The regional assistant head of community commissioning – let’s call them Jamie, so as not to shame them, responded to her email for help, by suggesting that the patient was given a leaflet from the National Podiatry Association that might help with ‘self-care’.

Of course, the reason that Joe had come to see his GP in the first place was because he can’t ‘self-care’; he can’t cut his toenails; he has balance problems, he suffers from epilepsy, he can’t bend over.  He is so ashamed he can’t walk – he can’t get his shoes on – and he won’t go out.

He was in hospital for several months a little while ago for skin cancer – despite his toe nails, like small horns, curled over under his feet, still nobody suggested he saw podiatry the whole time he was there.  Later district nurses came to his home to dress his skin cancer wounds, but the toe nails weren’t their problem either so again nobody sorted the problem.  Unfortunately, Jamie’s idea of giving Joe a leaflet is also not likely to sort things.

Jamie wrote ‘I recognise that this (an approach of simply signposting through a leaflet) is not ideal for older people who require support with personal footcare including toe nail cutting, but given the challenges I think the above response (the leaflet) is reasonable and pragmatic.’

I’m not a clinician but like most of you I have read the data.  I know that taking care of the small and unglamorous things – vigilance over diet, toe nail cutting, living situations, saves lives and reduces the need for high cost interventions.  I’ve read the work of Atul Gawande – Jamie probably has too – so I know that what they call ‘pragmatic and reasonable’ is in fact the very opposite. Jamie is talking a sort of double-speak in their refusal to acknowledge what Joe needs and the difference between sign-posting and care.

How did we get here?  I want to come back to this, but first, let me tell you another story.

About Kate.  When I first met Kate, she was slumped in a chair that is too small for her bulky frame, her eyes cast down.  In a monotone she listed her ailments: she’s anxious, she also has painful feet, she’s tired but she can’t sleep, she thinks she’s depressed, her back aches, her weight has been creeping up and up, she has been diagnosed with diabetes.

I’m sure this story sounds familiar to you.  Kate’s medical notes were full of the acronyms of modern illness: TATT, MUSand the records of countless prescriptions, each one written by a different and harried doctor faced with the impossibility of really helping Kate in the 10 minute slot allowed.

We are not feeling well.

And the health service is struggling to cope.  At the sharp end, GPs can reach again for their prescription pads and commissioners like Jamie can numb out recommending leaflets and refusing to acknowledge what needs to be done.

But it’s not just we the people who are not well, it is our health systems too. Despite the dedication of clinical and support staff, the coming together across departmental divisions and hierarchies that we saw in the early stages of the Covid-19 epidemic, and the long hours worked, our waiting lists are spinning out of control.  We are haemorrhaging talented people and basic humanity and common sense is too often squeezed out.

We are gathered here in a gale of words: transform, improve, innovate, integrate – I’ve heard people talking about secret weapons, others of patient pathways –

What is really going on here?

I chose the title of my talk – Radical Health (although I actually wanted to call it Marooned on a Toe Nail) – because radical means going back to the root of things.

I want to spend my time with you today asking, what would happen if – instead of focusing on fixing the National Health Service, we went back to first principles and asked; how can we create and sustain health; how can we always attend to the small things…as intended by the founders of our systems.

What does it mean to flourish as opposed to simply surviving?

Kate was part of an experiment I started over 10 years ago.  Setting up in GP surgeries we asked GPs to send us their heart sink patients – those like Kate and millions more who suffer from a complex range of social, emotional, economic and physical ailments that can’t be addressed in a 10 minute appointment.

Recognising that chronic health conditions are part of every-day life, we did not focus on any specific condition and when we met Kate and the thousands of others who used the service we eventually called Wellogram – we did not actually ask them about their health.

We asked them about their lives and what they would like to change.

Sitting with Aimée – a Wellogram worker – Kate said in a barely audible whisper ‘I’ve lost myself’.  They sat for a while in a shared silence and then, Kate shifted in her chair – ‘you’re really listening’ she said to Aimée.

Kate explained how she is the carer for her husband and her son and how, as Kate has been increasingly overwhelmed, things have unravelled with Kate herself becoming ill.  This too is a familiar story.  Together they worked out a plan.  Kate felt that the thing that would most help her would be to take up her embroidery again.  Just to have that moment to herself.

Kate and Aimée agreed to meet again in a few weeks.

This story is part of a pattern.  Almost no-one when asked chose a health intervention to start with but slowly, in every case health improves – we know because we have the clinical data -it’s one of the advantages of working in the GP surgery.

Listening takes time – time that busy doctors don’t have, but this open listening – the sense of truly being heard is empowering.  The ‘psy’ disciplines understand -and have evidence – that to make change you have to be able to tell a story about yourself – to have a sense of direction, to imagine new possibilities – to make shifts in how we see ourselves and what we can do.

