Communities and health

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The role of communities in improving health is receiving increasing, and long overdue, attention in health policy and practice. Stronger recognition of the role communities can play and greater involvement are needed if there is to be a successful move to population health systems. As part of this shift in focus, sustainability and transformation partnerships and integrated care systems need to take the role communities can play in improving and sustaining good health seriously. 

There is a long history to draw on and much expertise – for example, in local government – of working with communities for health, but the approaches that are used are understood in many different ways and can be confusing. While this explainer cannot do justice to the full range of approaches, it is a starting point for those wishing to understand more. We provide a reading list for those who want to explore this topic further. The Fund will also be doing further work in this area over the coming year.

What is a ‘community’?

A community is a group of people joined together by a common interest or experience. The definition adopted by the National Institute of Health and Care Excellence sets out a number of factors that can define a community as they relate to the experience of health, including geographical location, race, age, faith, or health need.  

In the specific context of health and care services, the term ‘community’ can be used in different ways: to describe a group of people with similar health needs (for example, a group of people with diabetes), or a group receiving similar health services (for example, a group of patients receiving the same diabetes intervention), or a group of people who shape or provide services. The local voluntary and community sector often both supports and represents such communities, and also provides services to them.  

What is the role of communities in improving health?

There is now widespread recognition that communities have a vital role in improving health and wellbeing. There are a number of (overlapping) reasons for this, including the following.

  • The communities we are born, live, work and socialise in have a significant influence on how healthy we are. Although estimates vary about how much influence, these factors have a much greater influence on our health than health care. 
  • For example, we know that for some communities social isolation is as bad for health as some common health behaviours, such as smoking. Strong communities are therefore good for health.
  • There are many ‘assets’ within communities, such as skills and knowledge, that can be mobilised to promote health and wellbeing.
  • From a health care perspective, communities have great insight and intelligence on what is needed from health services, and on what works in improving health. Linked to this, directly engaging people from the most marginalised groups and those most likely to be affected by health inequalities is important in addressing these inequalities both through formal health services and other means.

These approaches are related to, but distinct from, those that support the greater involvement of individuals as patients in health service design and decision-making, and from the commissioning and provision of formal community services. The focus of ‘communities and health’ is broader, about how people, bound by common experience or interests as set out above, improve or are helped to improve their health; and where the solutions to health problems are not solely about the provision of services in the community. 

Health policy and the role of communities in health

Recognition of the important link between communities and health has grown in recent years. This has been reflected in the growing importance and voice of community-focused organisations and partnerships and through national programmes and policy.

In 2014, the NHS five year forward view set out the vision for the NHS as a ‘social movement’, arguing that the NHS would not be sustainable without support for communities to take greater control over their health. The Realising the Value programme was set up to support this vision, sharing evidence and best practice to help communities take an active role in managing their health. Other groups and organisations, such as the New NHS Alliance, aim to bring organisations and people together around the goal of creating a sustainable, community-based health and care service. 

Next steps on the NHS five year forward view reinforced the importance of this work. In our view, sustainability and transformation partnerships and integrated care systems will not be successful if they do not take the role of communities in improving and sustaining good health seriously. Local authorities, in particular, have a track record of community involvement that the NHS can learn from.

Examples of community involvement in health

There are many ways to support communities to improve their health. Community development and community commissioning approaches are often focused on strengthening and mobilising capability within a community and helping communities to improve their health themselves, while involving communities in service design and pathways of care by definition involve closer connections with formal health and care services.

Examples of approaches to supporting communities to improve their health are given below. However, in practice at local level most activity involves a blend of these approaches. 

Diagram showing the four main approaches to working with communities in improving health.
Visual overview of approaches to supporting communities to improve their health.

Community development

These approaches involve strengthening communities, so that they can improve their own health – or factors that affect their health – without necessarily relying on formal health and care services. Community development often focuses on equality and inclusion, by promoting the voice of those communities who are less often heard. 

