“4D Cities exploration has been an important starting point around governance structures relating to health and care”
Eddy Adams is a public policy adviser, consultant and writer. He has a background in economic development, urban regeneration, social innovation, skills and learning. He is URBACT Thematic Pole Manager with responsibility for Social Innovation and Human Capital. Eddy has participated in some of the 4D Cities project activities, thus at the time of closing the project we wanted to interview him to capture his observations and feedback based on his view and experience of the project.
-What is the relationship that citizens should have with the health sector to become co-creators and not just receivers of services?
-Although it is difficult to generalise about Europe’s health andf care systems, there are a number of clear patterns that we can identity. One of these is the change in Europe’s demography. For a variety of reasons, we are living longer, and although this is good news, it places greater pressure on our health and care systems. At a time when public budgets are diminishing, this is a particular challenge, and many Member States are reviewing their health and care structures and the way in which they engage with the public.
Again, we can see a number of broad patterns emerging. One of these is an increased emphasis on citizen wellbeing and stronger messages about lifestyles and consequences. Another important shift relates to the traditional role of service users. Certainly, in those countries with strong welfare state models, there has been a prevailing culture built around a mantra of ‘the experts know best’. As a consequence, patients have taken less responsibility for their own health and have expected the professionals to know all the answers.
We can see this traditional relationship model being challenges in many parts of Europe. Several drivers are at work here. First, there is the recognition that the ‘medicalised’ model is unsustainable, even it was desirable, as demographics change. Secondly, citizens have rising expectations about public services, and through the Internet, and better informed than every before. Thirdly, there is a greater emphasis on the self-management of conditions, ideally within the community and not in hospital.
Therefore, although the situation is fluid and uneven, the direction of travel is towards a more collaborative model, where professionals and service users work together. But of course this has some important implications, for example in the way we train medical professionals and in the balance of investment between physical medical facilities and personnel.
Finally, as well as the ‘doctor’ patient relationship – which is beign rewired – there is the question of how we create spaces that allow different stakehlders to co-design and develop optimum services, based on service user fedback loops and professional knowledge and experience.
So, in summary, these relationships are in transition, and 4D Cities is provides an ideal platform to observice the way this change is playing out across different parts of Europe.
-Could you give some good practices in this field?
Identifying good practice examples is always a risky business! But here are some recent examples that I have seen first hand, and which I think represent different dimensions of the trends I have outlined above.
• Genius York
York is a city in the north of England with a population of around 200,000. Initially supported by NESTA (The National Economic, Science and Technology Agency), the city has developed a collaborative platform to involve citizens in tackling its problems. The model involves the city authority issuing a series of challenges each year, and inviting citizens to come up with solutions. The platform consists of a web portal, complemented by a series of activities – workshops, focus groups, hackathons, etc.
Several of the challenges issued so far have related to health and care. One examined ways in which local services could be improved. The other explored ways in which York coud become a ‘dementia friendly’ city. In both cases, the process engaged a wide range of stakeholders – carers, health professionals, software designers, NGOs, etc – who generated a wide range of ideas which were distilled into a small number of specific proposals.
The city has a Development Innovation Fund (DIF) which funds the development of new service and product prorotypes emerging from the process.
York is now looking to transfer this approach – influened by open innovation practices- to other European cities through the Genius Open URBACT transfer pilot.
• Zip-bob, Seoul, South Korea
Mental health is often an overlooked area. Many European cities record rising levels of mental health issues, amongst all ages. There is evidence emerging about the rising incidence of isolation and depressio amongst younger people, raising questions about the impact of social media. At the other end of the scale, increased levels of dementia and loneliness are recorded amongst older people.
These trends are not confined to Europe. In Seoul, South Korea, rapid urbanisation, the destruction of old neighbourhoods and modern living patterns have been identified in factors in worsening levels of isolation. Supported by the city’s mayor, Won Soon Park, Seoul has supported the development of a range of ‘sharing economy’ initiatives, party designed to bring citizens together.
One of these is Zip-bob. This is a food-sharing project which engages entire local neighbourhoods to come together to produce, share and enjoy healthy food. Through a moderated process – involving team games and enjoyable activities – citizens of all ages get out, engage with their neighbours, and share god healthy food.
• Active Ageing, Udine
Udine, in north east Italy has, like many Italian cities, a fast growing proportion of older people. Based on the WHO Vancouver Protocol, the city has undertaken innovative work to engage older peole in the analysis, design and redevelopment of municipal services. This process has included using GSI mapping of older people’s residential locations to inform the plannign of facilities including pharamacies, clinics and bus routes.
Older people’s groups have played an active role in these developments. As a result, a range of activities have ben developed to encourage physical and mental activity – such as ‘Orti urbani' (urban orchards) and Camminamenti, a group which combines discussion and walking groups.
Again, this successful approach is being transferred to other cities via the URBACT Healthy Ageing Citirs transfer pilot.
-Why is citizens’ involvement essential?