Aimée is what I call a relational worker – she listens and through this active process, she forms a bond.  Almost everyone who took part in Wellogram knew what they should do  – they don’t need education or leaflets because they are aware of the behaviour changes required.  But practising change and sticking to it is hard – this is where the relationship comes in.  Aimée knows – and this is the most challenging bit – how to support Kate to make her own changes.  She is there as a trusted and steadfast support but she does not solve Kate’s problems for her.

When Kate came back a second time to see Aimée she confessed that she hadn’t really expected anything to happen; ‘ I just expected you to tell me things’ she said but it was so much more useful than that.  Kate was feeling more confident, she trusted Aimée and they were ready together for the next step, to look at Kate’s diet.

This was how Wellogram worked: a series of simple steps, each one guided by the growing confidence and the participant’s sense of what they can tackle next.

In the beginning no-one is keen to meet other new people, but once confidence is built, finding good company is important.  Wellogram is about weaving people together – at the right moment – to support continued good habits and to combat the social isolation that underpins so many problems.

Operating at the level of say, a London Borough Wellogram would cost £20 per person per year to run and our clinical data based on the long run outcomes of the first 2,000 people we worked with was impressive.

New Shoots: Open Relational Work

Wellogram is part of growing body of work and evidence that shows how open, relationship-based approaches in which workers have autonomy over their time, budgets and work, and in which clinicians are deeply integrated with their communities, makes lasting change.

The work of Birgit Valle in Norway for example.  Birgit is a clinical psychologist who leads a mental health service for families and adults in the Stange region of Norway.  Like leaders in the UK she received a huge number of weekly emails from others in the system informing her of new guidelines, new approaches her staff should be trained in, new innovation methods and so on.  What she noticed though was that the waiting lists for her services were growing and at the community level there was a pandemic of stress and ill health. Her teams were also suffering, overwhelmed by the workload.

Is this really the best we can do Birgit was asking herself?  She decided to go out and observe her services, and then to sit in homes and listen.  The results were radical.  The service introduced two things.  Firstly, they abolished all their assessment criteria – the tools by which they managed their waiting lists.  They invited everyone in.  It turned out that inviting people in, as opposed to managing the lists rapidly created less work.  In part due to the second factor.  Clinicians practised a new form of rigorous feedback: every patient was asked to feedback at the end of a session and this qualitative conversation informed the next step of practice.  The professionals were asked to adapt, to divert from their learnt pathways and this often meant smaller, but timely interventions.  There were failures along the way, but today Birgit Valle leads with a different culture and very different results.  She’s written a book called Beyond Best Practice if you are intrigued to know more – and she runs a podcast talking to other health leaders around the world that have taken similar steps.

There is Buurtzorg in the Netherlands a model in which nurses and carers work in self-managed community teams.  Some of you may be familiar with Buurtzorg because there have been attempts to replicate the model here in the UK.

Buurtzorg was first started by a nurse Jos de Blok in 2005. As health costs spiralled in the Netherlands and consultants and efficiency drives moved in, he wanted to provide a very different from of health care, one he was sure would be possible if the 30% of resource that was being channelled into bureaucracy was instead diverted to the front line.  With four nurse colleagues he set up a non-profit and started to experiment.

Today there are over 10,000 Buurtzorg nurses and carers.  They work in small autonomous teams making all decisions about the work together.  Technology is used to support the admin tasks in deft ways.  Communities taken care of in the Buurtzorg model need 40% of the interventions required in other parts of the Netherlands and there has been a two thirds reduction in hospitalisations.  The nursing teams are stable – the enjoy their autonomy and the pay is good because there is no extraction for management costs or private sector profits.  In Buurtzorg, the finance system is transparent – nurses know what they must achieve for good care and for the business model – Jos describes it as a psychological contract.

Brendan Martin leads Buurtzorg in the UK. Often attempts to replicate the model in the UK have struggled because the NHS commissioners have not given full autonomy over management or budgets.  But in Medway something different is happening.  Nurses involved speak about how the system treats professionals like children and how they have been freed.  Brendan calls the model ‘retro-innovation’ because of this important way Buurtzorg restores autonomy that was once taken for granted in our health systems.  Early work in also shows signs of success, demonstrating that the Buurtzorg modela can be adapted for a new culture.

These new models are always less costly (although that is not their purpose – flourishing is their purpose and savings are a by-product).  Many of them come from parts of the world where relationships are strong but resources are scarce.  Another example is the community health work in Westminster started by the GP Cornelia Junghans.

Borrowing from a very successful low-cost model which has been running in Brazil since 1994, Connie and her team have trained local residents from the Churchill Gardens estate as health workers -they make monthly visits to residents regardless of need to build relationships with the entire family.  It’s a model that could – should – revolutionise population health and you can hear Cornelia talking about it here.

These are the shoots of a new health system – I am sure you have your own examples in the places that you live and work.  These are the stories that are told in the innovation boxes of formal reports – the challenge for us is how to bring the work of Aimée, the toe nail cutters, the community health workers, the professionals with new ideas, into the heart of our systems.  We need to turn things inside out and move this work from the margins to the centre.

