Problematisation within CCC and resultant practices

The most profound basis for the problematised ‘need for CCC’ comes from the articulation of a series of somber observations. Sawyer et al. (Reference Sawyer, Higgs, Porter and Sampson2021: 21) cite an ‘impending crisis of care’ and Vanderstichelen et al. (Reference Vanderstichelen, Dury, De Gieter, Van Droogenbroeck, De Moortel, Van Hove, Rodeyns, Aernouts, Bakelants, Cohen, Chambaere, Spruyt, Zohar, Deliens and De Donder2022: 2) describe this as “one of the largest public health challenges in history”. These constructs reflect a well-recognised ‘death as public health crisis’ narrative that foregrounds various demographic and epidemiological pressures (Whitelaw et al., Reference Whitelaw, Bell and Clark2022); growing numbers of older people, increasingly experiencing poor health, increased numbers approaching death and ultimately, associated care challenges (Byock, Reference Byock2001).

This suggests the need for novel approaches based particularly on the belief introduced above that death as a ‘natural event’ has become removed from its social context and is articulated in two CCC narratives. First, Vanderstichelen et al. (Reference Vanderstichelen, Dury, De Gieter, Van Droogenbroeck, De Moortel, Van Hove, Rodeyns, Aernouts, Bakelants, Cohen, Chambaere, Spruyt, Zohar, Deliens and De Donder2022: 2) highlight social developments like “individualization, decreasing nuclear family size, and the proliferation of 2-earner households” that have weakened traditional care models. They then note an “increased medicalization and professionalization of serious illness, death, dying, and loss (that) stimulates a decrease in community resilience, capacity, and confidence to respond to end-of life issues” (Vanderstichelen et al., Reference Vanderstichelen, Dury, De Gieter, Van Droogenbroeck, De Moortel, Van Hove, Rodeyns, Aernouts, Bakelants, Cohen, Chambaere, Spruyt, Zohar, Deliens and De Donder2022: 2). This latter theme suggests that policy focus has historically contracted and that CCC reclaiming these eroded social and community resources could form a “radical challenge to existing, traditional approaches to care” (D’Eer and Sallnow, Reference D’Eer and Sallnow2024: 8).

The key driver of this innovation centres on the multiple resources contained within The Ottawa Charter and consequently an expansion of policy orientation from solely ‘care’ to wider ‘social policy’: specifically, from the structuralism of ‘contributing to healthy public policy’, ‘creating supportive environments’ and ‘re-orienting healthcare services’; to the empowering ethic of ‘strengthening community action’; through to the individualistic aspiration of ‘developing personal skills’ (Raeburn, Reference Raeburn2007). Indeed, in their review of CCC-related activity, Dumont et al. (Reference Dumont, Marcoux, Warren, Alem, Alvar, Ballu, Bostock, Cohen, Daneault, Dubé, Houle, Minyaoui, Rouly, Weil, Kellehear and Boivin2022: 7–8) conclude, “all of the 5 strategies….have been reported”. This opening-out of scope is complemented by a contrasting narrowing dynamic; conceptually, The Ottawa Charter being articulated as a single symbolic entity (O’Neill, Reference O’Neill2012). Practically, this accommodation is also reflected in a desire to identify activities common to all CCC initiatives, with González-Jaramillo et al. (Reference González-Jaramillo, Krikorian, Tripodoro, Jorge, Orellana, López, Vélez, Noguera, Montilla, Felber, Zambrano and Eychmüller2025: 6) identifying a set of ‘core’ activities.

A degree of differentiation, particularly between compassionate cities and compassionate communities is occasionally articulated; the former associated with a ‘top down’ approach to the fulfilment of pre-set actions (Kellehear, Reference Kellehear2020), whereas the latter is inclined towards a more open-ended orientation derived from expressed community need (D’Eer et al., Reference D’Eer, Quintiens, Van den Block, Dury, Deliens, Chambaere, Smets and Cohen2022); González-Jaramillo et al. (Reference González-Jaramillo, Krikorian, Tripodoro, Jorge, Orellana, López, Vélez, Noguera, Montilla, Felber, Zambrano and Eychmüller2025: 13) suggesting the need to ‘leave room to include….aspects specific to each community’.

Discussion

Building on this descriptive base, the above ‘crisis’ narrative has been shown to be problematic in that its objective basis can be erroneously amplified – tempered predictions become unequivocal forecasts (Whitelaw et al., Reference Whitelaw, Bell and Clark2022). Beyond straightforward concerns for objective rigor, the exaggeration of demographic and epidemiological data (recognized as ‘public health catastrophism’) has been considered unsuitable as a rational foundation of policy development, associated with “a rhetoric of fear” (Jones and Greene, Reference Jones and Greene2013: 1208) and an equally problematic accompanying ‘heroic’ response, “capable of fixing the problem” (Shanahan et al., Reference Shanahan, Jones, McBeth and Lane2013: 460).

