Can the real ‘anchor institutions’ stand up?

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In 2004, Kevin Bond became the general manager for mental health services in Grimsby and North East Lincolnshire: a typical set of ‘Cinderella’ services, understaffed, underfunded, and discretely hidden in a large hospital trust. Kevin was determined to right institutional injustices for people with mental health problems. By 2006, he had persuaded his local primary care trust to take over the services so it could provide leadership and investment. In 2008, he and his staff left the NHS to create a new social enterprise, NAViGO, so they could have more control over their work and develop services in partnership with their community. Over the next decade, Kevin and his colleagues transformed NAViGO’s services. They eradicated practices that inflict pain on patients: face down restraint, prolonged seclusion, rapid tranquilisation. They eliminated ‘out-of-area’ placements and brought people back to their communities. But this wasn’t even the main story. There was something even more revolutionary going on.

When Grimsby’s fishing industry shrank in the 1980s, unemployment shot up. So too did levels of physical and mental illness, alcoholism, drug taking and neglect, and the effects continue to be felt in the community three decades later. NAViGO welcomed local people into the organisation as ‘members,’ with authority over how the organisation was managed. It put local people on the recruitment panels for new staff and asked them to make decisions on how resources were used. As it built relationships with its community, NAVIGO looked for ways to support people through economic and social challenges. These were often small, but practical things.

If you walk around NAViGO’s services today, you realise that this is an organisation led and run by local people in the interests of the local community. The organisation hired service users to run its catering and maintain its facilities. It offered training so they could become nurses and administrators. It plugged gaps, such as a lack of affordable housing, and offered rent guarantees so people could get their first tenancy. It took over a Victorian glasshouse to run a café and support young families. When a garden centre came up for sale, it bought it to offer employment and sustain a community hub.

The economist William Easterly makes the distinction between ‘planners’ and ‘searchers’ in the development support offered to lower-income countries. Planners are leaders like Gordon Brown and institutions like the World Bank. They set inspiring goals such as universal primary school enrolment and halving the number of people living in extreme poverty by 2015. Once they have set these goals, they develop equally ambitious plans for achieving them: big programmes to roll out public health, education and transport infrastructure. In Davos in 2015, Bill Clinton and Bono became convinced that simply getting bed nets to African countries would help eliminate poverty. The bed nets did not eradicate poverty or even malaria, but they did serve other purposes. They made excellent fishing nets and wedding veils.

'[Searchers] live with the local community and hire local staff. They start by asking people what matters to them and what could make a real difference. They ask what small changes might allow more parents to send their girls to school, or what they could do when the water supply is interrupted.'

Searchers are a different breed. These are often community-based non-governmental organisations such as Partners in Health in Haiti or Gonoshasthaya Kendra in Bangladesh. The leaders of these organisations do not apply a preconceived plan for development in lower-income countries. Instead, they live with the local community and hire local staff. They start by asking people what matters to them and what could make a real difference. They ask what small changes might allow more parents to send their girls to school, or what they could do when the water supply is interrupted. Only a tiny proportion of the world’s development aid goes to searchers. Most goes to planners. But what they do seems to make a tangible difference.

It is fantastic that NHS organisations are, right now, committed to acting as ‘anchor institutions’: organisations that play an active role in protecting the economic resilience of their communities. However, making a tangible difference may be harder than people think. In the United States, some organisations have adopted a narrow definition of anchor institutions and the actions they should take, focusing exclusively on large organisations such as hospitals, universities and local authorities. But this definition excludes community-based organisations such as Partners in Health or NAViGO and aspects of their approach.

'If half a century of development aid and the experiences of organisations such as NAViGO have taught us anything, it is that organisations committed to tackling deprivation must start with their relationships with their communities, before they even consider what actions they might take.' 

If half a century of development aid and the experiences of organisations such as NAViGO have taught us anything, it is that organisations committed to tackling deprivation must start with their relationships with their communities, before they even consider what actions they might take. Planners are almost always outsiders. Searchers are almost always insiders. If you want to offer effective support for a>  community, you must start from within the community. Before NHS organisations start developing plans, some of the first issues to consider are: how much does the workforce of your organisation represent its local communities, at the top as well as at the bottom; how much influence do local people have in leading and running your organisation, as volunteers, advisers and actual decision-makers; how well do you know the small local organisations already playing an anchor role and the other resources in your communities; have you talked to these partners about your new anchor role and how you might work together?

Taking this approach will run counter to how large NHS organisations are wired to operate. There are NHS managers, right now, tasked with developing their ‘anchor institution strategy’ in the next few weeks. But without deep connections into communities, they will not have the insight to put in place useful support for local people, the feedback to know that their strategies are working, or any meaningful sense of accountability for success or failure. 

> Read the accompanying report on social enterprises in health and care

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