William House, Chair, BHMA trustees

Published in JHH15.1 – Transformation innovation in healthcare

This article is partly autobiographical, so I will just say that my practice of medicine, my role in the BHMA and my approach to community development have all been strongly influenced by my interest in the creative arts. I owe this to my late parents and to my wife and our children who have all valued creativity and inspired me in their own unique ways.

My reading showed me the central role of nature in understanding the human predicament Click To Tweet

The world is never starved for want of wonders, but for want of wonder.

GK Chesterton

I will start my story six years ago, though like all good stories it really started long before. On February 20 2012 I sat with a group of good people around Sheila’s dining room table. Sheila is one of those wonderful people who dedicate themselves to their community. My admiration, even awe, comes from my own inability to be like her, though we do share one quality: we never give up! Sheila had been working with her community for 30 years, while I had been preparing for this moment of sitting around her table, for a mere 14 – but more of that later. There were four of us round the table; the others were Andrew, an Anglican clergyman from South Africa but now working with our local parish, and Christina, another dedicated community worker involved with launching a small community centre in a deprived part of the town. As for me, I had just retired after 32 years as a GP, nearly all of it serving our small predominantly middle class commuter town, Keynsham, between Bath and Bristol in south west England. There are many like it, but they are all unique and require unique solutions; just like people.

I had undergone my own transformation from a tall, thin and geeky, just 18-year-old, starting at medical school, keen on art, motor mechanics and science; to a rather stooped and bald 64-year-old, enraged by political folly, NHS managerial and strategic ineptitude and widespread failure of imagination. By 2012 I had somehow managed to sublimate my anger into a passion for change, vaguely formed at first. But crucially I knew this: the patients, many of whom I had known through the lens of suffering and medical ritual for 27 years and had grown to love, they will be the agents of change.

A key outlet and influence since settling into general practice was behind the converted barn to which we moved in 1987: a large plot, lately the concrete farmyard, converted by the developer into waste ground with rubble and opportunistic and aggressive ‘weeds’. This was to be our wildlife garden – more on this later.

So this is a story of three transformations: my personal one, the transformation of the waste ground, and the transformation that Sheila, Christina, Andrew and I (and now very many others) are striving towards. I am doing this because only the ordinary people have the power to achieve the depth and scale of change that our culture requires. But surely, you may say, the power sits with our government and our parliament through our elected representatives! Think again! These things are too important and much too difficult to be left to the politicians.

Never doubt that a small group of concerned citizens can change the world. Indeed, it is the only thing that ever has.’

Margaret Mead, cultural anthropologist

For a long time I had not believed what Margaret Wheatley and many other writers had been saying. But neither could I understand why our society seemed unable to address, or even admit to, many of the obvious societal causes of ill health which wreak havoc in all communities, poor and rich. As GPs, we were required to diagnose and provide remedies for disease. We were not required to ask awkward questions. When we did, the managerial response was to ignore both the question and the questioner. By 1997, 16 years after joining the practice, I could take it no longer. I took an expensive option: a five[1]month sabbatical leave from the practice. With the help of Bristol University’s newly appointed professor of ethics in medicine, Alastair Campbell, I began my transformation.

The professor gave me a reading list. The first book was After Virtue by Alasdair McIntyre. I was daunted! Being a very slow reader I had never developed the reading habit. But this had to change. At the age of 50 I started to read – slowly, diligently, painstakingly, always making notes as I went along. At first it was mostly philosophy, then expanded ever wider into science, creative arts, theology, economics, human ecology and much besides. I found myself writing reflections in the form of a novel with a GP as the central character, and the critical, sometimes mocking, voice of the philosopher whispering in his ear. It was liberating and fun! At the end of the five months I returned to work full of excitement and inspiration. It was as if I had been half blind and could now see. I was like a young child again, wanting to tell everyone about my discoveries. But all the people reacted just like my own parents had, they did not want to listen: too tired, too busy, too difficult. So I searched for the centre of power so I could influence and persuade, even becoming a GP commissioner in practice-based commissioning days. But as Bertrand Russell famously said:

From any particular perspective, the locus of power is always somewhere else.