The utilisation of The Ottawa Charter also causes concerns. The ability for a movement to accommodate a range of perspectives and activities within a simplified single frame has already been established as tactically beneficial. The symbolic nature of The Ottawa Charter has also been recognised and here, its evocation provides such a frame into which the breadth and variety of CCCs activities can be accommodated. These tendencies to obfuscate can be associated with Stone’s (Reference Stone2002: 159) identification of a policy tactic of tolerating “constructive ambiguity” as a means of avoiding potentially damaging conflict and as such being able to consensually move policy forward.

In foregrounding the uniformity of The Ottawa Charter, the CCC literature also offers little discussion of potential tensions within it and between its elements. Tesh (Reference Tesh1988: 70) suggests that the WHO “hides its politics” by concealing ideological tensions and as a WHO-derived resource, a case can be made that CCC narratives do likewise, particularly in relation to ‘structural/deterministic’ and ‘individualistic/voluntaristic’ orientations (Whitehead and Irvine, Reference Whitehead and Irvine2011).

This variability is specifically evident within CCC in relation to tensions between ‘top down’ policy-based ‘compassionate cities’ and grassroots-oriented ‘compassionate communities’, Quintiens et al. (Reference Quintiens, D’Eer, Deliens, Van den Block, Chambaere, De Donder, Cohen and Smets2022: 423) suggesting that a “clear conceptual demarcation between both is lacking” and Nawaratne et al. (Reference Nawaratne, Dale, Mitchell and MacArtney2024: 2082), contending that more needs to be done to “make clear that there is a distinction between the 2 approaches”. Kelley (Reference Kelley2023: 9) alludes to a potential division, being wary of the potentially imposing nature of the ‘compassionate cities’ ethos, contending that “development cannot be imposed from the outside”.

Furthermore, despite the allusion of CCC activity across the 5 Charter domains, some challenge the empirical robustness of this assertion. Dumont et al. (Reference Dumont, Marcoux, Warren, Alem, Alvar, Ballu, Bostock, Cohen, Daneault, Dubé, Houle, Minyaoui, Rouly, Weil, Kellehear and Boivin2022: 7) note that the distribution is skewed and that, “not all strategies are equally represented in practice”, with the elements ‘strengthening community action’ and ‘building healthy public policy’ particularly under-represented. This imbalance is problematic in two ways: first, given that Abel and Wood (Reference Abel and Wood2023: 3) suggest an aspiration that “the five (Ottawa) points must all be done together”, it weakens CCC’s holistic ‘ecological’ identity; second, it alludes to ambiguity in its core identity, particularly, as will be developed further, a tension between CCC as a force for radical change and/or an adjunct to existing practice (D’Eer and Sallnow, Reference D’Eer and Sallnow2024: 6).

Radical aspirations are certainly articulated hypothetically and prospectively within ‘revolutionary’ CCC narratives. Kellehear (Reference Kellehear2005: 105) for example evokes both the notion of a Kuhnian ‘paradigm shift’ and Schopenhauer’s (Reference Schopenhauer1942) belief in the existence of groundbreaking but unrecognised social ideas as interpretative frames for CCC. However, the parts of The Ottawa Charter ‘package’ that align with this radical policy ethic (community-led change, service re-orientation and challenging healthcare hegemonies) are those least represented (Dumont et al., Reference Dumont, Marcoux, Warren, Alem, Alvar, Ballu, Bostock, Cohen, Daneault, Dubé, Houle, Minyaoui, Rouly, Weil, Kellehear and Boivin2022: 5).

This theme begins to suggest the politicised basis of movements and can be associated with deeper tensions expressed within the ‘settings’ literature (Whitelaw et al., Reference Whitelaw2001) and articulated in Baum’s (Reference Baum1993: 32) suggestion that the ‘Healthy Cities’ movement’s uses “the language of radical social movements” whilst ‘operating within a bureaucratic logic that stresses consensual, incremental change’. In this context, the fact that the majority of CCC work tends to be associated with either adjunct on-the-ground care that “alleviat(es) stressed healthcare” (Quintiens et al., Reference Quintiens, D’Eer, Deliens, Van den Block, Chambaere, De Donder, Cohen and Smets2022: 435), “leav(ing) palliative care services more time for complex case management” (Kellehear, Reference Kellehear2013: 1072) or ‘educational’, “contribut (ing) to improving the knowledge base, and ultimately death literacy of a community” (D’Eer and Sallnow, Reference D’Eer and Sallnow2024: 7) suggests an affinity to the latter rather than former position.

