Where previously old power models prevailed, in an age of radical connectivity the potential to utilise new power approaches in health and care is exploding.Kathryn Perera
In his book Why David Sometimes Wins (2009), civil rights campaigner and farm workers’ organiser Marshall Ganz recounts the Old Testament story of David, the young shepherd boy who faces off against Goliath, a fearsome warrior. Goliath appears to have all the world’s resources at his disposal. David, slight of build with neither sword nor armour, has five smooth stones that he finds in a brook. Yet with a single shot of startling precision, the boy David slays the giant. And by so doing, he frees his people.
The story of David and Goliath dramatises questions about which many of us remain intensely curious:
These are all questions of power. It’s a word we use often, without often pausing to consider whether we have a shared understanding of what it means and how it works.
For those committed to promoting “people powered health” in our NHS and wider public services, how might we think about power? I’m drawn to the definition offered by the great philosopher Professor Bertrand Russell, who described power as “one’s ability to achieve goals”. In a more activist vein, Martin Luther King Jr described power as a person’s ability to achieve purpose. Common to both definitions is the invitation to think of power as a neutral concept, neither inherently good nor bad. It is simply the ability to act. What matters is how those who have it, in various forms, choose to use it.
The notion of power as neutral is deceptively simple. Before joining the NHS, I ran a social enterprise called Movement for Change, which used the methods and approaches of Community Organising to develop local leadership in communities across the UK. So often, the people with whom we worked were initially resistant to the idea of wanting power at all. They associated ‘power’ with power over: domination for one’s own ends. Whether cleaners and students campaigning for the Living Wage, or young women channelling their experience of domestic abuse to positive ends, it took time and a great deal of work for us to explore the possibilities of ‘power’ as a necessary, creative source of social change.
In New Power: How Power Works in Our Hyper-connected World (2018), the social change activists Jeremy Heimans and Henry Timms argue that there is a growing tension in the world between two means of exercising power: what they call ‘New Power’ and ‘Old Power’. They describe old power as operating like a currency, a finite resource held by a few, pushed down and commanded through closed networks and hierarchies, based mainly around ‘what we do’ and ‘how we do it’.
They contrast this to new power. New power operates like electricity, creating energy among many (an infinite resource), which is shared and relies on radically open networks to grow and spread. It is based far more on ‘who we are’ and ‘why we care’ than on any notion of programmatic action.
Put it another way. Tetris was the number one computer game of the 1990s. It’s the biggest game, in fact, of all time. Tetris works like old power. It is top-down. Blocks literally drop onto your head. Your job is to make everything fit into neat lines and it gets faster and faster until you break down. Contrast this with Minecraft, now the second biggest computer game of all time. While Minecraft is also a block-based game, it works very differently. Minecraft starts as a green space. There is nothing in the game until the users start to build it together, piece by piece, from the bottom up. Everything that exists has been built and refined through collaborations which create a shared vision in a virtual world.
The contrast between old and new power speaks to an increasingly explicit tension in the world. Where previously old power models prevailed, in an age of radical connectivity the potential to utilise new power approaches in health and care is exploding. Neither way of thinking about power is right, or wrong, in itself. Each can be applied usefully in different contexts. Yet the tension between the two approaches to power is real, and more explicit than at any other time in our history. Those who have been raised in the Tetris tradition are coming up against those with a Minecraft mindset. The impact of ubiquitous connectivity on our ability to organise power in different ways will be fundamental.
Where there is tension, there is opportunity. Yet to realise the opportunities in health and care, we must first acknowledge the trade-offs inherent in exercising power. A generation ago, Professor John Gaventa described three faces of power: visible, hidden and invisible.
Visible power is the most widely observed and understood form of exercising power. This is power in terms of public victories and losses; observable decisions about how we spend resources, what we prioritise and what we ignore. In short: who gets to sit at the table and make the decisions?
Hidden power is readily observable in various forms, and has long been a subject of study in political science and related fields. This is power in terms of the biases and exclusion that may keep us (or others) from being part of decision-making processes. In short: who even decides what gets to the table in the first place?
Invisible power is the third form of power, the least observable, the most often overlooked. This is the exercise of power in contexts where individuals may be unaware of their rights, unable to use exercise voice, or perhaps even unaware that they have one. The exertion of power or domination over others may have come to be seen as ‘natural’, or at least unchangeable, and therefore not publicly questioned.
As professionals in health and care, these different dimensions of power present us with profound challenges. In all aspects of our work, it calls on us to ask:
In the traditions of Community Organising, the primary means by which we start to address these questions is by transcending individual control through building relationships with others. This idea of ‘power with’ and through others, growing their confidence and skills to act together in their own self-interests, may be the next curve of change in health and care. Currently in healthcare, we focus primarily on the individual. Patient activation measures. Self-care. Individual involvement in designing healthcare of the future. If we are to meet our future challenges to providing quality health and care for all, our capacity to act together, with intention, to grow our collective agency, will be critical. As the great philosopher Alexis de Tocqueville once wrote:
“Knowledge of how to combine is the mother of all other forms of knowledge; on its progress depends that of all the others.”
Kathryn is Head of Transformation at NH Horizons, specialising in ‘new era’ approaches to large-scale change, collaboration and spread across the NHS and wider public sector. NHS Horizons’ current priorities include the co-design and support of national transformation programmes with a projected collective impact in excess of £1.5 billion.