We can’t fix the NHS Instead we need a fundamental pivot: in our thinking, in our systems, in our imagining of what health today in this century really is.

The Pivot

When modern industrialists, the designers of our digital systems, spot a fault or a failing in their designs, they have to decide whether to persevere and fix the problem or whether to pivot – to change course.

The decision to pivot looks ostensibly like a matter of reasoning – a logical response to questions around the resources available to fix the problem: is it likely the fix will work or would it all be too expensive, not viable, would it be better to start again?

The pivot seems like something that would be an objective response to quantifiable data.  Let’s get a toe nail cutting service up and running in the community, it will save us so much money.

But the reality is very different.  The pivot is all about emotions, about embracing a failure in our thinking, our plans, our mind-sets and starting again.  It takes immense courage to pivot, even when the evidence is in front of us.  The voices in our heads say ‘I have already invested so much time and money and energy in this current way of working – surely it’s worth one more try, one more adjustment.  Just imagine the upheaval if we changed course, let’s keep on pushing forward…’

In fact, the decision to pivot is so difficult that most organisations don’t make it and subsequently fail.

A pivot you see is not just another word for change.  The pivot is a special kind of change that involves a new vision, a different solution and a new economic model.  It offers the potential for transformation.

The pivot requires a particular form of leadership: one based on collaboration and the ability to take others with you on the journey.

The image below is a portrait of Chief Plenty Coups, the last leader of the Native American Crow Nation.  Plenty Coups lived through a time of profound upheaval.  The buffalo on which the Crow Nation were culturally and economically dependent disappeared.  There was nothing to hunt, nothing to trade with, no purpose to the rituals that glued the nation together.

Let’s just hang on, live in hope, walk a little further, persevere, many of Plenty Coups’ people argued.  But Plenty Coups realised that an old way of living had gone forever.  He knew a Radical Plan was needed and he also knew that a different set of possibilities were already present.  His people had started new ways of learning, new forms of agriculture – it was just that these things existed almost unseen at the margin.

Plenty Coups could see the need to pivot, to champion these emergent new systems and he could persuade his people to follow him into the unknown.

The story of Plenty Coups is told in a remarkable book called Radical Hope written by the philosopher and psychoanalyst Jonathan Lear.  Lear writes:  ‘at a time of cultural collapse, the courageous person has to take a risk on the framework itself’.

I’m not necessarily arguing that we are at time of cultural collapse although it seems likely that we are on the verge of eco-collapse and we are in a deep state of health collapse: of physical and nervous exhaustion. Many, many health workers feel this collapse and they are voting with their feet.

And the business models which underpin our industrial health systems are also crumbling: industrial and vertically organised public systems cannot flex, give the required autonomy at the frontline, or relate in new ways to the population.  Whilst extractive market models set the wrong incentives and, in their siphoning off of profits leave too little to go around.

It is clear that the shifts in our economic, social and health realities are so fundamental that we too need to take a risk on the framework itself.

Like Plenty Coups we have to acknowledge that things are going to change in ways beyond which we can currently imagine. We know that we can’t face the future in the same way we have been doing.  We can’t plan another re-organisation or hope we can bid for some new pot of funding and carry on.  With others in our community, with like-minded leaders, we must open our imaginations to a radically different set of future possibilities.

What I am saying is, that it is no longer appropriate if you are leader in our health systems to persevere with ideas of efficiency, to tinker with new forms of payment, outcomes or work force reform, or to hide behind an innovation project whilst the rest of the work continues untouched.

You have to have the courage to address the profound re-design needed.  You have to take a risk on the framework.

Three Reasons We Cannot Continue

The nature of the problem has changed – our health systems are modelled on the idea of the cure. The cure is produced in vertical systems of command and control – but you can no longer cure – you need to prevent, care and support – and this needs a completely different way of working.

Care – Beveridge and his contemporaries did not know how to address the problem of care – they swept it behind our front doors decreeing that tending for small children, for our elderly parents, for neighbours in need would be women’s work.  But this system broke down in the 1960s – as Helen Gurley Brown wrote in Cosmo ‘women just want to go out and have sex’ – – more importantly men and women want to care and, as I have written here,  this requires a profound re-organisation of work and our social systems.

Today the lack of care, can’t be hidden behind our doors it is threatening to bring the whole edifice down.

But neither can care be ‘delivered’ through new systems that simply replicate the industrial, post war organisational models of the NHS   – or through trying to stitch together threadbare public health models with exploitative private forms of care.

Like Plenty Coups we can look around and see radical new forms of care– Wellogram, Circle, Buurtzorg, Shared Lives, Somerset Cares – we know the models and we need to fund them and support these new cultures to spread.

The third reason we cannot go on is Poverty – health is rooted in poverty and inequality – and the gaps between us are now chasms. Jamie assumed that Joe is old – in fact he is the same age as me, but his life chances have been very different and his body – his toe-nails, tell the score.