Policy narratives within CCC

As well as this tangible substance, the nature of the associated policy discourse within CCC is noteworthy. It tends to be bold, normative and exhortative in nature, assuming incontrovertible value and effectiveness. This comes in relation to either unquestioned pre-suppositions of the present, [“Compassionate Communities strengthen community ties and networks and promote power-sharing, ownership of care, and community support” (Vanderstichelen, Reference Vanderstichelen, Dury, De Gieter, Van Droogenbroeck, De Moortel, Van Hove, Rodeyns, Aernouts, Bakelants, Cohen, Chambaere, Spruyt, Zohar, Deliens and De Donder2022: 1393)] or more commonly, claims of potential future status, [“‘compassionate communities’ ….can be developed” (Sawyer et al., Reference Sawyer, Higgs, Porter and Sampson2021: 2); “harnessing the power of compassion….could provide invaluable information on how to promote optimal levels of healthcare” (Librada-Flores et al., Reference Librada-Flores, Nabal-Vicuña, Forero-Vega, Muñoz-Mayorga and Guerra-Martín2020: 2); “compassionate communities…should be adopted” (Aoun et al., Reference Aoun, Breen, White, Rumbold and Kellehear2018: 1378); “compassionate communities must….be positioned as an equal partner within a shared network of care” (Mills et al., Reference Mills, Abel, Kellehear, Noonan, Bollig, Grindod, Hamzah and Haberecht2023: 1); “we implore….policy makers to support….compassionate communities” (Mills et al., Reference Mills, Abel, Kellehear, Noonan, Bollig, Grindod, Hamzah and Haberecht2023: 2)].

These exhortations tend to have the notion of ‘responsibility’ at their core. Kellehear (Reference Kellehear2013: 1071) for example frames end-of-life responses as “everyone’s responsibility” with this accountability being located in ‘communities’ (Librada-Flores et al., Reference Librada-Flores, Nabal-Vicuña, Forero-Vega, Muñoz-Mayorga and Guerra-Martín2020), ‘families’ (Mills et al., Reference Mills, Abel, Kellehear, Noonan, Bollig, Grindod, Hamzah and Haberecht2023) and in the context of Compassionate Cities, settings like workplaces, churches and schools (Kellehear, Reference Kellehear2005). The basis of this responsibility is seen to rest in relation to both pragmatic care benefits (D’Eer and Sallnow, Reference D’Eer and Sallnow2024: 6), but also as collective ‘moral’ (Sawyer et al., Reference Sawyer, Higgs, Porter and Sampson2021: 3) and ‘civic’ (Abel et al., Reference Abel, Kellehear and Karapliagou2018: S3) imperatives, fulfilled predominantly by women’s labour (Sutherland et al., Reference Sutherland, Ward-Griffin, McWilliam and Stajduhar2017).

The status of CCC is promulgated further by a narrative suggesting novelty. Kellehear states that he “wanted to bring a new way of doing palliative care” (Hooker, Reference Hooker2022: 502) and a host of expressions follow: CCC as variously a: “new vision” (Librada-Flores et al., Reference Librada-Flores, Nabal-Vicuña, Forero-Vega, Muñoz-Mayorga and Guerra-Martín2020: 2); “new paradigm” (Quintiens et al., Reference Quintiens, D’Eer, Deliens, Van den Block, Chambaere, De Donder, Cohen and Smets2022: 423); “brave new horizon” and “new wave” (Sawyer et al., Reference Sawyer, Higgs, Porter and Sampson2021: 21). This suggested originality extends into profound notions of being “pioneering” and “innovative” (Vanderstichelen, Reference Vanderstichelen, Dury, De Gieter, Van Droogenbroeck, De Moortel, Van Hove, Rodeyns, Aernouts, Bakelants, Cohen, Chambaere, Spruyt, Zohar, Deliens and De Donder2022: 2) and part of a “healthcare revolution” (Abel and Wood, Reference Abel and Wood2023: 1), “revolutionizing the way people view, access and experience end-of-life care” (Sawyer et al., Reference Sawyer, Higgs, Porter and Sampson2021: 21). This narrative also juxtaposes this new’ with the ‘old’, expressed within ‘rediscovery’ and ‘reclaiming’ expressions; for example, a belief that “community is having to be rediscovered in the modern world” (Abel and Wood, Reference Abel and Wood2023: 1), realising a “regaining what was formerly unremarkably common – community care of the dying” (Kellehear, Reference Kellehear2005: x) and “create(ing) new (or rediscover old) forms of solidarity and compassion” (Wegleitner et al., Reference Wegleitner, Schuchter, Prieth, Wegleitner, Heimer and Kellehear2017: 109).

