Recently, I was asked whether I’d seen a model or relevant description of what partnership looks and feels like when you’re working with a systems mindset.
It made me think about mindsets, and how important they are to our work, and the way I have needed to shift my mindset in the dual role that I have for GM Moving and GreaterSport. More on that later.
So, I started asking around and gathering stories and different perspectives, and Warren Heppolette started to put this diagram together in response to the question, which we discussed and added to.
“I had seen it as a continuum where the perspective or mindset develops with the ability to realise objectives according to new frontiers”.
Individual Mindset: Manage to job role. Capability restricted to skills and capacity. Possibility realised through what can be developed.
Organisational Mindset: manage to direct accountabilities. Capability restricted to organisation. Possibility realised through what can be controlled.
Partnership Mindset: Manage to reciprocal agreements. Capability restricted by breadth of partners. Possibility driven by what can be agreed.
System Mindset: Manage to framework of rules. Capability restricted by breadth of partners. Possibility driven by who can be attracted to participate.
Societal Mindset: Operates through norms and values. Capability & possibility extended through both the absence of barriers and the ability to act.
There’s a question for me about whether it’s a continuum, whether one is inherently ‘better’ than another, or whether we need to be able to apply different mindsets in the different spaces we occupy? I can’t think of the ‘right’ diagram, but perhaps more like this:
Why does it matter?
Because more and more of us are working for community, societal and system outcomes as much as/rather than partnership and organisational ones.
As we adopt place based, integrated ways of working, in service of and alongside people and communities, our mindsets are critical. We are finding a new balance between internal leadership and external leadership; representing the needs of our specific organisations and representing and giving voice to the needs of our people and communities. To live out the principles of reform and transformation in practice, mindset shifts are key.
Personal reflectionson roles and mindsets
Just over a year ago, I took on an organisational leadership role, alongside my system leadership role on GM Moving. GM Moving is a shared ambition, a whole system approach, a movement, a plan and many other things- but not an organisation.
We thought hard about whether this was the right move for GM Moving, for the organisation, and for me personally, as I’d spent the previous three years leading the movement in a ‘co-owned and co-located’ role for Greater Manchester, with an permission (actually, an expectation) that I would take a societal/system mindset. This had proven itself to be vital to the approach and the progress we were making together.
This GM Moving system leadership role is funded by GM Combined Authority, GM Health and Social Care Partnership and Sport England, and hosted by GreaterSport, a charity and the Active Partnership for Greater Manchester which plays a vital leadership role in the system.
The original role had no organisational drivers, no organisational ego, no territory to protect, no team to manage, no budget to maintain. (And on a personal level, it was quite liberating to turn up to work each day solely with shared purpose in mind). The boards, the investors in the original role, and some trusted colleagues challenged the thinking from different perspectives and considered it carefully before, and as we took the steps forward, and we have kept returning to the conversation to check and challenge throughout.
As Warren reflected, when we talked about this today “there was/is still a risk to be managed, because we are tying ourselves to things we cannot manage or control. So it’s not without challenge, but the positivity comes with the expansion of possibility“.
In the dual role I now hold, it’s important to ensure that organisational considerations are not in the way of shared purpose or mission, and to ensure that the system mindset doesn’t undervalue or limit the organisational role or contribution. So far, I think we’ve got it just right. We keep talking about it. It iterates forward and evolves.
Practically speaking, each day I spend some time with an organisational leadership mindset, some in the system leadership of GM Moving, some in the wider Greater Manchester system leadership, and sometimes supporting national leadership and thinking too. Sometimes I occupy these spaces all in one meeting or conversation and have to shift my mindset multiple times.
They aren’t mutually exclusive, of course. They usually complement and feed off each other in a mutually supporting relationship. The leadership role GreaterSport plays in GM Moving is fundamental to it’s success. GM Moving is fundamental to the success of the wider Greater Manchester mission and to the national ‘Uniting the Movement’ strategy.
How does it feel?
The original question was how does partnership look and feel like when working with a systems mindset.
This sums it up for me: liberating, hopeful and full of possibilities.
Leading in service of and alongside people and communities is easy. People, relationships, trust are at the heart of every day. Work is fun and it feels creative to explore possibility with others working towards shared purpose and ambition. I’ve written before about the difference between collaboration and partnership working, which also feels relevant.
Of course, it’s not always easy. Many people would find it particularly difficult to work in a dual or blended role like this. I enjoy the challenge and relish shifting my mindset and translating understanding and experience from one space or conversation to another. There are things that help, such as making the dilemmas and potential conflicts explicit, talking through any issues that arise openly and honestly, and working with people who are comfortable in complexity. Holding multiple perspectives is key. Being able to step outside of role and see the world through others’ eyes.
As I’ve thought about it, there are lots of examples where people are playing these blended roles. Greater Manchester local authority Chief Execs all hold GM-wide responsibilities, aswell as responsibilities and accountabilities to their place. Our political leaders take on portfolio leads for themes aswell as community and locality leadership roles. We have all needed to straddle between individual, organisational, partnership, system and societal spaces as we have worked togehther through the pandemic. It’s easy when the outcomes all align. Less so when organisational drivers are at odds with partnership or societal ones.
There are a couple of other questions worth exploring on another day, if mindsets matter so much:
Is there a set of mindset ‘characteristics’ that best enable culture change and system change?
If so, how do we support mindset shifts that best enable change?
There’s plenty out there to help us think about this and more work to be done.
Scott Hartley reminded me of the Patterning Instinct book that we’d both read a while back, and had led to our blog on culture change.
He spotted this, from the Social Change Agency, which offers something to the conversation too:
We are doing some work with colleagues across the system and our evaluation partners on the mindsets and capabilities to work in complexity, and the human learning systems work has much to offer in this area.
This is a challenge for many of us and it holds some tensions and dilemmas at times. The organisational challenge can also be influenced by factors external to the partners who are trying to work together differently. There are many examples of this; regulators, funders and ministers to name a few.
I also wonder whether operating with a system or societal mindset is only really possible when we can come from a place of security, confidence and abundance rather than one of scarcity, fear and threat? If we are fearful for our livelihood or not confident about our individual needs being met, we may find it very hard to to think with an organisational, system or societal mindset. If we fear our organisational role or position, are we are more likely to adopt an overly protective or territorial mindset and struggle to think about partnership or system outcomes?
And are our measures of ‘success’ the continued existence of our job role in it’s current form? or the role of our organisation?, or would success be achieving the community and societal outcomes we set out to, even if our role is no longer needed in it’s current form. Leaving our individual or organisational ego at the door is often difficult when we have one eye on job role/security and the sustainability of the organisation, and it can challenge our objectivity and impartiality too.
It all takes courage, trust and confidence in the power of what we are doing to balance these dual/blended roles and hold different mindsets at the same time. It’s not ‘either/or’, so there is lots to draw on from Lederach as usual; about how to turn potential conflict into transformational change, work in multiple timeframes and with multiple lenses. It’s worth reading this blog.
What feels important as we work this out together, is that we are thoughtful about it. That we notice mindsets that help and hinder, and observe our thought processes and those of our teams/colleagues. That we feel able to talk about mindsets, behaviours and ways of working that are narrow and are hindering progress towards shared societal purpose and ambition.
We’d all welcome other things to read and link to, and welcome hearing about your experiences. Why does it matter? How do we create the conditions for transformational change? What are we learning about ourselves along the way?
Look forward to hearing from you!
Warren shared the diagram on twitter, ahead of the blog being published. That in itself prompted some good observations, which I’ve included below:
And some further reflections from @annarandle, Collaborate which make good sense to me.
“I think you are right that it’s not a linear progression, but an ability to shift between different mindsets that is the skill. I wonder if it might be experienced as a progression in one’s professional development, perhaps, as you realise there are other ways to view problems and you begin to expand the lens; but I don’t think one replaces another/others completely…. Or perhaps even more specifically, I would suggest that perhaps the skill is holding multiple mindsets simultaneously (rather than moving between) – ie your big picture objective may always be societal or systemic (improving physical activity; establishing collaboration as a route to social change; and you need to work through different mindsets (or lenses) to achieve it – systemic, organisational, individual etc, often at the same time“.
And some more observations from Elle;
“Part of why I like Kegan’s model is that it’s about development, as in you can (with effort) gain greater capacity and maturity, and see more things as object. But it doesn’t view the stages as milestones, rather it assumes you fluctuate between different states and encourages you to be mindful of which one you are exhibiting in different circumstances or different relationships. We all have the tendency to be quite stage 2 when we’re hangry for example, our need for food takes over and we become more impulsive and less capable of considering other people! One of the things that it has helped me see more clearly is when a disagreement is because the lens people are looking at the issue through is from a different stage”…..
“The transformation from stage three to four is what the experiential learning approach of adaptive leadership tries to bridge. It’s a tough ask for people. Often it’s about reaching a capability frontier where they realise that being seen to be the best cog in the machine (a crude version of stage 3) is not enough to achieve what they want. And it can be quite destabilising particularly for people who have been cultured to think that external validation is the key to success (grades, promotions etc). But it’s vital for the kind of work you’re talking about.“
The Activity Alliance Strategy has launched today, at the same time as a group of GM Moving partners were continuing their work, started in the pandemic, to build back fairer with disabled people and those living with long term conditions.
