How can the contribution of small community-led agencies and associations be recognised and maximised in the new local systems of health and care?
This was part of a series of events to explore what can be done to reduce health inequalities and improve social care, in our communities, and nationwide.
Lara Rufus-Fayemi, our thought leader on the theme of ‘joining forces’, opened the discussion by pointing out that many organisations claim that they bring about positive social change, but the truth is that most social change is complex and challenging and cannot be achieved by a single organisation on its own. We need to build a practice that goes beyond organisational self-interest, she said, combining with others to make a real and enduring impact.
She gave the example of Tower Hamlets Together, a coalition of statutory and voluntary organisations in East London, which is setting up a new health inequalities fund, aiming to bring about a culture change with a focus on preventative activity by voluntary and community organisations able to operate on the ground, with better integration into the wider system.
Anne Bowers, Newham Council’s strategic lead on community engagement in public health, then spoke about the critical importance of continuing to build mutually respectful and open partnerships and relationships, of the kind that happened early in the Covid pandemic. The pressures we now face, with cost of living for example, are unequally distributed, and are already creating challenges for health outcomes.
To address the ‘social determinants of health’ we need to support communities, which we are all part of, to be health-promoting and health-enabling. And when people are not healthy, they need services which are accessible, relevant and trusted. For all this to happen, the relationships with voluntary organisations and with community associations are critical, she believes.
In some cases, where the voluntary sector organisations really understand the problems and hold the relationships, e.g. with people with no recourse to public funds, the council needs to respect this, and its role may be convene and to channel resources, and advocate for policy or practice change, but not to try to control everything itself.
Anne gave an example of commissioning some insight-gathering via a local organisation, which works with new mothers from Black and Asian backgrounds. Here the council has taken care not to be prescriptive about the method or set targets for number and types of people to be contacted. All this has been left to the organisation, on the basis that they know best how to approach the task, they are best placed to cultivate the relationships that are needed to produce the real insights.
Anne explained that the council’s overall aim is to encourage, enable and enhance ways in which residents can take action to promote their health. Methods include small grants and a participatory budgeting programme. The council is also able to use its convening power, bringing people together, understanding that in doing so it can’t always predict what will happen. It is reviewing its strategy, including how best to build internal and external capacity, and how to establish shared governance and oversight, and make it possible to better assess whether the various activities are achieving the outcomes which are collectively wanted.
When is enough, enough? she asked. Statutory services, more and more, are relying on community champions, those able to convince others in their communities of the value of a particular health intervention, e.g. the Covid vaccine. But the failure to engage lies with the statutory system. Are we putting our problem on other people to solve? It is implicit in the language we use, she suggested, that it’s the responsibility of communities to keep themselves healthy, or heal themselves, yet often the responsibility truly lies with decisions taken in the statutory system, often at national level. It's hard to create partnerships and trusted relationships when people feel that a huge burden of responsibility has been placed, unfairly, on them.
Sometimes the council needs to share a problem, in an open way. For example, cost of living and access to food is a shared problem, which belongs to everyone in a community. The council has some capabilities, but so too do communities and community groups. We need to let go of the idea that the council is fully responsible for the solution, and act on the basis of shared responsibility and mutual respect.
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Here are some of the points that emerged from the subsequent breakout and plenary discussion:
Many of the policy statements from the NHS and local councils are excellent, it was felt. But practice is lagging far behind.
Budgets are not being devolved in a significant way. Attempts to do things differently, for example through social prescribing, are undermined by under-investment in community organisations.
Where there is funding for small community organisations and associations, a much lighter-touch approach is needed from statutory agencies and large charities. There are good examples of this, e.g. in place-based work in Cambridgeshire.
People are tired of being asked for their expertise with no financial recompense – ‘we are not here to service large organisations and make them look good,’ one said. But we know it is possible to work with people in a more positive way. We heard about a university/voluntary sector collaboration in Bristol, where a research project is using arts and community development methods to establish a respectful, not exploitative set of relationships with people from a local community.
If the formal institutions want to engage well with people in their communities they need to establish a reciprocal relationship, with reward and recognition - offering something of value in the here and now: money, or support, or a change of practice.
Fundamentally, we need to shift the perspective that the leadership that’s is needed to bring about a more healthy society comes from above, ‘it can come from all around you’ as someone pointed out.
Shifting power in favour of those experiencing health inequalities
The topic for this meeting of our Sharing and Building Power Cell on 30th May 2023 was to consider: “What can be done to shift power in favour of those experiencing health inequalities?”
The meeting heard from the cell’s thought leader (Arvinda Gohil) who shared insights into a number of community-based programmes related to health including people with HIV, older people in the Asian community and in poor and disadvantaged communities. The reflection from Arvinda was that these project-based interventions have made an impact on the targeted communities because bridges have been created between statutory services and communities struggling to access those services because they are not always presented in a way that is reflective of who they are and what they need.
Our provocateur (Samira Ben Omar) asked us to think about how we scale up what works in a way that presents a real change and shift in equalities and she asked us to reflect on the following:
We have the data but the inequalities still exist - there are examples of programmes and projects that are transformational but it is in silos and is not making the change that is required.
The system is set up to do exactly what it is doing so it is not broken - we need a paradigm shift and so need to think about what that might look like.
The system does not want to give up power.
Is there a real and genuine commitment across the system to addressing inequalities?
Finally Samira told us that communities are not waiting for permission - they are mobilising and demanding and bringing about change - so what can the system learn from this?
The meeting than considered the experiences shared by Arvinda and the provocations offered by Samira and considered what can be done to shift power. Here are some of the points that emerged from the discussion:
We need to use the power that we have wherever we are in the system.
