As I write this commentary I speak as much to myself as I do to Ollie Smith, a member of the Executive of the Creating Health Collaborative, who recently commented that it would take more than a list to climb the mountain of ‘creating health’. He was referring to the Collaborative’s recently-published report, Eleven Principles For Creating Health.
I work at Ko Awatea, an organisation dedicated to health system innovation and improvement in Auckland, New Zealand. We have embarked on exploring what ‘health beyond health care’ might look like, embracing community organising as an approach to enable our population to take control of their health. When I look at what we have achieved over the last three or so years I find myself, like Smith, more often underwhelmed than elated with our progress.
However from a systems perspective, as much as we might like to make things go faster, we are limited by the nature of the system itself. As the pioneering environmental scientist, Donella Meadows, teaches, we will deplete the “stock” of our investment in a bio-medical model only at the rate that the system allows. The rate of depletion is not subject to our will. All our will is capable of is aiming to effect change and resolving to learn how to achieve this aim.
What we know about systems is that under certain conditions progress gets easier over time. Building on Smith’s metaphor of a mountain, think for a moment about Mount Everest, and the social system that evolved around learning to climb it. Until Edmund Hillary and Tensing Norgay scaled its peak in 1953, summiting Everest was an illusory goal. But now, over 60 years later, more than 4000 climbers have summited. In 1990, 18% of attempts to summit were successful, compared with 56% in 2012. In 2013, 685 people summited, including an 80 year old and a man without arms.
There is a powerful lesson for us here and it reminds me of principle nine in the report:
Accept that it’s going to take time
The Collaborative’s remarkable work of articulating the principles for creating health allows for a crucial component from a systems’ perspective – the potential for a reinforcing feedback loop through which we will learn. This shared learning will enable the Collaborative’s members to hone their practice while emboldening others to start. As attempts to ‘create health’ become more and more prevalent, the Norgays and Hillarys of our system will emerge. Like scaling Everest, what it takes to ‘create health’ will be emergent, and once established will become easier and faster.
Vesting our “steely determination”, as Smith called it, in confidence that small steps in the right direction will become amplified over time, and leaving the pace and scale of change to the system itself, are essential as we take the time determined by the system to catalyse practice.
This brings me to an important ‘missing’ twelfth principle; that of sense-making. It is, in essence, what the Collaborative is already doing: bringing people together to reflect on practice, and building knowledge and support about health-creating communities. This sense-making principle is what turns the other eleven principles into a dynamic feedback loop, rather than a linear check list.
Two other dimensions support the addition of the twelfth principle.
The first is the importance of helping people in community initiatives to see the bigger system that their work is impacting. While a principal may primarily want to transform the nutritional value in her school, while a community organiser may primarily want to develop representative social structures in a disempowered community, and while a social innovator may primarily want to develop a programme to help parents at risk of losing their kids to state care, we are able to help them see their work as part of something bigger, a health creating ‘social movement’. To facilitate this ‘sense-making’ we have to establish connections across disparate community initiatives focussed on diverse social needs
The second is the importance of developing our praxis; how we operate within systems. While we know a lot about systems in theory, we know relatively little about how to practice within them. We need to deepen our practical understanding if we’re to achieve social change of the magnitude aimed at by the Collaborative. The principles are a vital first step in this regard and the Collaborative should be deliberate and conscious about sharing what its members are learning about how to disrupt and nudge systems towards goals as they progress in their work.
In summary, from a systems perspective, a list at this moment – with the inclusion of sense-making to turn it into a reinforcing feedback loop – is precisely how we climb the mountain of creating health.
