David Colin-Thome, Independent Healthcare Consultant and Visiting Professor, Manchester Business School, Manchester University, UK and School of Health, University of Durham

Brian Fisher, GP and Patient and Public Involvement Lead, NHS Alliance

Key message

If Health and Wellbeing Boards are to make a real and lasting impact on the health and resilience of the populations they serve, they must revitalise the principles of community-oriented primary care, with its values of health protection, social justice and community development.

Why this matters to us

When I (Brian) started GP practice in 1976, I found a community-development programme a few steps from the health centre in south-east London. It was founded on principles of social justice and values of co-operation and challenging power. It changed my life (and I married the community worker…) and I have tried to put these values into operation across the NHS ever since.

When I (David) began GP practice in 1971 I was greatly influenced by Dr Julian Tudor Hart and Dr Geoffrey Marsh who, as GPs, focused on the individual and the population of patients. Later, I was influenced by my friend Professor John Ashton as we explored the GP practice as a public health organisation, and further shaped by my work as  a local councillor.

Key message

If Health and Wellbeing Boards are to make a real and lasting impact on the health and resilience of the populations they serve, they must revitalise the principles of community-oriented primary care, with its values of health protection, social justice  and community development.

Health and Wellbeing Boards are one of the innovations in the Health and Social Care Act of 2012. They could herald a long overdue new public health by harnessing community activity such as asset-based community development.  Health and Wellbeing Boards are intended to span the worlds of public health and primary care.

The Role of Health and Well-being Boards

Each top tier and unitary authority will have its own health and wellbeing board. Board members will collaborate to understand their local community’s needs, agree priorities and encourage commissioners to work in a more joined up way.

  • Health and wellbeing boards will have strategic influence over commissioning decisions across health, public health and social care, integrating services.
  • Boards will involve democratically elected representatives and patient representatives in commissioning decisions alongside commissioners across health and social care.
  • Boards will bring together clinical commissioning groups and councils to develop a shared understanding of the health and wellbeing needs of the community.
  • Through undertaking the Joint Strategic Needs Assessment (JSNA), the board will drive local commissioning of health care, social care and public health, bringing in other services such as housing and education provision.

R.H.Tawney said: ‘The poor have remained beloved by the Gods being afforded excellent opportunities for dying young’.  This remains a truth today despite the huge improvements in the public’s health and in healthcare. These improvements have disproportionately benefitted the more advantaged.  Narrowing these inequalities should be a priority of Health and Wellbeing Boards. Can they deliver this when so many public health policies of the past have not? We argue that they can, and they must. To do so they must complement the present public health approach that is concerned with discrete interventions targeted at individuals, with on-going interventions that help whole communities and families to help themselves.

General practice has always had a population responsibility (the registered list) as well as a responsibility to individual patients. These twin responsibilities lie at the heart of what it means to be ‘family and community-oriented’ – concerned not only with treating the diseases that a patient has, but also recognising the impact of their social context – family relationships, jobs, crime and so on. Indeed, this is one of the main reasons why  decentralised generalist healthcare systems are more effective than centralised specialist-led systems. In the words of Berwick:  “general practice and primary care is the soul of a proper, community orientated, health-preserving care system’[ii]. In the words of Starfield: “The well known but underappreciated secret of the value of primary care is its person and population, rather than disease, focus[iii]

Clinical Commissioning Groups  now have their hands on the reins of the NHS. This presents an opportunity to meaningfully span the general practice role of personal care and public health in collaboration with their local authorities through Health and Wellbeing Boards. General medical practices are statutory members of CCGs and have to work together to achieve the aims of Clinical Commissioning Groups to reduce costs and retain quality. As has been described in recent papers in LJPC, it is becoming increasingly common for clusters of 10-20 practices who serve populations of about 50,000 to come together to develop collaborative practice – to share the load of overwhelming demands, for mutual support, and for improved care. Different places have called them different things – ‘Local Health Communities’, ‘Health Networks’, ‘Cells’ and ‘Hubs’.

