Even on a freezing February morning, the Bromley-by-Bow Centre is light and bright. Leaves are on the trees. Weak winter sunshine streams in through stained-glass windows, and the whole building buzzes with the low rumble of voices, activity and energy.
This is a part of London carved into distant school history lesson memories for philanthropy and charitable work; for political activism and social reform. But the buzz at Bromley-by-Bow is more about agency, ownership and community, than charity.
The area’s proximity to London’s docklands saw it bombed heavily during WWII, and its depopulation coincided with a push to move people from the inner cities and out towards new towns and suburbs in neighbouring Essex and Kent in the post-war period. Bromley-by-Bow saw huge amounts of new arrivals in the years after – many, though not exclusively, from Bangladesh. Today, 40% of people who live in the borough are of Bangladeshi origin, and 50 languages and dialects are spoken within a ten-minute walk of the building.
The communities we live in have a profound effect on our wellness, both physical and mental. In the UK, a man from one the country’s most deprived areas can expect to die nine years earlier, and have over 18 more years of ill health, than a man in the least deprived area. Women’s health inequalities are similarly polarised. We know that social and economic inequalities – from finance to social environment, biological and psychosocial factors, behaviour, education, occupation and ethnicity – influence our health. To tackle these issues from a conventional medicine perspective seems to sketch over so many parts of the whole.
The centre was started by Andrew Mawson, who arrived in the area as minister of the local church in 1984. “He would wander the streets to find out who was living here,” says current chief exec, Rob Trimble. “The stained glass in the windows and table we’re sitting around were made by people living in this community. He found people working in their front rooms – it was the largest artistic community outside Manhattan, living and working in their homes, and not making any money. Artists were the first group of people we met. We gave them the space here for nothing, in order to give skills to the local community.”
In his later book, The Social Entrepreneur, Mawson recalls his purpose clearly: “This would not be another tacky, rundown public sector building,” he says, “but a ‘centre of community and entrepreneurship’ defined by innovative design, a welcoming environment and quality furnishings, with hard work, enterprise and creativity at its heart, not ideology and theory.”
The Chilean sculptor Santiago Bell founded his wood carving studio at Bromley-by-Bow, and was one of the first group, including local artists Frank and Margy Creber, Sheenagh McKinlay, Paula Haughney to give the centre its distinctive outlook. “It was an eclectic group of artists,” says Trimble. “Because of those roots, we take the view that art and creativity should be at the centre of any initiative. Not because you should consult them, but because artists bring things out in communities that you couldn’t otherwise…”
As the centre drew interest, other groups emerged. Local parents Yvonne Begley and Steve Goode set up a co-op to take care of children, ripping out the inside of the underused church to create a nursery. A dance school started in the old church hall; resident Sue Fox wanted to run a cafe, so took delivery of a second-hand AGA and built a kitchen. Trimble says: “Nothing was rocket science – it was very simple stuff: tea and coffee and toast and soup; somewhere to drop in to after dropping the kids off at school. Many people had been to school together, but lost touch. We had a workforce here, but no-one would employ them.”
A daycare service supporting people with learning difficulties sprang up. “They were the first volunteers,” says Trimble. “It was based on one-to-one relationships, and – in doing so – those women became enormously effective. What had been a run-down derelict church suddenly had a lot of life in it. They created a culture of saying ‘yes’.”
Trimble arrived in the early 1990s, when his wife, Allison, a community health worker, became one of the centre’s first employees. By the mid-1990s that centre had shaped a vision for the services it would support in the local community. It was, says Trimble, the community’s response to the sad death of Bromley-by-Bow volunteer and friend Jean Vialls. “There is always a critical human story in the middle of what you do, which is which is why things happen. Jean was a volunteer in our community care project; a single mum with two kids, who was also the principal carer for her mum and dad. She was diagnosed with cancer and died within about 20 weeks, but her treatment fell through the net of statutory provision. Everything that could have gone wrong, did. There was a breakdown in communication between her GP and the hospital; social services lost track of the kids, and she desperately needed respite care for her mum and dad.”