Discussion

These features can be seen in the context of aforementioned social movement theory. That the emergence of new movements tends to be associated with accentuated positives, overstated successes and minimized critique is perhaps unsurprising (Buechler, Reference Buechler1995). CCC narratives therefore simply adopt a common trajectory to its parent Ottawa Charter ‘self-proclamation’ template; characterized by Nutbeam et al. (Reference Nutbeam, Corbin and Lin2021) as possessing idealized and normative tones, non-falsified acceptance of the veracity of its principles and citation of isolated successes as universal.

The use of ‘new’ is a familiar policy narrative device. Fairclough (Reference Fairclough2000: 18–19) identifies its prominent expression in policy discourse, offering what Petersson et al. (Reference Peterssona, Olssonb and Popkewitz2007: 50) term a “future-oriented” status. The new/old juxtaposition and notions of CCC ‘rediscovering’ and ‘reclaiming’ care models is also recognised as a powerful stratagem. In alluding to an idealised past, it reflects a “nostalgic” rhetoric, (Müller and Proksch, Reference Müller and Proksch2024: 993). Whilst nostalgia can be seen negatively in policy worlds driven by innovation (Boym, Reference Boym2007), Reynolds (Reference Reynolds2011: xxiii) coins the qualifying phenomenon of ‘retromania’ – a “living in, off and with the past”. In seeing nostalgia as “restorative”, Reynolds (Reference Reynolds2011: xxvi) considers the phenomenon as both “longing for an old social order” whilst reflecting the progressive ideal of a “paradise lost and paradise regained”. Here, Boym’s (Reference Boym2007: 13) cites the term nostos (return to a lost home) as a way of “coevaling” past and present policies. In Fairclough’s (Reference Fairclough2000: 18–19) eyes, this bringing-together allows the possibility of “reconciling themes which have been seen as irreconcilable” and again the possibility of CCC achieving Stone’s ‘ambiguous accommodation’.

Finally, the use of an ‘everyone’s responsibility’ frame [captured in Kellehear’s statement in Hooker (Reference Hooker2022: 502), “people will take more responsibility for their health”] is significant in the context of the tension introduced above within general health and death-specific discourses around principles of voluntarism and determinism (Burrows et al., 1995; Koksvik, Reference Koksvik2020). Rooted in the emergence of “popular individualism” with its voluntaristic ethic (Clark, Reference Clark2019: 983), it appears to mirror 1976’s famously contentious DHSS document ‘Prevention and health: everybody’s business’ that contended, “the weight of responsibility for his (sic) own….health lies on the shoulders of the individual” (DHSS, 1976: 38). The significance of this framing lies with its affinity to ‘neo-liberal’ policy discourses that suggest the potential for voluntary activity to be used to compensate for deficiencies in statutory provision generally (Navarro, Reference Navarro2007) and end-of-life care specifically (French et al., Reference French, Hansford and Moeke-Maxwell2023).

Conceptual bases represented in CCC

The identified CCC literature alludes to multiple contributory conceptual and theoretical resources. The core concepts of ‘compassion’ and ‘community’ get some attention. In relation to compassion, Islam et al. (Reference Islam, Ruez, Rahman and Altaf2024: 563) feel it is seen as a “morally superior virtue” and Dumont et al. (Reference Dumont, Marcoux, Warren, Alem, Alvar, Ballu, Bostock, Cohen, Daneault, Dubé, Houle, Minyaoui, Rouly, Weil, Kellehear and Boivin2022) note religious connotations and associations with forms of solidarity. Librada-Flores et al.(Reference Librada-Flores, Nabal-Vicuña, Forero-Vega, Muñoz-Mayorga and Guerra-Martín2020) cite definitional work by Sinclair et al. (Reference Sinclair, Norris, McConnell, Chochinov, Hack, Hagen, McClement and Raffin Bouchal2016) that express compassion in relation to seven categories, including virtues, relational space and virtuous response.

Community is seen as embodying a ‘lay’ orientation (Mills et al., Reference Mills, Abel, Kellehear, Noonan, Bollig, Grindod, Hamzah and Haberecht2023) involving expressions of ‘network’ theory (Sawyer et al., Reference Sawyer, Higgs, Porter and Sampson2021). Variously, “civic engagement” (D’Eer and Sallnow, Reference D’Eer and Sallnow2024: 5), “community capacity” (Abel, Reference Abel2018: 7), “social capital” (Roleston et al., Reference Roleston, Shaw and West2023: 947), “empowerment” (Abel et al., Reference Abel, Kellehear and Karapliagou2018: S7) and “resilience” (Vanderstichelen et al., Reference Vanderstichelen, Dury, De Gieter, Van Droogenbroeck, De Moortel, Van Hove, Rodeyns, Aernouts, Bakelants, Cohen, Chambaere, Spruyt, Zohar, Deliens and De Donder2022: 1393) are cited, fostered practically by “community development” (Vanderstichelen et al., Reference Vanderstichelen, Dury, De Gieter, Van Droogenbroeck, De Moortel, Van Hove, Rodeyns, Aernouts, Bakelants, Cohen, Chambaere, Spruyt, Zohar, Deliens and De Donder2022: 1394).