For power to be shared then people need to give up power – when they don’t, the system stays the same.
There is a need for a stronger partnership between the NHS and the community in order to encourage people to access services.
The voluntary sector often acts as a conduit to communities, but does not have an equal voice at the table within the health system.
There is a need for space for the community to be engaged in the discussions but the system already has systems - these are top-down and what we need is bottom-up. We are too often mirroring the system rather than disrupting it.
Co-production is being misappropriated and is becoming a tick box exercise.
The data about health inequalities is there. Endless demands for more data should be resisted - and we do not need to collect more, we just need to take action.
There are two types of systems change - tweaks and fundamental. A Better Way recognises is that it is important to change oneself as opposed to first-off demanding change from others.
Efforts to shift power in favour of those experiencing health inequalities must recognise the central importance of relationships and trust.
It takes a long time to build trust and the funding system needs to understand this, and move away from funding short term projects.
We must remember that change is possible – we have seen that we have been able to share power when there is a crisis, not least during Covid.
Poverty Truth Commissions
Poverty Truth Commissions bring people with direct experience of poverty into the same room as local decision makers. They do so over a sustained period, to build mutual understanding and trust, and find better ways to tackle poverty. In this event we explored what we can learn from this.
Martin Johnstone, co-Director of the Poverty Truth Network, introduced the discussion. He shared a little of his own story - he has spent a great deal of time alongside people experiencing poverty, and feels he has gained much wisdom and knowledge from them. He has also spent time with people in positions of authority, and discovered that they can display compassion. The need, he said, is to bring the two worlds together, and this is what he sought to do, when setting up the first Poverty Truth Commission in Glasgow in 2009.
The way it works is that 12-15 Community Commissioners – all ‘experts by experience’ - spend time together, preparing to tell their stories, and subsequently come together with a group of 12-15 Civic and Business Commissioners, building relationships of trust so that difficult conversations can emerge. They may consider service design, policy changes – any areas where the group has an ability to act and make a difference. It is a model of ‘spectacular simplicity’ said Martin, ‘not them and us - just a bigger us’. To date, 30 different Commissions have been established across the UK.
We also heard from two people who took part in a Poverty Truth Commission in Bournemouth, Christchurch and Poole. Carrie-Anne Mizen (Community Commissioner) explained that while a few Community Commissioners dropped out, others stuck with it, and for them it was a way to build confidence - a chance to be heard and make a difference. Mel Hughes (Civic Commissioner) works at the local University, and was impressed by the method – in this case the initiative was led by those experiencing poverty: ‘we were invited into their world’, she said. The Business and Civic Commissioners needed to learn to hold themselves back – restraining themselves from acting as rescuers, avoiding taking over and problem-solving. They needed to learn to listen. And to discover they could connect as people, not according to title or rank. They only started to discuss what they were going to do together after nine months had passed.
In a Q&A session that followed, we learnt more about the model:
All-in all it’s a three-year programme. The initial stages are critical. Typically, six months to decide to proceed, six months to assemble the community commissioners. The stage of working just with the community commissioners takes around six months and it doesn’t work to short-circuit that.
It needs the equivalent of one full-time facilitator, ideally split between three people, with different tasks including administration of the groups, helping the civic commissioners peel away their ‘protective layers’, encouraging good relationships to flourish.
It’s best to avoid prescriptive definitions of poverty. ‘If you experience it, you don’t need a definition.’
Tangible changes do emerge – it is always best to under-promise and over deliver.
In the breakouts and discussion that followed, we considered: Could this way of working be applied more widely? And if so, what would need to change?
There isn’t a ‘manual’ for how Poverty Truth Commissions should operate. They draw on the shared wisdom of the earlier Commissions, and the relational skills of people like Martin.
This methodology is ‘a beautiful practice’, one person said. It should not get ‘stuck in a poverty silo’, it should become the pattern for how we live and relate to each other in our communities. Estrangement runs so deep in our society – this is deeply problematic, and we need practices like this to become widespread and normalised.
The Poverty Truth Commissions point us in a direction away from professionalised services which seek to deliver short term fixes. ‘Listen, and keep listening.’ Slowing down is the right thing to do. Professionals resist giving time to exercises like this. But there is a transformative experience, when people realise that they don’t need to be endlessly busy.
Building community, across social divides, is more likely to achieve progress than setting out to change the world, which can only lead to frustration and disappointment. Being in company, crying and laughing together, is a worthwhile outcome in itself. But you also need to keep the conversation honest - ‘this is all very well, but there’s still no milk in the fridge’.
We need to hold both sides of the coin: an asset-based community development approach on the one side, and a recognition that injustice is structural, and requires a wider systems change, on the other.
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Niall Cooper, from Church Action on Poverty, responded to the discussion with this poem:
Poverty Truth: A Better Way
Nothing About us Without us is for us
Bringing worlds together
Gaining wisdom, friendship, insight from being alongside
Great compassion, wisdom and intellect amongst civic leaders
Beyond stereotypes of suits and scroungers
If you want to go far, go together
Listening beyond words
Experts through experience
Confident in your own story
Building trust
New perspectives
Owned locally
Stepping into our territory: Owning the space
Looking like our local community
Painting a fuller picture of the struggle against poverty
Bowled over by brilliance, the treasure of people
Not problems to be fixed
Sharing the truth
Carrie and Mel
A chance to be heard, to really make a difference
Building friendships
Sharing stories: My story really matters
Something needs to change: This shouldn’t happen
Humanising the process
Housing and home
Empowered communities
Nothing About us without us is for us
Powerfully facilitated
Planned randomness
How much it takes to make it happen…
Amazing tools and methods. Seamless
Check ins, lifebuoys, talking to the person next to you
Crying and laughing together
Check outs
Happy, motivated, confused, my brain is a mush
Honest
Having people on your side, on the end of a phone
Even more scary for civic leaders
Sitting round with cups of tea, playing games
Peeling down layers of protection
Connecting as people, relationships first
Beyond unequal partnerships
Checking in between meetings,
Sharing coffee, one to one
Stopping problem solving and rescuing….
