Pay Attention to the Surprises

It’s the surprises that matter.

I’ve been exploring ‘community health’ for almost seven years now. The one thing I’ve learnt is that deep within every half-decent project there is a surprise waiting to be discovered. Whatever it is may not be surprising to those doing the work but it often is to others. 

Earlier this month, I published a conversation with Chris Dabbs of Unlimited Potential, a community-based organization in Salford, England. Unlimited Potential has helped agencies, such as health care, engage the people that they traditionally struggle to reach – something that is sorely needed in an area where the mortality rate was twice the national average. 

Important work though that is, it’s likely what many CBOs claim to do. What’s surprising about Unlimited Potential’s work, however, is how they do it.

“The traditional approach is for agencies, such as health care, to assess the needs of local people, and then seek to meet them by providing services,” explains Chris. “At Unlimited Potential, our approach includes asking the agencies what their most difficult or even apparently insoluble problems are.” 

Those are my italics. It seems to me that all too often CBOs are asked to meet a need pre-defined by agencies. As Chris explains further: “We do not want to have a transactional relationship with a commissioner – ‘we will pay you to do X, set targets, and hold you to account for what you achieve’. This restricts creativity in thinking about what the solutions might be and prevents working with local people and communities.”

By insisting on parity in the conversation, by politely refusing to be just another provider of a pre-defined service, Unlimited Potential is changing the traditional relationship between agencies (or systems) and CBOs. And by asking people within agencies what their difficulties and challenges are, Unlimited Potential is making clear that it’s not just ‘on the side’ of community residents, but also ‘on the side’ of people within agencies. Unlimited Potential seeks a bi-directional role.

Last week, I published a conversation with Emily Yu, Executive Director of The Build Health Challenge. At the heart of BUILD’s work is the idea that cross-sector work is only possible when you invest in collaboration. That is likely not surprising to you. Nor is Emily’s contention that to advance “health equity…it’s not helpful to rely solely on health outcomes”. 

But what I did find surprising was how BUILD is unearthing a framework to gauge progress in advancing health equity. By observing the efforts of the 37 communities that it has supported, it has identified milestones for each of the aspects of BUILD – Bold, Upstream, Integrated, Local and Data-driven – and plotted them in a per-letter continuum.

For instance, with L for ‘local’ a community health project could rely on representation from community-based organizations (the beginning of the continuum) or have a process to engage a large number of residents (the far-end of the continuum). Understanding where your work is on the continuum can help you assess whether it’s likely to make health more equitable.

Are bi-directional roles important for the long-term success of community-based organizations? Will BUILD’s continuum help its new grantees be any better at advancing health equity? I don’t think any of us know but, at the same time, I do think we often fail to unearth these details – for me, surprises – in our endless pursuit for solutions in community health that might replicate or scale. 

Over the past six months, I have published 10 interviews and 10 Community & Health newsletters. The interviews largely stemmed from my UK-based project, Beyond Systems, which sought to understand why systems, such as health care, fail to respond to those most in need. The work included structured discussions with 34 ‘key informants’ and the core of what we learnt was that there needs to be greater parity between systems and citizens. 

The clear next step was to build a community of practice to support those already working on this basis of parity. However, we found that few funders were willing to support such a community. Although it saddened me to close the project, I wanted to shine a light on some of the excellent work that I learned about, especially their surprises. 

Paul Taylor may work in housing but his organization sees itself in the well-being business, their aim being to help people step into their power. Andrew Harrison may work in evaluation but his experience tells him that people often want to hide the value they’re creating. Toby Lowe may be exploring what it takes to work in complex social environments but his research has shown him that being human and focusing on learning are key. David Relph shared his experience of cross-sector partnering and how embracing health as a consequence of place requires a deep conceptual shift. Maff Potts is building ‘public living rooms’ because he’s realized that having friends and a sense of purpose is all that really matters. Graham Duncan may be running a successful community centre but he delved deeper to better understand how his work builds confidence and hope. And Chris Dabbs, as described above, is clear that his role is as much to help people in agencies as it is to help the residents of Salford.