These new clusters of general practice could provide a shared space for collaboration between public health and primary care. In these spaces multiple agencies could work together to provide in our cities and towns what pioneers like Julian Tudor Hart in South Wales[iv] and achieved in small communities – improving whole community capacity and resilience as well as personal medical care. They could translate to the 21st century the vision of Sidney Kark’s ‘community oriented primary care[v] and Ashton’s ‘New Public Health’[vi],

Health and Well-Being Boards  could make this happen, by ensuring that general practice and community services plan and act in concert with public health, local authorities, schools, voluntary groups and many other organisations, to synchronise their efforts for health improvement. Conventional individually-focused approaches to health promotion (e.g. smoking cessation, healthy eating and physical activity) could be complemented with social approaches that harness the energy in communities (termed ‘asset-based community development)[vii].  This approach helps people to help themselves – more effective than imposed solutions. As Kretzmann says: “healthy communities have never been built upon their deficiencies but have always depended upon mobilising the capacities and assets of people and place[viii]. It means recognising that health is more than the sum of their medical diseases, and includes a sense of coherence that Antonovski calls salutogenesis[ix] and MacIntyre calls Narrative Unity[x].

In this paper we revisit the evidence that a social approach to health improvement is effective at improving health and that it is cost effective. From this we suggest what Health and Wellbeing Boards can do to shape a winning course.

A community development approach improves health

Community development builds confidence to act for health improvements. For example, community development work on the Beacon estate in Cornwall showed sustained improvements – when the community realised that they could make a difference by working together, their motivation to act increased and they caused sustained improvements in housing, education, health and crime[xi]. Similar results have been seen in Balsall Health[xii].

The key link is that community development extends and strengthens social networks. These are the links between people that shape their sense of identity – making them feel that they belong and capable of making an impact. Social networks are formed in thousands of ways everyday brief encounters – in pubs and shops, clubs and schools for example.  Social networks are good. A meta-analysis of data across 308,849 individuals, followed for an average of 7.5 years shows a 50 % increased likelihood of survival for people with stronger social relationships.  This is consistent across age, sex, cause of death and is comparable with risks such as smoking, alcohol, Body Mass Index and physical activity[xiii].

Social networks and social participation also protect against cognitive decline and are associated with reduced morbidity and mortality[xiv].  Low levels of social integration, and loneliness significantly increase mortality[xv].  Social networks are weaker in more deprived areas and poor social participation is associated with mental ill health[xvi].  Improving social networking and social relationships reduces the risk of depression[xvii].

Those areas with stronger social networks experience less crime[xviii]   while enhancing employment and employability[xix].  Social cohesion and informal social control predict a community’s ability to come together and act in its own best interests and is derived, in part, from participation in local associations or organizations[xx].

There are a variety of models of different kinds of community development to examine, many of which have improved healthcare services. For example the “Linkage plus” programme developed and deepened social networks for older people while redesigning health services with their participation. Significant improvements in health and independence resulted[xxi].

Two examples of what has become to be termed ‘Asset Based Community Development’:

The Health Empowerment Leverage Project, HELP

HELP  focuses on the creation of a long-term problem-solving neighbourhood partnership between residents and front-line services from health and other agencies. The partnership is led by residents but generates parallel action and learning amongst agency staff enhancing the development of confidence, skills and co-operation and creating a cumulative momentum so that such developments are self-renewing so the whole atmosphere of the neighbourhood becomes more positive.

HELP adopted a method known as ‘C2’,   which displayed exceptional success over 15 years across 6 deprived rural and urban estates.  A review of the longer term effects of a C2 project run on the Beacon Estate in Penwerris, Cornwall found improvements between 1995 and 2000 in education, health, employment and crime.18

HELP has developed an approach that can assist Clinical Commissioning Groups and Health and Wellbeing Boards to assess the social capital of their communities and track changes that have taken place as a result of intervention.

Connected Care in eleven sites since 2006.

The Connected Care project,  part of the organisation Turning Point, set out to build on existing social capital and resilience to improve health and social care outcomes for local people in Owton ward in Hartlepool.

Community Researchers were recruited from the local community and supported by Turning Point and local agencies. Two hundred and fifty one local residents participated in an audit via one to one interviews, focus groups and a community “have your say” event.

The results of the audit informed the development of the Connected Care service that is delivered through a local community social enterprise, incorporated as a Community Interest Company. The service includes navigators, a debt and benefits advice service, support for older people to stay in their own homes for longer, supported housing for young people as well as a gardening and handyman service. It also includes a time bank to utilise the skills of local residents and co-ordinate volunteering between local people. Connected Care is now managing 32 flats in Glamis Walk that are owned by Accent Foundation who have now commissioned Connected Care to manage the whole estate.