Slowing down. Just. Listening.
Sometimes things are so urgent… you can’t afford to do them quickly
Nothing About us without us is for us
Being invited into someone else’s space
Putting people first
No short circuiting
No take over
No short term fixes
Under promise and over deliver
Change starts to happen as soon as you ask the first question
Changes for individuals
Changes in minds
Changes in organisations, in policies, in practice
Commissioners getting the credit
Embedding the impact
Deep culture change
Participatory democracy in practice
Building a network
Building a movement
Building a community of people… to change the world
Nothing About us without us is for us
Why are so many people being criminalised, and what can be done about it?
This online roundtable brought together people immersed in work in the criminal justice system alongside others from the network who could bring wider or different perspectives.
We had two opening presentations:
Pav Dhaliwal, CEO of Revolving Doors
Pav pointed out that national policy is driven by political expediency and is failing to respond to the evidence base. We have the highest prison population in Western Europe, nearly doubling from 44,000 in 1990 to over 80,000 in 2022, with 96,000 expected by 2026. Disproportionately these people come from particular sections of the population, not least Black and racially minoritised communities. We are spending vast amounts of money (£5bn a year on prisons, and £18bn on costs of re-offending) on a system that is unfair and simply doesn’t work.
We know there are alternatives. For example, community sentences are more effective than prison, but their use has decreased in recent decades. It would be possible to divert funds towards more effective sentencing, and to addressing root causes. Most people in prison have a combination of problems in their lives – poor mental health, addiction, homelessness etc. Judges do have the ability to refer people for help, but only for one issue at a time! To make real progress we need a shift in political will.
Penelope Gibbs, CEO of Transform Justice
Penelope described a five-year campaign she co-ordinated when working at the Prison Reform Trust, to reduce the under-18 prison population. It was a daunting task, as the number of children in prison had risen steeply, to 3,000.
There was no political appetite to bring prison numbers down, so the campaign decided not to focus on changes in legislation. Instead, they engaged with youth offending teams, who were able to make a significant difference by influencing sentencing decisions. They also ran a ‘name and shame’ campaign, establishing a league table of local authorities, shining a spotlight on those councils where the percentage of children in prison was highest. And they sought out those in the system who were already concerned about child imprisonment, to work with and support them.
Other factors were also at play. New Labour had set ‘offences brought to justice’ targets, which encouraged police to push for convictions at every opportunity., and children and proved an easy way to hit the targets. When, eventually, the targets were abandoned, the pressure to imprison children started to fall away.
All of this made a difference. After five years numbers had reduced by a third. And the trend has persisted – today numbers of under-18s in prison are down from the peak of 3,000 to 456. And Penelope pointed out that placing far fewer youth offenders in prison has not generated wider problems for society, in fact the overall level of youth crime has decreased.
Despite these remarkable successes, it has not yet been possible to translate these approaches to the adult prison population. And while the reduction of under-18s in prison has been dramatic, the campaign failed to address the racial bias – the proportion of children in prison from Black and racially minoritised communities is now even higher.
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In breakouts and subsequent discussion, (including responses from Gemma Buckland, Director of Do It Justice, and Sonya Ruparel, CEO of Women in Prison) we considered the current situation and what can be done. Here are some of the points that emerged:
Government is investing heavily on prison infrastructure, much less on preventive action. There is strong evidence which points to benefits of reducing imprisonment, not least of women in prison, but the evidence continues to be ignored. A lot of crime is petty offending (a quarter of people in prison are there for theft) and the prison population could be halved if short and diversionary sentencing policies were adopted. The ‘joint enterprise’ rules fall harshly on racially minoritised groups and on women – for example, in 50% of cases the women were not present at the scene.
People’s experiences as victims of crime are often negative. Public spending on criminal justice has been squeezed, there is a huge backlog in the courts, and underfunding of the probation service is allowing dangerous people to roam free. All this is driving up public demand for imprisonment. The dominant public view is that deterrence, including harsh prison sentencing, is necessary and that it works. Moreover, there is little public confidence that alternatives are effective.
Most national politicians both reflect and encourage this way of thinking. Every 10 or 15 years a justice minister emerges who tries to drive positive change – David Gauke was cited as one example. But they rarely last long. We cannot simply rely on change coming from the top of the system.
Tactically, it may be that most will be achieved working ‘under the radar’, seeking out people with determination and influence within the system who see the need for change.
Indeed, there are a great many people inside the system who really would like things to change, who are passionate about this, and very determined. Independent organisations, including grant making trusts and foundations, are playing a valuable role where they can channel support in their direction.
While many police still see their job as locking people up, there have been efforts from within the police service to work in different ways, e.g. join forces with other agencies, to provide help to people at the right point.
Some other initiatives also point the way. For example, the Family Drug and Alcohol Court [FDAC] is an alternative family court for care proceedings, in which parents participate in a ‘trial for change’. This is a period in which they work on interventions agreed in a personalised plan which the team, family and other professionals come up with together.
