In Practice: Communities Tackling Health Inequalities
What can health professionals, councils, charities and communities do when they come together to work on reducing health inequalities? At Stronger Things, changemakers behind some of the most innovative practice come together to talk practical reponses, hacking the NHS and keeping hope alive.
- Dr William Bird MBE, GP and Founder and CEO, Intelligent Health
- Dr Andy Knox, GP and Associate Medical Director, Population Health, NHS Lancashire and South Cumbria Integrated Care Board
- Kal Kohli, Assistant Director – Early Intervention and Prevention, Birmingham City Council
- Iain O’Neil – Managing Partner for Health, TPXimpact
- Chair: Laura Charlesworth, Head of Health Research, New Local
Laura Charlesworth: We’re going to start our session by asking you to do a little bit of framing of the context for us around health inequalities, why health inequalities are so challenging in terms of tackling them, and also thinking a little bit about integrated care systems (ICSs) and their potential role in tackling health inequalities.
Iain O’Neil: It’s great to see so many people here, who are hoping to come together to try and solve some of these issues and who are probably equally outraged about the fact that these avoidable inequalities persist. This is a result of the choices we make as a system, and I think we’re at a pivotal point around systems and choices.
With the ICBs [Integrated Care Boards], I had great kind of optimism when I was in NHS England, mostly because it sounded like the centre was going to give money, and get out of the way and let people do good stuff. At a population level that intuitively feels manageable. From a technology perspective, you could see how it might be possible to share data. You can see how it’d be possible for people to meet in a room and come together and share ideas.
I think I’m less optimistic now, unfortunately, because of some of what I see and hear from colleagues about the challenges of delivering where people are. I think it’s a very difficult challenge, to pull a lever in the centre and see change happen. Some of the things the panellists are doing is very much where people are. It’s local, it’s understanding the context that you’re working in, it’s knowing who to speak to, and who to kind of engage with around the system.
My hope is that we can begin to demonstrate the effectiveness of coming together at that level and get NHS England and the Department Health and Social Care to do things they don’t like doing – like trust people to get on and deliver. And I think hopefully from today will surface some evidence and some good ideas of what is possible.
Laura: We know it’s challenging tackling health inequalities. But we have got some brilliant examples to share with you of some successes that are happening out there. We will also address some of the challenges during this conversation. So if I can come to Kal first, can you tell us about some of the work that you’ve been doing and Adult Social Care of Birmingham City Council?
Kal Kohli: I’ll just give you a little bit of a backdrop before I do that. I’m going to go back to 2017. With regards to adult social care, we were in an absolute mess, we had a deficit budget of £50 million in the city, we had poor ASCOF ratings in terms of our measures around care and support, poor outcomes for citizens, increasing costs around packages of care, really fragmented pathways from hospitals into communities – we were really challenged by long delays around that. So in 2018, we created a new vision for Adult Social Care. And it was based around having good conversations with citizens within communities, supported by a community social work model.
As a local authority, we stood back and watched it happen, couldn’t have done it that fast. That was the impact of that investment, that journey, that trust.Kal Kohli
Those of you who are as old as I am, will remember the centralisation of social work and the damage that did. And we coupled that with ‘everybody leads’, so a culture of owning and driving performance at whatever level you were at within the organisation. But more importantly, it was about rebuilding our relationships with citizens and communities, and our community and voluntary sector partners. So we invested over £30 million back into the community and voluntary sector. We also pulled in lots of government grants, and really start to shift that investment into communities, starting to protect that community-based activity. And that was going to be the basis of our model.
We spoke to our good friends in Leeds City Council. And we borrowed their neighbourhood networks model, and we adapted it to the city. That’s very much around giving the voluntary and community sector the power to commission at a hyperlocal level, working with citizens within communities, understanding their aspirations, so it’s strength-based not deficit. You start with a conversation of strength. Through that, we enabled organisations to commission activities rather than services – so things to do, places to go – really having an impact in terms of those relational life outcomes. Through that, we were able to support 10,000 people a year, distributing over 700 grants to date.
We also put a lot of money into commissioning teams that worked alongside the community, and created a community grants prospectus, reaching out to 25,000 people a year through those initiatives. Through to some joint commissioning efforts with our ICS colleagues as well, particularly around unpaid carers, and really focusing on things like social justice, and deepening our understanding around asset based community development.
The outcome of that is as I sit here today, we have a balanced budget, better outcomes for citizens… it’s a journey, you know, it’s not perfect. We have more motivated staff, and just a better presence within local communities.