Beyond these foundational concepts, The Ottawa’s Charter’s ‘supportive environments’ element provides CCC with the key resource of ‘settings’ (Hancock, Reference Hancock1993); in CCC, encompassing “healthy communities” (Kellehear, Reference Kellehear2013: 1072), “healthy cities” (Roleston et al., Reference Roleston, Shaw and West2023: 946) and “area-based” (Quintiens et al., Reference Quintiens, D’Eer, Deliens, Van den Block, Chambaere, De Donder, Cohen and Smets2022: 422) orientations. All suggest the need for “whole-systems” (Vanderstichelen et al., Reference Vanderstichelen, Dury, De Gieter, Van Droogenbroeck, De Moortel, Van Hove, Rodeyns, Aernouts, Bakelants, Cohen, Chambaere, Spruyt, Zohar, Deliens and De Donder2022: 2) and “new public health” approaches (Kellehear, Reference Kellehear2013: 1071) with a “socio-ecological” orientation in environmental, social, economic and political domains (Wilson et al., Reference Wilson, Herrera Molina, Librada Flores, Kellehear, Abel and Kellehear2022: 117). Additionally, ‘Compassionate City’ status is granted on the basis of them being required to “develop and support the 13 social changes to the city’s key institutions and activities” (Abel and Kellehear, Reference Abel, Kellehear, Abel and Kellehear2022b: 303).

Finally a series of auxiliary concepts are cited, including, “social marketing” (Kellehear, Reference Kellehear2020: 116), “social prescribing” (Abel et al., Reference Abel, Kellehear and Karapliagou2018: S5) and various forms of ‘literacy’ – “health” (Hooker, Reference Hooker2022: 502), “death” (Mills et al., Reference Mills, Abel, Kellehear, Noonan, Bollig, Grindod, Hamzah and Haberecht2023: 1), “grief” (Breen et al., Reference Breen, Kawashima, Joy, Cadell, Roth, Chow and Macdonald2022: 425) and “cultural” (Kellehear, Reference Kellehear2020: 115).

Discussion

Despite the existence of some conceptual substance described above, in keeping with the tendency for social movements to simplify their nature, the predominant sense is that CCC’s theory base is relatively light. Indeed, Sawyer et al. (Reference Sawyer, Higgs, Porter and Sampson2021) identify the lack of a unified theoretical approach and Roleston et al. (Reference Roleston, Shaw and West2023: 946) suggest that CCC is a “common-sense model”. These deficits exist at various levels.

In relation to the articulation of ‘compassion’, its conceptualization is generally brief, thin and uncritically deployed (Zaman et al., Reference Zaman, Inbadas, Whitelaw and Clark2017). It is seen as definitionally ‘vague’ (Librada-Flores et al., Reference Librada-Flores, Nabal-Vicuña, Forero-Vega, Muñoz-Mayorga and Guerra-Martín2020) and ‘tautological’ in that definitions flow from outcomes rather than processes (Vanderstichelen et al., Reference Vanderstichelen, Dury, De Gieter, Van Droogenbroeck, De Moortel, Van Hove, Rodeyns, Aernouts, Bakelants, Cohen, Chambaere, Spruyt, Zohar, Deliens and De Donder2022: 6). Abel and Townsend (Reference Abel, Townsend, Wegleitner, Heimerl and Kellehear2016) also submit that ‘creating’ voluntary, free-flowing compassion is difficult with Islam et al. (Reference Islam, Ruez, Rahman and Altaf2024: 563) suggesting that it forms a “‘straitjacket strategy’ to extend a moral legitimacy”.

Detailed conceptualisations of ‘community’ also tend to be under-represented in CCC discourse with the operationalisation of dimensions like, ‘who constitutes it?’ (encompassing ‘…of place’, ‘…of interest’, ‘…of action’ and ‘…of practice’ (Richman, Reference Richman and Skidmore1997)) and ‘what power relations are present?’ [differentials within and between communities and statutory agencies (Ledwith, Reference Ledwith2010)] lacking. Whilst Kellehear (Reference Kellehear2005: 100–101) did draw attention to the potential to deploy either non-specific or stereotypical concepts, subsequent reflection is considered lacking (D’Eer and Sallnow, Reference D’Eer and Sallnow2024: 6). When articulated, this happens predominantly on a ‘consensual’ (Hooker, Reference Hooker2022: 502) or ‘romanticised’ basis, where “any initiative labelled community development is deemed inherently laudable, without further critical analysis” (Sallnow et al., Reference Sallnow, Bunnin, Richardson, Wegleitner, Heimer and Kellehear2017: 10).

