How communities can lead systemic change in healthcare
Margaret Hannah, director of health programmes at the International Futures Forum, introduces Well-placed: The impact of Big Local on the health of communities. The report, produced by New Local, looks at how community-led decision-making has had an impact on health outcomes through the Big Local programme.
Many healthcare systems around the world face the same challenge – to meet current and future demands for care and treatment within finite resources. In practice, they are struggling with budgets either showing inexorable and unsustainable increases or they face impossible efficiency targets.
Incremental innovation abounds – making our existing systems work better, smarter, cheaper. But while necessary, this is clearly not sufficient.
Systemic problems call for systemic change. We need fresh understandings of what drives the current system and what might be avenues for renewal. Some clues to these new ways of thinking are offered by Well-placed, a report from New Local which examines the impact community-led decision-making has had in improving health and wellbeing through the Big Local programme.
Health initiatives in Big Local areas
The Big Local programme focuses on 150 ‘hyperlocal’ neighbourhoods which, in 2011, were each given £1million to spend over the course of 10-15 years.
Putting money and ownership of decision-making into the hands of communities provided them with opportunities should they wish to fund initiatives to improve health and wellbeing. The New Local report explores ways in which they did this.
Well-placed describes a wide range of health-related activities in Big Local areas. These included initiatives focusing on diet and physical activity, support for people’s mental health, ways to improve children and young people’s health and opportunities to develop new skills and programmes to tackle the cost of living crisis.
Some Big Local areas had good relationships with local service providers and used some of their funding to sustain activities which would otherwise have ceased because of funding cuts in local agencies. Others were less successful in connecting with local service providers and just finding a way to start the conversation counted as significant progress.
One interesting finding was a bigger change in self-reported health in people living in Big Local areas compared to the rest of England between the 2011 and 2021 censuses. Despite being in some of the poorest areas of the country, these communities were reporting improvements in their self-reported health.
These years have been noted for cuts in public services, static household incomes, economic decline and a pandemic, which suggests this could be an important finding.
A community-powered NHS
In 2022, New Local produced a blueprint for a community-powered NHS, which advocated for more community participation in decision-making, discovering the strengths and assets within communities that can be grown and working on organisational culture such that it becomes more community-focused.
This recent work goes further and illustrates clearly that given the chance, people will take responsible action to promote community health and wellbeing. I have been fortunate to work with one Big Local area in the North of England and found a committed group of community leaders who had a clear vision for improving the lives of people in their area.
They had inner strength in their sense of belonging, the longevity of their trusting relationships and a new-found confidence they could make a difference when given the opportunity to do so. Above all, they had a spirit and were willing to fight for their community’s interests.
Their strong sense of fairness and their lifelong skills in managing on low incomes ensured they took great care in their funding decisions and made sure they got the very best value for money they could achieve.
Community resilience in adverse times
Within large statutory organisations, most funding is allocated to existing services and based on historical patterns of use. As described in my book, Humanising Healthcare, the mindset is dominated by the clinical gaze, an emphasis on efficiency and risk aversion.
What if the NHS and Integrated Care Systems were to really question these assumptions and beliefs?
What if we were to believe in the strengths of communities who, whilst living through adverse times, are able with relatively small budgets to make a meaningful difference in people’s lives?
What if the function of commissioners was to enable people to offer mutual and reciprocal support to each other, with enabling healthcare infrastructure wrapped around and in service of this activity? How might Integrated Care Systems begin to grow this new pattern of community-led health and care?
By healthcare standards, the sums of money involved in making these differences to people’s lives are tiny. In the single year 2021-22, NHS England allocated on average £2.6billion to each Integrated Care Board. This is 2,600 times more than the ten-year allocation to one Big Local area.
By releasing a tiny proportion of its allocation to enable these community-led programmes to continue and grow, Integrated Care Systems have the opportunity to meet contemporary patterns of illness through an approach that restores effectiveness in health systems, reduces inequalities and enables people to live healthier lives.
Margaret Hannah is the director of health programmes at the International Futures Forum.