Cash and collaboration – promoting health in South London

Taking time out from the future of work I have been reflecting on a research report commissioned by the Guy’s and St Thomas’ Charity, a 500 hundred year old foundation committed to improving the health outcomes of the residents of the London Boroughs of Lambeth and Southwark. 

The publication, ‘Personal perspectives on urban health and wellbeing’ is a rich and thoughtful examination of the specific challenges facing the residents of inner city South London. It was written by design consultancy uscreates and is more about analysis than prescription nevertheless it raises important issues for organisations seeking to achieve social impact by working alongside communities.

In summary, the report identifies the specific health and wellbeing challenges facing Lambeth and Southwark as emerging from the nexus of three factors:

• Urban environments can provide proximity to many health services and opportunities such as employment and social activities that help people keep healthy and well. However, the city also brings with it unhealthy lifestyle opportunities, safety concerns, noise and air pollution, and the busy and transient nature of it can also be stressful and isolating.
• A diverse mix of people in terms of age, ethnicity, sexuality and culture can foster strong communities, including social and faith groups, which can provide informal networks and support. However, it also means a complex mix of specific requirements from the health system which are not always met, positioned or communicated in a way which achieves take-up. This can be compounded by language barriers and different assumptions and practices around managing health.
• Deprived areas are often unhealthy settings, with poor quality housing and high air pollution. However, deprivation does not automatically equate to ill health. Among the people interviewed living in deprived areas, many demonstrated resilient behaviours and aspirations. For many though, high living costs mean they’re focusing on trying to make ends meet rather than how to prioritise their health. They often don’t have the time, headspace or money to actively manage it. Instability of housing was a strong theme and had a significant impact on people’s ability to establish and maintain social support networks.

There is much that can be said about these conclusions but a key implication is that in a setting like Lambeth and Southwark traditional forms of public service engagement and delivery can be problematic. Quite simply, the complex, changing, unpredictable (and to an extent unknowable) nature of urban social life is not well suited to the tendency of public services to treat local citizens as if they are the same as each other, need the same as each other or want the same as each other.

In ‘high touch’ service areas like health, public sector productivity arises from the quality of design and delivery but also, crucially, the degree to which that provision elicits responses from citizens. Outcomes arise from the way services, civil society and individuals connect. But, however hard managers try to be agile and sensitive to difference, public services tend to make an offer based on a universal conception of need. The more complex, diverse and under pressure a community the less likely this conception is to match the reality on the streets. The challenge here is not simply to make the public service offer more responsive (which is, of course, made harder by austerity) but to help shape community capacity, need and aspiration so as to get the best outcomes. 

For charitable foundations, and those of us who might advise them, this suggests two imperatives. First, as much money as possible needs to be placed in the hands of citizens themselves. As we know from the growing evidence about cash payments in places like refugee camps putting resources, even quite limited resources, in the hands of people themselves tends to lead to the money being used more efficiently and more creatively than if that money was spent on their behalf by well-meaning agencies. Health promotion isn’t the same as humanitarian aid so it would be a matter of giving money to community activists to instigate projects rather than direct payments to individuals, but still the practical and ethical principle of putting as much money as possible directly into the hands of communities applies.  

Second, the value added of foundations lies not so much in delivering or commissioning things themselves but in facilitating the civic economy. This means supporting civic actors with bespoke skills and advice, putting in place light touch incentives to help dispersed funds get used effectively, making connections between people and groups so they can collaborate and learn from each other, having the trusted capacity to intervene when things go wrong or tensions emerge among civic activists, and helping to smooth the connections between diverse community initiatives and regulated public service delivery. Community activists and civic entrepreneurs can be highly effective in mobilising social action but they often lack the time, confidence and resources to work at the edges of their practice, publicising, connecting, scaling up. This is where overarching foundations can really help. To put it another way, it is less about being a supplier in the civic economy and more about being an investor, market maker and facilitator.

The Guys’ and St Thomas’ report helps us understand the nature of the community it serves but, arguably, its most important implication lies in the way charities like this develop their role.