Feature
Co-operating for health
Despite two decades of individualism in health policy, co-operative approaches to promoting good health are alive and well all around the country, say Katherine Gaskin and Jill Vincent
In 1992 the Health of the Nation strategy signalled a move towards holism in health policy by acknowledging social and environmental influences on health. This policy shift reflected a changing climate of thinking about health, more in line with the World Health Organisation’s influential Health for All declaration. Health of the Nation was seen by some to adhere to a medical model of health and a traditional ‘blame the victim’ approach to health promotion by apparently placing responsibility on individuals for health improvement. But through its emphasis on ‘healthy alliances’ and community-based health care, it allowed new scope for community development and community action initiatives.
In 1995, the Department of Health commissioned us to carry out research on ‘community well-being centres’ and co-operatives in health, and their potential contribution to meeting Health of the Nationtargets. The prototype community well-being centre was the famous Peckham Pioneer Health Centre, built in London in the 1920s.
Peckham was founded by two biologists on the principle that, given opportunities and choices, people would opt for health enhancing activities. Its essential features were its holistic focus on health rather than disease and the provision of a beautiful environment with facilities free for members’ use. Non-directed self-help and self-determination were guiding principles — described as ‘a kind of anarchy’. Health checks and family consultations were provided for the local families who made up the membership, and organic nutrition was advocated and supported by a cafeteria and centre farm. Although not structured formally as a co-operative, Peckham was an example of a community enterprise working for the benefit of its members and not for profit.
Peckham closed in 1950, but its vision has been kept alive by the Pioneer Health Centre Ltd, run by people who experienced its life-changing impact. The principles of the Peckham experiment continue to provide an important model for community-based health provision.
In the course of our research we found over 300 centres and schemes operating in England and Wales with community well-being and co-operative principles. Despite variation in scale and focus, there were common themes in philosophy and methods, with particular emphasis on an empowering approach to changing health-related behaviour.
“We found over 300 centres and schemes operating in England and Wales with community wellbeing and co-operative principles”
Participation and ownership by users is central, althouth the extent varied from place to place. ‘Top-down’ provider-generated schemes, run by health or local authorities, followed a community development approach, with some more radical than others. ‘Bottom-up’ user-generated projects set up by community or voluntary groups usually had high levels of participation built in from the start. Co-operatives, with democratic ownership, participation and control, are particularly suited to these principles. Health co-ops are growing throughout the world and are rapidly establishing themselves in the UK.
There are a limited number of large-scale Peckham-like centres, including the Canal Head health and leisure centre being built in Southwark, the West End health resource centre in Newcastle upon Tyne and many more modest projects. We also found community well-being principles in action in primary care resource centres, multi-agency resource centres, Healthy City strategies, and locality and neighbourhood programmes. While most are in deprived urban areas, the approach also lends itself to tackling rural problems, like the healthy village project at Brockenhurst or Gwynfi Community Co-operative near Port Talbot, described as ‘a remarkable experiment in village regeneration’.
Because of the breadth of the holistic concept of health, projects and schemes operate community well-being principles in many different fields. Projects may place their main emphasis on any number of themes, such as: primary care; health promotion; complementary therapies; leisure and recreation; exercise and fitness; nutrition and food; community and personal care; support and therapy; the arts; education; housing; transport; economic regeneration; employment initiatives; community development and action; or environmental issues.
Many of these developments have been set in motion by workers in health services, with multi-agency alliances formed to plan, staff and finance them. The formation of alliances is essential to the success of projects, especially those which involve all interested parties including community groups on a more or less equal basis. Alliances, however, rely on genuine organisational and attitudinal change within agencies. The traditional philosophy of ‘provision’ from above can hinder attempts to engage and empower participants. Bureaucratic boundaries and different ways of working tend to fragment services; workers who are under pressure from organisational change and inadequate funding tend to become territorial. Grassroots initiatives and those which bridge organisational categories can be marginalised and fall between criteria for funding. Funding is, as ever, the stumbling block for many schemes and proposed centres.
