Ed Rosen, Principal lecturer, London South Bank University Faculty of Health and Social Care; director, Lambeth GP Food Co-op

Published in JHH13.1 – Shaping the invisible

I became involved in learning how to support change in the NHS firstly as education advisor at London Deanery where I led early work on patients as partners in post[1]graduate medical education. Learning to help the system better understand itself and change effectively and humanely brought me into leadership roles in workforce development, which launched my short-lived career as builder of new national learning systems otherwise known as NHSU where I was Head of Learning and Teaching.The Lambeth GP Food Co-op represents all that I’ve learnt over more than 20 years in working with communities and individuals both in the NHS and beyond. I am an experienced inventor.

We have learnt to take a flexible approach to engage in the co-design process Click To Tweet The Lambeth GP Food Co-op is a co-operative of patients, doctors, nurses and local residents. We build gardens in GP surgeries which are designed for food growing. Patients, many of whom are socially isolated and have long-term health conditions, are invited to become actively involved in food growing. The co-operative is the first of its kind in the NHS but the ideas which have inspired our work are not new and some of these ideas predate the creation of the NHS.

The borough of Lambeth is located in South London with a population of 313,000 and is an inner-city borough, it has significant levels of social and economic deprivation as well as nearly 40,000 residents with one or more long-term health conditions. Last year, the borough’s Food Banks reported that nearly 15,000 people had accessed food supplies from one of the five Food Banks in the borough. There are also pockets of conspicuous wealth dotted across Lambeth, each of which reflect the growing prosperity of significant numbers in our local community. We will return to this dynamic between unmet need and emerging abundance as we explore the key themes which have influenced our thinking since the Lambeth GP Food Co-op began its life in March 2013.

The Lambeth GP Food Co-op emerged as an idea from conversations that included patients, GPs and others at Lambeth Walk surgery in May 2012. These informal conversations had been going on for some time and were focused on engaging patients specifically from the Expert Patient Programme on exploring new roles that they might take on within general practice and a wider NHS environment. We were interested in discussing how new roles might be best supported within a transformed environment in general practice. The informal discussions allowed us to think far beyond the role definitions that we had begun exploring, and these included patient facilitator, patient mentor and patient navigator to include patients and professionals being engaged in transforming the actual space in which general practice exists. It was a ‘what if’ conversation.

Could we transform and creatively use unproductive space in a GP surgery to engage patients in productive activity? Could we transform an alleyway into a food growing garden? Could we create a network of food growing gardens linking separate GP practices into a borough-wide organisational network? Could we co-design and develop our own model of people-powered health across our community?

Funding was secured from Lambeth Council’s Co-operative Investment Fund and match funding from the newly established Lambeth Clinical Commissioning Group. We began a three-year development cycle from Spring 2013 with the following aims and objectives:

• Work collaboratively with GP surgeries to create a resilient borough-wide network.
• Transform unused space in GP surgeries into food producing gardens.
• Engage patients especially those with long-term health conditions who are often socially isolated and lonely in gardening.
• Create a community-led co-operative embedded in general practice as a model for a wider health community
• To build a new social business which would sell locally-grown produce through procurement to a local hospital.
• Provide employment pathways into the horticulture/ fruit sector for local residents who are currently inactive due to poor health.

We began a three-year developmental cycle which included creating a sustainable network of GP surgeries, ranging from a single-handed practice to a multi-partner organisation. We worked with a diverse range of GP surgeries with the aim of deepening our learning about the project’s fit with different organisational forms of primary care. A further aim was to deepen our learning about change in general practice by working with a diverse collection of GPs and their organisations. One of the challenges we faced was to introduce a food growing garden which went beyond one model fits all. We worked as far as possible with patients and staff on a co-design process which more often than not resulted in a food growing garden designed to fit with the spatial requirements of the individual surgery and the cultural acceptance of the project as presented in the form of a garden. This was time consuming and required skilled, patient facilitated dialogue which enabled everyone with an interest to find his or her voice and contribute to the eventual launch of a garden in the GP surgery. We have learnt to take a flexible approach to engage in the co-design process which has often resulted in us changing our original ideas and expectations. For example, we began probably naively, thinking that we could build gardens in all GP surgeries who were interested in working with us. This was not the case and for example at Edith Cavell surgery, we discovered that there was absolutely no physical space onsite for a garden except on the roof which had no railings and therefore was impractical.

We overcame this problem by linking Edith Cavell into a large garden at Gracefield Gardens at Streatham High Road, with Gracefield Gardens becoming the “hub” for Streatham High and Exchange surgeries as well as Edith Cavell.