Connected Care is being rolled out across Hartlepool building on the service delivered in Owton ward and community research activity across the town over the last 18 months.

The programme in Hartlepool has expanded from 100 people receiving support to over 500 people benefiting from the range of services – including benefits and welfare advice, luncheon clubs, social activities, gardening and handyman services, and meals on wheels. This service is expecting to triple again the number of people in the SAILS programme over the next year. On the back of this expansion the Council has awarded Connected Care the contract to provide luncheon clubs and reablement support for elderly people leaving hospital.

Cost-benefit of Community Development Initiatives

The evidence above shows that community empowerment improves health, and there are good reasons why general practice should contribute to leadership of such community empowerment; also the contemporary clustering of general practices into geographic areas provides a new practical shared space for it to happen. Surely Health and Wellbeing Boards and Clinical Commissioning Groups must therefore ensure that it happens.

But there is one important other piece of evidence – is it cost-effective?

Studies show that community empowerment is cost-effective, not merely in deprived areas but in all economic climates[1]. When people in an area take charge of their destiny, they can better contribute to the design of cost-effective and humane services that improve quality and contain costs better than when they are unable to contribute.  Making resources available to address the association between poor health and poor social networks and break the cycle of deprivation has been shown to decrease health care costs[2].

Social Return on Investment19 is a social value approach to measuring an economic return on investment. It has been used to track the cost benefit of a community development worker in four local authorities, identifying, supporting and nurturing volunteers within their areas to take part in local groups and activities.

An investment of £233,655 in community development activity was found to have created approximately £3.5 million in social return, a return of 15:1. The time invested by members of the community in running various groups and activities represented almost £6 of value for every £1 invested by a local authority.

Lomas shows that harnessing social networks has an effect comparable to bio-medical interventions. He estimates for every 1000 people exposed to each “intervention” per year

  • Social cohesion and networks of associations would prevent 2.9 fatal heart attacks
  • Medical care and cholesterol-lowering drugs would prevent 4.0 fatal heart attacks in screened males

HELP was asked by the Department of Health to explore the cost-benefit of community development . Examining the HELP interventions in three neighbourhoods across England,it was estimated that serious medical events would be reduced by 5% per year – an NHS saving of £558,714 over three years on depression, obesity, cardio vascular disease. This is as a result of local interventions such as exercise groups, dietary interventions and deepening of social networks.  This is a return of 1:3.8 on a £145,000 investment in community development over the three years.  Adding savings produced by reductions in crime and anti-social  behaviour would produce a further saving of £96,448 a year per neighbourhood using directly age standardised mortality rates per 100,000  £868,032 across the 20% most disadvantaged neighbourhoods of a local authority and £130m across England. This represents a return of 1:9.

What should Health and Wellbeing Boards Do?

It is understandable why there has been so little general practice leadership of community empowerment – medical training that emphasises the treatment of discrete diseases and the science of collaboration and empowerment is largely absent from formative and continuous medical education. Health and Wellbeing Boards must act to reverse this, firstly at the post-graduate level, working with Local Education Training Boards to develop skills to lead this in the new clusters of general practices.

It is understandable why there has been so little collaboration between general practice and public health practitioners to lead community empowerment – general practices have operated in isolation to deal with patients on a one-to-one basis. Previously attempt to systematically build community resilience and social cohesion have only been realistic in small communities where the shared boundaries are given by nature. In larger areas the absence of shared boundaries fragments collaborative initiatives. Health and Wellbeing Boards must act to consolidate these new clusters of practices as a shared developmental space where local authorities, public health business and third sector organisations can contribute to a New Public Health.

It is understandable why there is not more evidence of the huge untapped potential of community empowerment to improve health. Databases in the NHS are focussed on individuals with individual diseases.  Health and Wellbeing Boards must ensure that Clinical Support Units routinely gather data of the effect of these clusters on things like unscheduled admissions to hospital, place of care for those who are dying, and a breadth of other indices that will be affected by the large number of small acts of kindness that happen in empowered communities. They must provide reports of these data on a regular (monthly) basis so local people can witness the effects of their actions.