An example of that was during the pandemic where the voluntary and community sector, off the back of the phone call on the Friday afternoon, before we went into lockdown, said, Do you want us to step up? And I said, Yes, please. And by Monday, they’d mobilised the voluntary and community sector response in the city. Just awesome. As a local authority, we stood back and watched it happen. We couldn’t have done it that fast. That was the impact of that investment, that journey, that trust.
Laura: What is next for you in Birmingham?
Kal: On the back of the prevention work, I was given a new job as Assistant Deputy Director for early intervention and prevention for the entire local authority. The question was asked, Well, if you can do it in adult social care, why can you not do it across the rest of the council? So we now have a new corporate priority for early intervention and prevention. And I’ve got the big task of realising that corporate priority.
It’s timely isn’t it? The cost of living crisis post pandemic – in our city alone 40% of children live in relative poverty. Life expectancy is four to five years lower than the national average. Unemployment rates are 4.6%, it’s 11% nationally. So you can see where we are and where we need to get to.
It’s not just about a new directorate, because that can be a new silo. It’s also about the culture change within the organisation. It’s about the pathways into our community partner agencies, and it’s about building upon the strengths of the voluntary and community sector as well.Kal Kohli
[Through] new corporate priorities we are driving the agenda for change. We’ve identified through our own learning [through examples from] Barking and Dagenham, Wigan, some core capabilities that will shape the formation of a new directorate. But it’s not just about a new directorate, because that can be a new silo. It’s also about the culture change within the organisation. It’s about the pathways into our community partner agencies, and it’s about building upon the strengths of the voluntary and community sector as well. But more importantly, sitting in the heart of our design principles is the voice of citizens and communities.
That’s the journey, we’ve got a set of principles. I heard it this morning – don’t wait years to carry out some research, get on with it. Well, that’s what we’ve done. There’s a cost of living crisis out there, we’re rolling out homes and money hubs across the city, really getting to people early. Because if you have a conversation about people and finances, it unearths a whole host of other inequalities and through strength-based conversations, connecting people to local community assets, support networks that are on their doorstep, you start to make the impact very, very quickly and get much better outcomes.
Linked to that is the proactive use of data. So alongside the strength-based conversations, you need to be able to target your populations, you need to be able to proactively nudge behaviours using strength-based conversations. So in addition to the rollout, we’re saying, Who is the most excluded? Whose voices are we not hearing? And how do we reach out to those communities and work alongside those communities as well? So a very, very big challenge.
Laura: What would you position as the biggest challenge that you are likely to experience as you go on this endeavour?
Kal: So nobody in this room will say prevention and early intervention doesn’t work. It does work. We all know that. But there’s there’s a cultural [issue]. I don’t know whether it’s muscle memory, or what within within big organisations, but it’s very much about evidence: prove it – prove it works. When it comes to prevention, you can come up with the best methodology using soft hearts and minds stuff around stories of difference, coupled with data, and it’s often picked to pieces. So my job alongside the council transformation is to build an evidencing methodology, which will stand up to that challenge. that’s my biggest challenge at the moment.
Laura: I’m going to ask Andy, if he would kindly think about how he might respond to that challenge that Kal presented for us.
Dr Andy Knox: Okay. So that’s what’s called a hospital pass in rugby, I think. So, for me two things. One thing that we’ve really discovered in Lancashire and South Cumbria is through the brilliant work of Jenny Popay who’s Professor of Sociology and health at Lancaster University, she is really passionate about putting research into the hands of communities. So actually, you can use community power as a way of doing research. She works around something called community journalism, where she goes into communities saying to the community, What actually matters to you about what we measure? What are the outcomes that we might see in terms of how we work together as a community? That is really really powerful because then the community are with you. They own the research. And it turns power on its head away from people looking in on a community, to communities themselves looking out. It’s what we term external gaze rather than internal gaze, allowing communities to look out and to challenge the structures of injustice that hold them in places of inequality.
The second thing would be, just find where the passion is, who are the rebels? Who are the ‘rebel alliance’ in your universities? And how do you partner with them? We’ve had the privilege of hosting a bunch of conversations across our four main academic institutions, bringing them together, and just laying out the issues of health inequalities and social injustice issues that we’re facing across Lanchashire and South Cumbria. And what’s been amazing is you then see professors with incredible big hearts [alongside] phenomenal brains coming together from massive multidisciplinary positions and saying, Okay, so from the school of psychology, we want to help you with this, from the school of architecture, we want to help you with this, from the school of design or the school of medicine, or the school of nursing… And then you bring people of different passion and hearts together, looking at different perspectives. So I think, give the power to communities to align the passion from the academic institution, and there’s some magic that can happen.
Laura: Thank you. It’s almost like we prepared him for that. William, will you tell us about your work with Intelligent Health and the Beat the Street programme?