We began building the Lambeth GP Food Co-op at a point in time when there was significant turbulence in the wider healthcare sector which we used as opportunity to introduce what appears to be on the surface a simple idea: building gardens in GP surgeries. The pause introduced by the Coalition government in 2012/13, with implementing the Health and Social Care Act provided an opportunity for beginning a local innovation through which several policy themes were interwoven. These included a more radical approach to direct patient involvement in the organisational life of general practice: readjusting relation[1]ships between the wider general practice workforce and the local community; exploring the creative use of ‘Public’ space in general practice and deepening our understanding of what it really means to work together as a community of co-operators. Could almost complete strangers, many of whom were not very happy co-operate? Our theoretical framework included for example, Richard Sennett’s: Together: The Rituals, Pleasures and Politics of Co-operation. The work of the Late Professor Bob Sang. (Better Health in Harder Times: Active Citizens and Innovation) on the Frontline. Policy Press 2013, provided a rich and radical conceptual landscape which helped us think about patient empowerment in a community context, its potential and its limitations. (Better Health in Harder Times: Active Citizens and Innovation) on the Frontline. Policy Press 2013, provided a rich and radical conceptual landscape which helped us think about patient empowerment in a community context, its potential and its limitations.

Our first photograph (above) shows members of the Lambeth GP Food Co-op building a garden at Mawbey Health Centre in Vauxhall. Andy who is seen at the fore[1]ground of the photograph is a member of the Lambeth GP Food Co-op but his real claim to fame is he previously built the stages at Glastonbury. He is contributing his professional skills, personal knowledge and organisational expertise developed primarily at Glastonbury and else[1]where, in helping build in a physical sense the garden needed to be used by patients who are unable to do so. This is community mutuality in action. It is one example of the hidden potential in all our communities to draw on what we have across our populations and to use people’s potential to create new forms of health generating people-centred social activity.

Our second photograph (p34) is of Hilda and Bernadette. Hilda is a midwife and master gardener who has been facilitating the group at Lambeth Walk surgery at Kennington. Hilda is a founder member of the Lambeth GP Food Co-op and represents the small group of nurses with expertise in food growing who have facilitated many of the patient groups involved in food growing.

Our third photograph (below) was taken in mid-July 2013, when we opened the garden at Lambeth Walk surgery to the wider community. If general practice is to survive in the future, it might need to become more community-based, and we think this photograph expresses how an empowered community could be engaged with its local health and wellbeing centre.

Buckminster Fuller once wrote:

‘If you want to teach people a new way of thinking, don’t bother trying to teach them. Instead, give them a tool, the use of which will lead to new ways of thinking.’

The Lambeth GP Food Co-op, from organisational change perspective could be understood as a tool for catalysing systems change at local levels. It has acted as a tin opener within the local system from which emerged the first signs of new thinking about social co-production, patient self[1]management and active citizenship. The concept of social co-production is being explored at different levels across the project’s activity and we are still at a very early stage in thinking about how models of social co-production resonate with our experience of working with patients, doctors, nurses and others in the actual task of building gardens, planting seeds and growing food.

If general practice is to survive in the future, it might need to become more community-based

We have extrapolated from the Expert Patient Programme, an approach to self-management which we have shaped to meet the needs of our project and have drawn inspiration from other self-management processes and systems including self-managed learning and self[1]managed work teams within management and business. To what extent has the project contributed to deepening our understanding of patient self-management beyond a disease specific context into a wider organisational cultural context? Do patients have the potential to become active and purposeful partners with health professionals in the future management and leadership of primary care. If patient participation was the answer, what was the original question?

We are a co-operative. We are a community-led co-operative at an embryonic stage in our development having spent three years developing ourselves, our networks and our vision. The co-operative provides a home for us to begin exploring ways in which the NHS in its widest sense belongs to us and we belong to it as taxpayers, users/patients, decision-makers, active participants and critical friends. (NHS Constitution 2012: ‘The NHS belongs to us all.

In June 2013, we were awarded the Best Sustainable Food Initiative in the NHS by Public Health England/NHS Sustainability Unit. This came as a wonderful surprise to me personally as we hadn’t actually grown anything. By early 2016, the project includes nine GP surgeries with more expressing an interest in joining the network. Last year, we extended the Lambeth GP Food Co-op into King’s College hospital. The Trust allocated the Jennie Lee garden for food production as their contribution to developing a partnership with the Lambeth GP Food Co-op. It is a rare example of a community-led, GP focused project working with a large acute hospital involving patients from local GP surgeries growing food in a hospital environment. The food grown from across the project will, in time, be used in hospital menus to feed patients. We hope Aneuran Bevan would be delighted to know that the Lambeth GP Food Co-op is blooming in his partner’s garden.