“Leaders who only think in terms of their own organisation are potentially harming the places we all share; an organisational focus creates a societal opportunity cost, which we all have to bear.”
Those words are from David Relph, the former Director of Bristol Health Partners, a cross-sector initiative across the city of Bristol in England. Working across sectors is all the rage these days. There’s a growing acknowledgement that individual systems, such as health care or housing, cannot adequately respond to social challenges without working with other sectors. But what is cross-sector working, and what can we learn from those that have tried?
David was given the chance to run Bristol Health Partners off the back of some work that he did arguing that health is defined by place more than by just the systems that serve that place. That caught the Board’s eye. They wanted to explore how that perspective might inform cross-sector partnering. Unfortunately, as you’ll see in my conversation with David, it seems that what that meant in practice was not something they were able to get behind.
Working on the basis of place requires you to consider the needs of your institution within a broader context. Often that means accepting that they are secondary. This isn’t easy for institutional leaders, especially, as was the case when David was running the partnership, when there are intense budgetary pressures and every penny needs to be justified. Leaders are forced to retreat to simple ROI measures that are framed solely by their institutional budgets.
That retreat is the problem. What David’s perspective told him was that working on the basis of place means being intentional about fostering collaboration between systems and institutions. Indeed, he believes that fostering collaboration should become the core purpose of each system or institution. He’s not suggesting that health care’s traditional focus on bio-medical outcomes should be discarded, only that if place really matters fostering collaboration should be primary.
Interestingly, he contends that the ROI case for fostering collaboration is “very strong” because the idea is not to invest in new resources but to unlock what is latent within our systems and institutions. In the same way that Uber unlocked the latent capacity of cars and AirBnB unlocked the latent capacity of rooms, David’s work helped to unlock the latent capacity amongst the people working in Bristol’s institutions and systems. The ideas, capabilities and capacity were always there, they just needed a forum through which to work.
Trying to frame work on the basis of place, however, forces you to explain what ‘place’ is. I suspect you think of a physical environment complete with homes, shops, places of work, and other things that you can see and touch. However, two researchers, Frohlich and Abel, contend that a solely physical understanding of place fails to appreciate how health is created or eroded. In their thoughtful paper, Environmental Justice and Health Practices, they propose a framework that considers people’s capital and capabilities.
The term ‘capital’ often makes us think economic, whether in terms of cash or assets. However, Frohlich and Abel encourage us to think more broadly. They argue that what also matters is people’s social and cultural capital. Social capital is whether people are part of networks that help them to achieve what matters to them. Cultural capital is whether people have recognised skills and knowledge, or access to institutions that teach or recognise skills and knowledge.
All three capitals interact, and they can be converted (for instance, money can be used to purchase education and hence skills and knowledge), accumulated (for instance, one can leverage one’s network to meet new people hence increasing the size of one’s network), and transmitted (for instance, when a parent passes on knowledge to his or her children). Crucially, Frohlich and Abel argue, this interaction is ‘conditional’ – having one type of capital potentiates converting, accumulating and transmitting the other types of capital. In effect, it’s synergistic.
But making use of all this capital requires the capability to make something happen. Now stick with me here because this gets a little dense. Frohlich and Abel unpack ‘capability’ by saying that it’s not just about being able to take actions to achieve what matters to you but also having the freedom to take those actions. They then unpack ‘freedom’ by describing it as not only having a wide set of choices but also being free to decide how you want to make those choices.
Assuming you haven’t got a splitting headache by now, you’ll see that thinking about place means thinking about the things we can see and touch, the types and levels of capital amongst the people in that place, the range of choices available to them, and how they’re able to make those choices. And, of course, the interaction between all four.
It’s easy to see why leaders of institutions might retreat to simple ROI measures.
But retreat we must not. Especially, when our systems and institutions are perpetuating inequality, as David contends, and inequity, as Frohlich and Abel contend.
So, if you’re in a cross-sector meeting this week, ask yourself whether the importance of ‘place’ is really surfacing in your work. If so, you’ll be valuing effective collaboration above institutional metrics, and exploring whether and how your ways of working are fostering choice and freedom. If not, you might be harming the very place you’re seeking to serve.
I know, I know, my head hurts too.
- My conversation with David Relph was published last week and is titled, Lessons from the Frontline of Cross-Sector Partnering
- The full title of Frohlich and Abel’s excellent paper is Environmental justice and health practices: understanding how health inequities arise at the local level
- I don’t mean to suggest that companies like Uber and AirBnB are entirely benevolent; indeed, I think they’re accelerating inequity and eroding neighbourhoods, the latter being described in this Financial Times article about some areas of London
- For some frontline experience of place-based working, see this article by Collaborate CIC, a consultancy, about demystifying the practice, although note that their framing does not explicitlyinclude capitals and capabilities
- Finally, if you’re interested in my work, see this interview with one of my UK speaking agents (and learn more about my speaking here).
Previous Issues of Community & Health
- 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
- The Politics of Measurement: How eliciting social definitions of value may make emerging partnerships between health care and CBOs more effective
- 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
- The Fallacy of Behaviour Change: How a flawed idea got traction and what you can do to fight back
The photo behind the title is by Adrián Metasboc on Unsplash.