Over the next 10 years I found ways of coping. I continued to read and make my notes. I abandoned the writing of the novel and turned instead to the more convivial writing of stage plays, some finished, a few produced. I also worked with one of the practice nurses to create and conduct small research projects within the practice often connected to the creative arts (Ferguson et al, 2012). At home was my artist wife, Poppy, our two teenage children, dogs and a wildlife garden. My family gave me meaning and love, but at first, the garden was seemingly unconnected to medicine and health – more an obligation to do something with the large plot of mud, stones and weeds that came with the house. But my reading showed me the central role of nature in understanding the human predicament – more on this later too. So I survived. The family was blossoming, I loved my work with patients, the research was inspiring, but still I was weighed down by the increasing stupidity of the system and the worry that by propping up a failing culture we were harming all our prospects for the future.

Then in 2006 everything changed. I received a phone call from the delightful and lively Annie Banbury from the local public health department. She was wanting to involve GP practices in public health work. In a flash, I knew what should be done – social prescribing (SP). This was an almost unknown term in those days but there had been a small SP scheme in Keynsham in the late 1990s which sadly folded. Soon I found myself, after 25 years as a GP in the town, for the very first time meeting with people involved in community development – surely a measure of the professional isolation of the medical fraternity. For me, it was a revelation! This project culminated in 2009 with an important publication on social prescribing (Brandling and House, 2009).

By then I had retired from my partnership at the practice and spent a couple of years as a commissioner, experiencing first-hand the obscure and paralytic top[1]down processes of NHS decision-making. So I was astonished when, on 6 November 2009, the practice[1]based commissioning board (I was hanging in there as a member) invited me to ‘do something about health and wellbeing in the community’. There was even some funding for a while. I jumped at this challenge. I would use it to set up my own organisation and it would work directly with the community and would empower the people so they had less use for the state.

My reading had shown me the potential power of a community and that SP was only a first step. I recognised that communities, just like the human beings that comprise them, are each unique and the desire and approach to change must emerge from within. It is vital that the actions taken are what the people want and not what outsiders think is good for them. Being more technical about this, a complex systems approach emphasises the importance, not only of the community’s history, but also the interactions between community members within interwoven community networks. This ranges from a nod and smile of recognition when passing in the street, to shared activities and thoughtful conversations. All of these contribute to a sense of belonging and of being ‘known’. This helps life to have meaning for the individual, but more widely, these connections generate human energy and establish the culture and values of the community in a dynamic way. Crucially, it helps people to care – about themselves, about one another, and about their environment. The built environment must facilitate opportunities for all of this. I tried to capture some of these ideas and other thoughts in an article published in the JHH (House, 2010).

It was shortly after writing this article that I realised that these plans were about creating a nurturing environment and how similar this was to the gardening for wildlife I had been doing for 25 years! Wildlife gardening involves creating a setting in which both humans and wild things can thrive. I had included five different habitats (meadow, hedgerow, pond/wetland, woodland and human – lawn, flower borders, vegetable patch, orchard – of course, the wildlife occupies all of it!) to attract a diversity of wild plants and creatures. Gradually, they were finding us, settling in and thriving. The garden was acting as a single ecosystem. Would a similar approach work with a community of 15,000 people and growing? My 2010 article became a blueprint for action, a new strategy for wellbeing and self-reliance (House, 2010).

So I now return to Sheila’s house, but we have fast[1]forwarded to March 2018. Our little group of four has grown to eight. We now welcome Alastair, retired diplomat and head-hunter, who is passionate about sustainable living; Sarah, once a doctor and now photographer, is strong on creativity and social media; Kathleen is committed to engaging with the local authority; and Mike is an Anglican priest with a remit for community engagement and (crucially) experienced in fundraising and business. The organisation that the group leads is now called Keynsham Action Network (KAN).

Keynsham Action Network is an experiment. We want to see if this mostly middle class town can come alive. We are doing this because the world needs people who have come alive.

Inspired by a quotation from Howard Thurman (Bailie, 1996)

So, how has it been going since that fateful meeting in 2012? KAN’s role is a cross between social prescribing and so-called ‘asset based community development’ (ABCD). But like so many labels, this misses the deeper truth essential to people ‘coming alive’. The transformative process requires a central place for the uniqueness of both the individual and the place. Fulfilled people become assets to the place but this is incidental to the personal experience of a new sense of belonging, of being ‘known’, recognised, valued, of feeling they matter. These experiences emerge from human interactions concerning shared values and aspirations. This needs community networks that give every person an opportunity to connect. Social media can act as signposts but not destinations. They do not substitute for the human smile, the touch, the recognition, the token of kindness. So if we think of social networks as the circulatory system of the community, it needs to be kindness, generosity, tolerance, shared enthusiasm and not least, imagination, that flows around those arteries.