Dr William Bird: I’d like to imagine a high street in an area where there’s some charity shops, a few clothes shops, you’ve got Poundland, and betting shops. And it’s pretty unruly in there. All of you can imagine. And you’ve got a lady there trying to find which bar of soap she’s going to buy, which is the cheapest, you’ve got a guy sitting slumped in the archway, you’ve got a mum screaming at her children who are unruly. And you kind of think, you know, obviously, is really awful, this is really bad, we’ve got to come in and do something. So we what we do is that area, of course, has got the highest smoking, the highest obesity, it’s got the highest alcohol [consumption], it’s got the crime, it’s got all the negative things and something must be done, we go in there, we do weight management, clinics, smoking cessation, all the things and of course, after a bit of reorganisation, the budgets run out, then everyone withdraws because nothing really worked. And we’re back to where we were again.
And yet that person, that man, sleeping in archway is a really skilled carpenter who just sort of got alcohol problems and came back, the mums screaming at her daughter, the daughter is a brilliant football player, but she can’t afford the boots and she doesn’t want to be seen with rubbish boots on so she doesn’t do any training. And the other lady looking at a bar of soaps is actually a chef and she’s training loads of mums on her street, how to have really healthy meals, but her kitchen is too small. And they’ve all got names as well. And suddenly you find the assets building up.
What we do at Beat Street is that we go in and create a game. And that game will attract mostly young families, but adults and older people as well. So in Burnley, we’ve just started last week, we’ve got 12,000 people playing out of a population of 90,000. And it’s the second time we’ve done it. And what you’ll find is that they will create a team of Alcoholics Anonymous, and that will be a community team, and that will raise the profile of there is some hope, and there’s some people and that will give him a massive role – and this is a true.
The lady who’s got the football boots will connect to the school through the school team. We’ve had a mum, who was the most biggest pain for the school, who actually got the most points for the school in the end and was awarded by the head teacher as being the best parent having been the worst parent for causing problems. And that kind of person gives them a kind of empowerment. There will be a lady who has a team of the women chefs, we’ve had mother runners as well, we’ve had others.
What you’re doing is you’re creating communities to come out and using Beat thet Street as a catalyst. And gradually the council can talk to those groups. The most deprived communities are the ones often most represented. And it gives that slow empowerment of connecting people to each other, to community groups, to places. We work with the Canal River Trust to get into the parks and green spaces. Often parents haven’t been there at all, even though they’re 100 yards away from where they live. It’s ‘what could be’ for six to eight weeks. We know the effect can last two weeks we’ve covered about 1.7 million people now and 140 areas.
I sometimes wonder if the NHS, and I include myself, understand what health really is.William Bird
Laura: I wondered William, if you might just pull out one or two key points on on the impact of Beat the Street and then maybe talk to us about your future plans.
William: It’s our 10 year anniversary at the moment. When we started, it was actually for physical activity for children in schools. But increasingly, we realised that to get communities together physical activity is the glue that holds it together. An inactive town is a dying town, you don’t have the volunteering, you don’t have meetings, it looks too dangerous to go to the parks, so the parks go to wrack and ruin, you’ve got to have people outdoors all the time, connecting. We found that communities connectedness increased, physical activity consistently increases and lasts for over two years, because now there’s a change of habit. And we find that there’s a connection to nature as well. And that’s been proven. There’s a whole week where we actually just with the council will work with them to go to places and double the points in the parks. So that people will go to events in the parks and Beat the Street leads them to the places where the Canal River Trust want or the parks managers want them to go to. You’re trying to get people to reclaim place and get them back again.
Laura: And what do you imagine will be your biggest challenge as you as you move forward?
William: I love the NHS, I was born above a waiting room of a doctor surgery, my dad was a GP, so I feel I kind of been in the NHS for all my life. And I love it. But I think the challenge is that what we we do as the NHS, we kind of go in, and we never listen to the communities very well. We are always putting our own targets imposing on those communities without understanding what their needs are. We run out of time, so we never gain the trust because there’s another reorganisation or the money runs out. And then we focus on disease, rather than actually what health. I sometimes wonder if the NHS, and I include myself, understand what health really is. We know what absence of disease is, but I don’t think – looking back to the WHO, to 1940, we know what is true health. So that’s my challenge. And how do we get the NHS to understand. I think other organisations and local authorities, are further ahead on that.
Laura: Andy, can I ask you to tell us a bit more about your work in Lancashire and South Cumbria?
Andy: About 10 years ago, I moved from the wonderful city of Manchester up to Morcambe Bay, mainly for a different quality of life with my wife and kids.