Such conceptualizations are clearly influential. For example, during the emergence of 1990’s ‘care in the community’ policies, with its assumption that a shift from institutional care to one undertaken by ‘the community’ was preferable (Davies, Reference Davies1994), a critical feminist perspective arose centering on the recognition that in reality, such care tends to be reduced to informal care by women (Himmelweit and Plomien, Reference Himmelweit, Plomien, Evans, Hemmings, Henry, Johnstone, Madhok, Plomien and Wearing2014). This issue was initially recognised by Kellehear (Reference Kellehear2005: 79) and fleetingly considered by Wegleitner et al. (Reference Wegleitner, Schuchter, Prieth, Wegleitner, Heimer and Kellehear2017) and Klie (Reference Klie, Wegleitner, Heimerl and Kellehear2017). However, apart from two particular cases (Pribula, Reference Pribula2021; Chan and Funk, Reference Chan and Funk2024) this issue has subsequently received little substantial attention.

Furthermore, Sawyer et al. (Reference Sawyer, Higgs, Porter and Sampson2021: 13) suggest that these stances disregard what they see as “the limitations of a collective culture” and wishes away community power-differentials and conflict within and between communities (Sallnow and Paul, Reference Sallnow and Paul2015). These issues impact on the negotiation of the distribution of responsibility within CCC and consequently, the extent to which communities are considered ‘passive’ targets or ‘active’ leaders in shaping end-of-life policies and practices (D’Eer and Sallnow, Reference D’Eer and Sallnow2024: 6).

The outcome of this positioning feeds through to the types of CCC actions that follow and the associated policy levels where this work is situated; essentially, that communities as ‘targets’ tends to result in individualistic, service-driven initiatives whilst authentic participation is associated with ‘citizen control’ and more critical and systemic-level impacts (Gómez-Batiste et al., Reference Gómez-Batiste, Mateu, Serra-Jofre, Molas, Mir-Roca, Amblàs, Costa, Lasmarías, Serrarols, Solà-Serrabou, Calle and Kellehear2018: S33). Dumont et al. (Reference Dumont, Marcoux, Warren, Alem, Alvar, Ballu, Bostock, Cohen, Daneault, Dubé, Houle, Minyaoui, Rouly, Weil, Kellehear and Boivin2022: 7) suggest that the latter scenario tends to prevail, communities being oriented to support existing care models rather than affect policy transformation. D’Eer and Sallnow (Reference D’Eer and Sallnow2024: 6) also highlight that the ‘developing personal skills’ element of The Ottawa Charter tends to be reduced to the ‘education’ of individuals about professionally-defined issues (knowledge about services or conditions) rather than community action or ownership, seeing community development as, “a process of implementing pre-packaged interventions…rather than of social empowerment” (Dumont et al., Reference Dumont, Marcoux, Warren, Alem, Alvar, Ballu, Bostock, Cohen, Daneault, Dubé, Houle, Minyaoui, Rouly, Weil, Kellehear and Boivin2022: 10). Broadly, this foregrounding of relatively pragmatic practice is suggestive of a conservative ‘reformist’ as opposed to ‘radical’ policy orientation (Tam, Reference Tam2019).

Next, the conceptual basis of CCC relies heavily on the claimed strength of The Ottawa Charter which, via predominantly self-proclaimed assertions has attained the status of a hegemonic ‘given’; for example: being “our Broad Street Pump” (Kickbusch, Reference Kickbusch2007: 9) and “a ‘Holy Grail’” (McPhail-Bell et al., Reference McPhail-Bell, Fredericks and Brough2013: 23). Again, for a new movement to associate itself with such an esteemed resource is understandable.

However, this eminence is not universally accepted and various critical concerns exist. As a movement, its essential status is problematised; O’Neill (Reference O’Neill2012: 4) considering it “symbolic” and Whitehead and Irvine (Reference Whitehead and Irvine2011: ii250) a “bandwagon”. Correspondingly, Petterson (Reference Petterson2011) bemoans a failure of substantial implementation. Its ironically ‘top down’ and restricted construction is also noted, emanating exclusively from representation from the Global North in its creation (Raeburn and Peters, Reference Raeburn and Peters1987) and in this context, McPhail et al. (Reference McPhail-Bell, Fredericks and Brough2013: 23) apply a postcolonial lens to the Charter suggesting it, “masked underpinning power imbalances and Western-centric worldviews….silencing non-Western voices”. Relatedly, compared to the socio-political orientation of its 1978 predecessor, the Alma Ata Declaration (WHO, 1978), Awofeso (Reference Awofeso2004: 708) considers its ethos ‘apolitical’. Again, this ground aligns with the tendency for CCC to adopt ‘reformist’ rather than ‘radical’ orientations.