I recognised that communities are each unique and the desire and approach to change must emerge from within

We do this by inspiring, encouraging and supporting both individuals and groups. We aim to foster a nurturing and nourishing environment within which the people interact and find their own wonder. Gradually social norms change. The website (www.keynshamactionnet[1]work.co.uk) gives some idea of the range of our initiatives.

So what has happened since that natal gathering in February 2012? Perhaps the most noticeable change in the town has been the spirit of collaboration between organisations. Keynsham was previously known as a place with much voluntary action going on, but little sense of connection or coherence. Now it is normal for the many clubs and organisations to work together rather than compete with one another. This is exemplified by the very successful ‘Live Simply’ project (http://live-simply.co.uk/ what-were-about). This started in 2012 with a group of church members approaching us for help in promoting sustainability. The response was to support them in putting on public events in Keynsham with international speakers on sustainability-related issues, often linked with Keynsham Music Festival. The most recent event in December 2017 featured Patrick Holden, Founding Director and Chief Executive of the Sustainable Food Trust. This was a collaborative event led by Live Simply with nine other local organisations. Among the many other speakers in the past six years were the ‘reverential ecologist’ Satish Kumar, and the Scottish human ecologist and activist Alastair McIntosh. Check the website (http://live-simply.co.uk) for other activities and events over the years. Live Simply is now a very successful independent organisation at the centre of a growing sustainability movement.

The most noticeable change in the town has been the spirit of collaboration between organisations

The vibrancy of community organisations and networks sets the scene for KAN’s most fundamental task: to connect the people. This goes beyond enabling individuals to feel that we belong and that we matter, it is ultimately about caring for ourselves, for one another and for our environment. This is not only dependent on the extent of the person-to-person networks, but crucially on the quality of the interactions. To enhance this quality of interactions, we previously tried an approach based on doorstep conversations but, for several reasons, this was not feasible. We just launched another approach called ‘Good Conversations’. This has emerged from a collaboration with members of the Fife Shine project and the International Futures Forum (IFF) both based in Fife, Scotland (Hannah, 2014). As I write we have just held our first training day for the Good Conversation skills, funded by the St Monica Trust. This was attended by a wide range of local professionals involved in health and social care (including two GPs), together with both volunteers and employees in local voluntary organisations. There is much excitement around this.

Finally, I return to the garden. In the Summer of 2017 four pyramidal orchids appeared for the first time in different sites across the garden. The seeds probably floated over the wall from the little churchyard next door – a meaningful connection perhaps? They had probably been in our garden soil for years, waiting for the right conditions. Wild orchids will grow only if the soil contains a certain fungal mycelium – a network to feed them. Without this, the microscopic seeds simply lay dormant, like so many humans who have become disconnected from life, from the caring and generosity that nourishes human connection. So the world is deprived of the beautiful orchid and the wondrous gifts that so many humans would have to offer. Now, like the orchids, they are beginning to emerge from the darkness in response to ‘…a patient and increasingly skillful love-making that [persuades] the land to flourish (Hawkes, 1951; Kellert, 1993).

[The] most important ecological processes are prominently manifest at the bottom of biological food chains.

Kellert, 1993

References

• Bailie G (1996) Violence unveiled. New York, NY: Crossroad Publishing Company.
• Brandling J, House W (2009) Social prescribing in general practice. BJGP 59(563): 454–456.
• Cooper DE (2018) Mystery and the way of the garden. Resurgence No. 306: 20–24.
• Ferguson P, House W, Nettelfield P (2012) We are not human beings in medicine any more, JHH 9(2): 38–44.
• Hannah M (2014) The patterning of hope, JHH 11(2): 7–11 (especially The Fife Shine Project p9).
• Hawkes J (1951) A land. New York, NY: Random House.
• House W (2010) The community and the chocolate factory. JHH 7(1): 20–23.
• Kellert SR (1993) The biological basis for human values of nature. In: Kellert SR and Wilson EO (eds) The biophilia hypothesis. Washington DC: Island Press, p47.

Useful reading

• Alinsky S (1971) Rules for Radicals. New York, NY: Random House.
• Capra F (1996) The Web of Life: A New Scientific Understanding of Living Systems. London: Harper Collins.
• Freire P (1970) Pedagogy of the Oppressed. New York, NY: Continuum.
• Illich I (1973) Tools for Conviviality. London: Harper and Row
• McIntosh A (2008) Rekindling Community: Connecting People, Environment and Spirituality (Schumacher Briefings). Totnes: Green Books.
• McIntosh A (2001) Soil and Soul: People versus Corporate Power. London: Aurum Press