Photography: Henry Smith
Community response
Anger about Jean’s death rippled through the local community, felt most keenly by her family, friends and fellow volunteers. “As Jean was being let down, a rota was pinned to the wall in the old church hall – going to the launderette to do her washing, to Tesco for shopping; one to cook for her mum and dad, and another one for picking kids up from school,” says Trimble. “There wasn’t a professional in sight. These were East End women who knew that Jean needed help. She needed a decent doctor and medical facilities, and be able to access the best treatments available, but the health of this community is primarily in the hands of the people themselves.
“It is about having a purpose, a decent home, and strong human relationships – that is borne out by academic evidence. Health is driven by those factors, and this whole project is designed to fulfil them…”
Mawson’s book picks up the story. “We started to formulate a plan for how we might be able to do things differently, and I went to the NHS with the plan. We would buy, for £1, the three acres of derelict land behind our buildings and would create the first integrated health centre in Britain. This would be built and owned by the people it was to serve, through a development trust.
“Our doctors would offer patients more than just drugs – they would be able to prescribe activities, including art courses, access to community care, and an allotment. Some patients would get the opportunity, through the health centre, to set up their own businesses. This would connect health, education, housing, the environment, enterprise and the arts.”
Bromley-by-Bow pioneered the idea of ‘social prescribing’ – the opportunity to support patients with broader activity, from healthy lifestyle, debt management or benefits advice to walking, cooking or gardening, arts and volunteer programmes. 90% of patient contact is with a GP, but much of it misses the contributory factors that play a huge role in our health.
In 1997, it became the first Healthy Living Centre in the UK, as both a practical response to the state of primary care in east London, but as a means of securing and expanding its range of services.
Caring communities
Ten miles south west, in Wandsworth’s Nightingale House, delighted toddlers and nonagenarians sing, dance and play together in the UK’s first intergenerational care home. Apples and Honey nursery, run by founder Judith Ish-Horowicz, moved into Nightingale House in September 2017. Japan was the first country to see the potential for intergenerational care over 40 years ago, when a Tokyo nursery school and care home were combined in 1976. The UK is still playing catch-up. Since then, successful schemes have run across Europe, Australia and the US, while in Singapore, the government has committed £1.7bn to improving the country’s experience of ageing, including ten intergenerational housing developments.
Stephen Burke, director of think tank United for All Ages, says: “Britain is one of the most age segregated countries in the world. For children, interaction with older people supports their learning as part of the early years curriculum. It boosts their confidence and their social development. Many children don’t have older relatives living close by, so contact with residents helps their understanding of ageing and issues affecting older people. For older residents, it can improve their mental and physical health and reduce loneliness and depression. Older people say how much they look forward to the activities with the children and talk about the joy of seeing them learn and grow.”
A 2013 study shows seniors smiling and conversing more among themselves, exhibiting delayed mental decline, lower blood pressure and reduced risk of disease and death compared with seniors in nonparticipating facilities. As Trimble says, close-knit networks and the care of local communities are central to our health.
Further south west still, the magazine Resurgence & Ecologist published informal results from a trial in the Somerset town of Frome in February this year.
GP Helen Kingston launched Compassionate Frome in 2013, as a response to the patients she encountered, where general practice typically treated clustered symptoms, rather than the whole person. The project identified five ‘building blocks to success’, filling gaps in provision in the community, patient-centred care planning, proactive identification of those who might benefit most and time for conversations and people – alongside a broader vision to apply the idea at scale.
Compassionate Frome plugged those gaps, with residents joining choirs, lunch clubs or exercise groups; they tried writing workshops or men’s shed makerspaces. Sometimes their issues included handling debt or housing problems, in a concerted effort to break the cycle of isolation and loneliness, which exacerbates illness.
