Ignoring the lens of community development in health Care is not only a missed opportunity; it brings hazards and long-run dangers too.
That’s the message of Cormac Russell’s recent paper Understanding ground-up community development from a practice perspective published in the open access journal Lifestyle Medicine. The paper describes the change of focus of Strathcarron Hospice near Falkirk, Scotland from community engagement to community development.
This shift between 2018 and 2021 has resulted in a different kind of relationship between the hospice and the community – increasing community-first initiatives, people asking questions before they needed support, increasing community capacity to support neighbours, higher levels of trust, and more awareness of the dangers of professional over-reach. In seeking to help in disempowering ways, the hospice realised that they may be doing harm. In this post I will first summarise Cormac’s points, and then look at some of the ways forward (and pitfalls we might foresee).
In the article, Cormac Russell presents three lenses through which the relationship between communities and institutions can be viewed:
The Relief lens: the well-being of individuals is seen to be the result of services provided by professionals. ‘Clients’ of these professionals have needs that only the professionals can address – they are ‘needy’, not ‘needed’ as at least part of the solution. (Professionals do of course have a part to play, and may need to take a lead in crisis situations – but this is not a desirable place to be long-term.)
The Reform lens: Usually layered over the relief lens, the reform lens stresses the need for systems and institutions to be reformed to help alleviate the needs of the community. While this is a step forward, it is still an institution-focused view. Non-profit agencies may seek funding to achieve this – funds which then don’t go to the community. The reform lens can indeed bring improvement for citizens, but mediated through those who speak the language of government and prioritise professional interventions.
While these lenses are both necessary in some ways, they bring hazards. This is where Cormac Russell’s article is startlingly clear. He clearly and concisely lists these hazards in a way I haven’t seen before. They are (quoting from the paper):
- Individuals and groups are labelled and defined by their perceived weaknesses and conditions, not by their strengths and capacities.
- Most of the money intended for communities ultimately goes to those providing services to them.
- Active citizenship and grassroots activity retreat into the background, overshadowed by institutional largesse and overreach.
- Regular people and associations see themselves as inadequate and underqualified compared to professional helpers. Consequently, they become disabled.
- Residents accept that professionals and programmes imposed from the outside are their best hope for responding to end-of-life support needs.
- Individuals and communities are understood and come to see themselves as consumers, not producers. Thus, they outsource death, dying, and other health- and well-being-related issues to a licensed professional or institution.
- Institutional progressives will speak of prevention of illness while rarely talking about community health creation, because the latter relocates authority and resources towards community alternatives and away from traditional institutional interventions. (Russell, C., (2022), Lifestyle Medicine e269, https://onlinelibrary.wiley.com/doi/10.1002/lim2.69)
While Russell related these hazards to the activities of the hospice and end-of-life Care, they surely have a broader truth. Community health creation (and the creation of well-being, safety, longevity, child-raising, Care and much else) is kept out of the picture, not least by professionals who seem to value retaining their expertise, power and funding over supporting citizens and communities.
Cormac Russell then presents his third lens:
The Community lens: The neighbourhood or community is the basic unit where health and other things are produced. Citizens “are recognised as having capacities to produce health, safety, and prosperity. This lens reveals neighbourhood associations as contexts in which to create and locate many sustainable supports, especially for those at the economic and social margins who are in need of Care and support” (Russell, 2022).
This is, of course, a paradigm shift in thinking about our society.
Cormac’s article continues with ways to set about building this new paradigm using Asset Based Community Development ideas. These are laudable and well worth exploring in terms of on-the-ground community building. One way to engage with these ideas is though Village In The City, which supports and encourages people to build micro-local communities in their own streets, blocks and neighbourhoods.
I’d like to set out here some of the ramifications of this paradigm shift to community-led work. If we are to make practical progress it will not (I think) be down to a lack of good ideas. Cormac Russell’s new book with John McKnight, The Connected Community, (published today) is a fine source of practice and wisdom. I think a bigger challenge will be practical stumbling blocks. As people start to encounter and engage with this new way of acting in community, it will feel a bit strange and there will be come unintended consequences. Here are some ways we can help ourselves as this shift builds and develops:
- Practical examples: The experience of Strathcarron Hospice is an excellent starting point. We will hope to hear more as they continue their journey. We will benefit greatly from more practical on-the-ground examples of communities coming to a point where they are taking a lead, setting goals, making plans and implementing them (with the help of, not in the teeth of, professionals).
- Doing it in a community way: Cormac Russell talks about evolving a local Stewardship group, to act in deepening the connections within the local association of associations. It would very easy for such a group to slip into being (or appearing to be) an institution. What forms of governance can support the combination of openness and responsibility that will come with financial, political and ethical considerations?
- Value small steps: This transformation will not come as an immediately useable complete package. There will be small steps – a small project with the community driving here, a small bit of strings-free money there. It will be all to easy to dismiss these small steps as ‘not enough’, ‘a gesture’ or ‘sticking plaster’. We must take Care to present them as early signs, forerunners of a new way of living.
- Prepare for local variety: There will be lots of ways to do this. Different places are bound to evolve different ways to achieve a residents-in-control level of participation. We must prepare to celebrate the differences rather than to seek to meld everything into a uniform approach. And yes, someone will complain about the ‘postcode lottery’ where people in one street have much more involvement than people in the next street. It’s part of the process, not a design flaw – cheer, support and use the difference as a driver for change, not something to moan about.
- Engage the professionals: They are not, despite the impression I might have given above, the enemy. They will take time to adjust to a revised relationship too. Make it clear that partnership with the community will make their professional lives better, as well as their day-to-day experience of living as citizens. They will need to be valued even more by the community – but in a different way, as supporters and highly-skilled team members rather than authority figures to be obeyed at all times.
- Treat slip-ups as valuable learning: There will be slip-ups and mishaps along this journey – times when things go wrong, slip through cracks, become left aside. There will be those who will shout that ‘this wouldn’t have happened if the professionals were still in charge’. Maybe not, but who would learn to walk or ride a bike if never given the opportunity? This points again to working with the professionals as allies, not seeing them as the competition.
These five pointers will help to make the shift to community-led living a firmer and more sustainable reality. The way ahead is hard enough without being prepared at some level for problems which will inevitably occur somewhere at some time (and probably in many places many times).
Mark McKergow, Village In The City