The NHS Confederation report The case for neighbourhood health and care highlights the importance of building on the assets of neighbourhoods and communities for a sustainable health service. Nigel Edwards, senior advisor at PPL, who wrote the report with Local Trust, explains further
The new government has an ambition to create a ‘neighbourhood health’ service. This echoes the current direction of travel as seen in the Fuller Stocktake and the development of place-based leadership and integrated neighbourhood teams. It also seems to be a recognition that power is overly centralised in the NHS and that there is a need for much more locally sensitive decision making.
It is also increasingly clear that the ambition to address social determinants of poor health and persistent inequalities and to have effective prevention strategies, requires local action working alongside national policy. It is well known that many of the causes of ill health are related to social and economic issues, deprivation and the wider environment. Many of these are outside the reach of the NHS and even other statutory agencies can only do so much.
There is a growing recognition that without the help of local communities the NHS will not be able to unleash the potential of neighbourhoods, with the new perspectives, creativity, and energy that they bring. And crucially, there is a growing body of evidence that, just as conventional ‘top-down’ approaches to health have failed, approaches based on working in active partnership with communities are much more likely to succeed.
There are many local community development initiatives in different parts of the country – sometimes these have been nurtured by local statutory providers, but many have grown bottom-up. Typically they bring together local voluntary organisations, individuals and others often within quite tightly defined neighbourhoods. Some of these are very small but they represent communities that have meaning to the people who live in them. They often involve participants from the statutory sector and often have close links to GP practices, schools and other locally based services.
They focus on issues identified with local people, often arrived at as a result of a combination of careful listening and dialogue with the community and also from the initiative of individuals from the community who have identified a need. Their activities include initiatives on loneliness, helping people find work, food and fuel poverty, exercise, skills and activities and training for young people. They tend to focus on a small number of priority areas but not to the exclusion of supporting individuals who have an idea.
What many of these have in common is that they bring people together to create connections and forge relationships. In the jargon this is called social capital and there is strong evidence that communities with higher levels of social capital are more resilient and more able to address the health challenges they face.
While many of these schemes are quite small the potential to make a difference is large. The statutory sector cannot create these initiatives or take them over, but they can catalyse and support them. This is potentially challenging for them because the change process is much more non-linear, non-hierarchical, less prescriptive, longer term and relationship based than the way that the statutory sector generally approaches change. It also generates more variety and variation than it tends to be comfortable with. There is also the risk that supporting the development of these approaches risks crushing it with kindness, multiple meetings for assurance, reporting templates and the other paraphernalia of statutory sector project management.
What can help is support with finding somewhere to meet in the community, providing practical support with recruitment, DBS checks, sharing standard policies (such as safeguarding) governance processes and structures for example. Using funding and commissioning approaches that are long term and light touch and offering high levels of discretion is also very important. This will feel risky but attempts to over manage this will stifle innovation and development. This means that a high level of trust is needed, and statutory organisations will need to accept that while the community work will generally be aligned to the long-term goals of the ICB this may not always be the case in the short term.
The community and neighbourhood models benefit from having inclusive approaches to leadership, which can prove challenging. Many had developed some administrative and management infrastructure which helps with the often-complex web of relationships and potentially conflicting priorities. The management role requires a good understanding of the community and the ability to work across different cultures often with people who do not directly report to them.
Encouraging the growth and spread of local community development models, perhaps combined with development in primary care such as community health workers, expanded social prescribing and other prevention strategies needs to be a key part of the government’s forthcoming 10-year plan. The NHS will need to learn some new ways of working to support this but the evidence from our work and from similar models in other countries is that this will be worth the effort.