I just wept at my desk. It got really close to burnout, because it just felt so overwhelming to have so many people with unbelievable complexity coming through our doors all the time feeling like we were failing to meet their needs.
I got to about three or four months in, and there was yet another initiative about having to decide whether or not all your fellow GPS referrals should really be referrals. It was a nonstop tide of people coming through the door, and then crazy amounts of paperwork. It got to the end of an evening one day, and I had this pile of referrals to read through and decide whether or not my colleagues had behaved appropriately. And I just wept at my desk. It got really, really close to burnout, because it just felt so overwhelming to have so many people with unbelievable complexity coming through our doors, all the time feeling like we were failing to meet their needs. Then all of these other things that were just being added on to our days all the time. It really got to the point of, I don’t know that I want to do this anymore.
A couple of years before I’d been in the city of Bristol, learning something called The Art of Hosting, which is about thinking of leadership as hospitality instead of heroism. How do we learn to sit with communities and talk together about the things that really matter to us, rather than carrying on the same old same old ways of just doing things because that’s the way we do it? And so I began a conversation with my community the following week, and I asked them, What would it be like if Carnforth became the healthiest town in England? I knew what the stats were like, I could tell them all the reasons we weren’t the healthiest town and they knew it. What was really humbling for me was all the stuff that mattered to the community was none of the stuff that I thought should matter to them, all the things that NHS England said should matter to them – they weren’t the things that mattered to my community.
Over the last 10 years I developed that work, and then we spread it around Morcambe Bay, and now we’ve developed this whole way of working across Lancashire and South Cumbria. And we teach this methodology in a leadership academy now, which is, first off, Who are you as a human being? What makes you tick? What are you passionate about? I think it’s really easy in the public sector to just train robots. Who are you as a human? What’s your soul food? How do you become your best version of yourself? How do you lead with compassion and kindness? How do you learn to really love the community that you serve? And then what does the data tell you about your community? Then rather than going back into the same old, Okay, that’s what the data tells me, I’m going to come up with a project to go and deliver to my community and fix them. You take that data and with humility, you go sit with your community, you learn the skills to just sit with people and listen and have different kinds of conversations. And then together with them, you then begin to find very different creative solutions to the problems that they and you are facing together. And actually, both those things begin to gel and mix.
What’s been really beautiful for me over the last year and a bit has been to see 44 other GPs across Lancashire and South Cumbria and advanced nurse practitioners and clinical pharmacists, we’ve paid them and gifted them the opportunity to come and take a whole day out of practice every month and just sit and be and learn and think about how they might get to know their communities better. And we’ve seen utter transformation in their own lives because people have said, I didn’t actually know any of my community. I just turned up to work and did my clinic, and they came through my doors and I tried to help them and then they went home but nothing was ever really changing. And suddenly we’ve got 44 leaders right across Lancashire and South Cumbria, who have spent a year drinking coffee with loads of different people in their communities who have had lots of space and time to think and learn differently about what the data shows us, how do we share that with communities? How do we bring that stuff together to begin to change the future? How do we build a social movement for change in our communities?
We’re seeing amazing things begin to happen. For example involving sex workers in Blackpool – I get emotional just thinking about it. To have a GP who now sits with the sex workers and wants to understand what’s the barriers here if you’ve not coming for cervical screening, because you don’t have to die 15 years earlier than and other women in Blackpool. Or people in Burnley who are in the Bengali community dying 20 years earlier from preventable things around diabetes and cardiovascular disease. Realising that the NHS designed diabetes courses are actually fundamentally a little bit racist because they completely forget to think about culture and language and sensitivities around all kinds of issues. And now we’ve got the Bengali community working with us to redesign those courses so they actually make sense in the context of the people who were there. Or what about in the Gypsy Roma traveller community understanding the complexities that community live with in terms of stigmatisation and racism, and how and why women aren’t coming for their breast screening and how we can change. Or how we can work with men in the Afro Caribbean community around cardiovascular health and hypertension and why it matters.
Why is it that communities aren’t engaging with us? It’s because we’ve done stuff to them for so long. But when we talk about power, we’ve really got to embrace humility, learn to listen differently and learn to work with our communities to see transformational change happen. And that’s what has been the joy of my work and actually hearing GPs and nurse practitioners and clinical pharmacists say, We’ve rediscovered joy in our work – joy is possible in our work, and we’re finding it all over the place now and it’s really beautiful.
Laura: Andrew, thank you. You’ve given us some examples. What do you expect your greatest challenge to be?