Citizen involvement is not essential, and health systems have traditionally run with little or no involvement from service users. But there is growing recognition that involving ‘customers’ is an invaluable aspect of continual service improvement. In this respect, the public sector is coming a little later to the principles of open innovation that have infuenced the commercial world for some time. We only need to look at the lengths businesses go to to gather customer feedback, to understand this.
It is important to note, however, that in the context of health, there are other complementary factors at work. One of these is the growing importance of securing value for money with limited public resources. Recent findings from the URBACT Amersfoort case study on social innovation (forthcoming) indicate that involving citizens in co-design leads to better results, achieved more quickly and with less money.
Perhaps most importantly, it would be an oversight not to mention the important role of the disability modement here. For many years, disabled people have campaigned for a ‘social model of health’ and an approach to service planning that places the service-user at the centre as an active player in the process. Using the mantra ‘Nothing about us without us’ disabled people have blazed a trail for ‘de-medicalising the health and care system, and these pioneers deserve huge credit.
-How local Administration can engage citizens, companies, health professionals, etc.?
Across Europe we can see the evolution and reinvetion of local authorities. Again, the drivers here are varied, and they include reduced resources and rising citizen exectations. And although the picture is, once again, uneven, this is no longer confined to the north west of Europe. In Greece, we see a rewiring of the municipal role, as the Crisis prompts a great Re-set. And, encouragingly, the wind of change is also blowing thorugh Eastern Europe. For example, our forthcoming Social Innovation workstream focuses on Gdansk, Poland, where a new city leadership model is using social media, independent NGO intermediaries and participative processes to improve its connection with citizens.
As we struggle to manage rising levels of citizen distrust within our established institutions, local authorities have a key role to play. As the form of representative government closest to the people, they have a pivotal function is building bridges and recreating trusted relationships.
Doing this successfully might require a changed role for civil servants. Rather than being primarily paper pushers, stuck in offices and used to telling citizens what to do, they will increasingly be expected to be outward facing, proactive and comfortable in a brokerage role. This is what colleagues in Amersfoort charmingly refer to as ‘free-range civil servants’.
Some civil servants are more ready forthis shift than other and in the coming programme period, URBACT will have an importast role in building this capacity.
-We are very focused on empowering the patient and placing him/her at the center of the health system. What obstacles and resistances will we have to be overcome?
I think we’ve already touched upon some of the key points already. Changing mindsets is a big issue – both within the health and care professions, but also amongst citizens. This doesn’t happen overnight, nor will it take place without incentives form the highest level within cities, and practical support to assist the change process.
Although I’m wary about the use of targets, which can shape institutional behaviours unhelpfully, I do think that evidence has a crucial role to play. It is not enough to say that involving citizens is better, and to leave it at that. We have a duty to explain why and, beyond that, to gather evidence to strengthen our arguments in the face of remaining sceptics.
It is also important to mobilise champions from all avenues of public life. This includes health practitioners, who ‘get it’ and who can speak with credibility to professional colleagues. Equally, we need spokespeople from within our communities who can share stories, inspire and support their peers.
-The Health System must, inevitably, adapt itself to the Social Innovation as a tool (not as an objective) in order to provide expected quality services?
This is not inevitable, and we must not be complacent about the scale of the challenge before us. There are huge vested interests in maintaining the status quo, so as with all change processes, we must be focused and realistic about our goals and timescales.
In some parts of Europe, the battle is well on the way to being won. For example, the innovative ‘People-powered Health’ work undertaken by NESTA and the Innovation Unit in the UK has been influential, but there is no sense that the ‘job is now done’.
This is complex work, crossing cultural and professional silos, which requires careful mediation and skillful moderation. It also relies heavily on effective and visionary leadership, and the rise of systems leadership is particularly intersting in the context of the health and care arena.
-Which is your opinion about the contribution that 4D Cities can offer to improve the Health sector thanks to all the stakeholders?
Following on from the previous point about cross-sectoral collaboration, the URBACT LSG model provides a useful vehicle for bringing diverse stakeholders together. The programme’s emphasis on participative and inclusive processes also aligns closely with the social innovation principles we have mentioned earlier.
One of the challenges we face on a wider EU level is the wide variation of governance structures relating to health and care. In many places, city administrations have no mandate or budget around this, and 4D Cities exploration of this has been an important starting point. This project has demonstrated that, despite these structural differences, it is still entirely feasible to operate a successful learning and exchange model between cities focused on health.
Beyond that, we have seen that within the network we have partners who are at the leading edge of applying innovative health and care approaches. Igualada with its virtual hospital concept, and Leeds with its integrated health and care hubs in the community, are only two such examples.
Another aspect of the 4D Cities project that I particularly like is its integrated approach. As well as focussing on the social aspects, the project has embraced the important question of business innovation related to health, as well as the role this sector has in generating future jobs. Two other current URBACT workstreams – New Economy and Job Generation – refer to the growing importance of the ‘white economy’ as Europe ages and demand for care services grows.
So, as the project draws to a close, a priority for us will be to ensure that the outputs and experiences emerging from this network are shared effectively and that the key messages are packaged in ways to ensure that we reach the diverse audience which wants to hear them.
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