Healthful communities do not emerge out of social and economic deprivation or through top-down intervention. The key is listening to what communities say is making them ill and creating partnerships to address these issues. This allows change to take off and gain a life of its own, explain Katrina Wyatt and Robin Durie.
“Local areas are complex systems in which the outcome of any single change is not linear. The outcome is unpredictable, depending on how that change affects numerous elements in the system. The overall impact of any change is determined by the strength of relationships that already exist between various parts of the system. It’s all about connectivity.”
Two decades ago, two health visitors, working in one of Britain’s most deprived housing estates, began what could be a revolution for public health. The lessons from their pioneering work could help to address two of the biggest issues that trouble this field of research – how to tackle health inequalities and how to create population health improvement programmes that work in different contexts.
On the face of it, those two health visitors did something very simple. They identified 20 residents whom they felt might create a residents’ association; five agreed, and these five have come to be recognised as among the bravest and most fed up residents living on the Beacon and Old Hill estates in Cornwall. These five people were no longer willing to tolerate their area’s decline within a generation from prosperous dockyards to a place of mass unemployment, poor health, educational failure and crime as well as being known as no-go areas for public services and the police.
The five, encouraged by the health visitors, knocked on every door on their estates to listen to the residents and what they thought about their neighbourhood. They personally invited everyone to a meeting to discuss the neighbourhood. More than a hundred people turned out on a stormy, rainy night to vent their anger at the way they felt that they had been abandoned. Public sector providers also attended. They listened. Crucially, they apologised for their failures and promised change – including some quick wins to build confidence in the longer term potential for change offered by working together in partnership.
Estate transformed within 5 years
This meeting marked the beginning of a physical and social transformation that led, within five years, to dramatic improvements in crime rates, housing, health and educational attainment as well as to big cuts in joblessness, unwanted teenage pregnancies and child protection registrations. Some 20 years on, the partnerships begun at that single meeting remain strong and the improvements to the community’s wellbeing have proved sustainable.
How did so much spring from such small beginnings? When we studied this dramatic change retrospectively, it became clear that the vital factor was the new conditions created by the two health visitors, which enabled a transformation in human relationships both within the community and in partnership with public services tasked with providing for the neighbourhood.
At the beginning, there were few possibilities for people to live differently and change the place, given the fragmentation of the neighbourhood. Even if people were able to alter their individual behaviours, connections between them and others were so weak that there was little possibility for these changes to spread around the community. The actions of the health visitors began to alter that dynamic. They enabled connectivity to emerge, creating the conditions for a new dynamic network, so that, as people and services changed, these changes fed back to others, influencing them. The system – the neighbourhood and its services – became energised, processes of change started to take off and gained a life of their own.
The transformation from an estate characterised by fragmentation and isolation to a neighbourhood bearing the hallmarks of connected network meant that the community, alongside the service providers, could now learn about themselves. That allowed the replication and spread of new developments that were working well, creating a virtuous circle by which good fuelled better.
Repeating the transformation elsewhere
We were interested in seeing whether this principle of dynamic, sustainable, change springing out of improved local connectivity could work in other low income neighbourhoods. Following this initial success, one of the health visitors created a similar resident-led, service/provider partnership in another low income neighbourhood of West Cornwall. We studied their work, this time from its beginnings, rather than retrospectively. We tracked a very similar process, rooted in developing networks and increasing connectivity in response to community identified issues, and again leading to transformational change in key indicators of social well-being.
This learning from these two case studies fed into the development of a learning and implementation programme called Connecting Communities, or C2. Since then, we have observed similar change in more than 20 communities across the country that have undertaken the C2 process. We have sought to understand what happens in these circumstances using complexity theory. Indeed, the development of C2 has been explicitly informed by the principles of complexity theory.
Complexity theory and neighbourhood improvement
Local areas are complex systems in which the processes of change and their outcomes are not linear. They do not work along the lines of simple cause and effect that are characteristic of, for example, typical medical interventions. The outcomes of non-linear processes are unpredictable, since they stem from the effects of changes to relationships in the system which cannot be modelled in advance. The overall impact of change is determined not only by the nature of an intervention, but, more importantly, by the nature of the relationships that exist between various parts of the system. Processes of change that bring about healthful outcomes are emergent effects of developments in connectivity.
When low income neighbourhoods work with us, we seek to create the conditions that enable the transformation of relations that constitute the neighbourhood as a networked system. Rather than public health problems being framed according to predetermined principles, these conditions allow communities and providers to co-identify problems as they are directly experienced, and on this basis, to co-create solutions that work in the local context. For each community that we have worked with, the problems have varied and involved certain details particular to that neighbourhood, to its local context and to its unique history. And, as a result, the co-created solutions have also been locally tailored.
So what does all this tell us about those key issues for public health research – and especially the fundamental challenges of health inequalities and ensuring transferability to local context?
Implications for public health research
First, our work has shown that creating resident-led, service/ provider partnerships that are grounded in the issues facing neighbourhoods can lead to more flourishing, healthful, communities. By contrast, any ambition to transform health inequalities and change behaviours without tackling connectivity is unlikely to lead to sustainable change.
Second, this work should warn us against a tendency to create fixed models for public health interventions with a view of then adapting them to the local context. Our findings suggest that a key necessary condition for improving public health and reducing health inequalities is, in fact, one that focusses energy chiefly on understanding the local context. We have to encourage new relations that enable processes which can discover and respond to local issues that cause ill-health and health inequalities. Such an approach fits comfortably with the current evolution of a less hierarchical, more democratic model of public health that is gradually springing from the shift in responsibilities from the NHS to local authorities.
These arguments might seem unsurprising to public health research theorists who are typically strong advocates of ‘co-production’ and ‘public-patient involvement’. However, supporting the creation of new relations in communities requires more radical shifts than these terms generally seem to envisage. We need a really fundamental change in the mind-set of public health research to achieve the community transformations that are required for the health gains that are on offer.
Dr Katrina Wyatt is an Associate Professor at the University of Exeter Medical School and Dr Robin Durie is a Senior Lecturer in Politics at the University of Exeter. Their research and understanding of complexity theory has helped develop the Connecting Communities Programme (C2).
Come along to their seminar on this topic on Tuesday, 12th April 2016 from 12.45-2.00pm in Room G1 (Mary Seacole room), LSHTM, 15-17 Tavistock Place, London WC1H 9SH
Follow the seminar chat on #sphrseminar