Feature

Pioneering or engineering?

Support for Healthy Living Centres comes mainly from those who know they will never use them. Steve Iliffe asks whether this is the right way to tackle the health problems of impoverished communities

Instead of picking up the prescription that they expect, patients could find themselves referred to health and fitness clinics, physiotherapy and chiropody services, or arts projects to improve their health.’¹ ‘Healthy Living Centres, funded in the short term from Lottery grants, are the vehicle for a supposedly new and positive approach to health, building the self-confidence, self-esteem and self-reliance which is the bed-rock of good health.’²

These two quotes are about the same subject but could not be more different. The first begins with a factual error – most patients do not expect prescriptions as much as their GPs think, although they want (but do not always receive) explanations. High expectation of a prescription is a characteristic of the least educated, who are to be re-routed, like parcels, to new and healthier destinations like fitness classes and art groups. In the eyes of some, Healthy Living Centres will teach the unschooled how to live a healthier life.

The second quote is a statement of social engineering intent that could well come from a public school’s promotional brochure. The unformed, untutored entrants to HLCs will emerge proudly standing on their own two feet, transformed by the right blend of healthy eating, physical exercise and mental discipline.

With £300m of pump-priming from the Lottery Fund on offer, bids for HLCs will proliferate in the target areas – Britain’s most deprived areas, particularly the Health Action Zones. Community involvement in their design, planning, development and operation is essential for a serious bid, and creative partnerships across the voluntary, public and private sectors will be favoured. No blueprints will be delivered from above but projects will need to secure extra funding from partnership sources from the outset, and have a strategy for survival after Lottery money runs out – in three years or less.

The HLCs are an important component of New Labour’s health strategy, complementing its more conventional health improvement programmes, and welfare strategy, which is to be targeted at the most needy and delivered in a mixed economy of provision. The aim is that a fifth of the UK’s population will be within an HLC catchment area by 2002.

The concept has two parents: the holistic approach embodied in the pre-war Pioneer Health Centre in Peckham (the Peckham Experiment); and the contemporary American experience of ‘senior centres’.

The Peckham experiment was seen by some contemporaries as the shape of the future, where citizens could find pleasure, health, fitness and company all under one roof. The forerunner of ‘health farms’, the Peckham experiment relied on a benign expertise that enlightened the less aware in gentle, supportive ways. It existed at the liberal edge of a utopian philosophy about healthy living that also included the fierce enthusiasm for vegetarian diets and nude sunbathing in Nazi Germany, and did not long survive the foundation of the NHS. Its romanticism still appeals and from time to time efforts have been made to revive it, until now without success.

American senior centres are much more substantial than Peckham ever was or could have been. At the end of the 1980s some 15 per cent of older Americans were members of the 12,000 or so senior centres strung across the US.³ Managed by older citizens and tailored to local needs, these centres survive on a small federal grant supplemented by Medicaid payments and local financing, including in some places a membership fee. They are designed to enhance the quality of life of older people, especially those with chronic diseases or disabilities, and include exercise classes, counselling, health promotion programmes, social activities and adult education. The 1965 Older Americans Act identified senior centres as the preferred vehicle for co-ordinated delivery of a range of services.

Healthy living centres could become the UK equivalent of senior centres, but open to the whole age range, from single parents with toddlers to pensioners on low incomes. Their defining feature will be the relative poverty of their clientele, for no-one is suggesting that HLCs are needed in affluent areas, where people already have the disposable income to use leisure centres, the education to make good use of existing health services and enough control over their work and daily life to seek and achieve a healthy, balanced existence.

This focus on the poor is likely to attract widespread support because there could be so many beneficiaries from these centres’ development.

They will provide a new outlet for municipal initiative, including community redevelopment and the professional expertise of planners and architects who want to make a local impact on neighbourhoods that may have been devastated by job losses, the collapse of traditional industries and the outward migration of younger people.

Municipal power has shrunk enormously over the past 20 years. Local government now acts mainly as a tax-raising body with regulatory responsibilities for education, a diminished social care safety net, and the environment. HLCs will offer a boost to local pride, and will act as shining new monuments for a municipalism seeking a revival. Built as supermarkets of health and well-being, they will exude modernity by bringing all the desirable elements of healthiness together under one roof.

HLCs also offer the possibility for communal living in an individualistic society, acting as an organising base for countervailing pressures against negative social forces. The market may wreck localities and lives, but HLCs could be defences for communities against ruin and alienation.

The old forms of resistance to the market have gone – trades unions battered by the Thatcher government and sidelined by New Labour are unable to create local resistance, and their community structures, the Trades Councils, have withered. Political parties compete for influence in the dwindling power base of local government, but are constrained by limited resources, fragmented and overstretched services and pervasive individualism. In such a bleak political landscape, HLCs offer hope to the remnants of the politically active left.

They could also help the political process by delivering evidence of the humanity of an enabling state at low cost. These centres will be cheaper to provide than the jobs and incomes that the bottom 20 per cent of the population lack, and they pose no redistributive threat to that part of New Labour’s social base that is averse to realistic levels of taxation.

The irony within the planned financing of HLCs is that National Lottery money comes disproportionately from the lowest income groups, which will see their spending recycled into provision for themselves, sparing the higher incomes of Range Rover Man and Cherokee Woman. Able to pick and choose between gyms and activity holidays, organic vegetables supplied direct from the farm and internet shopping, the Offroad-ocracy will live easier in the knowledge that their poorer neighbours at least have access to the good life’s equivalent of Kwiksave.

Those struggling in welfare institutions designed for the earlier part of the century and distorted by market imperatives may also welcome the collaboration between agencies that HLCs require.

The romantic blurring of boundaries between health, education and leisure could resurface in the building and running of the centres. Although the lion may not lie down with the lamb, some social workers will work alongside some health professionals in these little Jerusalems, and the Peckham experiment may live again.

In doing so they will tap into prevalent and understandable feelings that modern medicine is dangerous, that its industries and professions are a conspiracy against the public, and that more natural approaches to health and illness are desirable. Complementary therapists will queue up to provide aromatherapy and massage alongside tai chi and aerobics, progressive GPs will seek space for coronary rehabilitation classes, and the Benefits Agency will direct unemployed youth to computer skills training.

What will all this add up to? Will Healthy Living Centres solve the problems of impoverished communities, or will they simply contain them? Certainly, their development seems assured given so many interested parties, and such potent central government support. In the short term, HLCs fit the current climate too well to fail. They may well do something to offset the rampant uncertainty that destabilises communities and families, and they may also restore human relationships to centre stage in the meeting of some needs, counterbalancing increasingly impersonal medical and social care.

Is this enough? In the background lies the reality of continuing economic instability, unemployment and widening income differentials. If we want to be healthy, self-confident and self-reliant then we need to live in families and communities which are consistent and responsive to individuals, not a society that is hot on success and tough on failure.⁴

The social exclusion in employment, education and access to leisure time and facilities that is such a prominent feature of our society is not consistent with the goal of a healthy nation. Health goes with wealth, and redistribution of income seems to be the best route to redistribution of well-being, even if it is not on the political agenda.⁵

Until the affluent social classes who support New Labour accept that their contribution to the nation’s common wealth must increase and their privileges decrease, HLCs will remain a popular idea and, like their American role models, a social necessity in an unjust society.