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This is a guest blog.
Guest authors bring different perspectives and diverse voices to our blog. They do not always represent the views of The King’s Fund.


The pivot: changing our relationship with the health system


What should we do with the National Health Service? Once the brilliant jewel in the crown of our welfare state, the health service helped transformed our lives. It was a system that was admired and emulated globally. But it no longer works.

‘Invest more money’ argue those on the left. ‘Better management’ counter those on the right.

The truth is that our troubles run deeper. And our possibilities are greater.

Anne is one of many people I work with in communities across Britain. She is unwell, in pain and overweight. Keeping appointments with nine specialist doctors is her full-time job. But when I meet the doctors, they tell me something Anne already knows – the drugs don’t work. Anne needs radical help to change the way she lives.

Anne represents the biggest challenge faced by the NHS, and health systems globally: how to shift from the last century’s fight against infectious disease to today’s challenge of living with chronic illness.

One in four of us have a chronic condition: ailments which include diabetes, depression and the complications of old age. Our health services can’t cope. 70 per cent of hospital expenditure is dedicated to managing these complex conditions which cannot be cured. For the dedicated health professionals involved it’s a near impossible situation. The crisis is systemic.

In Radical Help I argue that the nature of the health challenges we face today mean that it is no longer appropriate to continue with our existing systems – to persevere with hopes of efficiency or technological fixes that serve only to prop up the old systems. We must have the courage to think again. We need to pivot.

And to do this we have to step outside the institutions and start in homes, communities and work places where health is created. These cannot be conversations that start with questions about how to fix this service or harness the public to an NHS agenda. Rather these need to be open conversations, a radical listening to everyday reality – about wellness and how to sustain it, about how we are living now and how can we create the support and conditions for collective flourishing.

Let’s take obesity, a condition associated with several long-term conditions, which cannot be cured within medical systems. UK obesity statistics are terrible: over half of us are overweight or obese. We are fatter than all our fellow Europeans. In most of the communities I work, conversations with parents – in the kitchen, at the school gates and in the pub – often turn to the subject of weight. Everyone is concerned and almost everyone knows what they should do. But alone they cannot swim against the tide: working hours make it hard to exercise, school lunches that look odd compared to those of others make children miserable – few of us can live against the grain. We don’t need better guidance or strategies, new apps or better services: we need collective support to live and act differently – to nurture our health through the course of our lives.

The approaches that could help us do this have a long history. In Radical Help I discuss the Peckham Experiment, a world-renowned health project started in the 1920s. Two doctors who were convinced that traditional clinical models and categories were hopelessly inadequate – unable to tackle the social factors that cause ill health – started a family club. The Peckham Experiment was an early attempt to work at a community level and to foster collective capability, understanding that health is not about the individual patient.

I work in a similar way. I design with people. I ask families isolated on tough estates, who feel angry and locked out, to draw on new support with transformative results. I work with older people on a community service that brings joy and affordable, warm care.

With Anne we create an alternative. Sitting in GP surgeries, we ask the doctors to send us their ‘heart sink’ patients – those like Anne they know they can do nothing for. What we offered was not a health service – in fact we were not particularly interested in patients’ clinical conditions. What we offered was a conversation – about life and what could be different.

‘You’re really listening’, Anne told Aimée, her relational worker and for the first time she looks up and meets our gaze. Together Anne and Aimée use simple tools to break down what seem to be insurmountable challenges. The remedies might look unfamiliar – change for Anne started when she was encouraged to take up her needlework again – but the clinical results impressed clinicians. The next step is about connecting people together because we can only sustain change in good company.

Radical as they may sound, these ideas are not new. They cost less money, but they are on the margins, working in spite of our post-war institutions. In Leeds for example, Mick Ward has for many years invested in community capacity for the long term – decent sums of money with no top down agenda – ensuring genuine care for elderly residents whilst also saving the council money (although this was not the starting point). And in Wigan – where I started working over a decade ago – a similar commitment to community and capability is creating significant change in the lives and health of families.

All this work shares some commonalities: it starts with a commitment to a bigger vision (rather than to meeting targets); the emphasis is on strengthening the bonds between us rather than on big institutional re-organisations, and those who are leading and working see possibility rather than emphasising risk. This work is about prevention, but it is also about something deeper – about allowing people to create the conditions for health with good support.

These are models that take care of everyone: those of us who need support (as we all do at some stage in life) and those whose work is to provide the caring and the expert medical attention when appropriate. Too often we hear promises to train more doctors, to hire more nurses or attract more carers. But we continue to hire into systems that are impossible to work within, that feel like battlegrounds. And where the front line is all about targets and plans, rather than human care and connection, we will continue to be thwarted.

It is we, the people, that create health. And it is the everyday bonds between us – our relationships – that sustain us in our good habits and our care for one another. It is our collective bonds that create the conditions for flourishing.

We need to pivot: to change our relationship with the health system, to enhance relationships within systems and between ourselves. The seeds of this new way of working are already all around us and I look forward to discussing how we can support them to grow at this year’s annual conference.