Wrapping Up the Commentaries on ‘Eleven Principles for Creating Health’

The whole point of the Creating Health Collaborative is to build a field of practice, one that better links the health sector to local communities with an explicit embrace of the well-documented potential of community agency. Of course, as befits an exploration, I didn’t know that when I started this work. I just wanted to understand why the health sector seemed to ‘innovate’ with little to no empathy for the communities it says it serves.

The Collaborative’s Eleven Principles for Creating Health is an aggregation of what we have learnt from the fifty-or-so innovators that have attended our three annual, invitation-only meetings in New York. Fifty is quite a lot of people when you consider that this work has largely been unfunded and relied upon the innovators wanting to share their struggles with fellow on-the-ground heroes. But it’s a small number if what we’re doing is trying to define a field of practice. To hear from more voices, we commissioned the recently-published 12-part series of commentaries on the principles (see end for the full list).

The one thing that seemed to attract the most criticism was the make-up of the Collaborative itself. In our report we asked how is it that we reconceive and describe health as something plural, culture-specific, and not solely professionally-provided. David D. Derauf of Kokua Kalihi Valley Comprehensive Family Services commented:

Who is this “we” that is spoken of? Is it the “we” of us as professional health practitioners, seeking to maintain our professional prerogatives through the language of the “new”? Or is it an intentional movement towards becoming a “we” with our communities?

I’d like to think it’s the latter, to which David says:

If the latter, then answering this means coming to terms with the reality that many communities already cherish a much broader conception of health, one that is already “plural, culture-specific, and not professionally-provided.” The question then becomes, how do we as health practitioners move in their direction?

One way to aid this movement would be to have them in the room. Worrying that the make-up of the Collaborative might actually be “inappropriate”, Peter R Doliber of the Alliance of Massachusetts YMCAs offered the following counsel:

I urge the group to include those they seek to impact, to include those struggling with basic personal security…as well as those who know what they want… I urge them to seek out and hear those that distrust outsiders and to let that influence their work.

Richard Smith, the former Editor-in-Chief of the BMJ, went a step further:

So I’m left with the worry that the Collaborative is mostly concerned with “poor folks,” not rich people like me. Perhaps that’s not a problem because poorer people have much higher levels of ill health. We rich can look after ourselves, but any enterprise that concentrates purely on the poor runs the risk of being patronising and creating stigma.

Not having communities in the room – or part of the report writing process – meant that our use of language betrayed our elitism, according to as Geoffrey W. Wilkinson:

The report’s emphasis on community engagement and empowerment is welcome… Language in the report, however, suggests the Collaborative has yet to incorporate these principles into its own work… [T]he proposal to “let” the community define what matters is not the language of empowerment. It is the language of the powerful…The question for those in elite positions…is not what to “let” community members do, but how to facilitate and support community empowerment.

I have to admit that I felt thoroughly chided by all this but to offset my growing despondency Julian Corner of Lankelly Chase wondered if the key to change is recognising what people have rather than only seeing them for what we ‘patronising elites’ think they need:

[I]f people are viewed in terms of what they have, rather than what they lack, then this is inevitably more empowering… [T]here is always an exchange taking place, that these assets are always being traded. And it is the terms of that exchange that are critical because they determine what can be exchanged or traded. The eleven principles suggest new terms of exchange… On current terms, service users have no option but to trade their problems. And this is because workers themselves are forced to trade their ability to solve problems. When permission to say ‘I don’t know’ is denied, workers are forced to operate in a hierarchy of expertise.

The health system definitely tries to be all-knowing and is hierarchical. According to Ian Burbidge of the RSA, getting systems to change is “technically difficult”. He goes further to say that he doesn’t think governments want the system to change, despite their rhetoric, so asks:

[W]hat can we do in the short-term to support people to make small scale changes in their working practice and culture…? The Creating Health Collaborative’s principles are a useful checklist to help practitioners with this vital work.

I’ve always subscribed to the view that a small number of dedicated people can create change no matter what the odds. The innovators in the Creating Health Collaborative are, to my mind, examples of such people and so it was good to hear Ian suggest that the principles might help other dedicated practitioners embrace a new way of working.