The meeting was another positive, hopeful and optimistic session, with leaders from our leisure trust network (GM Active), Seashell Trust, Empower You, GreaterSport and Sport England. Activity Alliance partners, usually in attendance, were quite rightly, busy launching Achieving Fairness.
The meetings started by considering the latest data and strategic picture with:
Alongside the data, evidence and strategy, we heard insight and stories from those who are delivering wellbeing, leisure and physical activity opportunities in the community.
Here’s some of what we heard:
“The drop in active lives data was expected, but what is good to see is that we are at the beginning of our journey back“
“People do want to come back“
“Demand has gone through the roof“
“People who weren’t previously interested in activity are just itching to get out“
“For some people, the online offer is what they want to stick with. It’s made life easier for some“
“We’ve been able to open up our facilities for specialist populationsas part of the Covid-19 response and support“
“Even when we get to June 21, we will still have some very nervous people, so we need to plan for that“
“We need to capitalise on the energy that people have and meet the demand in different ways“
“Some people want to come back to the activity the way they had it, which isn’t always possible at the moment, so we need to be honest and explicit about what is possible and keep communicating clearly with people“
There was a real sense of wanting and needing to share expertise, learning and experiences in this time, and a recognition that we all have a role to play in this.
“We’ve done a lot of activity online, and we’ve seen the benefits to the individual and to carers aswell“
“There is a need for online, outdoor and indoor offers to provide opportunities for all different mindsets and needs with regard to the recovery“
The group has been working together on a commitment to inclusion of disabled people and people living with long term conditions, which we agreed this morning to share shortly. This commitment describes what we are aiming for together over the next 10 years as part of the GM Moving in Action strategy and will create a framework that individual organisations can use to guide their approach and work.
The group are keen to learn from people’s digital experiences over the past year, and there is a proposal to conduct some local research to understand what has worked that we can keep, build on and adapt for the blended world that we are moving to, which we will be able to share more information about soon.
There is real potential to work together as collaboratively as a group of providers to meet the needs of disabled people, those living with long term conditions and carers, and to ensure that digital inclusion is at the heart of this.
The group agreed that Activity Alliance’s 4 key objectives should shape our collective approach within the GM Moving in Action strategy, which we are writing together. This is an important next step in clarifying our shared purpose, objectives and ways of working.
All in all, a very exciting and energising conversation with a committed, passionate, experienced and skilled group of people.
As a follow up to this blog, written last year, we brought a few people together from the world of sport and physical activity sector to explore the question in more depth.
As part of the GM Moving Strategy Refresh, we also convened a conversation on this topic, the write up of which is here.
A small group considered the following questions and have agreed to share these reflections…
What it is/what feels important for sport to play it’s part in a whole system approach to active lives and tackling inequalities?
The approach needs to be place based, building on the strengths of people and places, with paid leaders working alongside people in the community with a codesign approach right from the start. It’s important that we lead with community engagement every step of the way. It’s also crucial to understand how communities organically grow…with the right conditions.
It helps if sport organisations are really clear about their purpose, their values and reflect on their culture and how this aligns with the approach and way of working.
There were some observations that small/micro scale approaches were helpful in the first instance, not dropping programmes and initiatives in for delivery from the top down. Uncovering local interest and need and/or existing activity and building on that is a great approach. Sometimes it helps for the National Governing Body (or other sporting/official body) and their brand, is invisible.
”It is not a case of selling what we do into areas but more supporting where we can, being flexible to help specific community needs and taking time to understand and build trust… also know and be comfortable that at the end of all this people and communities may not need and want your help“.
It was also recognised that some of the things we need to change, are out of local reach. There are macro, policy issues that we need to tackle, – connect between Dept for Transport and Dept for Education.
Some helpful observations on approaches that aren’t helpful, in our experience so far..
Parachuting in programmes and products
Not doing ‘to’ people
Programmes that are the same no matter where you are in the country.
Top down ‘delivery’
We considered what is the art of the possible, that feels helpful…
Working across activities/sports…. could we get to a place where a sport body is enabled to care about ‘active people and tackling inequalities’ aswell as the number of people engaged in their sport, member of their club or NGB?
Connecting people to their assets and places.
A systemic approach
Walking, running, cycling, swimming, fitness and football- 6 key activities that drive 90% of active minutes.
Complex, systemic and interconnected issues- safety and fears around safety.
Imagine if all sports organisations supported people to cycle to their activities?
What helpsus to work in this way?
Data, mapping, insight and local knowledge is key. As is an understanding of places, institutions, organisations and ‘folklore’.
Conversations are key. Engagement in the community, human to human relationship building and understanding is best developed through conversations.
Bringing people together across the teams is important too For example, bringing communications leads together with insight, data and place based leads and other members of the team. If the marketing and communications leads don’t understand the approach, it can really jar when branding and style of communication doesn’t align with the approach.
Novel approaches to capturing change and measurement are key, as a lot of the value of the early work is invisible; relationship building, collaboration, developing trust, connecting people across communities and organisations isn’t easily measured and put into a spreadsheet.
Different funding mechanisms and different approaches to investment can really help, and in equal measure, there are procurement and funding approaches that really get in the way of innovation and local leadership. The GM Moving evaluation has brought forward some enablers for change that I’ve written about before, here. And just as these things can ‘enable’ change, they can also block and disable change!
Bringing together diverse people and perspectives is really important.
Knowing that it will take time
What can get in the way?
It can feel alien to work in a place based way- not just to work in communities, but to work with them. It takes a different mindset, set of conditions and skills.
Branding of institutions and organisations that are seen as ‘outsiders’ to the place.
When funding and investment is tied to programmes, it can stifle creativity and the ability to respond to local need.
Lack of knowledge.
Language- eg the language of systemic approaches, Asset Based Community Development (ABCD) and so on. We need to use simple language that people can understand.
Language of ‘events’ ‘pop ups’
Mentality of build it and they will come
Assumptions and stereotypes about who people are and what they do/don’t do.
Perceptions of who something is for….
There was an interesting spin off conversation about sport, and how competition, badges, awards, races can be offputting for people of all ages. The idea that when you engage with sport you will need to work towards further, faster, better, longer is offputting. What about it just staying fun and social?
Language came up a lot. We talked about reclaiming the terms or running and cycling (runner / cyclist). People feel like that isn’t them.
There was also a conversation about local clubs. Some want to deliver their sport. Some want to play a wider part in their community. What should the expectations be of any club or organisation that receives public funds?
“Clubs need to be clear on what their purpose is. They might be a really competitive club and that’s their focus. And that’s ok”.
“Some clubs want to be a place where kids hang out after school- and that’s ok too”.
“All clubs ‘should’ be thinking about inclusion- everyone should be thinking about equitable approaches“
What does this approach take of us personally?
A learning approach
Developing new relationships
Moving from a supply focus to enabling
Comfort with not knowing- we don’t know what we’re going to deliver (yet) because we haven’t engaged with people and communities.
Shifting away from ‘plans, action plans, methodical approach’….
Looking forward to our next get together, where everyone has been invited to bring a friend along.
Some observations and thoughts that followed:
The brand being invisible….there are dangers to this which I have experienced. Involvement in delivery where the local provider was the focal point, their logo (the one that people recognised) was the one the one that was consistently used which in the end was to the detriment of other organisations which were contributing. I don’t disagree with the notion of invisible…just needs to be understood in terms of long term implications.
Regarding influencing….”not the case of going in and selling”. The role that we think Parkour UK have is one that is more as an influencing body than a governing one. We have a structured part of our community that ‘governing’ is relevant to…we equally have an unstructured part of the community which ‘governing’ is wholly irrelevant to. Its ‘influencing’ which is the key. We are developing a bit of a theory on this…
Regarding “approaches that aren’t helpful”…this made me think of the notion of a set of conditions within which some are turned up and down dependent of the area. Have you read ‘Poverty Safari’ …. a brilliant book by Loki / Darren McGarvey where he explains poverty and its impact. The most powerful chapter is The Ellie Harrison / Glasgow Effect one (towards the end) it is such an honest account. The last line about checking what you are punching before you connect is a lesson for everyone….essentially he misunderstood the messaging and I suppose this is what ‘sport’ needs to be careful of.
Regarding ‘competition’…the idea that it isn’t right for some is true but the idea that it isn’t right for anyone is false too. Parkour is an example of this…in its third generation it is exploring the question and for some it is very important. The first generation remain against …. it was and it art du deplacement (ADD) non competitive / spiritual etc.
I’m doing some thinking about networks. The networks we value. The ones that connect us to diverse voices and perspectives. Examples that come to mind are from my work life and my community life. Especially my community life. It’s how the different networks have points of connection that help to spread or grow a movement. The best example of this in the recent past was our community help/mutual aid network where I live. But the whole community works in a networked way, with PTA, Community Association, WI, Youth Club, Friends of the Park, the running group, cycling group, Adult Day Centre, Special School and beyond all having points of mutual contact so that conversations and ideas spread.