Health and Wellbeing Boards should also support pilot projects within these clusters, and create mechanisms for results to be fed back to Clinical Commissioning Groups so others can learn and change. Health and Wellbeing Boards should encourage such long-term capacity-creating interventions as an antidote to the usual old-fashioned projects that have short-term focus. They should work with universities to support evaluation of these initiatives.

The literature about Asset Based Community Development is particularly worth reviewing. This involves residents identifying local skills and experience, then discovering what they care enough about to change, then creating mechanisms to act together to achieve those goals. HELP and Connected Care use this approach.

If Health and Wellbeing Boards perceive their roles narrowly they will chart a traditional course with two or three key priorities focused on (probably medically-perceived) priorities. And they will fail. But if they claim a wider role (and they should), they could position themselves as enablers of a new public health that provides the training, the conditions and the evidence that community empowerment produces better health at lower cost.

References


[1] Knack S. Social Capital, Growth and Poverty; A Survey of Cross-Country Evidence. Social Capital Initiative, Working Paper No. 7, Washington, D.C.: World Bank. 1999

[2] Fair Society, Healthy Lives Strategic Review of Health Inequalities in England post 2010 p139 The Marmot Review February 2010 © The Marmot Review ISBN 978–0–9564870–0–1 Xiix

[ii] Berwick DM. A transatlantic review of the NHS at 60. BMJ 2008;337:a838

[iii] Starfield B, Shi L, Macinko J. (2009) Contribution of primary health care to health systems … quality of care in England. N Engl J Med. 361(4): 368–78

[iv] Hart J. A New Kind of Doctor. (1989) Merlin Press

[v] Communityoriented primary care: the legacy of Sidney Kark. American Journal of Public Health. 83(7):946-7, 1993 Jul. Gillanders WR)

[vi] Ashton J, Seymour H. The New Public Health. Milton Keynes:  OUP, 1988

[vii] Morgan M. & Ziglio.  Revitalising the public health evidence base: an asset model in Morgan & Ziglio (Eds) Health Assets in a Global Context: Theory, Methods, Action, Springer. 2010.

[viii]  Kretzman and McKnight.  Building Communities from the inside out. 1993.

[ix] Antonovsky, A. Unraveling The Mystery of Health – How People Manage Stress and Stay Well, San Francisco: Jossey-Bass Publishers, 1987.

[x] MacIntyre A. After Virtue. London: Duckworth, 2000

[xi] Developing sustainable social capital in Cornwall: a community partnership for health and well-being (The Falmouth Beacon Project) By Hazel Stuteley O.B.E. and

Claire Cohen Cornwall Business School, 2004

[xii] Atkinson D. Civil Renewal . Brewin Books 2004 ISBN1 85858 267 9

[xiii] Holt-Lunstadt, Smith, Bradley Layton Social relationships and mortality risk: a meta-analytic review..Plos Medicine July 2010, Vol 7, Issue 7.

[xiv] Jenkins R, Meltzer H, Jones P, Brugha, T and Bebbington, P. Mental Health and Ill Health Challenge. London:Foresight. 2008.

[xv] Bennett K. 2002. Low level social engagement as a precursor of mortality among people in later life. Age and Ageing 31: 165-168.

[xvi] Berkman LF and Kawachi I (2000) ‘A historical framework for social epidemiology’ in Berkman LF and Kawachi I (Eds.) Social epidemiology. Oxford: Oxford University

[xvii] 9 Morgan E and Swann C. Social capital for health: Issues of definition, measurement and links to health. London: Health Development Agency. 2004

[xviii] Ed. Fulbright-Anderson K and Auspos P. Fear of Crime and Neighbourhood Change. Community Change: Theories, Practice, and Evidence. 1986

[xix] Clark P and Dawson S. Jobs and the Urban Poor. Washington, D.C.: Aspen Institute. 1995

[xx] Ed. Fulbright-Anderson K and Auspos P. Fear of Crime and Neighbourhood Change. Community Change: Theories, Practice, and Evidence. 1986

[xxi] Willis M and Dalziel R. LinkAge Plus: Capacity building – enabling and empowering older people as independent and active citizens. Department for Work and Pensions Research Report No 571 2009

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