To further aid this, Brian Castrucci and Lloyd Michener, co-editors of The Practical Playbook, offered tools and strategies to support five of the principles:

• Principle 2: Acknowledge power imbalances
• Principle 3: Share power
• Principle 4: Let the community define what matters
• Principle 8: Acknowledge that no one can do it alone
• Principle 10: Build the right team

Also walking the talk, Nancy Adler and Erin Hagan of Evidence for Action (E4A) described how they’re embracing the idea of sharing power (principle 3) by looking for meaningful partnerships between researchers and those whose lives are most impacted by the research:

In E4A, we’ve tried to recognize the complementary roles of researchers and community stakeholders. Community-based organizations (CBOs) or other non-academic entities can serve as the lead applicants for our grants; and we do not require principal investigators to hold advanced degrees, although it is important to have a member of the project team with demonstrated research capacity.

The presence of practitioners, a useful checklist, and tools and strategies to support at least five of the principles on the checklist suggests there’s a growing ‘movement’ out there. But, thinking of the health system, and especially of doctors, as key stakeholders in this possible movement, John Craig, formerly of the Innovation Unit, warned:

As a movement, we need a story in which doctors can see a richer version of their own vocation. We need to describe how a more open approach to health can create the support and space in which doctors can thrive and evolve into a better version of themselves.

One doctor embracing a “richer version” of her vocation is Megan Sandel of Boston University Schools of Medicine and Public Health. As she says:

I have enjoyed coming back again and again to the Eleven Principles for Creating Health…[It] challenges us to relearn what we should have learned in medical school: listen to our patients so they can be healthy.

So, what have the above 10 commentaries taught me about the principles? First and foremost, it’s taught me that we need to be more inclusive in our work (ironically that’s an echo of Principle 1: Embrace an Inclusive Definition of Community). Second, despite their potential elitism, the principles do suggest and, in some cases, underpin, new ways of working. However, not enough of the principles have practical tools to aid their application.

The two commentaries I’ve not mentioned yet are the ones that debate the value of a list. Ollie Smith, a member of the Executive of the Collaborative, felt we needed to do more:

[J]ust refining principles is not going to be enough to catalyze practice. Knowing that some group has generated a list of things to bear in mind when trying to create health beyond the lens of health care doesn’t mean that people will follow. My hypothesis for this is that everyone has to start the journey – from bio-medical health to community-defined health – in their own way, airing their own prejudices and hang-ups, and arguing about meaning until a common language, understanding, and resolve is reached.

In response, Alex Twigg of Ko Awatea suggested:

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.

As a result, he suggested a twelfth principle:

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.

Since commissioning the commentaries we’ve had our third annual, invitation-only meeting (see the recap). We’ll be writing a report of the meeting soon, and will also weave in thoughts from these 12 commentaries. My hope is that we develop a more inclusive tone and I can also see us reducing the number of principles based on what we’ve learnt.

More on all that soon but in the meantime I’d like to thank Ollie, Alex, Richard, Peter, Brian, Lloyd, Julian, David, Megan, Erin, Nancy, Ian, John, and Geoffrey for contributing to the series and being forthright about our work.

The 12-Part Series

1. It’ll Take More Than A List To Climb This Mountain, Ollie Smith
2. A List Is Precisely How We Climb This Mountain, Alex Twigg
3. Returning Health To The People, Richard Smith
4. The Artist, The Cook and The Pang of Work Incomplete, Peter R Doliber
5. Achieving Health – How We Can “Just Start”, Brian Castrucci and Lloyd Michener
6. When Problems Become Assets, Julian Corner
7. [Co]-Creating Health, David Derauf
8. Listen To Your Patient, Megan Sandel
9. Making What Matters, Matter, Nancy Adler and Erin Hagan
10. Why Can It Be So Hard to Make Stuff Happen? Ian Burbidge
11. Be Plain, Inspire and Include, John Craig
12. Look Back When Reaching Forward, Geoffrey W. Wilkinson