People power: lessons from the health care response to the Grenfell Tower fire

Background

On 14 June 2017, 72 lives were lost at Grenfell in what was a preventable tragedy. The community, and many of those who have been working with them, want to ensure that lessons are learnt both from the tragedy itself and how public services reacted in the aftermath.

Overview

• The fire in Grenfell Tower in June 2017 was a preventable tragedy that claimed 72 lives. The event has had a devastating impact, not just in terms of the number of deaths but also with regard to the trauma and displacement that former residents and the wider community have experienced since the fire. Health and care services needed to be put in place in response to the substantial physical and mental health impacts caused by the fire. This report records experiences of that response and how it evolved from the perspectives of community members and those responsible for commissioning and providing the services

• When it became clear that the health care response was falling short of what was needed, the survivors and bereaved and the wider community, whose concerns had been ignored before the fire, were not going to be silenced again, and stepped in to make their voices heard. There had to be a recognition, driven by the community, that a different approach was required – one that moved away from one-size-fits-all solutions driven by organisational expectations to one driven by what the community needed.

• Local health and care organisations then had to begin a journey, in which they increasingly prioritised listening to their communities and planning and delivering services with them. Listening to communities, and being prepared to act on what they say, is a simple proposition but has been difficult in practice. It has involved addressing power imbalances; it has meant acknowledging and confronting structural racism and disadvantage; and it has identified that some services, in which staff may be heavily invested, are not what people need and should be changed or replaced. Addressing these challenges, bringing colleagues and partners on board, and sustaining progress over time requires skilful and compassionate leadership.

• The Grenfell Tower fire is an extreme example of what can happen when public services do not listen to – and even disregard – what communities say they need. But the fire, and the response to it, cannot be dismissed as an exceptional set of circumstances. The challenges that they laid bare – from not valuing community voices, and not working effectively in partnership with the voluntary, community, faith and social enterprise (VCFSE) sector, to structurally racist policies and practices, and lack of co-ordination across providers and commissioners of services – are well-documented challenges for the wider health and care system. By the same token, the important learning about how it is possible to change ingrained ways of working, and that listening to communities can clearly result in services that better meet their needs, also has a wider applicability to other health and care systems.

• These new ways of working are still developing and embedding in services in the Grenfell Tower area. This report offers insights into how they could develop further and what could create risks for them. As so much of what we found is directly relevant to other health and care systems, the report also offers a series of insights and questions for health and care systems and individuals in leadership roles to compare themselves against.

Why we did this work

This report provides a record of people’s experience of the health care response to the Grenfell Tower fire and is an acknowledgement of what they have been through and what they have achieved.

It describes a process of learning to work differently in a more community-driven way and with the relationships and leadership that requires. Our aim was that other health and care systems should be able to reflect on that learning in order to improve services and to respond better to what the communities they serve need.

What did we do?

We started by reviewing a wide range of literature about the Grenfell Tower fire and its aftermath. This included academic literature, policy documents, local plans and needs assessments, outputs of the public inquiry into the fire, and a National Theatre play that used verbatim accounts from survivors.

We carried out in-depth interviews with 30 people representing a diverse cross-section of the local community, community organisations and health care services. We also spent time in the local community. We followed an inductive approach to build up a picture from what people told us and what we observed (rather than starting off with a hypothesis).

Finally, we held a workshop with local and national stakeholders. Its purpose was to report back our analysis and facilitate reflection on the learning for local services and health and care systems more generally.

What did we find?

There was a history of distrust between Grenfell Tower residents and local public services, and we heard many examples of people being talked down to or ignored and having to fit in with services that were insensitive to their needs and preferences. Survivors and the bereaved were therefore highly critical when the health care response to the fire was initially decided top-down and based on expanding existing clinical services as a one-size-fits-all approach that did not correspond to what they needed.

The community refused to be silenced and organised themselves so that they could feed back on what changes were needed. Some health care leaders responded positively to the feedback, rather than reacting defensively, and over time the relationship between the community and public services started to change. Health care leaders started asking the community and people using health services ‘What will work for you?’, and they began to work together to plan and deliver services.

Working as partners required a different leadership approach. Leaders needed to actively go out into the community, build relationships, and develop an understanding of what people felt was important to them. They started to encourage person-centred, rather than rigidly guideline-driven, care; they experimented with new services; and, above all, they took action on what people told them. They acknowledged the ingrained racism and insensitivity to diverse requirements and worked with community organisations to make services more culturally competent, including with staffing that better reflected the communities they serve and that were more connected to those communities.

This work has often been challenging – for example, by requiring staff to change and by acknowledging and confronting racism. We heard that really listening to people, and being prepared to let go of the greater power that public services inherently have, were the two key qualities that enabled progress.

These new ways of working have not yet been developed across all services and, in many cases, are still not well embedded. Nevertheless, significant progress has been made, indicating that although it takes time and can be difficult, it is possible to move to a more community-focused approach. There is a risk that these ways of working may be seen by some as a time-limited approach in response to an exceptional situation, and that there will be a return to top-down ways of working when the additional funding following the fire runs out. This would be a backwards step. Further progress in the following areas may reduce the risk of that happening:

• Greater depth of community involvement in decision-making, which will require greater transparency in decisions and openness to shifting where resources are spent.

• More transparency so that public services can be held to account by local communities for funding decisions and the outcomes they achieve.

• Going further in working as one joined-up system, rather than individual services working with communities in silos, and individual services or institutions defending their status quo.

What next?

Looking ahead, other health and care systems, and individual leaders within them, need to consider the learning from the health care response to the Grenfell Tower fire. The same challenges exist in other health and care systems – failing to value community voices, power imbalances limiting partnership working, structural racism, and siloed working are well-known and widespread issues. We highlight five key insights for the wider health and care system.

National bodies such as NHS England and the Department of Health and Social Care have important roles in setting the strategic direction, expectations and culture that support community-focused approaches. In doing so, they will need to balance ensuring accountability with allowing local delegation, focusing on outcomes rather than directing the detail. Just like local leaders, they will need to listen and engage honestly and not deny challenges or complexity. And they need to recognise that shifting to a community-focused approach is a long-term endeavour.

There is no simple recommendation that will deliver the change needed. The journey of learning and establishing a different organisational culture will vary from one place to the next, but leadership is the common thread which enables that. In this report, we set out a framework for leaders to reflect on their role and their practice, structured around four themes:

• How well connected are you to the communities you serve?

• How well are you listening to your local communities?

• What are you doing to tackle racism?

• How are you modelling this community-focused way of working?

You can download the full report, People power: lessons from the health care response to the Grenfell Tower fire here.