Futures from past to present
In our EHFF Newsletter, posted October 23rd, I promised a review of EHFF’s changing view of the future over the 15 years or so that EHFF has identified as a futures organisation. Here’s the sixth and final lever for change in the process of healthcare transformation that we had identified. I’ll also summarise the findings from the series of six overall.
Social movements
Very thoughtful and comprehensive examinations of the threats and barriers to a sustainable health and healthcare system (Kluge 2012(What will our health systems look like in 2050? Presentation: 15th European Health Forum Gastein, 5 October 2012), Scrutton et al https://ilcuk.org.uk/creating-a-sustainable-21st-century-healthcare-system/ 2015) were limited by their requirement for substantial investment from governments that are well informed and decisions that are not contaminated by political expediency. Unfortunately, the passage of time tends to confirm that such an expectation is simply unrealistic. The problem, is also that their recommendations are based largely on improving the current model of service, not transforming it, and while the latter is an extremely challenging endeavour, there is logic in suggesting that in the end it needs be the only solution, given the huge pressures, financial, human, and environmental on the current model, which are unlikely to reduce significantly.
Our approach, in part funded by the Johnson and Johnson Foundation, was to use the 3 Horizons model of scenario planning to help us examine the current policy environment. The resulting vision derived from the foresight study was based on 32 survey responses yielding 600 distilled answers divided into the three horizons of the present (H1), the desired future (H3), and a possible pathway between them (H2). Essentially, the generated vision indicates a pathway moving from overall health system failure to a resilient ecosystem supported by health literacy, planetary health, and the development of a well-being economy. The vision highlights the urgency to act on the current gaps, building on a new culture of education and engagement for the health of the public and the planet (add Ref: when it is finally published!) Untangling the rhetoric, while many of the factors identified in the causal loop diagram are familiar, the novel features were the emerging planetary health agenda and the mobilization of social movements and cultural values which can help drive the change necessary for the transformation between the present and the vision presented.
The key to exercising the transformation is H2, representing the potential pathway to change. While many of the factors identified in the causal loop diagram are familiar, the novel features were the emerging planetary health agenda and the mobilization of social movements and cultural values which can help drive the change necessary for the transformation between the present and the vision presented.
The emerging planetary agenda was recognised more than ten years ago, with increasing concerns about the possible impact of climate change (e.g. Kluge 2012, already quoted), but this is currently clearly impacting health, and there is a growing recognition, not only of the importance of planetary health for human health (e.g. the loss of biodiversity and its consequences: (WHO Newsroom, 2015) but reciprocally, the need for more environmentally sustainable healthcare practices (e.g. OECD 2019 https://www.oecd-ilibrary.org/environment/pharmaceutical-residues-in-freshwater_c936f42d-en ) This underlines the relevance of seeing health and healthcare, not in a silo, which is characteristic of the current position, where one government department or its equivalent is responsible for delivery (via a top-down strategy) but recognising the holistic nature of a society where every element connects to every other, such as the whole-of society approach
In the context of the mobilization of social movements and cultural values to drive change, the Runnymede Trust: Laybourn-Langton, L. et al: Making Change: What Works https://www.runnymedetrust.org/publications/making-change-what-works (2021) reviews success or failure factors for such movements. The conclusions of this report point to four insights: firstly, that evidence alone cannot change the world: what is needed is to close what they call the salience deficit, helping people to recognise the existence of the problem, and the power deficit, helping communities to find better ways to use their potential influence. To be successful, movements need a well-developed ecosystem of influence, that is breadth (diversity), depth (capability) and inter-connection (community). They are rarely organic: they require active cultivation by organisations/agents that do the work that is in everyone’s interest but no-one’s individual responsibility (cf. the transformational catalyst idea, below). Finally, successful movements prepare for and then harness external events but need the resources and capacity to understand the moment, create a new narrative, and effectively intervene in debates.
The findings of the above study should also be considered in the light of other literature on system transformation, for instance the concept of transformational catalyst introduced by Waddock and Waddell (Transformation Catalysts: Weaving Transformational Change for a Flourishing World for All. Cadmus (2021) 4, 165-182). The role of transformational catalysts is in aggregating, cohering and amplifying actions of transformation initiatives and change-makers working towards fundamental socioecological systems. Transformational catalysts connect other actors synergistically together towards system innovation, alignment of efforts, and transformation. The mantra in the approach is focusing on seeing and sensemaking, connecting, and radical action and learning. In her subsequent book Waddock (Catalyzing Transformation: Making System Change Happen, Business Expert Press 2024) teases out other important elements of the kind of change process being examined: the notion of a new social imaginary (basically, the vision), the importance of narrative in engaging participants, and the values and principles that need to be used to underpin both. Transformational catalysts are needed to accelerate the transformation sketched in our foresight study. This is the model we are following with our ‘cultural creatives’ experiment described in the previous section.
Returning to the original topic, that of social movements, the other work which needs to be considered is Asset Based Community Development as exemplified by the work of Cormac Russell (https://www.nurturedevelopment.org/asset-based-community-development/ ). This work has not been extended adequately to Community Health, but our work so far suggests that it has considerable potential by adding a bottom-up element as a change agent in what is predominantly a top-down system.
Future of community movements
EHFF believes that there are again green shoots here, the pioneering work of Dr Helen Kingston in Frome, Somerset, England, the Gezondheidspact in Utrecht, Netherlands and an overview of other countries (in Europe, e.g. Scandinavian colleagues : https://www.nuffieldtrust.org.uk/resource/building-community-health-and-care-capacity-reflections-from-other-countries ). However, although ‘Caring communities’ and the whole issue of moving the focus of continuing care from hospitals to the community is one element, EHFF is concerned about the dominance of the medicalisation of social problems. Treating the increasing prevalence of anxiety and mild depression in society as a whole as ‘an epidemic of mental illness’ is in our view symptomatic of a significant reversal from self-sufficiency and an understanding of health matters one would hope for with increasing health literacy. Rather, it parallels the kind of passivity developing in modern society associated with the increasing use of AI for communicating, the fall off in serious reading associated with short attention spans and people endlessly scrolling on their devices through what is mostly trivia.
What we look for is an extension of the ‘hospital at home’ concept, not just for treating genuinely acute conditions, but the idea of a health literate community oriented towards care, both for oneself and for others. Much more geared to the Socratic ideal of helping people live a good life, where ‘care’ is a central notion, rather than ‘healthcare’, with its inevitable association with patronage.