The particular Ottawa Charter-derived feature of supportive community and city ‘settings’ is significant to CCC. The diverse conceptual and practical foundations of this approach have been extensively and critically examined (Whitelaw et al., Reference Whitelaw2001), particularly the feasibility of its implementation in complex and potentially hostile contexts (Zucca et al., Reference Zucca, Long, Hilton and McCann2021). Given the existence of these resources, one would expect to see their expression in CCC literature. Yet, despite isolated citations [Kellehear (Reference Kellehear2020: 117) and Wilson et al. (Reference Wilson, Herrera Molina, Librada Flores, Kellehear, Abel and Kellehear2022: 118) allude briefly to a ‘settings approach’], these considerations are largely absent.

Similarly, whilst Kellehear (Reference Kellehear2005: 52–55) does suggest concerns associated with the ‘Healthy Cities’ movement (but still within a belief that its “basic ideas are sound”), there has been little subsequent discussion, particularly in relation to a series of concerns such as: the fundamental appropriateness of cities as sites of egalitarianism and civic participation (Nielsen, Reference Nielsen2025: 1007); its implementability (Barton and Grant, Reference Barton and Grant2013); a lack of evidence of effectiveness (de Leeuw and Skovgaard, Reference de Leeuw and Skovgaard2005); its ability to foster deep policy change (Goumans and Springett, Reference Goumans and Springett1997); and the potential for it to create inequities (Cole et al., Reference Cole, Shokry and Connolly2017).

Finally and returning to the ‘Charter’ basis of Compassionate Cities being conferred on the fulfilment of “13 social changes” (Abel and Kellehear, Reference Abel, Kellehear, Abel and Kellehear2022b: 303), this approach follows other WHO-related ‘settings’ movements who confer status via externally mandated ‘standards’ (e.g. Health Promoting Hospitals and Health Services) and ‘guidelines’ (e.g. Healthy Workplaces), Here, Compassionate Cities’ ‘charter’ status is granted on the basis of being required to “develop and support the 13 social changes to the city’s key institutions and activities” (Abel and Kellehear, Reference Abel, Kellehear, Abel and Kellehear2022b: 303). Some suggest that these circumstances are problematic, shoe-horning organisations into pre-prescribed criteria and as such, shifting motives for development from a (preferred) intrinsic one towards incentive being driven by restricted extrinsic demands (Rosenblatt, Reference Rosenblatt2011).

This lack of criticality is also reflected in ancillary concepts deployed in CCC. For example, of ‘health literacy’, Kellehear suggests “it pretty much speaks for itself” (Hooker, Reference Hooker2022: 502) despite the existence of a significant critical literature on the diversity of this concept (Sørensen et al., Reference Sørensen, Van den Broucke, Fullam, Doyle, Pelikan, Slonska and Brand2012) – particularly that of ‘critical health literacy’ (Sykes et al., Reference Sykes, Wills, Rowlands and Popple2013). In keeping with CCC’s policy ambiguity, the same point can be made for the blunt use of ‘social capital’ and whether the expression being referring to is conservative ‘bonding’, community-building ‘bridging’ or politically-motivated ‘linking’ capital (Poortinga, Reference Poortinga2012). The potentially problematic nature of it, what Villalonga-Olivesa and Kawachi (Reference Villalonga-Olivesa and Kawachi2017: 106) call the “dark side of social capital”, is also side-stepped.

This exclusion of conceptual critique is concerning in two respects. Within the general Popperian belief that all propositions should be open to challenge in a policy context (Popper, Reference Popper1992), it lacks the deductive testing required to actively falsify positions (Ingrams, Reference Ingrams2020). It then reflects what Ketokivi and Mantere (Reference Ketokivi and Mantere2010) term a ‘problem of induction’, where past policy ‘success’ is inappropriately extrapolated into the future. Here, some aspects of CCC appear self-serving - an unfalsifiable ‘utopian’ policy resource (Ingrams, Reference Ingrams2020). In this context, it is interesting to note that examples of the most penetrating contemporary critiques have come from early career academics with no prior affinity to the movement, for example: Islam’s (Reference Islam2020) doctoral study of Compassionate Louisville as a form of neo-liberal governance and subsequent publication (Islam et al. Reference Islam, Ruez, Rahman and Altaf2024); and Pribula’s (Reference Pribula2021) blog that applies a feminist analysis to CCC, concluding that most care labour falls upon women.