Today our health services are designed in such a way, that they not only fail to address inequalities, they in fact create them.  The porters, the cleaners, the carers – the thousands of workers on which the health service depend are paid a minimum wage or less.  This is not only unjust, it creates ill health.

These are injustices of race and gender which were designed into our health services and must now be changed.

‘Your body is tolerated, your value is economic’

‘I’m just a number’

‘If anything happens to me, it won’t be long until they find another’

These are just some of the shocking statements made by Black and Brown nurses in the film Exposed in which health workers tell their story of the pandemic. If you have not seen it, I urge you to do so because when we think of the pivot, we have to think about systems that take care of everyone, to address the legacies of injustice – to do anything else is not only exploitative, it is like pouring water into a leaky bucket, liking hunting for buffalo that are now extinct.

What can we do?

Everything is possible.  Just as in the time of Plenty Coups – new ways of caring and supporting health are all around us.  Despite the oppressive conditions and exhaustion, the health service is full of extraordinary individuals and you are leaders – you can ditch all the speak about pathways, improvement and transformation – you can lead in a different way – one which will release the abundant resource that is actually around you.

Here is how you could pivot

• Tell a new story

Just as Kate found a new way to live and to flourish, by re-weaving a new story about her life, so we can the same – do not under estimate the power of a story in which we can see our lives reflected.

Don’t talk about fixing the NHS, don’t run focus groups or participation exercises around how to improve your services.  Start outside the system, where people are and create a story about what health means and looks like in your place.

This has to be a baggy story – it’s not a management document – it’s a tale that resonates that can bring together everyone in your system that is creating health – the dinner ladies with new ideas, the parish priest, the small group of local podiatrists that do want to cut toe-nails, nurses, doctor’s receptionists, a clinician with different ideas – find them and weave your story.

• Organise horizontally – build a coalition of the willing

Today the health service is an industrial, vertical system with power and resource concentrated at the top. This made sense in the era in which it was designed but it does not make sense today.

Today we need to think horizontally – to form new bonds between institutions, professionals, the community.  Don’t spend time trying to convince others at the top of the system, connect horizontally to the energy that already exists in the places you lead.

All the new models I have talked about are dependent on new relationships between clinicians, public workers in the broadest sense, and the community.

• Create Possibility

Fund everyone that is bringing your story to light.

The new Integrated Care Boards have the power to do this.  Use it.

Don’t have innovation pilots.  Do as the founders of our systems did – have a clear strategy to switch resource – to Wellogram, to those who want to create independent Buurtzorg models, to the Birgit Valla’s that are prepared to throw out the rules and invent something new, copy the work of Connie Jurgens, take a risk on the framework.

I just want to say a word about risk. Today it is risk models that prevent change – they work against possibility because the more we focus on managing risk the more we focus resources here, again diverting from the new and stifling possibility.

The thing about risk is that the models only work in conditions of certainty– but you are all operating in conditions of uncertainty – ageing, physical and mental illness – these are uncertain things – no amount of data, modelling and talk of managing risk will help.

‘A reliance on data driven modelling leads large organisations in particular to make decisions on the basis of what is easiest to justify rather than what is the right thing to do’.  These are not my words but those of Mervyn King the former Governor of the Bank of England and John Kay a leading orthodox economist.  I really recommend their book Radical Uncertainty for those of you trying to convince colleagues that risk-based models are the problem. These two establishment figures recommend ditching statistical models in favour of narrative – stories, and they emphasise the role of our humanity and intuition, rather than data in good decision making.  They understand this is a moment of paradigm change.

• Take care of everyone

If I had to sum up my own book Radical Help and my work in one line – it would be this – ‘take care of everyone’.  People are your precious resource.  In our systems I think it is critical that we do not distinguish between those who are doing the work – clinicians, receptionists and so on – and those who are in the community and need support to create health.

We have to grow capability in every part of our system and just as Aimée has to allow Kate to feel attended to, before she can make change – so it is for everyone in the system.  If you are afraid that you will be blamed for trying something new, if you are so over-worked that you cannot listen to your instincts, if you are so badly paid that most of the time you are doing calculations in your head about your rent and your heating, then you cannot be part of a healthy system.

If you are a leader here today don’t pretend your systems can cope – listen and be honest with the people you lead.  They have already shown you under the pressure of the pandemic how they can pivot – so ask them what you should do together – this would be Radical Health.

Talk delivered at the NHS Confederation June 16, 2022

So often the two seem locked in a zero-sum game, a competition, in which the fate and popularity of one rises as the other falls?  But could we instead re-imagine the relationship between the local state and communities in ways that allow both to develop a narrative of renewed common purpose, new ways of working together and with others to create the futures we are seeking.  This is the question at the heart of a project I call theThe Radical Way.

We can see from history that at moments of paradigm shift a broad range of actors (business, civil society, intellectuals and the state) are called on to play new roles.  We see breakthrough, the creation of something new, when these diverse groups are able to re-imagine their relationship to one another as part of a new, bigger story.