But generally, where there is preventative action, or attempts to divert offenders away from prison, schemes tend to be very short term. A lot of effort is little more than tinkering at the edges, not looking at the system as a whole, not trying to make a more fundamental change.
Victims of crime, and the public at large, need to be offered a just outcome, it was suggested. So that victims can have some measure of closure, and can see that the offenders have taken some responsibility. The restorative justice movement is one means to achieve this. But attempts to mainstream restorative justice as a cost-cutting measure are unlikely to turn out well, some felt.
There is a need for broader, more generous sense of what brings people into crime, including early years’ trauma, the care system, institutionalised racism, for example, and avoiding ‘othering’ such people as inherently different, inferior, dangerous.
For example, three in five of all women in prison have experience of domestic abuse. But this is not widely known.
The voices of people with lived experience can be compelling, and these voices can help to build a more fair-minded story. Civil society organisations have a big role here, to help those voices come to the surface. But it is very hard for the independent sector, by itself, to build a national narrative in ways that really change public perceptions. There is a necessary role, some felt, for Government to set out the ‘contract’ with the public in fresh ways, but we don’t see that happening any time soon.
It was pointed out that this is not simply a justice issue – it is better seen as a social justice issue, including racial injustice and gender injustice and class injustice.
To make practical progress in this direction will require a shift from the top-down, centralised system of criminal justice towards a much more ‘community-up’ social justice approach. An example in Merseyside was mentioned, where a local coalition of agencies, including shopkeepers and other local businesses, are coming together to find better ways of responding to people who commit minor offences.
Finally, it was suggested that the four elements of the Better Way behaviour model (putting relationships first, joining forces, sharing and building power, listening to each other) could provide a helpful template, with potential for creating spaces for a different kind of discussion, right across the system.
Better leadership for health and care (second meeting)
This was the second of two meetings on the topic ‘if we don’t like command-and-control leadership methods in our health and care systems, what are the alternatives?’ The note of the first meeting is here.
Tom Neumark, CEO of the 999 Club, a charity which works with homeless people in Lewisham, was our introductory speaker.
He described how he built relationships, over time, with key individuals at the South London and Maudsley NHS Foundation Trust (SLaM), and eventually this resulted in the charity bidding for and winning a contract to deliver a new mental health service. During this process the charity wanted to engage with the statutory health and care system in a spirit of partnership, but ‘on our own terms’, not allowing mission creep, and therefore not simply responding to a tender specification.
The 999 Club wanted to achieve the goal of creating a friendly, and safe well-being space with enough freedom to build a community where people with multiple and complex needs could be supported in their journey towards better health according to their individual circumstances.
So, the 999 Club set out an offer along these lines, and was eventually successful in the tendering process. The willingness of senior leadership in the statutory sector to consider different ways of doing things was vital to achieving this, and Tom praised the qualities of many of the leaders he worked with. Tom also noted that many NHS policy statements and principles are very supportive, placing emphasis on participation, inclusion, community, and relationships, for example.
But the system on the whole does not always match this – transactional service design still predominates, and the contracting process is very hard for a small charity to navigate. It is clearly designed for much larger organisations – even though it is so often the smaller charities and community-based organisations like the 999 Club which are best placed to ‘bring alive’ the abstract principles espoused by the NHS and Integrated Care Boards. Tom said he was very grateful to his charity Board which provided strong support during what was a very demanding process.
Here are some of the key points made by speakers and in discussion, following breakouts to consider what can be done to make better leadership more widespread in the systems of health and care:
It was emphasised that leadership which is committed and determined to follow through on the principles that the Better Way promote, is needed both in the health institutions, and also in the community and voluntary sector, to break through the old ways of doing things which remain so prevalent.
It is extremely difficult when leaders are in the thick of things, overwhelmed with constant pressures and urgent demands, to make a real change in how things are done. It is ‘hard to talk about the colour of the wallpaper in the living room where there is a fire in the kitchen,’ as one person said.
So, a fundamental mindset shift is required, an epiphany or moment of realisation – not least that the role of a leader is to create opportunities for others in the system to produce the solutions and design the services, not to take the responsibility for doing this all to oneself. Realising that a good leader listens, takes hands off, supports others – understanding that the task is to be in service of the front line. And appreciating the value of a permissive and supportive culture, e.g. ‘from now on, everyone’s going to be brave’.
And rather than only trying to fix the immediate problems, leadership should be seen as building a better understand of why the problems have arisen in the first place and what can be done to prevent them recurring. And leaders should be encouraged to do more to bring people together into a creative space to share experiences, and generate the ideas that can drive positive change, using different methods (arts for example) to make this possible.
The NHS has promoted a culture of leadership as ‘expertise’ – it now needs to move from this to a culture of ‘shared wisdom’. And we need to be talking about system leadership, not just individual leadership.
The NHS is massive, and needs to find ways to support its managers to be people, not machines, and ‘to experience the joy again’. Better leadership is more likely to flourish where organisations are willing to let go of monolithic control from the centre, and work in a more distributed way, with largely self-managing teams.
A lot of good practice can be found, but remains sporadic, marginal, or out of sight. We need to ‘elevate what exists’.
But it is a mistake to try to ‘cut and paste’ a successful model or method, and hope it will achieve the same results elsewhere. Generally, processes don’t travel, but principles do. Local leaders need the freedom to design what feels right in their locality, informed by the set of shared principles. And commissioning needs to get better at allowing and supporting things to evolve and adapt, and move away from fixed targets.