Expressions of power and associated implementation within CCC

One final feature associated with the tendency for CCC narratives to be optimistic centres on its assumptions of inter-sector equity and consensus in matters of implementation. Here, beliefs in a “foundational inter-dependency” (Abel et al., Reference Abel, Kellehear and Karapliagou2018: S5) and assumptions of “shared responsibility” and “collaboration” between communities and associated healthcare professional groupings tend to prevail (Sawyer et al., Reference Sawyer, Higgs, Porter and Sampson2021: 12).

A series of implementation barriers are acknowledged, located in the mainstream healthcare context, for example: resistance to innovative ideas; medical and professional dominance; clinicians being unwilling to engage; a lack of service capacity; a shortage of volunteers; and concerns for CCC ‘quality’ and patient safety (Kellehear, Reference Kellehear2005; Kuo et al., Reference Kuo, Lin, Kuo, Chen, Chen and Hwang2021; Mills et al., Reference Mills, Abel, Kellehear, Noonan, Bollig, Grindod, Hamzah and Haberecht2023; Smith et al., Reference Smith, Lowrie and Dawes2024). Of these, Roleston et al. (Reference Roleston, Shaw and West2023: 11) suggests that there are “few strategies or solutions to overcome them”.

Discussion

The optimism expressed in these consensual assumptions around ‘partnership working’ between communities and formal service agencies can be associated with those in the movement becoming what Walter (Reference Walter2017: 1) terms ‘death entrepreneurs’ proactively ‘selling’ the unquestioned value of the concept (Kellehear, Reference Kellehear2020: 116) via staff training and capacity development (Abel et al., Reference Abel, Kellehear and Karapliagou2018: 7). For emergent social movements, again this is predictable –foregrounding CCC positives and not meaningfully engaging with possible resistance (Christiansen, Reference Christiansen2011).

When the existence of ‘barriers’ are accepted, they tend to be located in a one-sided perception of them being located within existing health systems. This aligns with Williams’ (Reference Williams, Snow, Soule and Kriesi2004: 97) recognition of social movements, “running up against extant ways of doing things” and for them to then express grievance with those antagonistic towards their innovative ideals. Kellehear (Reference Kellehear2005: 105) reflects this possibility within CCC, suggesting that “anger and pique is the usual reaction towards new ideas by those who are the guardians of the old ones”. Williams (Reference Williams, Snow, Soule and Kriesi2004: 97) however counsels that movements should look to pragmatically exist within established organisational cultures, understanding their opposition and seeking to resonate with them.

Additionally, this tendency for CCC to circumvent real world healthcare politics also brings into play the possibility established above that social movements can be as much symbolic as material, particularly within the deployment of multiple Charters and Declarations, culminating with the recent publication of the ‘Bern Declaration’ (PHPCI, 2024). Whilst Inbadas et al. (Reference Inbadas, Zaman, Whitelaw and Clark2017: e7) see these statements as, “part of the international palliative care landscape”, they also critically recognise indefinite rationales and question their impact. Others offer more pointed critiques; Hills and McQueen (Reference Hills and McQueen2007: 5) contending that they, “represent the loftiest and often unobtainable goals of the creators”.

These developments are associated with a related phenomenon that Goodson (Reference Goodson2012: 31) terms ‘social movement branding’ involving a ‘commodification’ of social practices (Hall, Reference Hall2023: 544). Connected to the aforementioned cache associated with the Compassionate Cities Charter, some see the potential for this to “define, distinguish, express and protect both issue identity and social mission” (Stronach, Reference Stronach2014: 567); for example, in relation to Plymouth Compassionate City logos, Wilson et al. (Reference Wilson, Herrera Molina, Librada Flores, Kellehear, Abel and Kellehear2022: 125), feel that “having a symbol that the city can identify with is powerful”. However, others suggest that these developments are potentially superficial with the commodification processes associated too closely again with a neo-liberal ethos (Buraway, Reference Buraway, Paret, Runciman and Sinwell2017).

Finally, these expressions can be situated in relation to the ‘stages’ that movements theoretically go through (Blumer, Reference Blumer and Lyman1995). Crafted by a tightly-knit and vocal group of protagonists, increasing CCC formality has been manifest in various respects: the creation of ‘Public Health Palliative Care International’ (an advocacy association for public health in palliative care); the formation of a ‘Public Health Palliative Care Reference Group’ within the European Association for Palliative Care; the founding of an associated journal, ‘Palliative Care and Social Practice’; the establishment of global hubs like Compassionate Communities Australia and Matsuzaki United Japan; the formation of a copyrighted charitable organisation (Compassionate Communities UK) with paid, tiered membership; the potential attainment of CC ‘charter’ status; with associated conferences, courses and events. So CCC appears to have navigated initial phases of ‘emergence’ and ‘coalescence’ with its formality suggesting that it has reached a ‘bureaucratic’ stage (Christiansen, Reference Christiansen2011: 18).