Community Health Creation – BIG stories
The Beacon and Old Hill estate in Falmouth, Cornwall
The community transformation in Falmouth is one of the best known examples of community regeneration in the UK and it was initiated by two health visitors.
The estate had become one of the most deprived areas in Britain. More than 30% of households were living in poverty and the unemployment rate was 30% above the national average.
“It was generally agreed by tenants and residents that, by 1995, the Beacon and Old Hill estate was in a state of terminal decline. It had the reputation of being a ‘no go area’ for the police. Crime and vandalism were spiralling out of control, and the community had become dissociated from the statutory agencies. At that time, there was no residents’ association and therefore no place where people’s voices could be heard.” (Community regeneration and complexity, in Complexity and Healthcare Organisation – a view from the street, Ed Dr David Kernick)
Health visitors, Hazel Stuteley and Philip Trenoweth, reflect on the incident that triggered their determination to act:
“The flashpoint came simultaneously for us both, literally in Rebecca’s case, when she witnessed the family car ignite following the planting of an incendiary device. She was 11 years old then and although physcally unhurt, she was deeply traumatised by this. She was already in mourning for her friend’s pet rabbit and tortoise, which had recently been butchered by thugs from the estate. This was the final straw.”
From Hazel Stuteley:
“As family health visitor for the past five years, I was a regular visitor to her [Rebecca’s] home. Her mum was a frequent victim of domestic violence and severely postnatally depressed. My caseload had many similar families with multiple health and social problems. Seeing Rebecca and her family’s deep distress, I vowed then and there that change must happen if this community was to survive. I had been watching it spiral out of control for long enough.”
The rest is history – as they say! In brief, the health visitors initiated a series of meetings with representatives of health, education, social services, local government and police. From the outset it was recognised that community involvement would be essential to the success of the project. Twenty key tenants were identified by the health visitors as having the necessary skills to engage their peers. Five of these agreed to participate. They received training to become proficient at submitting grant applications and forming and maintaining a constituted committee. Later, this became a formal tenants’ residents’ association. In 1997 this developed into the multi-agency tenant and resident led Beacon Community Regeneration Partnership, an organisation that has endured. By 2000, the overall crime rate had dropped by 50%. Affordable central heating and insulation had been fitted to 60% of properties. Child protection registrations had dropped by 42%. Educational attainment of boys age 10-11 was up by 100% and in 1999 teenage unwanted pregnancies were down to NIL.
This general approach is called ‘Asset Based Community Development‘ or ABCD for short. It comes in various forms, but crucially it is based on the assets of the community – in this case a general awareness that something must be done and the energy, drive and skills of often a small number of motivated residents. Implicit in this is that the action is planned and undertaken by members of the community, leaving the outside agencies in an advisory and facilitating role. It is not done ‘to’ but rather done ‘by’ those who are most affected.
This is not rocket science. It is ancient wisdom:
Go to the people, live amongst them, start with what they have, build with them, and when the deed is done, the mission accomplished, of the best leadership, the people will say, ‘we have done it ourselves.’ Lao Tze (600 BC)
We can attribute much of our current understanding of community development to the work of Paulo Freire in Latin America, especially during the 1960s and 1970s. His book The Pedagogy of the Oppressed has been immensely influential. His primary contribution was to identify peoples who are marginalised or in poverty as ‘oppressed’ but generally unaware this. He then developed the educational and experiential methods that became contemporary community development. By enabling the unveiling of reality ‘though common critical reflection and action, they [the oppressed] discover themselves as its permanent re-creators’. The quality of dialogue remains central to this process.
Following the success of the Beacon and Old Hill transformation the methodology they used has been formalised as C2 Connecting Communities for which learning programmes are offered by the Health Complexity Group at the University of Exeter. The C2 method has been successfully used all over the UK and overseas. A detailed account of the method has been published by the University of Birmingham. Also emerging from the University of Exeter and helping to explain what happens in such community transformations, is the notion of Distributed Leadership.
Community is a living organism as much as each human being that comprises it. Wendell Berry challenges us to see every sick person in terms of their community context:
“I believe that the community – in the fullest sense: a Place and all its Creatures – is the smallest unit of health and that to speak of the health of an isolated individual is a contradiction in terms.”
If you are used to thinking about health in terms of individuals – yourself, a friend, a family member – then Wendell Berry’s quotation on this page may seem strange. For healthcare professionals to do their jobs by seeing every sick patient primarily as an integral part of a community, may seem even stranger. Wendell Berry’s ‘place with all its creatures‘ can range from a family (including pets and birds in the garden), to a homeless hostel, a street, a place of work, a school, the local bar, a run-down housing estate (such as The Beacon and Old Hill in Falmouth – see opposite) … right up to the nation and the planet. Which ‘place’ or context to consider will depend on what helps to make sense of the particular problem. But a context there will always be.
Delving into that context to find the problem’s roots will often reveal the root solutions. These are usually more satisfying and sustainable than the ways people often use to cope – alcohol, smoking, arguing, self-harming, harming others, taking prescribed medications or becoming lost in the NHS labyrinth. So how can you delve into the context and roots of the problem whilst still taking the immediate problem seriously? This is a great skill. It is the famous Patrick Geddes dictum “Think global, act local” applied in the intimacy of the consulting room or wherever a conversation happens. In terms of medical practice it probably applies to the majority of primary care consultations to some extent. Often this involves listening to what the person says, rather than what they mean. The crucial condition is a combination of compassionate presence, mindful listening and moral imagination (this is a link to CONNECTED dimension – return with ‘back button). Health visitor, Hazel Stuteley, has a fascinating story of successful transformation of context from her time working in Falmouth (see main panel this page). Hers was a very particular set of circumstances from which a great deal can (and has been) learned. Other approaches such as Social Prescribing are more widely applicable and dealt with in the next section.