Earlier this year, funded by the Emerging Futures Fund (TNLCF) I had a series of conversations with leaders in Local Authorities about their desire to create deep change in the way they work.  Open ended conversations covered long run changes and challenges in funding; the opportunities of the pandemic – many places have seized the emergency to work in new ways and they don’t want to go back – and the ways in which ‘innovation’ has become stuck: all too often de-coupled from wider questions of economy and ecology. One finding from these conversations is that there seems to be almost an inverse relationship between places who are large purchasers of ‘innovation projects’ and any real change.

I called this enquiry the The Radical Way in homage to Julian Cameron’s best seller the Artists Way.  The Artists Way is a twelve-step guide to (re) finding creativity.  The reader/participant – and there have been millions – follows a set of tasks that encourage inner reflection and practical change.  From the first page of this book you are invited to be an artist, what follows are dynamics that build inner courage and exercises that stretch both the imagination and practical skills whilst potentially widening connections to others following a similar path.

I wanted to explore whether, through a social imagining of Cameron’s work, I might be able to produce something that would respond to those seeking ‘help’ with the implementation of Radical Help.

I had thought, based on the thousands of enquiries I have received for help with the implementation of the capability-based approaches that sit at the heart of Radical Help, that a similar form of guide might be helpful and that such a guide could be developed through conversations and workshops.

In fact, it rapidly became clear that this light touch approach would be insufficient.  What is required for those who are genuinely committed to this path (a group who are still few in number as the enquiry also surfaced) – is nothing short of a new infrastructure for imagining a future story, for sharing a capability based philosophy, for barefoot practice in place (a practice that builds local skills rather than those of London based consultants) and for finance that re-capitalises a shared social infrastructure: one created, made and maintained through the new relationships in place.

I am immensely grateful to Cassie Robinson and the team at Emerging Futures for funding this work – a start in facing up boldly to what is needed.  And to those who joined me in both the exploratory conversations and a later workshop that discussed emerging findings. You can read the story of this enquiry The Radical Way.

All you need is love?

A 21^st century health system is much talked about and far from happening.  This is because most efforts at change start in the system with institutional reform programmes.  It’s the wrong place.  Change needs to start with people, in their communities – where health is made.  And this sort of change requires a different sort of leadership.  Showing a deep understanding of the challenge Brigid Russell and her colleagues at Project Lift, in collaboration with the Scottish government have designed an experiential programme they call leadership3 (leadership cubed). I have been lucky enough to be a small part of the work over the last 12 months and I was able to join the team again in East Ayrshire.

Last week love was the theme of the meeting. This was in part a homage to the publication of the Scottish Care Review – an outstanding example of participatory policy making – which places relationships and children’s need for love front and centre of its recommendations.   It is clear that to make change in our lives we need to talk about love in the radical way embodied in the Care Review.  And – as everything I saw later in the week in East Ayrshire demonstrates – cultivating a culture of kindness allows for real system change.

And yet, I don’t actually think that ‘all you need is love’.  At a personal level, many of us have grappled with challenges of addiction or depression and we know that love for someone close to us is fundamental but not enough.  And at the system level change is about understanding power dynamics and being able to invert and sometimes confront the status quo.  I talk a lot in my work about relationships but I have been careful to ground my thinking and advocacy for relationships within the capability framework of Amartya Sen and Martha Nussbaum in recognition of the critical inter-play between emotions, material realities and power.

The theme did provoke a brilliant discussion – participants commented that we had gone deep – and what a gathering. It was a treat to be in conversation with Donna Hall, Katie Kelly, Fiona Lees and Maureen Swannie, so warmly facilitated by Grecy Bell.  All these women leaders had powerful insights but more than that they have done/are doing this work in practice: handing power to communities, embracing capabilities and their full human qualities in their style of leadership.

Home Link

Family life is hard in modern Britain.  I have written about this at length – about the ways that families need light touch, timely support but instead find themselves faced with a centralised, scrutiny based social work system where the emphasis is not on family development or kindness but rather social workers are forced to emphasise managing risk.

Home Link in East Ayrshire is family led, light touch and the antidote to the dominant system.  This Scotland wide initiative sits within education and is meant to grapple with challenges of low school attendance and attainment.  In the communities of East Ayrshire this brief has been deftly interpreted.  A small team work within communities and see themselves as at the service of all families.  If things are tough they arrive to make a cup of tea bringing the milk and the bread for toast (it is a shocking reality that hunger is a constant issue for so many of the families I met last week).

Home Link workers might spend time playing on the carpet with children or taking a walk round the block with an angry teenager.  They are building relationships and trust; they are ironing out the wrinkles that might mean a child is not in school or might be a warning of deeper troubles beneath. Because they are allowed to work without an agenda and because they are linked in the communities’ minds to the primary schools rather than the much-feared social work systems that threaten child removal, they are welcomed into homes and the results are tangible.

