Joining forces for Integrated Health and Care
The advent of the Integrated Care Systems should be an opportunity for organisations across sectors to join forces in a way that was not possible before. But it all seems a bit daunting. ‘So how should this best be approached?’ was the question we explored in this meeting.
Our first speaker was Samira ben Omar, previously Head of System Change at the North West London Collaboration of Clinical Commissioning Groups, and now working independently.
Our second speaker was John Mortimer, previously at Vanguard Consulting, now also working independently.
Here are some of the key points made by speakers and in discussion:
The formal health system cannot bring about good health by itself. 80% or more of the drivers of health are elsewhere. The NHS needs to join forces with others.
There are serious problems of health discrimination and inequality, made more evident during the pandemic. So when joining forces, it is always necessary to consider who is included, who needs to be reached, and what discriminatory policies or practices need to be tackled.
It is important to unlearn, in order to shift towards a more creative and relational set of practices. In particular, we need to move away from the proliferation of committees, which have often become a ‘place of performance’, rather than drivers of improvement or change.
Instead, we need to establish new spaces for people to come together to share power, from neighbourhood level upwards. The ‘Us & Them’ culture is toxic in the health system. We will only address that if we create more opportunities for people to discover their shared humanity.
It is important not to make assumptions about what people want. Instead, we need to shift the whole system towards person-centred design. This includes asking open questions, listening together, bringing back answers. It also means giving front line teams the freedom to organise their work differently: to understand at first hand the experiences of individual people in the system, then experiment, prototype, and make normal.
Public sector organisations need to ‘let go’ more. Communities do most when they can decide for themselves, it was said.
We need to remember that in partnership working the quick fix is never successful. Worthwhile change will take time, and commitment must therefore be long term.
We need to resist pressure from NHS England or elsewhere to meet immediate targets, and we should be wary of putting too much faith in new structures. It’s the shared purpose held by committed people connecting across organisations and sectors and hierarchies that will get the best results.
New Public Management, with its fixation on target-setting, cannot co-exist with Integrated Working, which needs the freedom to practice relational methods. The former has failed to drive down costs and improve health outcomes - the latter now needs to be given a chance.
Sharing and building power: participatory grant-making
The topic under discussion on 9 February 2022 in our Sharing and Building Power cell was how to make participatory grant-making work and become more widespread.
Our first opening speaker was Cameron Bray, from Barking and Dagenham Giving, who explained how an endowment fund of £1 million had been created from external fund-raising and income from social housing and half of this is being determined through participatory means, using various approaches in a ‘big DJ mixing deck approach’, as follows:
A panel model, with participants being representative in terms of geography and also community of identity. Members shape the priorities of the fund and take the final decisions.
A community steering group was being developed to design investment policy from scratch with the freedom to determine priorities.
a closed collective pilot run by a young people’s network, where they collectively make decisions and are sharing the power and accountability between themselves.
These approaches need a lot of resources, he said, including paying people for their time and induction, but they had found the process was valuable in itself as an investment in the community and its empowerment.
Lucy Gilbert, from the Quartet Community Foundation in Avon, then told us about her experience of participatory budgeting, explaining that they were part of Bristol City Funds, set up in collaboration with Bristol City Council and Bristol and Bath Regional Council, which was implementing a ‘One City Plan’ to deliver systemic change. They too had found that processes were almost more important than the money itself and they had been exploring different ways for shifting power:
setting up a grant panel for their health and well-being budget of £1.3 million, where 40% of the panel had lived experience and members are given both training and payment for their time.
a panel of 100% people with lived experience making decisions for the Bristol Local Food Fund, which is a £60K fund raised through crowd-funding specifically to go to local food organisations. Members will be trained and paid at Living Wage rates.
a pilot ‘City Lab’, with decisions for a fund of £14,000 over 6 months devolved to people with lived experience of mental health dificulties and local organisations and involving a community research exercise to come up with solutions, and committed to developing fundable projects.
Key points made in discussion in breakout groups and the plenary include:
participatory grant-making is not just be about bringing communities into decision-making about who receives resources, but is also about allowing them to shape the agenda and the priorities for new funds.
As well as improving decision-making, it brings other benefits, helping to empower and grow community and creating new collaborations. It can be life-changing for those involved and build capacity and confidence in the community.
The process itself is important, including training and payment for volunteers. Local authorities can sometimes help by recruiting stakeholders from the community. One approach that’s worked is to bring in previous recipients of grants into the decision-making process. It is not enough just to bring people into the room - true collaboration with the community is required.
There’s a lot of potential but current practice tends to be focused on relatively small budgets, so there is a need to grow confidence in the approach.
Barriers to getting this right include culture, risk aversion and ‘white saviourism’ and that is why there is a need to build capacity across all of those involved, including funders who are not always comfortable with sharing power in this way.
There’s a lot to learn from others, rather than just reinventing wheels, including from Scotland, where 1 % of local authority budgets have been earmarked for this approach, and internationally, for example in Brazil. It’s important that practice is shared.
Moral Imagination
This was a first meeting to address the question ‘How can we unlock our humanity and imagination?’
This time we were exploring the idea of Moral imagination - what is it and how can we use it increase our power?
We heard from Phoebe Tickell from Moral Imaginations who is working with civil society organisations, local authorities and communities to embed imagination into place and is working on an Imagination Lab to bring leaders together to strengthen the role of imagination in their work collectively and individually.
Imagination is an extremely powerful force for change, Phoebe says, and humanity can build bridges and power us to change. Imagining allows us not just to see a different future but to feel it. The problem is not that we lack imagination, but that we have often blocked it.
Here is Phoebe’s presentation, in three parts:
An introduction to moral imagination
An imagination lab in Watchet, Somerset
The Impossible Train Story - a must-watch four-minute video
Some key points coming out of the event include:
Imagination is a powerful force but there is a massive capacity that is not being used, rather like a muscle that has been atrophied.
Developing imagination requires dedicated time, space and prompts, including tools and exercises (like the Imaginary Train one above) which remove the fear of performing and give permission to explore.
Phoebe had worked with a community in Watchet creating a portal for the community to go through to imagine a ‘dream economy’ for their community. We heard from Georgie Grant from the Onion Collective who were undertaking this work. She told us it had been a four day lab bringing together 20 very diverse people and that initially people were scared, thinking that this would be ‘too hippy’, but after 4 days they expressed real grief that it had ended, so they followed it up with regular zoom meetings. The process proved impactful for the community and transformative for some individuals.
This is about taking future thinking out of the boardroom and into communities.
Imagination at scale is something different to individual acts of imagination, and could be transformative. What kind of world do we want to live in and how can we make it happen?
Phoebe Tickell has written more about how to ‘rewild the imagination’ here; and Audrey Thompson has also penned an essay for our collection, Building a Bigger We about unlocking imagination and humanity in a community in the 1970s.