Community Health Creation
– from tidy medicine to messy medicine

There is a fundamental structural difference between mainstream healthcare (where the ill are cared for), and communities (from whence illnesses emerge). Essentially healthcare has become overwhelmingly rational and hierarchical, whilst communities, particularly communities of residence, have always been essentially developmental and organic. This difference in culture is such that each has trouble in understanding the other.

Cultural Structure Diagram-2cropped

 This diagram aims to illustrate differences in cultural assumptions. Most of the UK National Health Service (NHS) sits firmly in the hierarchical and rational half of the picture. This is largely through the dominant influence of science and technology and the hierarchical and competitive culture of big industry. Rational thinking is often called convergent – it narrows towards a definable solution. The opposite, divergent thinking, describes the world as an ‘unfolding process’. This expression comes from a very accessible article on systems thinking by Martin Sandbrook from the Schumacher Institute in Bristol, UK . Rational thinking is often also linear thinking – following a line of thought from a definite starting point to a definable conclusion. The opposite here is non-linear or complexity thinking characterised in the ‘Developmental’ corner of the diagram. For a clear and concise explanation of this, using some of the vocabulary of complexity theory, go to the article by Anthony L. Suchman.

The use of dominant rational, convergent, linear thinking has led to remarkable achievements in the treatment of serious diseases. This has shone a bright, even heroic and glamorous, light on this aspect of healthcare. But bright lights cast deep shadows. Lurking in those shadows is the caring part of health and social care, along with the root causes of illness within communities. The structure and dominant assumptions here are quite different. These are generally neither heroic nor glamorous. Extreme examples such as the Beacon and Old Hill estates prior to their transformation were a miserable and often terrifying mixture of poverty, deprivation and casual violence. On the other hand, the community development described in the social prescribing and the acts of kindness examples are moving and gratifying, but not heroic, nor glamorous.  Trying to tackle any of these through hierarchical structures and rational argument are doomed to failure. However, being wholly ‘Developmental’ or ‘Clan-like’ risks achieving no change at all. The Falmouth transformation started with an innovative and creative set of actions arising from the grass roots of the community, and using divergent, non-linear thinking (green corner of diagram). But essential to change was the incorporation of a partnership organisation. This required shifting slightly towards the blue corner and occupying a space somewhere in the centre of the diagram – an area of paradox and uncertainty. Complexity theorists tell us that this is the best place – being at the ‘edge of chaos’. For an explanation of this and other complexity science terms go to this article from the University of Calgary.

Kermit Ruffins – New Orleans jazz legend

 GP leader, Marshal Marinker, famously described general practice as the ‘jazz of medicine’ and the general practitioner as the ‘bohemian amongst doctors’. This corresponds to the green corner – the top-right Developmental part of the diagram. But bohemians tend to freeze in unheated garrets! Norwegian professor of general practice, Per Fugelli, warns that we should not linger too far towards the top of the diagram!

“…souls and blues are valuable parts of general practice, but so must be research, construction of our scientific foundation and self-critical appraisal. Our humanistic profile, our commitment to the person, our identification with the art of medicine may be a hiding place of incompetence or a masquerade for professional stagnation.”

This is another plea for occupying the centre of the diagram. UK general practice, though embedded in the NHS, is not an integral part. This gives practices the freedom to adopt a structure which seems to best suits their needs and gives the possibility of enjoying the edge of chaos. Unfortunately, recent financial inducements, legislative change, commercialisation and almost an obligation to follow guidelines constructed by specialists have dragged general practice away from the zone of complexity down to the bottom of the diagram where community engagement is much more difficult.  

Wendell Berry’s quotation in the panel at the beginning of this dimension is a plea for us to seek out root causes. This requires us occupy the zone of complexity – an uncomfortable place for some. Here we need different thinking, different knowledge and different skills from technocratic medicine. So should we leave the root causes to the politicians, local and central? NO! Ultimately, solutions will require government action but because of a web of vested interests, lack of understanding of the true issues, the inertia of institutions and often lack of imagination and courage, they are very unlikely to initiate the major changes that will ultimately be required. Only the people can start this process of change. Healthcare practitioners have a very important role in this because of our/their understanding of the nature of suffering at the local level. Whether a healthcare practitioner or not, there is now an urgent need to engage with the ideas in this dimension.


Community-minded: connect, notice context, relate, belong, embrace complexity, think ecologically, recognize social determinants of health, network, nourish, notice the natural environment, seek root-causes, be altruistic, practise reciprocity, uphold justice, pursue solidarity, beware of vested interests, seek inspiration, trust, be vulnerable.

Find out more and resource list in the ‘Discover’ and ‘Take Action’ pages