What the initial data appears to show is that community group and volunteer support has the potential to reduce hospital admissions dramatically for isolated people with health problems. In the three years of the study, hospital admissions in Somerset rose by 29%; in Frome during the same period, they fell by 17%. The Guardian quotes Julian Abel, consultant physician in palliative care, and the draft paper’s author, as saying: “no other interventions on record have reduced emergency admissions across a population.”
While a formal paper awaits peer review, Kingston reports that patients who once asked, “What are you going to do about my problem?” now tell her, “This is what I’m thinking of doing next.” No longer are they a set of symptoms, but people with agency.
Photography: Henry Smith
Ownership matters
Today, Bromley-by-Bow is an exemplar in the field of community health and enterprise. Working in partnership with the NHS, the organisation works with 2,000 people every month and turns over £4.5m a year; it runs 60 projects, and works with 27 venues in east London. The GP practice serves 40,000 registered patients and a 365-day walk-in centre cares for 35,000 unregistered patients.
Trimble says that, in spite of Bromley-by-Bow’s scale, the model is a simple one. Based on the idea of trying to address the holistic needs of the community, he likens its success to the John Lewis department store. Firstly, ownership matters. “An NHS sign would change the relationships with our customers,” he says. Secondly, it’s about accessibility. “Retailers are good at this. We ask, does the thing we’re about to do help or hinder the service? So, no, we don’t have CCTV – why would we film? There’s no signing in or out –research shows that your pulse and heart rate goes up in health facilities – and there are no push-button entry systems. If you don’t speak English as your first language, that won’t hinder your access to the service.”
Looking around, there are few signs at Bromley-by-Bow. “They disadvantage visitors,” says Trimble. And encourage human interaction. “We did a survey before Christmas to try and work out how many human conversations happen here every week. We defined a conversation as something lasting more than 90 seconds, and worked out that we host 12,000 conversations a week. It is the single biggest and most important thing we do as an organisation. While most public organisations do the opposite, we encourage people to loiter with intent.”
Picking up his John Lewis theme, he continues. “GPs are regularly named as the most trusted people in a community. When you combine their popularity with chronic illness in communities with high illness, people talk of ‘inappropriate presenting’ as a disaster. But that’s just footfall to retailers. It makes sense to build a centre around the practice, because people were coming here anyway.”
That early cluster of entrepreneurs and artists from the ‘80s gave Bromley-by-Bow its enterprising zeal. Businesses making furniture, graphic designers, a gardening business building children’s playgrounds and painting public art murals sprang up, and has become key to its community-led ethos. Not only does it support its local community, but it creates local jobs, opportunities and wealth, and helps raise aspirations.
It now runs a social entrepreneurship investment programme Beyond Business, offering local residents investment of between £17,000 and £25,000 to start sustainable, profit-making businesses, which also generate social outcomes. Advertising in the local free press, each round regularly attracts 500 enquiries and 150 expressions of interest, which has led to the launch of over 70 social enterprise businesses in Hackney, Tower Hamlets and Newham. Their rolling survival rate is over 85% – twice the national average.
Funded by specialist bank Investec, which aims to “support budding entrepreneurs who want to make a sustainable, positive impact in the local community,” the programme has created over 370 jobs in businesses generating a combined turnover of over £6m. And Bromley-by-Bow is increasingly exercising its option to take a 5% in the businesses, says Trimble. The core of the centre’s philosophy is, naturally, the social capital created, and the communities formed. “They’ve got each other,’ says Trimble. “Over 60 trading businesses connect with each other – that’s where the real value lies.”
Trimble would like to see one of these GPs practices in every community up and down the country. “The media, politicians… they’re focused on the downstream elements of health. Medicine should just be making a cameo appearance in health. It’s hard to see how the NHS is going to survive in its current form with the economic realities of what it faces, without fundamentally redefining what it means by health. We have old fashioned public health campaigns to get people to stop smoking. But how do we give people skills to get a job and get a home? We’ve become used to a bio-medical model where we chuck more medicine at it and think it’ll get better, but that’s not tackling the causes. Diabetes; loneliness; mental ill health. We have to stop throwing medicine at things. Creating vibrant communities is the driver for us.”