It’s worth thinking about how our social and community networks function at their best, and how they organise themselves differently, as they offer some insights into where our professional networks could work better.
A networked, social way of working is key to all my work in reform, transformation and change, and so is the formal system that my work locates itself within. So the question is how to make the best of both the formal and informal worlds and ways of working.
Thinking about the networked, social worlds we occupy.
When they feel good and make positive change happen, how do they feel? What are the characteristics that matter? Here are my emerging thoughts, which I’m still adding to. Some of these characteristics are visible and audible, some invisible, inaudible:
Diverse people, diverse perspectives, invitational, welcoming, growing, connecting to other networks and smaller networks within.
They enable/create conditions for smaller networks within/connected spaces
Interacting with formal and hierarchical structures easily and productively.
It feels important to share some of the problematic characteristics of networks too, so we know what we need our networks to feel ‘less like’ aswell as ‘more like’.
What came to mind for me are these:
Networks that it feels that we need permission or authorisation to convene- it feels good when things spin off and connect back informally- a bit like the second diagram below. In our community, new groups and networks develop and when they connect to the existing ones, good things grow.
The formal structures or cultures that mean that we hold back from connecting to someone that we’ve met and want to follow up with. It feels great when there’s an invitation and an explicit culture created around connecting outside of the formal spaces and structures. This happened for me last week when I met some new people in a network, and a few of them followed up outside for a meeting. And I was confident that spin off conversations would be seen as a positive by those who had convened the initial conversation.
Networks which feel overly controlled or managed from the centre or top. There is definitely a need for some convening or enabling capacity, but it’s best when this is fairly invisible. This can evolve over time, and it takes intentional effort in the ‘centre’ to create the conditions.
When I’ve convened or initiated a network, I love finding out that people are making connections that I don’t know about. This has happened with a lot of networks in our community; our running group, cycling group and others come to mind. That is a sign of success, for me. A sign of a something good growing. It’s not always easy to create this sense of ease or permission though- as people tend to look back to the centre for permission. So it needs to be an explicit invitation/ask and a sense of ‘celebration’ when people build relationships outside of the original network and do great things together.
In our recent health integration article, Sam Keighley and I explored the question of how to create the conditions for a flourishing ‘garden’ in place.
A question that keeps coming up, often with an element of tension and jarring is one about how to do things at scale, across the whole country. Scaling up, and “rolling things out” across the country, regardless of local conditions, contexts or needs are approaches that we need to move away from.
But how do we ensure that we are not just learning the same things and repeating the same mistakes all over the country? How do we enable transformational change to happen more quickly, if we are not in the business of top down, mandated approaches, and we know that the imposition of national programmes and projects aren’t often the solution to local needs?
So, I’ve been asking the question of a few people this week. What are the approaches that help the good stuff, the learning, the brilliant local approaches and innovations spread and grow? How do we create the very best conditions for change without duplication of effort and the risk of great solutions never being shared with colleagues in a different place?
Much of what people said took me straight back to the brilliant Garden Mind metaphor. People thought about their gardens and allotments and I asked them to think about how learning, expertise, produce, seeds and stories are shared between these places and spaces…
The overriding message is that we need to spread and grow the good stuff organically, without creating a monoculture that depletes the nutrients in the soil in the process…
Here’s what they said helps, and what feels important in it.. all entirely transferable into the world of leadership and change.
Swap seeds and cuttings
A teaching plot on the allotment for newbies
Sharing tools or expertise
Lobbying and influencing together for the things that matter to everyone (a tap, or a borehole)
Talking and sharing over a brew or a beer
Social spaces on the allotment for easy conversation- play plot for kids, clubhouse
People feeling close to their communities
Social membership for those who don’t want to grow stuff
Pooling resources and expertise
Giving away what we don’t need
Within all the sharing, collective action and generosity, there were great stories of healthy competition and the value in creating a sense of tolerable envy (a story of the size of someone’s marrow was shared!) and the ‘competition’ of the annual produce show, which perhaps drives innovation, aspiration and inspiration for the year to come… and hopefully doesn’t descend into sabotage or anarchy. Because of course, it’s all about good relationships, trust, care, compassion and a sense of perspective about what really matters.
MEASURING AND UNDERSTANDING WHAT MATTERS
Is it the size of the marrow that matters in the end? Or how good it tastes? Measuring and understanding what creates the conditions for healthy, tasty produce is surely as important as the number of things we grow?
In our work, the evaluation of process aswell as output and impact is vital. As John Hannen said in response to the first draft of this blog “Impact evaluation tells you how much/many, gives you a number and helps you with marketing your approach… process evaluation helps you understand what elements work, what conditions are necessary and gives you design guidance.”
And Jane McDermott added “process evaluation is where reflection or learning happens, it should also allow us to pivot or stop when what we are doing, experimenting and creating with isn’t working. It’s the space we ask for help, share knowledge and perspective to feed innovation.”
Measuring what matters and capturing the real value of our efforts is important. I’ve written about this before here, and in this poem.
Enjoy growing, sharing, spreading and creating the conditions for flourishing. Please let us know what works for you…
Last Friday was an important day in Greater Manchester. The Independent Inequalities Commission published their report, following their six month mission to examine inequalities across the city-region, consider how they should be tackled and outline specific, ambitious recommendations.
The report came in the same week that Jen Williams wrote her exhaustive (and exhausting to be reminded) report on the way the pandemic has played out in communities in the north of England.
Both of these reports highlight the structural and systemic inequalities between different places across country, and between different communities of place and demography within regions, localities and communities, and the disproportionate impact of Covid-19, which follows the same trend lines and can be mapped across to the data on deprivation, health inequalities.. and for my work, physical activity levels by place and by demography.
There is also the notion of a syndemic rather than a pandemic aligns with the independent commission’s frame. This article in the Lancet is a worthwhile read, in this context.
Even before the pandemic, Michael Marmot’s Health Equity Report had highlighted some pretty stark realities:
“Since 2010 life expectancy in England has stalled; this has not happened since at least 1900. If health has stopped improving it is a sign that society has stopped improving. When a society is flourishing health tends to flourish“. (p4)
“Large funding cuts have affected the social determinants [of health] across the whole of England, but deprived areas and areas outside London and the South East experienced larger cuts; their capacity to improve social determinants of health has been undermined” (p.4)
In his more recent report, Build Back Fairer, Marmot highlighted that “the levels of social, environmental and economic inequality in society are damaging health and wellbeing“.
inequalities in social and economic conditions before the pandemic contributed to the high and unequal death toll from COVID-19.
the nation’s health should be the highest priority for government as we rebuild from the pandemic.
the economy and health are strongly linked – managing the pandemic well allows the economy to flourish in the longer term, which is supportive of health
reducing health inequalities, including those exacerbated by the pandemic requires long-term policies with equity at the heart.
to build back fairer from the pandemic, multi-sector action from all levels of government is needed.
investment in public health needs to be increased to mitigate the impact of the pandemic on health and health inequalities, and on the social determinants of health.
“The links between ill health, including COVID-19, and deprivation are all too familiar. Less so have been the findings of shockingly high COVID-19 mortality rates among British people who self-identify as Black, Bangladeshi, Pakistani and Indian. Much, but not all, of this excess can be attributed to living in deprived areas, crowded housing and being more exposed to the virus at work and at home – these conditions are themselves the result of longstanding inequalities and structural racism“.
I could quote ‘Build Back Fairer all the way through this article, but it would be better to read it all. It makes for depressing reading, but it also give a sense of hope and optimism as it sets out some very clear recommendations for change.
So despite the fact that a tough challenge just got event harder, we can also see this is a a new milestone. It is a moment for us to collectively reinvigorate and reinvest the journey we started together. And we now have up to date evidence to support that.
What is the relationship between Covid-19, inequalities and physical activity?
Active Lives data for adults, that covers the first two months of the pandemic, Greater Manchester saw a steeper decline in activity levels than the national trend. Our children and young people data shows the same. Influences on activity levels are complex, and even more so in the past 12 months. But we saw concerning indications from early on, of a disproportionate impact of lockdown restrictions by place, by socio economic status, disability, race and ethnicity, age and gender.
Sport England and others have reported this through their ongoing research and insight through the pandemic, and we have continued to use it to guide our priorities and response to the ever changing context of a year of physical restrictions, fear and concern.
As Jen Williams says in her report;
“The disparity is familiar, mirroring Sir Michael Marmot’s brutal ‘10 years on’ report into health inequalities, published just days before the pandemic burst into the public consciousness a year ago. England’s health was ‘faltering’, he found, after a decade during which public health policy had drifted. Gaps were widening and as a society, we were effectively going backwards. And the North, with its pre-existing high levels of poverty and post-industrial economic weaknesses, had particularly faltered. Life expectancy was already falling backwards in some parts of it, even then”
Our team and networks have been studying health inequalities and physical activity data alongside wider social and economic trends for some years now, and we know that Marmot’s approach to proportionate universalism holds a key to turning things around.