Community Organising in the 21^st Century

There’s a curious double talk pervasive in our country right now.  Number 10 – and therefore the national press – are full of the stories of ‘Levelling Up’, the investment that has been promised to the communities of Northern England and beyond.  But the present reality for local government is still one of making budget cuts.  Most councils have got to find further savings this year on top of the deep, cruel cuts already made.  East Ayrshire is no exception.   They have decided to invest in people not fixed assets: their social infrastructure.  (If you are not a public servant it might be hard to understand just how hard and brave a decision this is right now).

The communities I visited last week – Netherthird, Rankinston, Ochiltree – can all draw on a community organiser to help them do whatever it is they want to do.  They have been handed back the assets – community halls, community gardens – and then with the support of the community organisers they have found new ways to do things.  Rankinston is a former deep mining village which was covered in snow and whipped by sharp winds the day I visited.  The warmth within the village hall could not have been more of a contrast.  Rankinston has shrunk in size and suffered very hard times.  Yet the warmth in the village hall was not just down to the heating, but the hubbub of mothers meeting and talking, the energy of the women who run the project and children of all ages playing during their half term.  This hall, once derelict was full, busy and once again at the heart of community life – run and owned now by the community.  The changes have been possible because of deep community engagement allowing for abandoned houses to be removed in return for investment in the village hall and playground – all facilitated by community workers and their peers in Home Link and Housing.

In Netherthird I saw the same thing.  A hall once run down and defended by razor wire is now open and thriving supported by a café, a gym and a vintage clothing shop.  Once slated for demolition this hall will now be expanded by the community who are raising funds to add more rooms for children’s play and for health and wellbeing services.  In Netherthird as in Rankinston this work is helped by a community worker who is clearly at the service of the community.  This is a power shift in action: it was clear that the plans and the vision belong to the formidable community organisations in these places.  They do not look to the Council for money but they do value the convening power, connections, skills and deep commitment of the community workers.

Ochiltree

In Ochiltree the community rejected the transfer of the building asking instead for land ownership.  With an audacious vision the community of Ochiltree raised over £2 million and built a gorgeous community centre with spaces to meet, dance, read and play.  Ochiltree Hub is a physical statement of the communities’ belief in themselves and their future, of worth and possibility.  A committed team of volunteers and a project worker are still learning how to make sure everyone visits and becomes part of the project. Ochiltree Hub felt to me like a modern-day Peckham Experiment in the way it understands well-being as a thing of social relationships and shared activity.  I hope they can make it work and in the meantime everyone who can should take a de-tour to the café which has one of Britain’s finest views.

The 50+ revolution

In every community it is older, retired people – and mainly, but not only women who are organising, learning to run community businesses and making the connections, confronting the economic and social troubles which remain very real.  So much talk, so many words of worry written about our ageing society – frankly where would we be without it.  The women of Rankinston and Netherthird I salute you.

Connecting is tough

In Rankinston it costs £6.50 to take the bus trip to the nearest town (this is necessary to visit the doctor, work, go to the Post Office or the super market).  This sum is almost three times the cost of a central London tube journey (£2.40) despite the fact that London incomes are almost three times the level of Rankinston incomes. Added to this, the bus runs every two hours so it also costs most of the day to take the trip.

And then there is the internet: in Rankinston many homes have no connection and for those that do the speeds are painfully slow – this is not a place you can run a modern business.

These are not original observations but it remains astounding that national governments of all political persuasions over decades have ignored the basics.  We can talk about relationships and levelling up all we like, but if we can’t connect, it is just that – talk.

Good Work

I chose East Ayrshire as the first location to explore my good work project in part because they have started their own very powerful work revolution.  The Council and the Health Service are major employers (over 12,000 workers) so Katie Kelly, Deputy Chief Executive, under her brief of building Vibrant Communities has asked how work could be re-shaped to better serve the community and individual workers.

The Community Workers and Home Link workers are part of this revolution able to define their days and priorities in response to community realities.  Housing teams too are working in a very different way.   ‘Our gas engineers can see much more than the boiler’ one local leader explained.  Changes started when a gas engineer returned to head office shocked by the poverty of one local gentleman whose house contained nothing more than a thread bare sofa.  We have to be part of a deeper change he told his colleagues, some of whom were suspicious at first: ‘we’re not social workers mate’.  But many more wanted to be part of change and innovations have included training for those with hard skills – the plumbers, electricians etc – in ‘coaching conversations’.  Housing teams have the ability to ask residents what is going on and get help in early before families are at the point they cannot pay their rent for example.  Housing Officers have also developed a text based service called ‘Our Street’ where residents can report any worries they have -anonymously if they like – which once again ensures small problems do not become bigger ones. All of this imaginative work has delivered necessary savings although this was not the driving force.

