is wrong. If we’re going to experiment with new ways of building society, politics, economics etc, we need to so on strong foundations. Once we have cleared the ground in our minds of what has been stopping us find kinder ways forward, we can then focus in on – ok – so what is good?

 

As a result of this approach in the Poverty Truth Commission, for example, we’ve been able to work together on designing the kind of job roles that would really help someone navigate the complexities of the health, social care and welfare system, when they are on the ropes. We heard the anger about where it isn’t working, challenged our own thinking that we can’t really change things and have begun to experiment with the ideas put forward by people on the receiving end of unkind and punitive processes. We’re creating a moral alternative economy. When our city council in Lancaster, recently voted to protect the rights of gypsy-travellers by buying their land and promising to ensure it is fit to live on – they also responded to the anger of deep injustice at what was being proposed (the selling of their land), challenged the inevitability that they had no choice in solving the matter and instead intervened with a moral alternative economy, that protected the ‘poor’ and actually worked for the benefit of everyone. Or, we could take an example from education: When a teacher refuses to tow the line to isolate a student and have them face a wall all day and instead finds a more creative way to understand their student’s anger, challenging the inevitability of school exclusion (and all that will lead onto) and finds an alternative way to help them process their trauma and make the system work for them, rather than the other way round – that teacher is creating a moral alternative economy. You see? We can begin to do it everywhere! And when we begin to experiment with new ways of being together in communities, we begin to tell each other a new and altogether more loving story than the one we’re currently living in. The more we experiment and either fail or succeed, the more we discover how to build a society that works for the wellbeing/peace of everyone and the planet. 

 

So, where do you need to listen more deeply, to allow yourself to be made uncomfortable by the palpable anger that is underneath the surface, or sometimes erupting onto our streets? Why is the anger there? What does it tap into? Where is it coming from? Who is it aimed at? Is that anger able to be channelled in a way that can leverage an altogether more loving and kind society? What inevitability in your personal or our corporate thinking needs to be challenged as a result? What ‘truths’ need to be questioned? What space might that clear for new experiments to emerge? What if those experiments began to interconnect and learn from each other, sharing resources and encouragement along the way? What might then become possible? What if we actually took a breath and decided to genuinely think and work in this way? Can you see the change ahead?! Go ahead and start creating it!

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How Does Change Happen?

Tweet 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 [Continue Reading …]

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Love Economics – Part 1

Tweet Is an Economics of love and kindness even possible? It may seem so beyond our current context that it may seem like a dream too far. However, economics comes from the Greek word Oikos, which literally means household. Whoever heard of a household that was really flourishing that wasn’t built on love and kindness? [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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The Poverty Truth Commission – Podcast

Tweet One of the things I have most enjoyed and also felt privileged to be a part of over the last couple of year has been the ‘Poverty Truth Commission’. Here is a podcast I have done with some of the incredible community commissioners, here in Morecambe Bay about how a ‘together with’ approach to [Continue Reading …]

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Black Swans and Poverty

Tweet 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 [Continue Reading …]

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Truth about Poverty

Tweet One of the best things I have been involved in over the last few years, is the Poverty Truth Commission and it has helped me to learn just how utterly complex and wicked poverty is as an issue. I’m currently reading an absolutely brilliant book by the theologian Samuel Wells, called ‘The Nazareth Manifesto’. [Continue Reading …]

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Health and Society – Can We Make A Difference? Part 2 – politics

Tweet In the second of this (actually 3-part!) series, I’m looking at how politics and social movement are vital at changing the health and wellbeing of our society, communities and the environment we live in. Together We Can!         Share This:

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Healthy Schools

Tweet Last week, I had the privilege of being at Morecambe Bay Community Primary School. The school is a beacon of hope in this area. I found it extremely moving to walk round, with Siobhan Collingwood, the visionary and big-hearted headteacher and see the incredible love displayed by all staff towards the amazing children there. [Continue Reading …]

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