We should remember that a shift in the direction we have been discussing is certainly possible – community engagement and distributed leadership used to happen more naturally before the advent of new public management in the 1980’s. In the NHS and elsewhere it has been all about frameworks and targets and milestones. This hasn’t worked. We need to be able to get back to talking about relationships, care, even love, and bring our humanity to bear.
And the Better Way principles and behaviours are a very useful guide, it was felt, and within our network we should grow our own confidence that ‘we are the leaders that we are talking about’ – the starting point is to do it ourselves, and tell the story of the Better Way in action. The more we show the way, the more others will follow.
A Better Way democracy
At our annual Gathering in December there was enthusiasm for pursuing the theme of what a Better Way democracy would look like in 2023, particularly as it cuts to the heart of our Better Way principle, mass participation is better than centralised power. We thought a good starting point might be to bring some people from within our existing network who have expertise in different dimensions of this to think about the issue and how to take this forward. This group met for the first time on 9 March 2023.
Caroline Slocock, the co-convenor of a Better Way, opened the discussion by saying that a lot of people are concerned about the health of the UK’s democracy. Surveys consistently show that many people feel the system of government isn’t working for them, especially those in lower socio-economic groups, and this is reflected in low levels of voter turn out, especially at local government level, and especially amongst certain groups, including young people, many of whom have ‘switched off’. Politicians tend to appeal to those groups most likely to vote, and respond to the issues of most interest to the majority, rather than also listening and responding to minority concerns or interests. A growing populist trend of stoking divisions and pursuing a ‘them and us’ agenda is undermining the potential for healthy dialogue.
She also pointed to growing calls for doing things differently in politics, including from the Mayor of Greater Manchester, Andy Burnham, who called last year for ‘a radical reinvention of the political system’, and Alistair Campbell, a former senior figure in the last Labour government and now an influential podcaster and commentator, who has expressed concern about people’s sense of powerlessness and has said that politics needs to be reinvented through the activism of young people. Last year, Sir John Major, a former Conservative Prime Minister, in a keynote lecture In Democracy We Trust, lamented the state of the UK’s democracy and called for a change in the funding of political parties. The 2022 Labour Conference overwhelmingly backed a motion to adopt proportional representation, though this has not yet been adopted as Labour Party policy. However, the Labour Party has committed itself to greater decentralisation of political power and is considering reform of the House of Lords.
Many of the Better Way principles point to a fundamental shift in how things are currently done in our political system, including mass participation is better than centralised power and local is better than national. Moreover, the changes we want to see, and many of the Better Way principles such as prevention is better than cure and building on strengths is better than focusing on weaknesses, cannot be achieved without a system which is better at building a consensus to deliver for the interests of future generations and everyone in society, she said.
The Better Way behaviours of sharing and building power, listening to each other, especially those least heard, joining forces and putting relationships first all point to the way in which a Better Way democracy might function, she said. In various discussions within a Better Way, many of the tools for doing so had been explored, for example, citizen engagement, participatory grant-making and Scotland’s Community Empowerment Act, and we had heard in a session with Dr Henry Tam about the importance of re-building trust in democracy through, for example, changing the power balance by building civic parity. The network is also exploring methods, such as the use of imagination and the bridging of divides, which could be relevant to a Better Way democracy and help take the discussion forward, she concluded.
James Perry, a founding member of a Better Way and a member of our core group, added a few opening reflections. He shared the need for systemic change in the way business is conducted which had led him to co-found the B-Corp model in the UK. It reprograms business to benefit all communities, people and the planet rather than just maximising profits for shareholders. There are now 1,000 B-Corporations in the UK, which is starting to shift the culture. However, he reflected that systemic change remains a long way off, because there is no such thing as a ‘free’ market. The current market is designed – through the complex set of incentives and regulations – to promote profit maximisation for shareholders. If we are to transition the economy to work for everyone, sustainably, we urgently need to redesign markets. Which requires functioning politics. But this is not possible because politics is similarly log-jammed in an outdated operating model. It has essentially become a duopoly - two entrenched legacy power-holding parties designed to oppose and preserve the status quo, rather than rewarding collaboration and progress.
Proportional representation is a first step toward that change, he thought, and it would be good to get behind that electoral reform, but it was also necessary to build a brand or narrative for a different way of doing politics which is exciting and engages the imagination of young people in particular.
Here are some of the points made in the discussion that followed:
the challenges to be overcome include: short-termism and the centralisation of the British state, alienation from and lack of trust in government, social divisions and political rhetoric which is dividing people, including the culture wars, changes to voter ID which may lead to disenfranchisement and threats to the independence of the Electoral Commission, and a fundamental lack of social connection and capital, promoting lethargy, atomisation and fear.
That said, the culture wars are not yet touching many people, there are positive long term currents, especially changes in social attitudes which are now majority views amongst younger people, and pressure for change is building up from below. It was also pointed out that our system does have some strengths, especially compared to some other countries in Eastern Europe, and has recently been shown to work in being able to force out Prime Ministers who have not followed constitutional norms.
There was a generally shared view in the group about the importance of proportional representation in helping to move toward a less oppositional form of politics and a longer term focus, but there was also a feeling that ‘turkeys don’t vote for Christmas’ so there was work to be done if this was ever going to happen in Westminster.
‘Message, movement and leadership’ are needed to build a consensus for a Better Way democracy, starting with clarity about the change required. The message must be grounded in issues that relate directly to people’s lives and there must be a clear narrative. It might help to tie into single issue areas which bring disparate groups together, for example climate change and social justice.