Katie Kelly has also been looking at the working lives of those who do some of the toughest but most important local jobs: clearing the grounds, digging the graves, driving Gritney Spears and the other wittily named gritting lorries that were so much in evidence last week. Work Transitions offers these critical workers the opportunity to multi task and to progress into work which is less physically demanding.  The role of a caretaker for example has been positioned as a progression rather than an either/or job choice in recognition that very few can or want to do tough physical work in their 50s but they have much to offer the community, so this can be a later life job.   A lot of pride was on show – in an organisation that has embraced the whole person and put an ethos of kindness at the centre. For Katie this is the first step in an idea that is growing around a different sort of community economy.

So much more to do

Every time I suggested to Katie, or to Fiona Lees the Chief Executive whose leadership and community commitment has led to the vision ( as in Wigan, longevity and stable local teams and leadership are a core part of the success story here) or to Joanna and Adam the Home Link workers , to Melissa a community worker, to Margaret the community leader in Netherthird or to Daniel a groundsman, that something  they were doing was rather impressive, they smiled and countered with a comment on how much more there is to do, or a story about what is not working and what they are grappling with.  A couple of years ago visiting Norway, the Mayor introduced a speech I was to give remarking, that we trust Hilary because she is always talking about the mistakes she has made.  His comments made me and everyone else laugh at the time, but I remembered them this week.  This culture of open learning, the sense that everyone has only just begun, despite the big changes already made was deeply inspiring.

Finally – are you cooking your rice right?  One person I kept bumping into last week was Chef Chris.  I got a new cooking tip every time starting in Rankinston where at a community cooking class he showed us an ingenious and new way to cook rice which works very well, particularly if like a lot of the mothers I know, you have only two pans and one hot plate/ring (see below).  Chef Chris exemplifies the East Ayrshire story.  Cooking with the mothers in Rankinston one day, later in the week he made soup and canapes for those who came to my workshops: the home link workers, the groundsmen and gravediggers and the local politicians who kindly dropped by later – we were all seated at beautifully laid tables and served delicious soup and home-made bread.  Chef Chris and his team buy everything locally,  It has taken 10 years to encourage local production to the levels necessary.  I don’t think Chef Chris can have anything as 20^th century as a job description – at least I can’t imagine how it would summarise everything he does – but his way of being and working exemplifies the East Ayrshire magic.

‘Rankie Rice’: the Chef Chris Recipe

Cover your rice with water – leave for 30 minutes.  Don’t drain – just bring to the boil.  Take off the heat – leave for 45 minutes.  Perfect rice.

Kilmarnock, February 2020

This year I am also focused on work (and its intimate connections to the climate challenge).  I am running a series of workshops across Britain where I will be asking those from all walks of life to join me in designing a vision of the good working life.  I am also asking those I call the New Industrialists to join me in thinking about their role in the creation of good work, flourishing communities and generative economies.

I started this conversation at Davos where I was joined by Ajay Banga, the CEO of Mastercard and Satya Nadella, the CEO of Microsoft in front of a live audience.  You can watch a recording of our conversation here.

Why ‘New Industrialists’?  History shows us that technology revolutions are always accompanied by social revolutions: the design of new social systems and the widespread diffusion of new cultural norms about what is right and fair.

This social change does not happen by accident.  It must be designed through a process in which stakeholders, who are initially opposed to one another, come together and re-think.  The state is required to set a new framework. Concerted action by civil society is key.  Without the rise of organised labour in the last industrial revolution, it is hard to imagine the gains that followed.  Thinkers and intellectuals also play a role.

And then there is a fourth group: the New Industrialists.  These new industrialists are leaders of businesses at the forefront of the new technology who dare to challenge their peers, arguing that a new future is possible – one which encompasses new forms of productivity and new forms of human flourishing – but only through the design of new, collective social systems.

These earlier pioneers include individuals such as Saint Simon (a prominent investor in canals and pioneer of new forms of work organisation -he argued that work needed to be meaningful if workers were to be productive), Robert Owen (a founder of textile manufacturing and the co-operative movement), the Quakers (who created companies such as Cadburys and Barclays Bank whilst founding numerous social institutions and moving to abolish slavery).

In the early 20^th century, figures such as Joseph Chamberlain a leading British manufacturer, was an important campaigner for mass education and a pioneer of land reform; in the US, the National Civic Federation of business (which brought together top business leaders with early unionists) moved to regulate child labour and introduce the first minimum wages; Rosenwald at Sears Roebuck pioneered kindergartens, low cost housing and recreational activities and, perhaps most famously, Henry Ford significantly raised wages with the realisation that workers needed to be able to afford his cars if he was to build his business.

What unites these figures is that firstly they dared to go against the grain of the normative thinking of their peers and secondly, they responded with innovation to the growth of economic inequality and social unrest which accompanied the early years of the technology revolutions they lived through.

What is also interesting about these pioneers is that they acted through enlightened self-interest.  We are not talking about philanthropy here – although this sometimes came later.

What the ‘new industrialists’ wanted to demonstrate was that the new forms of technology that underpinned their businesses, could lead to higher productivity and a different sort of society.  In other words, they were pragmatists: they understood that support for new working conditions and social lifestyles would be critical to diffusing the potential of technology and therefore their business growth.

