How can we cultivate healthier and happier communities? - RSA

How can we cultivate healthier and happier communities?


  • Community and place-based action
  • Health and wellbeing

Our personal health and wellbeing, and that of our friends, family and communities, are important to all of us. However, it’s not always in our control. Here, Ella Firebrace and Riley Thorold explain how we might look to our futures and shape, what it means to lead healthier and happier lives, through participatory practices that involve citizens and NHS staff.

Along with Colin Briggs (Director of Strategic Planning) and Rebecca Miller (Head of Strategy and Development) at NHS Lothian, we’ve been supporting NHS staff and Lothian residents to think creatively about our longer-term futures using a range of participatory practices. In May, we spoke about our experiences and the approaches we used as part of the Living Change events series

Global pandemics, ageing populations, increasingly complex health conditions, climate change, deepening inequality and rapid technological developments are all shaping our futures and having vast impacts on our health and wellbeing.

And yet, short-term thinking remains pervasive. It’s a challenge to think long-term when you’re faced with the immediate pressures of the here and now.

This can mean those with decision-making power make significant choices under pressure without considering the long-term consequences on people’s lives. On the flip side, the people and communities most affected by decisions (who are themselves facing day-to-day pressures) are frequently not engaged, listened to, and heard.

Our work with Colin and Rebecca from NHS Lothian alongside a fantastic group of NHS staff and Lothian residents has focused on surfacing ideas from diverse perspectives. We’ve worked to build our collective capacity for long-term thinking, considering what’s possible now and in the future to promote the health and happiness of our communities.

We’d like to tell the story of this work which has built on a range of methods and tools referenced below as well as our research including A Stitch in Time: Realising the Value of Futures and Foresight and Transitions to Participatory Democracy.

NHS Lothian: the context

NHS Lothian and its partners have been coping with the emergent challenges presented by Covid-19 on top of the pre-existing challenges of operating across a health and care system that serves a population just shy of 1m and has over 20,000 employees and a £1.6bn budget.

The Covid-19 pandemic has acted as an accelerant for the Lothian Health & Care System. Changes in how society operates that previously may have taken years have happened in days and weeks, and we have delivered services in very different ways. We have also seen performance in some elements of care deteriorate, and a widening of inequalities across the population we serve.

Colin Briggs & Rebecca Miller

The priority has therefore been to develop mechanisms that can amplify innovations and embed them in mainstream practice whilst letting go of obsolete or unnecessary practice.

This led to what has been a fantastic working relationship between the RSA and NHS Lothian starting in 2020 where we initially worked alongside a whole range of staff to uncover opportunities and barriers using our Future Change Framework.

Our work with NHS Lothian residents and a cohort of 12 selected NHS staff helped NHS Lothian develop their new strategic direction and development framework.

NHS Lothian residents discussion group

There is a pressing need to democratise the field of long-term planning, and empower communities and residents to have an active role in defining and designing their futures.

This is why - in the autumn of 2021, we worked with NHS Lothian to recruit an NHS Lothian discussion group – a 20 person resident panel tasked with imagining and elaborating a future vision for NHS Lothian. We recruited as diverse a group as possible and engaged them through a range of activities including online workshops, one-to-one calls and online surveys.

Our question was broad and bold…

How can we make Lothian a healthier and happier place, now and in the future?

The ideas were eclectic and exciting: a set of creative and farsighted ideas for the future of the region.

NHS Lothian workshop - RSA blog

We think the process we developed, which had three main stages based loosely on Bill Sharpe’s ‘Three Horizons’ model could be applied elsewhere to spark similarly creative conversations about the future.

  1. Looking back - We began by asking how individual experiences, shared legacies, old decisions and past inheritances have led us to the present. Participants considered the constraints imposed and opportunities afforded by what has come before. Starting with the past allowed participants to build their future visions on a critical engagement with the past, rather than assuming that the present is a neutral starting point.
  2. Looking forwards - Participants then cast themselves into the future, to a hypothetical world where Lothian is far healthier and happier than today. Participants described life in Lothian 2030 and thought about how they, their communities, the NHS and other organisations all contribute to this ideal outcome. Participants considered two alternative future scenarios – a community-led future and a technology-driven future – and worked to develop and refine their vision of Lothian 2030.
  3. The present - Finally, we asked participants what NHS Lothian, working with the wider Lothian community, could do to turn Lothian 2030 into reality. This is when the ideas began flowing. A vast range of ambitious, cross-sector recommendations involving everything from new education curriculums to innovative service delivery models, and community-led care approaches to wellbeing-based planning obligations.

NHS Lothian is currently responding to the recommendations, but it is already clear how valuable this process has been for diversifying perspectives on the future, developing new and genuinely innovative ideas for change and democratising conversations about health and care.

NHS Lothian entrepreneur programme diagram

NHS Lothian public entrepreneur programme 

Alongside resident voice, staff commitment and energy in the NHS are fundamental to spotting and realising the challenges and the long-term opportunities for health and care.

Over six months, we’ve been working with a cohort of 12 NHS Lothian staff across clinical and operational teams, supporting them to pursue their ideas for creating positive change within the health and social care system. Some of the approaches we have taken include: 

  1. Insights from the past: Just as with the resident’s group, mapping insights along a timeline of key events and moments in the history of Lothian offered perspective on the extent and potential of change across time. This also helped us spot patterns of events and underlying value and belief structures that not only impact who we are today but on how we imagine the future. 
  2. Challenging assumptions: Whether we are aware of it or not, we are constantly operating within deeply rooted sets of values, beliefs, and norms. Listening to SITRA’s short audio dramas, we unpacked what assumptions we were making which were influencing what our visions for the future might look like. 
  3. Futures Wheels: To stretch our imaginations and look at the ripples of impact that can radiate from a single transformational change, we used the Futures Wheel designed by Jerome Glenn. This was a fun and surprising exercise that helped the group grapple with new ideas and unexpected outcomes of present-day interventions. 
  4. Storytelling: Stories are a key part of forging different futures. We drew on the work of Narratives and Systems Change practitioner, Ella Saltemarshe, who describes the many benefits of stories ‘as glue, as light, as web’. We imagined the news headlines in the year 2052 and adapted Sohail Inayatullah’s Causal Layered Analysis to dig deeper into the worldviews, myths and cultural values that sit at the base of the stories.

We’re still learning and know there is a wealth of knowledge out there about how we might better work together alongside people to imagine better futures, taking action today.

Watch out for two big pieces of work developed in collaboration with RSA Fellows and other partners from across the globe exploring emerging practices in this field:

  • Follow the Unboxed ‘Collective Futures’ work. A global exploration of the potential for collective imagination and creative collaboration to shape better futures for people, place and planet. 
  • Learn more about the insights gained and methods used in our soon-to-be-published ‘Rough Guide to being a public entrepreneur'.

Are you working on a project or programme designed to improve the physical and mental health outcomes of your community or area? Do you have experience of engaging with people and communities to discuss the future of health and care? We'd love to hear your experiences in the comments below.

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