Back in 2017, when we wrote the GM Moving strategy, we developed a whole system approach to tackling inactivity, with the aim of reducing inequalities.
From 2018, with investment from Sport England and the Greater Manchester Health and Social Care Partnership, we’ve been learning how to operationalise that approach in practice.
The design of our Local Delivery Pilot work with Sport England, was aligned to the proportionate universalism approach, influenced by Linden Rowley and her work in Greater Manchester and elsewhere. The approach was as follows:
Universal, population-wide interventions to engage and reach the whole of the city region’s 2.8 million population,
Locality wide interventions and approaches across our ten boroughs,
Targeted approaches by audience (people with or at risk of long term conditions, those out of work or at risk of worklessness, or children and young people) and by neighbourhood.
As such, our time, energy, resources and funding would be directed with a universal and targeted approach.
Our Walking City Region ambition was developed following an evidence review and analysis of the investments that work for physical activity (ISPAH link), and resulted in an approach that again, designed in investments for the whole of the Greater Manchester population, alongside targeted work to reach and engage priority audiences. This has evolved over time as we have developed new networks and ways of working to apply principles in practice.
The whole system approach of GM Moving seeks to address all the influences on physical activity behaviour; changing culture, systems, policy, the built environment, organisational and social factors, to create conditions that are ever more likely to shift the barriers to active lives and tackle inequalities.
It’s still early days. This is a long term strategy, and we have a long way to go. The pandemic has shone a light on and exacerbated the economic, social and health inequalities faced by people and communities across Greater Manchester, and we must all play our part in addressing them.
It is not enough for us to fix our gaze entirely on physical activity. We need to broaden our lens, and ensure that we play our part in tackling these wider inequalities. If we don’t, we will be creating unintended negative consequences at worst, and at the very least we will be pedalling hard into a fierce headwind.
*Say what the Marmot city region means and the Good lives for all in Greater Manchester. What is it that is moving the agenda forward? What is different – or intensified from what we are currently doing?*
Greater Manchester has committed to operating as a Marmot City Region. And we now have ‘Good Lives for All in Greater Manchester’ as a further guide to where to focus our efforts.
We also now have a set of national conditions that better create the context for a Marmot approach to active lives and tackling inequalities, in Sport England’s new Uniting the Movement Strategy, launched in January.
If we can work to these principles across the country, then we will have a far greater chance of making significant population scale change. But we need to ensure that we understand what this asks of us, as leaders, as places and as systems.
We have some challenges in this.
We need to tackle the causes of inactivity, not just the symptoms. Working together as a Greater Manchester system is the key to this. And we need to collectively influence the wider national context that keeps inequality and inactivity stuck where it is.
Michael Marmot’s work is powerful and compelling. In Greater Manchester, we know it holds a key to the way forward together. However, we are tripping up over our words, our understanding of the language, the data and the translation of Marmot principles in practice.
So together we need to articulate clearly, simply and positively, what people can do, and how they need to do it, if we are to give people across communities, organisations, sectors and systems a sense of self efficacy and turn the words into meaningful and impactful action.
For those in the sport and physical activity sector, Martyn Allison has made a helpful start. His Sports Think Tank article here is well worth a read, and something that leadership teams should be digesting and exploring together.
We all need to be having urgent conversations about what the Next Level report, and the commitment to Proportionate Universalism mean for:
Strategic decision making
Deployment of our teams
Programme and service delivery
Our collective public narrative
Our leadership behaviours
The good news is, that these principles in action are completely aligned and strengthened alongside our commitment to public service reform, people and community centred approaches, health and care integration. It’s not different. It should give us confidence that we were on the right path.
Now, we need to take it to the next level.
*What needs to happen, at different layers of the system? (national, GM, local, neighbourhood)?*
At the Greater Manchester level…
*And what needs to happen with the physical activity agenda alongside this?*
It is important that we are involved in wide ranging conversations and have seats at the the ‘main’ tables where people come together to address inequality. There is a need to play our leadership and influencing role in a sensitive way that helps others see the symbiosis with active lives, rather than risk the physical activity sector being seen to demand to be heard or coming into conversations in transactional ways, seeking funding, resources or to be commissioned.
Still need to add in..
Substance Consortia work on inequalities in activity data.
ICS – purpose and principles and the structure needs to flow from that. 2.8 million people. Then targeted work to place, communities of demography and identity.
This week, we held a meeting of over 140 people from across the city region, and with national colleagues, to consider the role of GM Moving in GM Recovery, as we start to look with greater hope and optimism for the future.
This session was a part of a phase of engagement in the refresh of the GM Moving Strategy, as we move into the next leg of the GM Moving journey. By the end of March, we will have listened to and engaged with over 500 people to consider the questions:
Why does GM Moving matter to you, and your work.
What are your GM Moving hopes for the next 10 years?
What will take us there and what might get in the way?
You can hear about this, in a short video, with Eve Holt, GM Moving Strategic Director.
You can read more about it here, and contribute by completing our survey here.
In the session this week, we also asked participants to consider what kind of ‘recovery’ they would like to see, as we emerge from the pandemic, how can being part of GM Moving help us achieve more than we can on our own.
I’ve written before about the journey and learning to date (2019 and 2020). This seems like a good time to reflect on where we are now and what next, as we are hopefully entering into a recovery phase.
Here’s a visual capture of the event on a slideshow you can scroll through, by Paolo Feroleto, which I love! You can see some of the key themes that came out of the conversations, in the presentation and in one of 16 breakout rooms on themes as diverse as culture, active neighbourhoods, inclusive economic recovery, health and care integration, mental wellbeing, building back better with the sport and leisure sector and system change.
Why does GM Moving matter to GM Recovery?
In conversation with Andy Burnham on the day, he was was clear that GM Moving is vital to recovery, and that our individual and collective recovery depends on it. His focus on mental wellbeing was striking. He said that we need to recognise the significant impact the pandemic has had on everyone, and use physical activity as the means to reconnecting with friends and family, enjoying the outdoors, nature and feeling better again.
Recovery needs to be for everyone. And there are very simple things that we can all do to support that. Throughout the interview he came back to mental wellbeing, to addressing structural inequalities, to the potential for health and wealth creation. He challenged me, and all of us across GM to lead. To create places, spaces and opportunities for activity and for wellbeing. A culture of moving. A movement that everyone can be part of. He reminded us of Active Soles. How simple, yet engaging that is. But challenged us to think of things that were even more inclusive… and to keep moving ourselves, to keep all of GM Moving.
So why does GM Moving matter to GM Recovery?
Where are we now, what do we need to do, and how?
Inactivity is the fourth leading cause of premature death worldwide, even before the pandemic. But since the launch of the first GM Moving Blueprint for Change, we had collectively been making great progress towards our goals.
Then Covid-19 hit, and even early on, the impact was big, for adults, children and young people. Greater Manchester has been impacted more severely that the country as a whole, and we have seen the widening of the gap in some key inequalities where we had previously been making progress together. These disproportionate impacts are as a consequence of deep rooted structural and systemic inequalities that exist between places, and between demographic groups. They impact on health and wealth, and they impact on activity levels. We knew this before Covid, and it has been brought into even sharper focus in the past year.
There are significant and ongoing risks to our people and communities at this time, which are deeply concerning.
The direct risk of Covid-19.
The physical consequences of deconditioning, loss of fitness, mobility and strength due to inactivity, accelerated frailty and deterioration of long term conditions.
Short and long term deterioration in mental health, and the rise of anxiety and depression, self harm, eating disorders as a consequence of lockdown, fear and isolation.
Longer term increase in the occurrence of non-Covid-19 conditions related to inactivity, such as Cardio Vascular Disease, muscular skeletal conditions, cancer, diabetes, mental health conditions, dementia and many more.
We are getting smarter about how we work with partners to gather, pool and layer disaggregated data to collectively paint a much more comprehensive and clear picture, so that we can better direct our efforts and resources to make the biggest difference to tackle entrenched inequalities. So we are working alongside emerging equalities networks to ensure we play our full part in putting Marmot principles into practice through GM Moving.
And yet, even in the pandemic, people have been resilient. This data from the GM mental wellbeing survey (Aug-Nov 2020) shows that exercise, spending time with family and friends, walking, gardening and spending time outdoors all featured highly in our ways to stay well. And we clearly recognise the importance green open space, of how our place feels, about good facilities, events and people behaving in a more community minded way are all key ingredients of wellbeing…. and this is what our work in GM Moving is all about. It has never been more important.
And it makes financial sense too. This research from Sport England and Sheffield Hallam University shows how we move and stay active is vital to the economy, to the public purse and to our individual development.
We knew all too well before the pandemic, that moving had been designed out of life. And we were starting to design it back in together. We were already changing culture, systems, policy, the physical, organisational and social conditions that impact and influence people’s activity behaviours. Because so many of these conditions are keeping the issue of inactivity stuck in place.