It was argued that an example that demonstrates the power of a clear message, effective leadership and movement building is the campaign to leave the EU originally launched by Nigel Farage (and regarded as a lost cause), which was narrative, story and character driven. However, although the campaign had delivered its target, it is a matter of debate as to whether it had delivered more power or control for ordinary people.
It is important not to reinvent the wheel and to be concrete about what will deliver change: there are already many system changes such as PR and participatory practices that have already been tested and are proven to work. It important to turn these quickly into specific, practical proposals that can be adopted.
There may be a role in bringing in people from the creative industries to bring some new energy and innovation into communications and campaigning. Support from popular figures like Gary Lineker might increase the reach.
Alliances should be built. Some work was already being done to reach out to charities to show the power of PR in their area. Dialogue with others in this space, for example, Citizens UK, the Northern Powerhouse and Acorn would be useful. There are also people within the system who are sick of it and connecting with them to form new allies would be valuable.
It was argued that a good place to start was with the local and grass roots movements - building change upwards rather than waiting for power to be devolved downwards. We should identify and celebrate the ‘community weavers’ who can help build the social fabric and cohesion around unmet needs.
In conclusion, the group talked about two ways in which this discussion could be taken forward.
First, the group agreed that as a practical first step it would be valuable for the group to meet again to share ideas and lessons from their own work and reflect on how a Better Way thinking might help. This might possibly lead to some coordination of their activities, for example. At the next meeting, it was agreed we would hear more about the work of Compass on PR.
Secondly, the convenors agreed to consider how the issues might be brought into other Better Way discussions to gain wider insights and ideas.
Creating a relational welfare state
The topic for this meeting of our Putting Relationships First Cell on 2nd March 23 was to consider; why we need a relational welfare state, one that is about health and wellbeing within the community and to consider what we need to do to make it happen.
The concept is not a new one:
Geoff Mulgan wrote about a relational welfare state over a decade ago.
Hilary Cottam in ‘Radical Help’ (2018) explored how we need to move away from transactional models of state delivered welfare services to focusing on helping each other and building strong relationships.
More recently, there appears to be a real shift towards this way of thinking but it as yet has not taken hold as a way of thinking at the systems level.
The topic was introduced by David Robinson from The Relationship Project, our thought leader for this cell, and David suggested that how we can think about this topic and might address it in two ways:
We can talk about work we are engaged with and how we learn from one another; some of the bright spots; tease out the principles and explore what relationships with the Welfare State might look like OR
We can look at it as a big picture and explore how we might re-found the welfare state if we had that opportunity.
In practice, we planned to look at this from both ends of the telescope in this session but, focusing on the second, he said that the initial giant evils set out by Beveridge in his report were: idleness; ignorance; disease; squalor; and want, and they became the structure for the ideas that followed, which was an organising system for a relationship between citizens and the state, where the state identified the problems and the solutions.
David posed the question; ‘If we were to go back to Beveridge with a blank sheet of paper what might be the 5 pillars that would underpin the development of the Welfare State now?’
He asked the cell to think about what good foundational assets might look like and to imagine the welfare state not as a relationship between government and citizens, but instead as relationships to each other, as communities to be nourished and not as a problem to be fixed.
David suggested that the 21st Century giant assets could include:
Our relationship to each other, maybe as prime responders, neighbours, family.
A community aggregated of one to one relationships.
Our diversity and breadth and depth of experience, celebrated rather than drowned out.
Artificial intelligence and the magic that technology that can facilitate; and how to use the technology to release people and time to focus on where real relationships matter most.
Love - this is never talked about in the context of public services but this is the key ingredient.
Building on David’s introduction, our first presenter, Laura Seebolm, who through her work with Changing Lives and the Maternal Mental Health Alliance has a lot of experience with the welfare state, shared the following highlights:
The Welfare State traditionally looks after the health of citizens but in 2023 it is not working for many people and has not been for many years.
Recent years has shown crisis for example with racism, poverty and Violence Against Women & Girls, and whilst there are some people who would expect to have a good service from our public services and are able to navigate for themselves and for family and friends, this is not the case for so many who do not expect to have a good experience and accessing some parts of the Welfare State is impenetrable.
For lots of people they are poorly understood, not supported, over-scrutinised and have little power and so the Welfare State can feel brutal for people and the outcomes devastating.
The tide is turning and talk about kindness, compassion and love is seeping into the mainstream narrative and policy documents are referring more to relationships, but this is hard to do in practice as it is not getting under the skin and structures.
Many people go into public service because of the difference they want to make but the services are inhumane, examples include Police Officers, Care Workers and Midwives.
The Welfare State operates on othering, paternalistic and western notions that are about saying we know what is wrong with you and we have the clinical expertise to respond - this is the medical model. There is also the commercialisation of public services and the individual becomes the object of an intervention. For example, in homelessness services, people have to go through a gateway and they are described as customers as if they have choices - but they don't.
Laura asked, how do we help bring about a culture, at scale and at population level, where people feel they belong as active and valued in our community and where there are feelings of love and care, both in the civil sphere and at the population level.
Laura concluded by saying that she felt optimistic and there is a massive momentum to change towards a new Moral Era (beyond the current Thatcherite/Blair era of standardised public services) but she cautioned that we are not there yet but a Better Way is integral to designing what is going to come next.
Olivia Field, from the British Red Cross (BRC), then followed on from Laura, providing what she described as a more ‘subjective feel’ and she focused on loneliness. Olivia reflected that everyone feels lonely some of the time and that BRC has been looking at how loneliness can be prevented for those who feel lonely a lot of the time. The work she has been engaged with highlighted the following:
Responding to emergencies has shown that connected communities are the most resilient and the most isolated and lonely are least able to recover from a crisis.
