Don Berwick’s paper Era 3 for Medicine and Health Care helped shape early network discussions. Era 1 was dominated by the professions. In era 2 market forces reshaped measures and accountability structures. Berwick looks forward to a moral era 3 with greater transparency, civility; and less greed. (In Berwick’s formulation this means embracing improvement science and a stronger citizen voice).

Others have charted similar shifts. New Local have promoted the ‘community paradigm’ that transfers power and resources from central government and public services to communities. The community paradigm succeeds the market paradigm of the 1980s with its attention to efficiency and cost. And before that the state paradigm (from the 1940s onwards) comprising strong state and professions and weak service users.

Network member John Hitchin uses the slide (below) to summarise ‘waves’ of change from 1997 to 2025. The pattern of change is at the same time similar and different to that described by Berwick and New Local. He notes the shift from state-led to neighbourhoods at the turn of the century. The introduction of personalisation and stronger accountability in commissioning in the mid noughties. The way in which austerity ramped up the focus on impact, value for money and ‘what works’. In recent times there is a renaissance in interest in community, collaboration, and relationships. John is concerned with the way these changes influence how we think and learn about place.

Cutting across each of these examples is the focus on what Robert Putnam and Shaylyn Romney Garrett call ‘I’ and ‘We’ (see entry number 2). By their analysis, the United States has been a society of individuals from the moment Bob Dylan went electric at the Newport Folk Festival in 1965. (This is an association not a causal relationship!). Their book The Upswing explores the necessary conditions to shift from a society of individuals to one that stresses our interdependence. (They find that it is rooted in the power of civil society).

The question for our network is: what are the implications of these analyses for the way we learn? Two points, both missing from the Berwick reflection, stand out.

First, the way in which we learn about ‘we’ -populations of people- creates different challenges to the way we learn about ‘I’ -the needs or well-being of individuals. Effecting change in a community or a place should be felt across the population. (One would not ordinarily expect change in individual outcomes to produce measurable impact across a community).

Second, the way in which we learn about community and, more broadly, civil society creates different challenges to learning about the impact of public services on the health and well-being of individuals.

These themes will be explored further in coming network meetings.


Don Berwick, Era 3 for Medicine and Health Care, JAMA, 2016

Adam Letts and Jessica Studdert, The Community Paradigm, New Local, updated March 2021

Robert Putnam and Shaylyn Romney Garrett, The Upswing

John Hitchin is CEO of Renaisi