An important challenge to the community well-being approach is how to measure and demonstrate success. This is particularly true when a project breaks new ground and needs to convince decision-makers of its value. In most examples we looked at, monitoring and evaluation were inadequate, often a casualty of tight funding.
There is undoubtedly an encouraging growth in holistic approaches to health. Very many different elements appear to be contributing to a shift in the culture of health service delivery and health promotion, in turn challenging the social and political system to respond creatively with new and effective forms of organisation. On the evidence we found, the approaches of community well-being centres and co-operative structures offer exciting new ways to realise the potential of individuals and communities in improving health beyond the year 2000.
Co-operating for Health is available from the Centre for Research in Social Policy, Loughborough University, Loughborough, LE11 3TU. Tel: 01509 223372. Price: £10. Please quote CRSP254. A free summary of the research is available from the Department of Health, PO Box 410, Wetherby, West Yorkshire LS23 7LN. Fax: 01937 845381. The views expressed here and in the reports are not necessarily those of the Department of Health.
Katharine Gaskin and Jill Vincent are researchers at the Centre for Research in Social Policy, Loughborough UniversityBromley by Bow Centre in Tower Hamlets grew from a church which opened its doors to the community in 1984. It is now an independent charity operating as an integrated community project with a focus on health, education, arts and environment. Being set in one of the most socially deprived inner city boroughs in the UK, with few recreational facilities or open spaces, has not dimmed the vision of the project:
‘We have purposely set out to create an atmosphere of excellence and beauty and tried to offer a wide and sometimes unlikely combination of opportunities. It is the integrated mixture of activities and events which creates the surprise for people as they discover new things about themselves. This in turn has generated a groundswell of enthusiasm and ingenuity which has informed the direction of the project and led us to engage with the wider issues of health and urban regeneration.’
The Bournville Project formed part of a Health Education Authority ‘look after your heart’ programme in Avon. It was set up on an estate with huge social needs, including high levels of heart disease, stroke and respiratory illnesses. The project worker wrote:
‘Traditional health promotion approaches have tended to blame the victim for the diseases they suffer. We looked at a completely different approach here. We’ve not looked at lifestyle factors (smoking, diet, exercise and so on) at all, initially. We’ve said a healthy community is a community where people feel they are part of it, they have some control over their daily lives, they feel empowered to make some decisions which affect them.
The project has produced very positive results, including setting up community activities, self-help groups and successful local campaigns for traffic safety and an outdoor play park. ‘What we have seen is health in its broadest sense, not meaning absence of illness but a positive and vibrant contribution by active local people in decisions which affect them. If you make a community change and people are active in the community they will then go on to make those changes in their particular lifestyles which can help them to live longer and happier lives.’
Brockenhurst Healthy Village Project in the New Forest was initiated by local GP Dr Derek Browne. Set up to counter rural problems of poverty, ill health, poor housing, isolation and poor transport, the project employed a part-time co-ordinator to identify health and social needs and to harness the ‘healing potential’ of the community. The project was based on a model of the community as ‘a resource for health’, helping to achieve ‘optimum health for the individual’. It brought together intersectoral agency support, and has led to a ‘health and care forum’ for local people, improved services, leisure activities and self-help groups. The project is now pursuing funding following a successful two year pilot.
Healthy pulses mean healthy hearts
Food and nutrition are a major area of co-operative development. Both worker-owned retail and wholesale co-ops and member-owned bulk buying co-ops are becoming common throughout the country. Setting up food buying co-ops is often a key element of health authority planning, with an objective to reduce heart disease clearly within the Health of the Nation strategy.
Sandwell Food Co-ops, funded by the health authority and City Challenge, promote the supply of healthy fresh foods ‘fulfilling Health of the Nation, community care, environmental sustainability and community enterprise objectives’.
The Walker Food Co-operative, part of the larger Walker Health Project in Newcastle upon Tyne, is ‘fundamentally an anti-poverty, community-led initiative, managed by local people who are both providers and users’.
