Local, local, local: the regeneration project that puts the community in charge of its healthBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4594 (Published 12 October 2017) Cite this as: BMJ 2017;359:j4594
- Anne Gulland, freelance journalist, London, UK
The NHS is “broken” according to Andrew Mawson, social entrepreneur and cross-bench peer. But unlike the “liberal Guardian readers,” whom he says produce reports and policy documents but don’t get things done, he is doing something to tackle the problem.
Mawson is the driving force behind the transformation of a community in Tower Hamlets, east London, the ultimate aim of which is to improve the health, wellbeing, and prospects of its people. Mawson wants to cut through the bureaucracy and “liberal rhetoric” that he believes is stifling any possibility of real change for deprived areas.
The St Paul’s Way transformation project that Mawson launched in 2006 has brought together a secondary school, pharmacy, housing association, Prince’s Trust centre, and—finally, in January—a general practice to help transform a road and the community around it. The idea is that all of these organisations working together—staffed by local people and involving the community—will be better able to deliver the change that Mawson desires.
Such cooperation can, for example, make social prescribing more powerful, says Joe Hall, lead GP at the St Paul’s Way Medical Centre. The concept, pioneered by the nearby Bromley by Bow Centre founded by Mawson in 1984, is one way the practice aims to fulfil its mission to address the wider determinants of health. Hall, who began working at the Bromley by Bow Centre in 2003, says that when a new patient comes in the consultation does not just cover health but other matters such as housing, education, counselling, or befriending. If necessary, the patient is referred to a social prescribing coordinator.
Hall says, “When patients have other needs, such as housing or education, doctors can feel out of their depth—they don’t know who to turn to. We’re able to introduce [patients]—sometimes physically—to someone who will be able to help them along their journey.”
Mawson compares this ethos to a department store—you may go in to buy a kettle, but while you’re there you might also treat yourself to a pair of shoes, pick up a birthday card, and have a coffee. “We’re not gatekeepers here, we’re gate openers. We want people to stay in our centres. We think health is all our business—not just the business of doctors,” he says.
There’s two way traffic: Hall is also chair of the school’s governing body, and the new practice premises have a laboratory where school students are conducting research on diabetes. Hall is hoping the local community will soon be able to make use of the school’s sporting facilities at the weekends.
For him, recruiting local people has been key to this community integration; he has replaced the whole clinical and managerial team. “When I took over it was being run by a private firm based in Paris,” Hall explains. “The practice is in one of the most deprived wards in the country—there are high rates of early mortality, chronic disease, and cancer.”
Practice manager Anwar Hussein went to the local school, and the reception staff and GPs live locally. “I recruited GPs who all committed themselves to transforming the area,” Hall says. “The reception staff are local people—it’s important that they have a connection with the local area.”
Mawson believes that the people who can transform services are the people actually using the services. “You have to give real money and real power to people,” he says. Every month the health centre holds a meeting with various local groups such as churches, mosques, the school, and community centres to ensure it is providing the service it needs.
It also trains a cohort of 20 people at a time to become health champions, work funded by financial services company Morgan Stanley. “They teach other people registered with the practice about the health service and how to manage their health better.
“They also volunteer in the practice. They often know better than us what doesn’t work and what improvements we should make. We have to trust local people to make better decisions,” says Hall.
The practice has a high consultation rate, so in conjunction with patient champions it is looking at ways of introducing online or telephone consultations and “educating” patients about how to get the most out of appointments. Hussein runs a monthly clinic where patients can discuss the running of the practice—patients told him they would like to be informed when appointments are running late so now the practice has a sign showing the length of any delay.
Patients can also put up displays on the noticeboards in the centre. The week I visited, local women had put up information about domestic violence: its effects on women and children, how to spot the signs, and how to seek help.
“This is not McDonald’s”
My tour of the project coincides with the end of the school day, and a gaggle of pupils in their smart grey uniforms with lilac piping are heading into a fast food outlet to buy chips. Does a purveyor of greasy, salty food opposite a secondary school fit within the St Paul’s Way ethos? Mawson purses his lips and mutters, “That’s planning for you.”
This sums up his beef with the public sector: that it does not work together and if you want to do anything new or different you get tied up in knots. The local council, Tower Hamlets, and the housing association Harca have been enthusiastic supporters of the transformation project, but the health centre was held up by NHS red tape—hence the 11 years between conception and opening.
Hall says the practice is now rated outstanding by the Care Quality Commission and has high scores on things such as vaccination rates. But he says any really meaningful outcomes for patients will take time. “If I have a Bengali patient who is pregnant and doesn’t speak any English—what’s just as important as good antenatal care is that she learns English, has access to welfare and benefit services, and can learn skills. That’s positive, but it will only happen 10 years or so down the line,” he says.
Mawson adds, “The fact we’re rebuilding the housing will have major implications for local people. It’s not about what happens in that health centre—it’s about the whole estate.”
When asked whether the St Paul’s Way model could be replicated elsewhere Mawson gives an unexpected answer: “No! This is not McDonald’s. Let’s not build the same thing everywhere.”
Support in high places
However, the model—or the idea, at least—is being introduced into 10 areas in the north of England under the “Well North” banner. Mawson is working with communities that have traditionally had poor health outcomes, trying to get local people to effect change themselves, as is happening in east London.
“There’s a whole new health village we could build opposite the teaching hospital in Bradford,” he says. “It would be unique to Bradford and led by the people of Bradford. All the issues I have seen on St Paul’s Way, I have seen in Manchester and Bradford. How many doctors have talked to the priest, or the pharmacist, or anyone else in the community?”
The model also has an enthusiastic and influential supporter in former NHS chief executive Nigel Crisp, now chair of the all party parliamentary group on global health, who has espoused its virtues in outlets as diverse as The BMJ1 and the Big Issue.2
Crisp is not quite as damning about the NHS as Mawson but is supportive of St Paul’s Way because he believes it is embodying the idea that health is not just the preserve of the NHS but of all society. “What I’m interested in is that the project is not about healthcare but about health and about health in association with everything else,” he says.
“The NHS is great, but it cannot do everything by itself and shouldn’t behave as if it can. If life expectancy falls, the NHS can’t do anything about that. It can’t do anything about people being lonely or the causes of mental [ill] health. St Paul’s Way is about creating a health creating environment.”
St Paul’s Way in numbers
The transformation project began in 2006 and the regeneration covers two housing estates, a secondary school, a general practice, and other community facilities
The new secondary school cost £40m (€45m; $53m); the regeneration of one housing estate £40m; the health centre £14m; and the new community centre £2.5m
The project is in the ward of Mile End in the London Borough of Tower Hamlets. According to council statistics from 2014 there were 16 532 people living in the area3
65% of residents are of black or minority ethnic origin, compared with the borough average of 54%. 42% of the population are of Bangladeshi origin3
26.6% of households in the ward are owner occupied, compared with the London average of 49.9%3
14.4% of residents have a long term health problem or disability limiting everyday activities in some way, compared with the England average of 17.6%3
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.