People across GM have done their utmost this year, to keep GM Moving, and it’s been amazing to see all the ways that people have adapted, innovated, created and supported different ways to keep moving. And we’ve seen culture, language, mindsets and values change really quickly due to Covid.
But let’s face it. Keeping moving has been really hard for many, with the barriers of the four walls of lockdown, with shielding, self isolating, fear of venturing outside. With the restrictions and limitations on sport, grassroots community activities. Many have been working and studying from home, glued to screens, with no active travel, not moving between meetings, and little time or capacity to build moving into lockdown life.
So we need to build on everything we have learnt about adaptation, the ways that people have engaged differently and digitally, and use this moment as an opportunity to innovate again, taking the best of what we’ve learnt together to design moving back into life in recovery as lockdown starts to release and the world opens up again.
And I have total confidence in our collective ability to do that. I believe we can quickly get those active lives graph curves heading upwards again, and bounce back as we redesign moving back into life, support health and wealth creation for all. For future generations aswell as for today and tomorrow.
Even in that one zoom room this week, and way beyond the room, we have people and organisations from across sectors, across the system, from every locality, and with our national partners who can work together to get GM Moving, connecting, socialising, having fun, playing and recovering together.
Because this is what we started together in 2015, and our people are our biggest strength. We have thousands of people who believe and understand why this matters. They have the commitment and energy to make change happen. We have influencers at the highest level in political and strategic leadership, and in every community across Greater Manchester.
We have people who can illuminate, explain and share stories. We have people who courageously step forward to lead, and people who courageously follow, bringing a crowd with them. We have people who hold and protect spaces in which people can do things differently, innovate, take risk, fail and learn. And we have people who shine a light on success, celebrate progress and lift everyone up when times are tough. And times have been really tough, so those with hope and optimism are needed more than ever.
This way of working hasn’t come out of the pandemic. We were already working to create the conditions for the people of Greater Manchester to work towards a shared vision of a healthier, happier, greener, more inclusive, and prosperous city region. And we knew that this would require a different way of working.
And we are learning what this takes in practice, through GM Moving.
Our evidence and evaluation work with Substance and Sheffield Hallam University is giving us the understanding we need, of what enables change to happen, when we’re addressing issues that are complex and stuck. This is helping us to illuminate, explain and share what works and why, and support each other to work in ways that will make the fastest and deepest impact. I’ve written more about about this here.
Katie Shearn from Sheffield Hallam University (part of the Substance Consortia Evaluation Team) explained what we have learnt, with some great stories of change from the local pilot, GM Active, on collective leadership for inclusion, working across sectors for mental wellbeing, and on how transformation of governance and processes is critical if we are going to remove barriers and blockages to engagement in the movement, and with people who want to move more.
These enablers of change are key to the way we need to work and lead together in this next phase of GM Moving.
So as we head into spring, and look forward to launching GM Moving in Action this summer, we are full of hope and optimism. We have total confidence in our collective resilience- as humans, as a place, as a system.
It feels like we have been pushing a rock up a hill, but we are optimistic that we are getting close to the top, and we can soon start to whizz down the other side.
So together, we can do this. And we know that people who lead and work in Greater Manchester support wellbeing and health in their teams, in their communities, in their social circles and families. GM Moving matters to all of us, at home, work and school and we all matter to it. We all have lots of parts to play.
I concluded my speech at this week’s meeting by sharing a few things that have given me hope and optimism every day of the past year. I see, feel and experience these things in every room and every conversation I’m in.
The absolute belief that moving matters. To people in every bit of our system. In every place and every community. This has never been in question during these dark days. GM Moving clearly matters to Greater Manchester more than ever before.
The commitment to making change happen together. Busy people, with demands and challenges have continued to show up and engage in this work all year. We can fill rooms ten times over with people who want to make their contribution to health creation. And thanks to the Zoom world, we can have bigger rooms and bring people together from many different places and perspectives, with ease.
A growing collective understanding of the enablers of change. So even though it’s a big challenge, and a complex one. There is great simplicity in it too. And we are creating the evidence base together about how to make culture change, sytem change and behaviour change possible.
And finally, talking to people just this week, I have been excited about our ability to bounce back.
A friend in Australia was explaining to me how readily people have returned to their activities, and have sprung back like rubber bands with gratitude for the opportunity. Ian was our team leader when I was a GamesMaker at London 2012. He said, in response to my question about grassroots sport in particular;
“Sport is the ‘last bastion of the miracle’, and Covid is no exception… your instincts are correct. The kids just run out like nothing’s changed. Parents are more grateful for the privilege of sport participation… so yes, like a rubber band, humans bounce back, I’m just hoping we all learn the lessons from lockdown… gratitude, simple pleasures and not being too busy for what’ important” (Ian Bond)
After talking to Ian, the roadmap out of lockdown was announced and we had our weekly Covid call the next day. A colleague who leads in the grassroots sport described a ‘frenzy’ of clubs, volunteers, parents and kids all keen to make plans and get things restarted. Not without it’s challenges of course, with damaged pitches from recent storms, and all sorts of new arrangements to put in place. But again. It gives me hope.
And even if sport is not for everyone, most conversations I’ve had this week with friends, family and colleagues have touched on the sense of relief and anticipation for the reopening of the things that matter to each of us; the gym, being allowed to go out more than once a day, walking with another family, group bike rides. And for many…the news of a vaccine, which will finally unlock the door of lockdown, take away the fear of being outside with others when particularly vulnerable.
The smell of the outdoors, the green spaces, the waterways and the chance to breathe, revive and start to recover.
The Chair of GM Moving, Steven Pleasant captured his key takeaways from the session, shared in italics below:
It was a brilliant session. It’s so important to find spaces to energise each other and not just transact. It was a privilege to participate and hear other peoples stories. I loved the inputs and the breakout groups. There is never enough time for the conversations we could have, but it does inspire and energise.
The key learnings from the day for me?
We’ve explored ‘moving’s’ clear role in recovery.
Andy said that GM Moving is the starting point at the heart of recovery – it’s the simplest way of people helping themselves.
And recovery is on many levels – it’s individual, families and community. Movement has a part to play for each of these.
The criticality is about looking beyond the physical health benefits that we’ve focussed on for so long.
We need to focus on mental health too – Moving is the key lifting your mood: As Hayley said – this is the immediacy of the impact. We feel these benefits in the moment, not just in the long term.
This is about wealth creation not just health creation? Active lives offer a massive contribution to economic well being and inclusive growth.
We have a big opportunity now:
Many more people are predisposed to moving – we have seen big increases in cycling and the number out on family walks. People been forced to explore the local – know their area, meet their neighbours (people have talked today about how more people being out and about in the neighbourhood gives a greater sense of safety; and success breeds success).
We have lots more champions and advocates. People want to feel better. We need an ‘army’ of advocates! There will be a high level of latent demand over the coming months.
There is an increased recognition of the benefits: People now understand the impact of moving to people’s mental health much more. It rings more true now than ever, and there is a wider link to natural environment not just on a treadmill.
We need to get the message right for this ‘moment’ – lift the mood, enjoy surrounding. Dave talked powerfully about how he used to frame physical activity in terms of fitness and now what it brings to him more personally and to connecting people and families.
There is a latent demand: for activity and connection. Many people are chomping at the bit to get out there and re-engage. That comes out loud and clear. Hayley talked about human beings’ propensity to spring back like rubber bands. We need to be ready for the demand, as it will bring it’s challenges.
So what is the challenge?
We need to rethink what we are doing, to be fit for the time we are going to enter. Andy set it out – but it’s not just what Hayley’s got to do (!) but is all our challenge.
We need to think about framing it for the individual: Kay from Alvaney GP Practice said “its about the small things ‘digging a trench’ – find the thing for the individual.”
We need to frame it to be inclusive; breaking out of the old paradigm of what physical activity is. Movement is whatever you want it to be – gardening, dancing anything. This is about designing movement into everyday lives. Actives Soles was a good lead in. The message needs to be: “keep moving”. It doesn’t matter how.
And we need to address the inequalities exposed by Covid (set out in Hayley’s slides) Katie Shearn highlighted the impact structural inequalities – reinforced by Shamime: how do we better the needs of women from different communities?
And also the impact of Covid: We lost the social aspect of physical activity for a while. What is our offer to shielders? Many have a loss of confidence in participating in activity. This was clear from the conversation in the chat.
Hayley’s hope comes from the fact that we are deepening our understanding of how we make change happen. The evaluationteam’s work is giving us a route map (as described above). Our strategic leadership enables collective leadership. We need to protect the space to do things differently. This is exemplified in our Local Pilot work together with our communities. Katie said we need more effective working across our sectors (and to break out of the silos). This echoed Andy’s call to get beyond our narrow organisational purpose to work towards our common ambitions. And we need the enabling infrastucture to facilitate our aim; such as legal, procurement, data sharing.