In my discussion with Ajay and Satya I asked; where are the new industrialists today; what should be the principles of a 21^st century social settlement and what are the particular challenges to designing change and good work in the face of ecological collapse?  I am grateful to them for joining me in this first conversation and to the team at the World Economic Forum who made it possible.  You can listen to our conversation and you can follow my work and read more about my ideas for a 5^th social revolution here.

January 2020

This week Adam Lent started an important conversation at the New Local Government Network, about how we enable a system shift away from a highly centralised mode of government to one which is community driven. He writes; ‘Currently it takes a rare combination of courage, persistence and vision on the part of local leaders to adopt community power while it is at odds with the overwhelmingly paternalistic and institutional status quo.’

Well put. This is something all of us who work within communities and alongside local government will recognise.  Adam’s proposal is A Community Power Act.  The Act will dismantle national power structures in order to tackle local economic development, public services and participation.  The Act will mandate collaboration and formally inspect that it is happening.  Inspectors will have the ability to apply sanctions.

The proposals address the core challenge we face: how to shift from industrial top down systems to new forms of collaboration.   The ambition that Adam sets out is exciting – and yet, something troubles me in the approach.

Firstly, I wonder how much of what is currently blocking change needs legislation.  Reading the proposed Act, I was reminded of a Minister who made an intervention with similar intent almost 20 years ago.  In 2002 Estelle Morris who was at the time Secretary of State for Innovation implemented a Power to Innovate.  The power allowed schools to ignore any piece of education legislation that they felt was blocking radical change they wanted to make.  Schools simply had to inform the department.  None did.  Not because they did not want to innovate but because in reality it was not law that was standing in their way but mind-sets.  Those that wanted to innovate could.

Times have changed and the room to innovate has narrowed.  Adam points for example to the impossibility of designing local labour market and skills policy when decisions and budgets are entirely controlled from central London.  I have grappled with this block in the system myself and know that it prevents any meaningful change.  The challenges in other words are real.  But still I wonder if legislation is the way to go.

The shift we seek is structural and cultural.  In Radical Help I describe this as a movement away from industrial / vertical power and organisation to one which is relational and horizontal.  The New Horizontalists as I call them, understand that it is rarely formal structures of power that stand in their way.  This group which includes radical GPs, long standing community organisers, those with lived experience as well as leaders in our more radical councils from Wigan to East Ayreshire, make change by using their soft power, by facilitating the relational foundations on which the new can be built to last.  So here is my second qualm.  We cannot equate community power with a transfer of assets to local government.  Whilst innovation is happening rapidly those in local government who understand how to collaborate with communities, how to devolve resources and how to do this horizontal work (which always involves grappling with incumbent power at the local and the national level) are still few in number.

And thirdly, I am concerned about inspection.  In the new world we would not need inspection because local, horizontal organising is by its nature based on trust and transparency.  Our dependency on inspection has grown alongside our dependency on centralised, market driven outcome models where those in power cannot see the effects of their commands and so must send out their troops to police implementation.  We could instead liberate the considerable resource locked in these institutions of vertical audit and convert inspectors into learners.  Their role would be to move between communities as channels of experience and best practice – a 21^st century form of barefoot expert.

If there was to be a ‘law’ that would bring about the change Adam is advocating and so many of us want to see it would be ‘don’t look up, look sideways’.  I fear that our dependency on an Act will engrain a mindset that still looks up – albeit in new ways.

But, if we need an Act – and I simply don’t know whether we do or not – I am writing in the spirit of enquiry, not critique – there is an alternative legislative framework available and in place within Great Britain: the Welsh Future Generations Act.  This might deliver what Adam is pointing towards but in a different way. Within this act there are no commands and no inspections – instead there is a framework for asking new questions.  The intention of the Future Generations Act is simply that, to raise questions: to change the framework by shifting the time horizon, bringing ecological perspectives into view and to encourage participation and new voices to take part.

Implementation has not been easy – many have been unsure at first how to work within the Act, how to ask the questions.  But the momentum is growing and there have been some important local environmental shifts.  When the Future Generations Commissioner Sophie Howe describes her own role, she says that she sees herself as a coach.  She sees it as her role to encourage, ask questions and sometimes to referee but never to command anything new.  I admire this response beyond measure – Sophie is modelling a new form of public leadership and explicit in her response is an acknowledgment that we cannot create 21^st century institutions by simply devolving power to a new level.  New collaborate models do require a new framework.  They also require very different behaviours amongst leaders at the local level – within government and without.

It is important that NLGN have started this conversation.  We can see where we want to get to, we can see examples of the new and – as Adam writes – we need a new way of ensuring the new gets the systemic support and resource it needs to grow and flourish.  But we also need to tread carefully.  To use the industrial levers to get us there will not work and may unintentionally suffocate what has started to grow.  I look forward to hearing how others think we should grapple with this immense and immediate challenge.

In friendship and solidarity.