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It is well known that socio-economic factors play a huge role in determining people’s long-term health, and contribute significantly to the health inequalities that exist across England.
Anchor institutions are large organisations that are unlikely to relocate and have a significant stake in their local area. They have sizeable assets that can be used to support their local community’s health and wellbeing and tackle health inequalities, for example, through procurement, training, employment, professional development, and buildings and land use.
This definition is not limited to public sector organisations, as anchor institutions are defined more by their link to a place than their sector. There are many private and voluntary sector organisations that hold a significant interest in the long-term development and health of their local areas. This includes organisations with their local geography as part of their identity or with responsibility for significant infrastructure, such as airports or water companies.
In this explainer, we focus primarily on the role that NHS organisations and local authorities can take to address the socio-economic factors that lead to inequalities in health. A number of the topics outlined in this explainer overlap with government ambitions: the government’s commitment to cutting carbon emissions by 78 per cent by 2035 alongside its 'levelling up' agenda, with a new focus on economic growth in areas particularly affected by Covid-19.
Opportunities for health and social care organisations
In terms of its role as an anchor institution, to date the NHS has focused on employment, both at the national and local level. The NHS Long Term Plan and 2020/21 NHS People Plan both outlined ambitions for the NHS to create new opportunities for people from more deprived areas to enter employment within the health sector by expanding apprenticeships, providing routes into employment for volunteers and working more closely with schools, colleges and universities. Creating new opportunities for local employment could bring benefits for people most at risk of the negative health effects of long-term unemployment, while also helping the NHS address workforce shortages.
The NHS and local authorities won't be able to solve the issues that lead to health inequalities by themselves, but integrated care systems (ICSs) offer an opportunity for NHS organisations, local authorities, voluntary sector and other local organisations to work together to address these issues. That's not to say that the responsibility for these issues lies with ICSs alone - in many areas in England, organisations across health and care have already started to come together or are working individually to support their communities as anchor institutions.
Health and care organisations acting as anchor institutions can have a positive impact on local communities in two main areas: the local economy and the environment. Both these areas have the potential to improve the health of individuals and communities, which is the main objective for organisations acting as anchor institutions in health and care.
Figure 1 The key areas of interest for anchor institutions in the health and social care sector
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Employment
The NHS is the largest employer in England and one of the largest in the world, with 1.35 million employees as of April 2021. In some local authority areas in England, the NHS accounts for as much as 7 per cent of local employment. Local authorities employ even more people if you take into account the number of workers employed in sub-contracted services. This means the NHS and local authorities can exert huge influence over local employment.
In some areas, NHS organisations are taking action to increase the visibility of NHS employment opportunities to people living in deprived areas. For example, Leeds Teaching Hospitals Trust has partnered with Leeds City Council to target career opportunities towards communities in their most deprived local areas; Bart’s Health NHS Trust has a proportion of roles reserved for local candidates identified by the local council; and University Hospitals Birmingham has partnered with The Prince’s Trust to establish a learning hub – a purpose-built centre that offers ‘pre-employment advice, training, guidance and direct links to jobs in the NHS to unemployed local people and those furthest from the labour market’.
A number of local authorities – including Wigan and Newham – have partnered with local universities to expand the opportunities offered to people living in their most deprived communities and develop professional skills within and outside of employment (see below).
Professional skills and development
Entry into the jobs market is only one aspect of the role employment can play in improving the health and social care sector and the local economy and wellbeing – there are also many opportunities for health and social care organisations to support professional development for existing staff. In many areas, health and social care is the largest sector in the local economy after retail. Health and social care organisations offer stable, secure work that can offer professional development at a time when employment has never been more uncertain.
The principle of high-quality employment isn’t just about the wider effects on the economy: retention has been a longstanding issue across health and social care and forms a key pillar of the government’s manifesto commitment to increasing the number of staff working in the NHS. Offering better training and development opportunities will help both improve retention across health and social care and the skill levels of local people in deprived areas where the NHS and social care form a large proportion of employment.