These surprises were only some of the ones we found through the 34 discussions – and it saddens me to think of how all that richness remains in documents on my computer rather than unleashed into a field constantly grappling for ‘evidence’.

My newsletters have tried to build on these interviews and provide insights for your community health work. I’m aware that they’ve not always been easy reads but it’s clear to me that the time for quick and easy solutions has gone – long gone. 

Over the 10 newsletters, I’ve asked a lot of you, including to: 

• Think of health-related behaviour as emergent and contingent
• See trust between staff and community residents as a strategic priority
• Explore whether you really understand the motivations of your colleagues and partners
• Examine whether you’ve considered the influence of your privilege and power on your community health work
• Think about whether you’ve really understood the informal infrastructure of care that you’re an adjunct to

That’s a lot – and likely too much. There’s no end of interesting stuff to read out there (although a lot of it is just hype from big health care players), the challenge is in finding time to read it, make sense of it, and then apply it to your practice. With that in mind, it’s time for me to stop writing and focus on the consulting, including speaking. 

Community & Health will be back in 2020, I’m sure, but my writing has almost always emanated from a project and I’m not sure what my next project will be. After almost seven years, I can’t help but ask myself if I’ve become ‘edutainment’, just another distraction for people that need to spend more time changing what they’re doing and less time reading about the change. 

See you in 2020.

Community & Health

1. Not Sentimentalizing Community: How understanding the flow of care made possible by social cohesion is fundamental – and may need more ruthless employers
2. Exploring the Nuance Under the Buzz: How looking underneath buzz terms like ‘deaths of despair’ and ‘asset-based community development’ is key to finding solutions
3. On Power, Co-Production and Feeling Overwhelmed: How co-production, self-management and health promotion all have the potential to increase social inequity, and what you can do about it
4. Why Provision is not Enough: How atomizing problems and providing programmes ignores what really matters in enabling people to turn their lives around
5. Sectors, Partnering and Place: How cross-sector partnering demands thinking about place, and why thinking about place means thinking about people’s choices and freedom
6. On Absurdity, Collusion and Silence: How our failure to effectively respond to non-communicable diseases may be because our science needs updating – if only our politics would get out of the way
7. The Politics of Measurement: How eliciting social definitions of value may make emerging partnerships between health care and CBOs more effective
8. The Social Determinants of Relationships: How other sectors are learning that the key to responding to social circumstances is deeper relationships with the citizens they serve
9. The Fallacy of Behaviour Change: How a flawed idea got traction and what you can do to fight back

Recent Interviews

1. Changing the Dynamic: A conversation with Emily Yu on how The BUILD Health Challenge is potentiating system change by putting CBOs in the lead role and investing in collaboration
2. Solving Through Relationships, Not Transaction: A conversation with Chris Dabbs on how Unlimited Potential has walked the line between serving community residents and serving commissioners
3. The Unseen Infrastructures of Care: A conversation with Andrew Binet about how the process of care can be mapped like any other form of infrastructure, and what planners should do with it
4. When Trust Is Not Enough: A conversation with Graham Duncan about building confidence and hope amongst marginalised populations – and the psychological processes underpinning it
5. The ‘Power Elephant’ in the Room: A conversation with Lauren Weinstein about how power differences are intrinsically present in co-production and what she’s doing to overcome them
6. Halfway Between a Stranger and a Friend: A conversation with Maff Potts on how 20 years working at the sharp end of society has taught it him that only two things matter, and what he’s doing about it
7. Lessons from the Frontline of Cross-Sector Partnering: A conversation with David Relph, formerly of Bristol Health Partners, on why collaboration has to be the core purpose of institutions concerned with health
8. The Need for Human Learning Systems: A conversation with Toby Lowe on his journey from baffled Chief Executive to a key figure in the movement to find more effective ways to work in complex social environments
9. The Challenge of Going Beyond the Usual Metrics: A conversation with Andrew Harrison of Revaluation and The Learning Studio on the promise and complexity of surfacing new types of value
10. Effective Housing Goes Beyond a Home: A conversation with Paul Taylor, Innovation Coach at Bromford, a housing association in the UK, on why building homes is not enough

The photo behind the title is by Candice Seplow on Unsplash.