Strong relationships and being connected can help people after an emergency and grow emotional resilience.
People think loneliness is about older people but it can impact anyone - including children.
Loneliness can be exacerbated by long term health conditions, career changes, unemployment, by people feeling discriminated against and other key life changes.
Feeling lonely isn’t good for us or our communities as there is evidence to show that loneliness impacts negatively on health and wellbeing and productivity, and it has been linked to a range of health conditions with people more likely to attend GP, hospitals and public sector residential care.
The BRC, in partnership with others, has been working on loneliness for the last 5 years and exploring how to meet non-clinical needs within health care systems and encouraging conversations about relationships and support networks in the same way the system asks about diet, smoking, exercise etc. The programme has been developing mechanisms to link people to non-clinical support e.g.social prescribing link workers. These programmes have community connectors who work with people who have been referred and who have self-referred to co-develop a tailored plan of activity, with small achievable goals and flexible one-to-one support over a three month period. This work has helped people to learn how to trust other people; has shown them what is good about humanity and helped them to reconnect with people they have lost connect with. Two thirds of those involved felt less lonely at the end.
Community connectors are now rolled out right across the NHS and are one model to incorporating relationship-building into the welfare state. She also described another model they were pursuing which involves working with young people who are frequent users of A&E, defined as 5 or more visits a year, though some people attend hundreds of times. These high intensity users make up 16% of A&E attendances and 29% of ambulance visits, which often occur because of gaps in community support and relationship breakdown. Again, they work intensively with individuals, seeking to de-medicalise and de-criminalise the issue and find out ‘what is right with them’.
The cell then considered what they had heard and explored how we could move towards a more relational Welfare State. Here are some of the points coming out of the discussion:
Many people were increasingly recognising that we live in a social world, we give to ourselves when we give to others and solidarity is important. Building the ethical foundations of society is important and is being neglected, for example by faith organisations, and this can be done regardless of the state.
There is a disconnect between common sense and how services are actually delivered and so the consequence is an overarching system that is constraining the nature of what it should be delivering, for example standardisation of services and treating people as consumers. But many practitioners are trying to work in a different way, sometimes in multi-faceted teams, and some have never stopped treating people as individuals and building on their strengths, what someone described as ‘old fashioned social work’.
The public sector is not always the right answer. The public sector asks people and communities what they need but they know that they do necessarily have the resources to deliver. There is a lack of proximity between decision makers and the problems - they are so far removed from it, it is unrealistic to expect them to find the solutions. An alternative perspective could be to consider what we can lever from social entrepreneurs & innovators, anchor organisations and those who have it within their gift to do things differently and think about how we link what is being done to those who want to do things differently.
Community is not a homogenous entity and in unpacking it we might see that it is fragmented, perhaps in a way it wasn’t in years gone by.
It was acknowledged that there are local authority areas with the inclination to do things differently, but we can do more to help them to connect with others in the space to learn how to do it and then keep reflecting and learning.
There is a movement happening around these ideas both UK and worldwide and as part of this there is lots of innovation and challenge.
There is a real lack of appetite for risk and a lot of fear and this impacts on designing and delivering new ways of working.
There is beauty and strength in animating the voice of the community through storytelling - but how do we capture it and respond to it? Storytelling can enable a long-term relationship that allows individuals and communities to process the trauma. The power of the story is very important as the language of management cuts out the individual, but if you can bring them into the story this can be transformative in encouraging people to create change. Story-telling can also help to cut through to the public, who in general seem more attached to services as they currently are than to a relational welfare state.
Caroline Slocock, the then co-convenor of a Better Way, concluded the session with the following insights:
Creating a relational state requires a change both to how services are currently delivered, as all the speakers had highlighted, and to how we relate to each other in society. The Big Society, which had ended up in an offloading of some state responsibilities to communities and the voluntary sector, failed partly because it did not change how the state itself operated in its core services.
Although there is a lot going wrong at the moment, the discussion created grounds for optimism. We may be entering into a moral era due to the fact that people are talking about this and, as we heard in the discussion, a lot of the academic disciplines, which are training the front-line workers of the future, are recognising the importance of relationships and relating to people.
At the Annual Gathering of the network at the end of 2022, members debated whether we were at a positive or negative tipping point and wanted to build wider momentum for change. Building a relational welfare state is a key area and storytelling might be one way to build momentum.
Connecting the connectors
As part of our wider focus on how to generate health and well-being in partnership with the NHS, we brought together a group of people working on health and well-being to discuss:
Whether they would like to continue meeting to share insights and build relationships between them.
To identify topics that might be of value to them for us to explore in the wider Better Way network.
This was the second meeting, following an initial ‘get to know each other’ session in 2022.
Caroline Slocock, a Co-convenor for a Better Way, began by updating them on what had been happening on health and well-being within the network. There had been a roundtable on the NHS and Communities to explore how to put the NHS’s recent guidance into practice. The network had also been holding a series of meetings looking at the kind of leadership needed to build health and well-being. The first was on practising well-being as leaders, and we had held another on the leadership needed to build health and well-being in society, which would be explored further on 17 April. A Better Way had also had discussion on why we need a relational state and how to create it.
Insights from these and other discussions in the network, which a Better Way was planning to explore in a session at the forthcoming NHS #StartWithPeople conference on 30 March, included:
Invest in communities’ capacity to engage with the public sector in an equal relationship so they have the power to shape the things that matter to them.
Take on people from the community as staff and volunteers, and develop the cultural competence to reach out to all communities.
