Community Powered NHS - Servant or Master?

Responding to the New Local NHS Paradigms Report

Here at the Neighbourhood Democracy Movement (NDM), we’re creating a peer-led network that seeks to midwife the shared future that is possible; to eclipse the current system rather than respond to its failings; to be generative in all that we do.

At times, that might mean we need to draw attention to misunderstandings which lead to a misrepresentation of community and of citizens.

We need to do this to prevent unintentional harm to the capacities, agency, power and narrative of communities and citizens. To recognise them as generative participants in a pluralistic and shared future, and as the people best placed to organise and produce solutions to the problems that affect them. This is vital to communities realising their potential and being properly recognised and resourced, and vital to institutions in helping them avoid institutional overreach.

That is why we’ve responded by augmenting the graphic below of the Three NHS Community Paradigms described in the New Local report. We’ve added a fifth column that we feel defined the ‘community paradigm’ with a vital and generative approach which centres communities and citizens. We have then re-badged New Local’s community paradigm’ as a ‘Public service reform / co-production paradigm’ which seemed to more aptly describe the approach advocated in the report. ‘

We hope this intervention sparks an important conversation. You can see the two different approaches below.

NDM Intervention:

NHS Paradigms Report Original:

It is important to take this approach. How will resources ever reach neighbourhoods if they appear in the diagram as contributors to service reform, rather than as producers in their own right? We can’t put neighbourhoods first or centre them without including them on the diagram in their own right. Claiming a seat at the table, rather than collaborating with the host, is vital.

There is ample space for the much-needed work of New Local. They play the role of ‘useful outsider’ – speaking the language of institutions and seeking to learn the language of community through the lens of public service reform. They act with good intent, and can unintentionally cause harm to the agenda they so fully support. We support the steps the report calls for, of national bodies and systems to enable the required shifts towards change (See pages 11-13).

However, whilst this call is admirable, it’s the framing of community and its function that, in our view, falls short. Whilst we see in the report, and in the thinking and acting of many institutions, a shift from passive recipient to participant, there’s still a strong sense of a lack of belief in the ability of communities to produce and organise in their own right – without a paternalistic framing of state. When addressing complexity, what is missing is the importance of social space with no agenda, the messiness of community and its contribution to health and wellbeing in its own right.

The report makes good reference to the fact that the Wanless vision has not been realised along with the aims of the NHS Five Year Forward View, yet misses the opportunity to connect that to the systemic eradication of community facilities and resources that support self-organisation over many years. The report doesn’t seem to recognise that in times of austerity institutions make choices that look after themselves, and cut facilities in local communities that keep people well – while in times of plenty they create new teams of professionals.

We see more social prescribers for example, the latest silver bullet, rather than keeping hold of community buildings that enable people to gather, and opening them up without charge for neighbours to share what they have and to organise. Instead they are disposed of, leaving neighbourhood groups with the headache of introducing charging policies for community spaces. In contrast, higher income communities tend to fare better in keeping hold of space. A real shift to a community paradigm would allow us to courageously work alongside neighbourhoods and redistribute resources in ways that would improve and enhance community wellbeing. Imagine a conversation about whether to employ a new link worker to signpost, or to use the money to open up every space in a neighbourhood for self-organising mutual support such as a Camerado living room? What might organically grow from such spaces if opened up to everyone, for free? The community paradigm described in the New Local report, led and hosted by the institutions, will not enable the emergence of innovative, redistributory and generative solutions, nor the much sought-after, mythical new NHS economic model that makes less add up to more.

The report also focuses on spiraling costs without detailing the wealth that is extracted from the health system. This seems to implicitly pass on responsibility for fixing the problem to communities. That’s hardly surprising, given the reliance on the Wigan Deal as the architecture for this work and its top-heavy representation throughout the report. If we are to believe that we change culture with half a day of “deal training” then we’ve become starstruck and caught up in the superhero story. This is a story that centres the institutions and systems, and is of course very palatable to those who work in them. Some might call this ‘familiarity bias’ or even ‘self-preservation bias’.

To imagine that leaders who are so far removed from these ideas will take them on board in the ways that we hope for is naive. It's like expecting a learner driver to navigate the roads around Naples. And we only need to look at history to see what happens when we hope that those new to the agenda will act in the way that we hope. Wanless and the 5 Year Forward View are examples of this – it's the antithesis of community power. Of course we need that push, but we also need to acknowledge that a reason that we’ve never quite succeeded is not down to ‘this time, or this leader,’ but the fact that we invest resources into the wrong place. We keep it rolling around in institutional reform rather than redirecting to neighbourhoods.

Given that many of these ideas have been suggested before, over many years, we at NDM are more interested in a generative methodology and would seek to propose a much deeper role for community and citizens organising together. As we all know, there’s NHS guidance galore aimed at supporting the involvement of citizens in all aspects of decision-making. Those who’ve been working in participation, engagement and development for the last thirty years can tell you little has changed – in fact decision-making has often become more centralised, with cuts to resources that support engagement and community development.

So the important question is: why so little change? Fear? Lack of trust in community? A love of power? Paternalism? An inability to see communities as producers in their own rights – as independent, autonomous, self-governing, self-renovating? What will make this time different? The hero story or the community story?

And so in a spirit of generosity and constructive criticism, we would ask that if a report designed to suggest changes to the NHS does not engage with these complex problems and the problems of redistribution at a systemic level, what true value does it have in terms of community power and in terms of implementing the kind of transformation that we need to solve problems where people are?

It takes months for small grants to arrive in the pockets of communities. There’s lots of bureaucracy and little trust, and there’s work to be done on shifting thinking and understanding around participatory and deliberative democracy – in making it easier to enable citizens and neighbourhoods to make good use of their commons.

And that is why ‘Community’ as we have described, requires its own column, to stand in its own space, if we’re serious about centring and resourcing neighbourhoods and the people who live in them.

Let’s open a dialogue and talk about the elephant in the room. Whether you agree, disagree or have something to add, we’d love to hear from you.

You can access the full report from New Local.

Join the Neighbourhood Democracy Movement.