Hayley also talked about belief: in how important moving is. Dave’s hope is that we can now get beyond the need to convince people why this is important. Finally, she talked about commitment and how much people invest. Eve reflected on the waves of united passion from breakouts, and Yvonne Harrison reflected on the energy and diversity of people and sectors contributing today, compared to the start of the GM Moving journey in 2015.
Steven’s final messages to the group?
Grow that shared buy-in and common purpose.
Thinking beyond your organisation to societal challenges.
Look after yourselves and each other.
His hope that everyone had enjoyed it, echoing Eve’s ask at the beginning and how important it is to find enjoyment in the work.
Now, relax and enjoy the journey.
I am very grateful to Steven for capturing these reflections, and to all those who contributed and participated in the session on Thursday. Now, that spring has sprung, and there is renewed energy, we have a real opportunity.
So, let’s do this together. Let’s Keep Moving. Let’s Keep GM Moving and do all the things we love, for all the reasons we love them. Design moving into life for everyone, and recover together.
And enjoy the ride!
PS- here’s the blog post from the equivalent event from last year. It’s good to look back, to see how far you’ve come, even when there have been setbacks along the way.
Tom Howarth posted a question on twitter the other day, which stopped me in my tracks.
I often, talk about sustainability in my work but how is best achieved?
This popped into my brain yesterday! Does this #continuum make sense? What are the attributes and or conditions that need to be stimulated to see a group move to #Independence ?
I was coming to the end of a week off, during which I’d been able to spend a bit more time and headspace than usual immersed in my community, and the work of the charity I’m a trustee of.
So, my train of thought when I read Tom’s question, has gone like this:
The vast majority of the activities that our community organisation has developed and enabled over the past 15 years have either become sustainable, or fizzled out naturally.
The organisation itself is sustainable- from a human and physical capacity and financial perspective (if you take the dictionary definition of sustainable: able to continue over a long period of time).
The one thing that is not sustainable is our building. It’s rotting and crumbling.. and we’re working towards replacing it.. and we can’t do that alone.
Tom clarified that he was asking the question in the context of the nature of the relationship between the local authority and a community group.
So, I kept coming back to this question throughout the day and am still thinking about all my dealings with our local authorities over the years, as a community organisation set up to improve life here through community and leisure activity.
I’ve tried to capture the best of what we’ve experienced, and the essence of what I have appreciated over the years, from our Parish, Borough and County Council.
What I’ve reflected on about when it feels good
It feels like we’re working alongside each other to the same aims. This feels particularly good with our parish council colleagues in recent years- and that’s all down to the character and approach of the people. A ‘can do’ attitude. People who are as invested as we are in what we are collectively trying to achieve.
Our paid/public sector colleagues are there, in the background, but we can check in for advice, guidance, practical support or information when we need it. The need has varied over the years- advice and engagement from parks officers, planners, legal teams, procurement services, information and advice about funding.
When it feels like the people are allowed to be human, and that they feel free to show that they care about people and the community as much as we do- so we’re working to a shared purpose.
When it’s relational, rather than transactional. The (long) process of asset transfer of our community building from local govt to community showed this at it’s best (and worst).
There isn’t one set of experiences that can describe the behaviour of whole organisations. The behaviours come from people.
However, organisations can create the conditions for their people to work alongside their communities… or not!
It feels good when communication is flowing, human, agile, appropriate to the needs at the time. People who pick up the phone, reply to emails and engage in honest two way dialogue are always valued.
When each of us play our best part. So the expertise, skills and experience of our committee, our wider group of community volunteers, are blended with the skills of those who hold paid roles in the organisations that serve our community. We will do what we can, with what we’ve got, and we need to know where and how we can draw on the support of others.
Those who hold public office or paid roles feel able to be honest. To be clear about the limitations on what they can do, and we all show empathy and understanding about the possibilities, limitations, timescales. And that we as volunteers show understanding (and manage our frustrations) when things can’t happen when or how we want them to.
When processes, whether funding, planning or procurement are appropriate to the size and scale of the project we are working on at the time.
And that we all seek to remove unnecessary or unhelpful blockages and barriers that stand in the way of progress- especially in terms of governance, finance and processes.
This is taking me back to two things.
The drivers for change, that have emerged from our work apply equally to my volunteering role, and could really help me as continue our efforts to serve our community through the pandemic, and hopefully rebuild our community centre.
Shared goals, values and principles may never be discussed between our charity and the other organisations we engage with, but we all instinctively know when they’re there… because there is trust, compassion, care in our interactions and relationships. It feels easy, flowing and responsive. Those in paid roles help us to oil the wheels of social change. And it’s fun! Because at the end of the day, we’re doing this in our spare time. And building better communities can be a great deal of fun. And these pointers for practice would serve us well in our communities aswell as in our work.
Pritesh Patel posed a great question:
In terms of #independence – is this something the grp wants? – what does it look like for them?
In our case, I don’t think independence is the goal. We are a group of volunteers who are doing our best to support our community, improve wellbeing and make it a better place to live. I want to know that our parish, borough and county council colleagues are always there to support us and work alongside us in that. I hope for the same from our local NHS colleagues, our CVS, our police and so on. I hope that we will all continue to work together on the things that matter to our people and place. Individual activities and organisations should strive for independence and sustainability, while they are still needed and wanted by the community. But the relationship between all the organisations and people in the community should grow and strengthen all the time. How much we interact will ebb and flow, but we can always be there for each other.
So the answer to the question for me is that it’s about interdependence and integration (and always should be) as we work to a shared purpose of a healthier, happpier, safer, cleaner, greener place to grow up, live and grow older in together.
And the secret sauce? For me, it’s probably summed up as shared purpose, values and trusted, ongoing relationships.
All of this could be seen when we came together one morning nearly a year ago, in my kitchen, to plan our community response to CV-19, which I have written about here.
All this links perfectly to the other blog I’m writing, with a Yorkshire colleague, on health integration.
“This builds on the route map set out in the NHS Long Term Plan, for health and care joined up locally around people’s needs. It signals a renewed ambition for how we can support greater collaboration between partners in health and care systems to help accelerate progress in meeting our most critical health and care challenges.
Over the last two years, ICS’s have been formed across England. In an integrated care system, NHS organisations, in partnership with local councils and others, take collective responsibility for managing resources, delivering NHS care, and improving the health of the population they serve. Integrated care systems have allowed organisations to work together and coordinate services more closely, to make real, practical improvements to people’s lives. For staff, improved collaboration can help to make it easier to work with colleagues from other organisations. And systems can better understand data about local people’s health, allowing them to provide care that is tailored to individual needs.
By working alongside councils, and drawing on the expertise of others such as local charities and community groups, the NHS can help people to live healthier lives for longer, and to stay out of hospital when they do not need to be there”.
The introduction to the paper makes it clear that this is about learning from what is already strong.
“We want every part of the country to build on the earliest ICSs’ experiences. It details how systems and their constituent organisations will accelerate collaborative ways of working in future, considering the key components of an effective ICS and reflecting what a range of local leaders have told us about their experiences during the past two years, including the immediate and long-term challenges presented by the COVID-19 pandemic”.
As we disussed the paper, with colleagues in health, physical activity and community organisations from Greater Manchester and West Yorkshire, we recognised that this was an opportunity to;
Notice and illuminate some examples of what is already going well in each place.
Share learning about the principles, ingredients or conditions for integration.
Consider how we build on what we’ve collectively learnt, to grow and spread integrated approaches.
We have captured some learning, examples and stories here, with the aim of those being a catalyst for a conversation with other colleagues in health, care, physical activity and beyond. The themes, principles and learning are widely transferable to any of us who are pursuing an ambition for health creation.
Sue Goss provides an amazing metaphor for how we can think about this, what we need to do, and how we would be well served by shifting from machine thinking to garden thinking in our change methodology;
“We won’t succeed using machine mind. If we want humans to thrive, if we want human connectedness, and want people to feel free to use their creative energies and be fully themselves, we won’t get there through policies that treat them like cogs in a machine“
“If we stop to think about what gardeners do, they spend a lot of time observing and noticing. They take time to understand the seasons, the soil, the environmental conditions, the cycles that life moves in. They attract the wildlife that helps to maintain equilibrium. They encourage diversity. They begin by creating a rich soil, in which everything can thrive.Then they work with the plants, finding them the conditions they need and protecting them from harm. Sometimes, discovering happy accidents of extraordinary beauty, they simply look, and smile. But gardeners, as well as tending and nurturing, also move firmly to control the growth of rapacious weeds and to prevent the spread of suffocating monocultures.” (p8)
It speaks so clearly of the opportunity we have; to continue to learn, grow and spread what’s good, cut back the approaches that are suffocating integration, and create the conditions for a stunning garden.
And we know that thinking and working together is better than growing things alone, so we’re inviting you to join the conversation and contribute from where you are.
Integrated systems support and enable active lives and tackle inequalities
The outcome Sam and I are committed to and have been discussing is that of health creation through active lives. We are taking systems approaches to tackling inactivity and inequalities in Greater Manchester and West Yorkshire which are taking root, growing and spreading. It is vital that our approaches make the most of the opportunities that health and care integration bring.