Andy: I think one of the biggest challenges is how we keep hope alive. We’re all here because we’re part of the Rebel Alliance. I think part of the problem is we know that working with our communities differently, building community power, tackling health inequalities is really where it’s at. We know that. And actually, that is the message that comes from the centre. But there’s also another message that comes from the centre, which is, your ICB is in an enormous amount of debt, please, will you pay us back very quickly. And then you get loads of KPIs and other stuff. And I think it’s that juxtaposition between how do we really do the work that is actually going to change the future, whilst recognising the pressures that come down to us from from on high? And in that context, when you feel like all of that becomes the complete focus, how do we keep hope alive? That’s the challenge.
When we talk about power, we’ve really got to embrace humility, learn to listen differently and learn to work with our communities to see transformational change happen.Dr Andy Knox
Laura: And we’re going to address that challenge in three sentences. William, first of all, to you,
William: There is hope, because the hope is actually in those stories you’ve just shared, those people who are forgotten, those people who have got unbelievable assets, but it’s not been brought up. So listening, listening, listening, I think that’s the one key thing – active listening to the community is one way of the hope. Then the system is wrong. We cannot just pay lip service all the time to a system that’s broken, and then try and compromise. We have to break the system, and then reform it in what we think is right. So I think there’s rebellion there. But there’s hope. It was great when you were choking up there because you really mean it and it’s a really important thing. And that’s what gives you hope and make you want to carry on forever.
Iain: It really resonates for me, because I was asked to join the public sector from the private sector. And I went in full of hope and thought, you know, we actually don’t need to do anything radical here. This is not landing a ship on Mars or anything we just need to do as well as you know, Sainsbury’s or you know, someone else [in the private sector] when it comes to service levels, transformation, etc. And truth is, when I joined TPX, I was damaged goods. I had ran out of hope. There’s a reason I left the NHS.
My advice would be to connect with people here today. Exchange email addresses, find your tribe, work together, support each other, look out for yourselves look out for each other. This is hard stuff when you are fighting against the system. And that becomes really difficult. So recognise that and help each other through it.
And then my only other piece of advice, because I’ve seen this in the centre of the NHS, I think there is a hack around getting good work to scale. In the NHS, I think there’s two ways of doing it. There’s the getting it right first time in a surgical transformation way, which is you ignore all the rules and all the guidance from NHS England. Then you just prove your effectiveness and you make the centre go, oh, well, these people actually know better than we do. Therefore, we’re gonna have to get behind them. But that’s quite a difficult, narrow path to get through.
The hack I’ve seen work more often is you find the people in the centre who care about the same problem as you do, the people who are on the hook to deliver it. There are national directors for every condition you can think of. They have budgets, they have accountability and responsibility. If you’ve got something that works out in your patch that ticks a box on the challenge they’ve got they’ll be really keen to hear about it. So find them, seek them out, show them what you’re doing and use the system to your advantage.
Kal: I think there is something about how we build the momentum around that culture change piece that’s needed. I love the rebel analogy. I think there’s also something about a quiet revolution as well. Just keep going. Get on with it and build up the initiatives. But the other point is, okay, so the KPIs are wrong. We need to challenge those. Let’s put forward more innovative KPIs that are more meaningful for our communities and citizens. And let’s make the case for them. You know, who are the changemakers in central government? You want to be collecting these instead.
Andy: I’ve been really impacted in the last few years by a philosopher called Valerie Forney. She talks about how we build social movements. She studied social movement theory for the last 150 years. And this is my gift to the Rebel Alliance, which is: first of all, you’re going to be outraged. We’re all here because we’re outraged about social injustice in our nation, because we care about inequality. So we’re, we’re already on the way.
Second thing is you then have to challenge inevitability. It doesn’t have to be this way. It doesn’t have to be this kind of inequality in our society. And part of that is about questioning the values upon which we build society. If you read Mariana Mazzucato, her work as an economist is evidence of what our values are, and what we value. So we need to challenge the inevitability of that and create new values together.
The third thing we need to do is we need to build moral alternative economies. There was a very famous man, a few streets away from here a few weeks ago, who said that we’re all gonna have to learn to live with less – a little bit rich coming from his mouth, maybe some felt. But the reality is, as we heard this morning from the main stage, funding isn’t gonna be massively increasing. We are in a real really tight bind, not just here, but globally, because we’ve been relying on a form of doing economics together that thought that we could have growth forever, without thinking about the effect of what that does to inequality and what that does to the climate. We have got to build moral alternative economies that allow us to do the work that is really important, whilst also caring for the wellbeing of the planet and for the communities we serve. If we can find the ways of experimenting in that space together, that’s where we find hope for the future for the long term wellness of our planet and the communities that we love, and turn up for work for every day.
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