Examples

  • Asset-based models that focus on a community’s capabilities rather than its needs. These approaches seek to identify and strengthen the assets within a community – such as associations, informal networks, skills and leadership to help communities have more control over the conditions that affect their health. The Health Foundation has detailed some case studies including Forever Manchester, which employs trained ‘community builders’ to support people to take community action at neighbourhood and street level.
  • Strengthening social relationships, through setting up structures that support existing networks, or by establishing new ones. Recovery communities, for example, support the development of relationships between people with a history of drug or alcohol misuse. Another example is time-banking, which enables people to earn ‘time credits’ by providing a service, and exchange these for a different service – which has knock-on effects on strengthening social networks.
  • Volunteering, for health and care services or beyond, supports individuals within a community to develop a wide range of skills. Volunteer roles range widely from specific roles in health and social care to befriending and other forms of peer support. Often those communities that would benefit most from volunteering are the ones that need more support to do so.
  • Social movements for health. Thrive London, for example, is a ‘city-wide movement’ that aims to engage people in working together to improve population mental health. NHS England has commissioned further work on social movements for health.

Community commissioning

These approaches give communities greater control over the commissioning of services they receive – both health and care services and other services that affect their health. It can mean community involvement in, or leadership of, any or all stages of service planning, from identifying needs to implementing and evaluating services. 

Examples 

Communities and service design

These approaches involve communities directly in the choice and design of services. 

Examples 

  • Citizens’ inquiries, for example, the Central Blackpool Health and Wellbeing Inquiry. These bring together groups within a community to share their experiences, identify challenges, and produce recommendations in the light of this. More broadly, several parts of the country have set up fairness and poverty and linked health commissions. These seek to involve citizens and communities more directly in strategic service direction and design which will affect their health.
  • Involvement in service design. At a more local level, communities are also directly involved in leading responses to issues of specific public concern about health and care services. For example, the Millom Alliance, was created following community concerns about the future of general practice in Millom, Cumbria, and includes a number of local health organisations and representatives from the local community.

Community organisations in pathways of care

These approaches involve expanding the scope of services the health system is able to provide, often to include those that support social rather than medical models of care.

Examples 

  • Embedding general practice in the community. The Community Wellbeing Practices initiative in Halton, for example, works with GP practices to identify patients’ wider social and other needs and to address these through community-based initiatives and services.
  • Social prescribing, or community referral, which enable GPs and other health professionals to refer people to non-clinical, often voluntary sector, community services, with the aim of addressing people’s needs in a holistic way. 
  • Voluntary and community sector organisations delivering services formally as part of commissioned pathways of care. Voluntary and community sector organisations – from large national charities to small local ones – are involved in care pathways covering a wide variety of services, including disease-specific care, and in co-ordinating care for those with multi-morbidity across different parts of a pathway. 
  • Co-location of clinical and non-clinical services, which aims to support people’s needs in a holistic way. These approaches seek to provide health service users with easy access to non-clinical support, for example, through the co-location of Citizens Advice within mental health trusts or general practice.

Our work and further resources

Communities and population health is one of the Fund’s strategic themes. Work of particular relevance to this explainer includes: presentations from our event on social prescribing: from rhetoric to reality; our report, Reimagining community services: making the most of our assets; case studies from our report on Volunteering in general practice: opportunities and insights; our forthcoming report on commissioner perspectives on working with the voluntary, community and social enterprise sector; ongoing support for the GSK Impact Awards; our work on developing a vision for the public health system, which will include a strong communities focus; and an upcoming event on making a reality of community-based health

More information can be found on our introductory reading list from our Information and Knowledge Services.

Comments

Anthony Dooley

Position
lead for Suffolk UNITE Community for reinstatement of NHS,
Organisation
Suffolk UNITE Community
Comment date
19 February 2018

Why would anyone want to be engaged in reducing services because of budget cuts? The forthcoming increase in the community charge is not to pay for services, they are being cut. It is to shift money from local communities to government to fund tax cuts for the rich and corporations. Billions spent on nuclear weapons, and other useless projects do not enhance the prospect of mine or anyone else's wellbeing. How is obliging millions to feed themselves and families using foodbanks, cutting benefits for the sick and disabled and the impact of Universal Credit in denying the poorest children a free school meal meant to improve health in the community? Unless and until everyone has a basic income to meet basic needs inequality in wealth will continue to produce inequality in health.

john monaghan

Position
Children's Epilepsy specialist,
Organisation
NHS
Comment date
05 September 2018

If we want to improve the health of the people we have to improve the diet of the people. DoH brought in it's healthy balanced diet in 1983 since when we have an increase in obesity, diabetes, heart disease all things it was supposed to reduce. Instead of asking itself whether it's healthy diet is in fact healthy, DoH attacks sugar, alcohol and fast food which may only be worthwhile after it has realised the "healthy" high carb low fat diet experiment has failed. If ever we return to a meat and two veg diet our health may well improve.

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