Two things need to happen:
Future integrated health and care ecosystems need to be part of the solution to addressing inactivity and inequalities in place.
The physical activity ecosystem needs to adapt and evolve to be a better part of the solution to health, wellbeing and reduced inequalities.
To understand how to create the conditions for these to happen, we all need to explore some key questions:
Observing and Understanding Meaningful Integration
When meaningful integration is happening, what do we notice?
What do we see, feel and hear that tells us that meaningful integration is taking place?
Growing and Spreading what is Good
What makes it that way? What are the enablers of change?
How do we illuminate the good, and consider the art of the possible?
What are the challenges, blockages and barriers in the way of meaningful integration?
How do we work together to remove them?
What are the indicators of change that can be made visible and captured and used to create greater change?
What have we learnt in West Yorkshire and Greater Manchester so far?
We are still near the beginning of our journeys, and as we are collectively working out where next, we know that sharing as we go helps us all to learn together, and change can happen more quickly and deeply.
We recognise the degree to which the national changes in the paper above, seek to solidify the way our systems have been starting to work. It presents some real opportunities to grow, and we take great encouragement from that. We will now have a national context to work in, that will create better conditions for the fertile soil we are nurturing in our places, to support growth. The new Sport England strategy, Uniting the Movement, also creates a better set of conditions in the policy sphere for systems working in physical activity.
We know that real change happens in place.
We have reflected how throughout our careers in health creation, community development and physical activity, we have always worked with people, communities and place at the heart. Even when our roles have covered much larger spatial footprints, such as a city or region.
We hope that this blog might help to demystify ‘place based working’ as leaders across the country and across systems engage with a place based approach to health. In the Integrating Care paper, the NHS has acknowledged the importance of ‘place’ and is seeking t find ways to engage and integrate at place level. It recognises it’s importance, and we hope that those who have and will continue to contribute to this blog are providing evidence of why place is so important, and how to put people and communities at the centre of integration approaches.
Connection, integration and action is taking place in our neighbourhoods, localities, better enabled by the conditions we can create at sub regional and at regional level.
In the examples and stories we share below, we have considered what makes integration meaningful at all of these spatial levels- and how past models that describe “horizontal and vertical” integration can evolve in our minds, into models that describe how everything from the sky to the soil are part of one ecosystem.
It’s important to say that individual examples or stories are like different plants in a garden. The beauty of any garden is in it’s diversity and in the variety of plants that bloom because of the unique conditions and microclimate.
In telling some stories from our places, we are not suggesting that we should grow the same things across the whole country. Each place has it’s own conditions which enable things to flourish in their own ways…and each place has it’s own weeds to deal with (barriers and blockages to overcome).
Thankfully, we can all swap seeds, transplant seedlings and enable things to grow in their own beautiful ways. And there are some common weeds, which we can find ways of removing together. Which is why we want everyone to tell their stories.
Stories of integration, change and growth.
At a West Yorkshire layer, Yorkshire Sport Foundation has been having collaborative conversations with West Yorkshire and Harrogate Health and Care Partnership for around a year, about how physical activity and sport can support a wide range of health and wellbeing objectives, including, but not exclusive to, the prevention agenda. This initially led to aligning / integrating physical activity within the ICS’s maternity system review last year; using a public health approach and using evidence and insight gained from expert groups including women and families, a set of recommendations were produced that are now being implemented at place (unitary local authority) layer meaning that physical activity messaging and services will be part of all pre, during and post pregnancy conversations and services.
From late spring / early summer, Covid 19 and the first lockdown significantly accelerated opportunities to align and integrate physical activity within a much wider health and wellbeing context.
Through whole system (including economy, health, academia, transport, sport and physical activity, local authority) Big Conversations convened by Yorkshire Sport Foundation (YSF), the huge value of physical activity as protection against Covid 19 and other infections,, including reduced symptoms, and in improving mental wellbeing became very clear.
A subsequent paper produced by YSF, which set out changes that could be made across systems to make it more accessible and normal for people from all communities to be active as part of their everyday lives (YSF Recovery and Renewal Asks). This paper led to a conversation between YSF and West Yorkshire and Harrogate Care Partnership about how to consolidate the alignment and integration of shared objectives . A paper was then taken to the System Leadership Executive Group in November which set out an ambition to integrate physical activity into all programmes and pathways across the Health and Wellbeing system in West Yorkshire. This was received very positively by leaders.
The challenge is now on to make this happen. There are 3 key challenges (at least!) for us here:
Connecting with our six places; this achieved with some parts of each local authority, including public health colleagues, but not wider local authority or wider system partners in every place. This is where partnership mapping will really help us.
Developing trust, understanding and collaboration, hearts minds etc of players across the system to make physical activity part of every touch point. We are keen to explore creative ways of doing this, to grow what we have started.
Making sure that if we can achieve the above, the conditions and support are there for people to be active; e.g. environment, VCSE sector, ‘leisure’ providers, transport, open and green space and other policies. Again, we are keen to explore our shared learning and thoughts around this.
What were the conditions which created these opportunities?
There were a number of conditionsin place and/or developed that generated momentum for strategic buy in and energy to turn the dream into reality:
A new Population Health Programme was established, including a Prevention Network providing the environment to build discussions and enthusiasm across a wide range of stakeholders.
There were physical activity champions in several layers of the ICS system; Population Health Manager, several other Programme Leads, local authority Chief Executives, Clinical Commissioning Groups Accountable Officers and other leaders within this system. This meant that initial exploratory conversations easily identified shared space to collaborate towards shared ambitions, creating the shared energy for collaboration.
Some of the ICS system leader champions were already involved in collaborative structures around physical activity contributing to societal challenges in their own local authority areas. One of these is the Calderdale Local Delivery Pilot which has done some successful work around integrating physical activity within the local social care system, link to Calderdale Director of Adult Services;
Capacity within the ICS system. Collaboration in West Yorkshire is well developed over many years which means resources are available where it is most needed. This presents opportunities to explore, think and actively work together.
As a result of capacity in the system, there is a growing history of the ICS working with place-based colleagues on wicked issues and learning. In effect physical activity has become a wicked issue.
As a result of capacity in the system, there is a growing history of the ICS working with place-based colleagues on wicked issues and learning. In effect physical activity has become a wicked issue. Over the last few years, Yorkshire Sport Foundation has also developed relationships with place base colleagues and supported the creation of structures and spaces which act as a platform for colleagues across place layers to come together with shared commitment and to provide leadership around physical activity. Working collaboratively, we have realised that many of these place colleagues are the same and this has made for constructive conversations around integrating physical activity across West Yorkshire health and wellbeing systems
In West Yorkshire then, the conditions presented good opportunities for collaboration, alignment and integration. What about if none or only some of these conditions are in place, making it more difficult. As a first point, it becomes more important than ever to enter conversations in listening mode, to really understand your local health system, how it works, its priorities and the pressure it is facing. Really listen here, and spot any opportunities you can where physical activity and sport can help achieve those priorities and/or mitigate pressures.
And are there things that national partners can offer, that help create better conditions for local collaboration? Collating and sharing learning about where things are working well, what is the best of this work for example. Sport England could play a really important role in this space.
We also know that there has been tension in the health system for many years about the need to invest in prevention to save money upstream – and extend years of healthy life- without being able to release resource from upstream for this work because the demand is high in the present. There is insufficient flexibility in local systems budgets to invest in test and learn prevention activity whilst maintaining the investment in clinical resources required until prevention activity reduces the demand for clinical interventions (Marmot’s description of the health service as failed prevention).
So, could national partners including Public Health England (or their successor body), Sport England or others, collaborate in ‘test and learn’ prevention programmes and, as part of that, contribute resource that to prevention activity to help provide evidence required to enable local system leaders to agree to invest local system resources longer term in prevention programmes. And what are the challenges we’ve identified so far?
In the week we were writing this, Sheffield GP Ollie Hart did this brilliant podcast with The Compassionate Leadership Podcast series. Their introduction gives a great insight into his approach and way of working.
“Ollie Hart is a GP at Sloan Medical Centre Sheffield, Director of Peak Health Coaching, Clinical Commissioning Lead, social media influencer, and innovation leader in healthcare and wellness.
His vision for the future of health and wellness in the UK involves inviting the individual and their community to take a more prominent role, as opposed to the healthcare system. All the research suggests that the impact of the system, based on a ‘medicalised model’ is far less than was imagined. The behaviour of the individual and the support provided to them by their community is the dominant factor in their health and wellbeing.
He believes the pandemic has demonstrated that alternative ways of doing things can be better: video appointments and the vaccine delivery model, involving collaboration between clinicians, volunteers and the community, are two examples.
Over time during his practice as a GP, Ollie discovered that the medical interventions he prescribed were often less effective than when he supported people in understanding their condition, and in adopting healthy behaviours. He learnt a lot of his health coaching skills in a pain clinic, where the drug treatment options were limited. He finds having good therapeutic relationships “recharging,” for him as well as his patients.”