Focus less on bringing people into committees and more on creating spaces within communities to explore together how to redesign services.
Put people’s needs and stories, rather than institutional agendas, at the heart of service design.
Invest in the time, resources and relationships to make it possible to really join forces.
More information on these is available in our annual roundup, At a Tipping Point?
She also explained how a Better Way worked and the benefits it could bring – as well providing a space for sharing ideas and building momentum for wider changes, members also appreciated the way in which the network helped forged new connections, strengthen relationships and deepen mutual understanding.
In the discussion within the group that followed, it was agreed that:
The group should continue to meet at roughly monthly intervals online for 1.5 hours, initially over a 4 months’ period.
It should start with existing members but consider over time who might also join it so that the group could become even more representative of the forces that shape health and well-being. It might be worth bringing in people from areas like housing, social care and arts and culture, for example.
The focus of the group should be on ‘what we can do together which we cannot do alone’, providing an informal space for discussion informed by presentations, people thought. Ultimately, the issue was how to build on the energy and work that already exists to form a movement that makes the Better Way principles and behaviours the norm.
Members could in turn use their own networks to communicate insights from the group and socialise new ideas outside.
The group also identified topics that might be explored either by themselves or more widely within the network. These included:
The development of participatory leadership, developing an open, exploratory mindset, in the NHS and elsewhere.
Understanding and communicating what sharing power really looks like and what it means when communities take it on.
How to overcome the moral injury being experienced by the health and social care work force because they feel they are not being listened to or ignored.
How to create a movement of people who care about and for others, at a time when the demand for care is outstripping the ability of formal services to deliver it, and create what the Archbishop of Canterbury called ‘a new social contract’.
How to change commissioning to support a more networked based approach.
How to develop genuine co-production and co-delivery, including peer support and developing peer leadership to develop agency, and move away from the ‘them and us’ mindset.
How to build a movement for change.
Better leadership for health and care (first meeting)
This was the first of two meetings, and the topic was ‘if we don’t like command-and-control leadership methods in our health and care systems, what are the alternatives?
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Nick Sinclair spoke first. He is the Director of the Local Area Co-ordination Network, the founder of the New Social Leaders network, and a thought leader for the Better Way leadership strand.
As Nick explained, in recent months in the Better Way we have been exploring a style of leadership which places high value in building positive and productive relationships, in nurturing power and accountability in others, in listening closely to others and engaging in the reality of people’s lives, and in acting in collaboration with others.
Luan Grugeon was our second speaker. She is a Board Director of NHS Grampian, and Chair of Aberdeen City Integration Joint Board, with a background in the third sector.
Luan described how ‘conversational intelligence’ can be a foundation for a different kind of leadership, less about command-and-control and more about building relationship, trust and collaboration. ‘To get to the next level of greatness, depends on the quality of the culture, which depends on the quality of the relationships, which depends on the quality of the conversations. Everything happens through conversations!’ - Judith Glaser
There are level 1 conversations which are transactional, Luan explained, level 2 which are positional, and level 3 which are transformational. When the work involves complexity and risk, and there is a need for stable alliances and fresh approaches, ‘level 3’ conversations are vital. This requires an openness of mind and willingness to look for mutual benefit and co-creation. It means investment in building trust, empathy and relationships, using accessible language, ensuring community participants have an equal voice, and welcoming different perspectives.
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Here are some of the key points made by speakers and in the discussion that followed, and by three respondents to the discussion: Sam Spencer Continuous Improvement Officer at Kensington & Chelsea council; Will Nicholson, independent Health and Wellbeing Consultant; and Olivia Butterworth, Head of Public Participation at NHS England.
Those in leadership roles should recognise the best starting points for service design are people and their experiences, not requirements imposed from above. Leaders should therefore ensure that real life experiences are always present in the room, in some form.
We need to abandon outdated hierarchical models of ‘strong’ or ‘natural’ leadership, and leaders as ‘fixers’. It is possible to flatten hierarchies, to ‘turn the pyramid upside down’ or even create circles instead.
We need a more human approach to leadership. Leadership should mean being in service to people and communities, and the truly strong leaders are those who can resist the controlling pressures from within or from outside, and create a safe space for the workforce to be curious, engage in creative conversation, make connections, and do the right thing.
Sometimes people feel trapped by a system that is just not working in the way it should, and oppressed by pressures of demand from below and target setting from above. There is a lot going on that needs to be called out - engagement exercises for example when the answers are decided in advance.
Yet despite the many difficulties it is not hard to find good people, who care, and who are often able – in their immediate sphere of influence – to make a positive difference. These are the true leaders, and the task of those who are in management roles should be to make it easier for them to do more.
We need bold, brave, radical conversations about the scope and purpose of our health and social care system. Not least to address the huge racial, gender, and class inequalities.
Building a movement of people who are encouraging each other to practice better leadership, is a powerful way to achieve widespread and lasting change, and more effective some thought than attempting to force change on reluctant politicians or on other national leaders who simply don’t want to change.
It some parts of the country there are determined efforts to improve the ways things are done, with public authorities demonstrating that it is possible to share power more – in Dorset, Somerset, Fleetwood, for example. Sometimes the initiative is coming from the NHS or council leadership, sometimes from a GP, or from a community activist.
A more honest open transparent style of leadership in the fields of health and care is therefore possible, to replace the closed, opaque defensive leadership styles that remain prevalent. But it won’t be easy – there will be resistance to change and negative scrutiny of those attempting to drive change. So supportive networks for leaders who are attempting to work in a better way are very valuable.
The note of the second meeting, on April 17th 2023, can be found here.