Procurement
Employment practices are not the only way that anchor institutions can affect their local economy. They can also redirect investment into their local region through their procurement practices. Health and social care organisations can reinvest in their local areas by giving local suppliers greater weight in procurement processes, which in turn can create new employment locally.
Legislation, in place since 2013, requires social value (defined as ‘economic, social and environmental wellbeing in connection with public services’) to be considered in the design of some contracts. In December 2020, the government updated its social value model to more explicitly address the ongoing effects of the Covid-19 pandemic on the economy, with specific criteria introduced around supporting organisations and businesses to recover and improving workforce conditions and health. In the NHS, there will be a mandatory 10 per cent weighting for social value in all NHS procurement from 2022, though NHS organisations are being encouraged to start working to this criteria now.
Some local authorities have been working with other anchor organisations to reinvest their expenditure in their local economy by procuring from local businesses and social enterprises. For example, local authorities in Manchester and Preston, have planned new procurement models around social value, creating quantifiable effects on employment and the local economy. Some NHS providers have looked for new opportunities by becoming their own supplier – producing clinical equipment in house, both saving money and creating jobs in the local area.
Housing, estates and land use
For many people, housing is the issue that has the biggest impact on their health, especially for those at risk of the worst health outcomes. Economic modelling has estimated that reducing excess cold in homes to an acceptable level would save the NHS £848 million per annum and reducing all falls in the home could save the health service £435 million.
Local authorities have been leading efforts to improve the quality of housing by moving beyond traditional planning and social housing responsibilities. As part of this councils and NHS organisations are looking at how they can use their own land and partner with others to create sustainable, healthier housing. This work also provides an opportunity to bring organisations together around other issues as well, for example, through providing support into employment (in some cases, training and recruiting people directly into health or social care roles) or by helping residents develop digital skills.
The NHS is one of the largest landowners in England, with an estimated 889.5 hectares of surplus land in its portfolio in 2018/19, an area three times the size of the City of London. Some of this is has been sold for housing, but there are many opportunities to use NHS land to improve health and wellbeing, for example, redeveloping unused high-street real estate that is owned by or available to the NHS to create new convenient places for people to access health and other services, particularly in more deprived areas.
In Liverpool, Mersey Care NHS Foundation Trust has partnered with local residents to redevelop and refurbish the local public library and theatre buildings into community centres that offer employment services alongside traditional community-centre functions, such as social activities and meeting spaces.
Sustainability
The NHS has ambitions to become carbon net zero by 2040 but starts from a position of producing as much pollution per year as Croatia. This doesn’t just have implications at the global level, it also affects air quality locally. The World Health Organization estimated that there were 21,135 deaths related to poor air quality in the UK in 2016.
Excess NHS land could also be used in a sustainable way, for example, for exercise or as green spaces in communities that currently lack them, which can improve wellbeing, or by repurposing unused or underused land for sustainable energy production.
As long ago as 2009, Birmingham Council made health inequalities the focus of its climate change strategy, with concerns around air quality and the risks to social housing in the area from flooding. In turn, this has produced opportunities to address multiple issues – by identifying spaces in need of protection from flooding, the council has also created new green spaces to support wellbeing that can act as flood plains.
Conclusion
This explainer provides a broad overview of how anchor institutions in health and care can work in partnership with other organisations. NHS England has already begun this work by laying out objectives around creating new entry points into employment, with the details and scale of activity left for individual organisations. But further work is needed, and local needs will need local solutions. If the targets and ambitions laid out by NHS England and the government are a starting point, then ICSs offer NHS, local authorities and social care organisations a new opportunity to create more ambitious partnerships based on their understanding of local needs.
Currently, many examples of health and care organisation working as anchor institutions come from areas noted for their level of deprivation or inequality, but health inequalities and the environmental sustainability of the health and social care sector are issues across the whole of England, even in areas noted for their relative affluence. Working as anchor institutions offers health and care organisations opportunities to act on the key causes of poor health and reduce inequalities.