At a Greater Manchester spatial layer, we have been working towards integration of the health, care and physical activity ‘systems’ since 2015, as the city region began its devolution, health and care integration and transformation journey in earnest and we wrote the first GM Moving Blueprint for Change.
GM Moving has been more and more integrated with the wider reform and transformation agenda since then, and our evaluation and evidence work has documented this journey and our learning so far. We are already better able to understand the enablers of change, the system, organizational and individual capabilities to make change happen. The most recent capture of this is shared here.
As we refresh GM Moving this year, we are drawing on the learning since 2015, and our growing understanding of what makes change happen. Creating the conditions for a movement to grow, and for meaningful transformation and integration to take place is as much about how we work, as it is about what we do.
At the Greater Manchester spatial level, strategic leadership across health and care, transport, public service reform, physical activity and VCSE sector form the GM Moving Executive Group. This group steers the work of the whole GM Moving Plan, enabling collective leadership across twelve priority areas, seeking to bring about culture change, system change and behaviour change together.
Enabling work on system leadership development, marketing, comms and campaigns, engagement and evaluation supports all of this work. A series of articles captures this journey, and the latest local pilot process evaluation can be found here.
In the ten localities and the neighbourhoods of Greater Manchester, the integration of health, care, physical activity for health creation starts to become more visible and tangible.
Our ten Local Care Organisations, the local VCSE infrastructure organisations, leisure trusts and other key parts of the system are working more closely together with people and communities at the heart. When this is working well, we see strategic leadership enabling collective and integrated leadership and decision making. We see governance and processes changing to better support person and community-centred approaches. We see local people involved and engaged, and effective work across the system.
All this has never been more evident than during the pandemic, in the way that neighbourhood hubs, mutual aid and vaccination efforts have worked, illuminating communities, public services, health and care systems playing to their strengths, and all playing their part in keeping GM Moving along the way.
When we started the Local Pilot with Sport England in 2018, the first thing we did was bring together people from across the system in each of the localities. The first ask was for each locality to bring a group of VCSE, public health, leisure trust/provider, commissioner and active travel leads together, to develop integrated approaches to work on all the influences of inactivity in a place. The pilot seeks to embed physical activity into the locally developed approaches to social prescribing, asset based community development and active travel. This story from Stockport shows how system integration is creating the conditions for change.
At neighbourhood level, the person and community centred approaches, asset based community development and system integration in Woodley provided the inspiration for the Local Pilot approach. It continues to grow in exactly the way that Sue Moss describes in Garden Mind, even down to the community allotment that opened last year.
There are a few films that bring all this to life. They show how people moving more and active lives are woven in to their approach, as they support and enable people to live better. The community connectors play a vital role in supporting strengths based conversations with local people, supporting their wellbeing in the widest sense. The opportunity that community connectors, link workers and other social prescribers offer across Greater Manchester and the whole country, is massive. There is much to learn from the Alvanley approach, and as is clear from the films. It’s all about the people, the approach, the values and principles that guide the work. And the passion, compassion and energy of people who care deeply about their place.
In Trafford, this story is a great example of how a text message from a GP can make all the difference in supporting and enabling people to get moving.
In Manchester, MCRActive have sought to build on local assets by partnering with Manchester City Football Club (MCFC), and a local family GP practice. This pilot aims to test whether the involvement of a professional football club alongside social prescription and activity tracking technology will help influence inactive residents of East Manchester to be active.
The partnership emerged out of conversations with the Chief Medical Officer of Manchester City, a GP at Five Oaks Surgery and staff from MCRactive. Their conversations were sparked by the population health challenge facing the region: “We were identified as recording the worst scores in every population health measure out of around 180 CCGs, with the inner-city proving the most unhealthy across the county. Activity levels were not good either.”
This situation was particularly frustrating due to the huge investment in sporting infrastructure in the M11 area, with the world class facilities including the Etihad Stadium, the National Squash Centre and Velodrome being located in one of the highest areas of inactivity:
“They are scared to get involved as thinking people would be clad in lycra. Despite the building being 50 yards away from their homes, they think it’s ‘not for us’”.
The programme named MatchFit targets those aged 40+ who are at risk of non-communicable diseases and are insufficiently physically active in the M11 postcode area of Manchester who are also registered Manchester City supporters. Patients who fall into this category have been identified through varying channels including direct mail from MCFC, leaflet drops at popular community locations, including the chip shop and pubs and through grassroots social networks. Once identified, individuals are invited to attend an NHS Health check at the Five Oaks Family Practice. During this initial GP contact vital health statistics are collected in order for the GP to run risk assessments. The mental health and wellbeing screening tool WENWBS, is also administered to the pilot participants.
After screening, patients are invited to attend a GP 1-2-1 session at the prestigious Tunnel Club within the Etihad stadium. This meeting takes place in an area of the stadium normally reserved for players’ families and high ticket-paying corporate hospitality guests. This provides a sense of excitement due to the kudos and exclusivity of the offer.
What’s the transferable learning?
The stories we’ve shared above are just a few examples of what has been happening so far in our places. There are examples right across our regions, and across the country, and we want people to talk about them. We could write a book on this topic, and one day maybe we will. But in the meantime, we’ve captured some of the key enablers and barriers to integration as we see them. Again, it would be great to hear yours.
Enablers: Creating the conditions for growth and flourishing.
Finding out what matters to people, and how that aligns with what matters to you. Finding the sweet spot where there’s an opportunity to work together. And in working together with shared purpose, relationships grow. Trust builds and many flowers bloom.
Progress requires engagement, leadership and action in all layers of the system; regional, sub regional, local authority place, neighbourhood (PCN or other) Place – regional, sub regional, neighbourhood levels.
Trust, collaboration, relationships are key. There are some key leadership approaches and behaviours that can enable change.
Honesty about the barriers and blockages, talking about them and working out how to shift them, is key. This can only be done once trust has grown.
People that approach complexity and conflict with curiosity, and who work together to find the blended approaches, rather than argue over binary views or choices. They look for the and, rather than the either/or. A conflict transformation approach is vital.
Place based investment approaches and principles of subsidiarity are important. We need to find ways of understanding what proportionate universalism looks like in practice and use it to guide our collective investment of time, capacity, resources and cash.
Blockages and Barriers: cutting back and controlling the weeds.
We all instinctively know, feel and experience what gets in the way of growth. We are getting better and talking about these things and opening up healthy conversations about what needs to change. These conversations can only take place where there is shared purpose and deep trust.
Otherwise, it’s an argument. It’s finger pointing. It’s them and us- whether that’s national to local or between those in the local ecosystem. We need to talk about the blockages and barriers, and work together to remove them, and create the best conditions for change.
Inflexible ways of working that can’t adapt or support integration.
Commissioner/provider split and commissioning approaches that aren’t aligned to shared purpose or outcomes.
Spaces and conversations where people are not able to participate as equals.
Old Power structures, dynamics and ways of working.
Measurement and targets that don’t measure what matters and drive unhelpful approaches and behaviours.
A national approach that sets out with the best intentions but doesn’t seek to truly understand people and place, or local assets, as leaders operationalise and implement the approach.
Indicators of Change?
At the beginning of this conversation, we explored the question of how the national changes could best create the conditions for change, and whether a set of national indicators would help. We need to think carefully through the consequences of the belief that we can mandate for change, control it or drive progress through top down measures and targets. This has failed us before and will fail us again. Mandation doesn’t grow ownership. It has little energy or discretionary effort. It leads to compliance bodies and rules which are distant from the people doing the work and those they serve. Mandation can be a real cap on transformational change – people will feel obliged meet the target, and no more. At its worst, it creates the conditions for adherence to rules and gaming of the system to hit those targets. Prescription removes the need for leadership and stifles its growth.
A different way…
It has served us better in the past, and will as we go forward to develop shared purpose to unlock contributions. The energy in this is boundless, and a movement grows. So we need to create conditions; a set of principles and ways of working that give a framework in which people can work towards the shared purpose. This can be grow real ownership locally and support us to work alongside the communities we serve. Permissive frameworks from national or regional bodies which challenge us on outcomes can be more useful than targets or instructions.
Those doing the work can then be challenged on the outcome and the ‘so what’, and what have we learnt that can help us to grow? The greatest transformational change happens when we garden together through shared purpose, principles and approaches. The soil and the groundwater are equally important as the sun and the rain. Bottom up, top down and middle-out approaches are key.
We want to gather more stories of meaningful integration and change. A bit like the open gardens each summer, where people look around, ask questions, learn together, enjoy the fruits of their labour, then return and plant things in new places, or try new things in their patch.
So please join in. You can share your stories in many different ways, and we’re not looking for show gardens. We’re looking for works in progress, with buds starting to open or areas of the garden that are blooming… even if other bits are still covered in weeds and need some attention. Certainly, our gardens are imperfect, but we have made a start in some areas, and they show great potential!
Comment below, tweet or share your stories online, or set up a zoom room and invite others to join a conversation. Meaningful integration of health and care offers us opportunities to better support more active, healthy, happy lives with our people and communities.