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 – the need for this focus has been underlined by experiences during the Covid-19 pandemic. Stronger recognition of the role communities can play in and their greater involvement in efforts to improve health and wellbeing are needed if there is to be a successful move to a population health approach and a reduction in health inequalities. As part of this shift in focus, integrated care systems need to take the role communities can play in improving and sustaining good health seriously, working at the place and neighbourhood level where the link to communities is strongest.    

There is a long history to draw on and much expertise – for example, in local government and the voluntary sector – 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 King’s Fund is actively working in this area as part of its programme of work on Healthier places and communities.  

What is a ‘community’?

A community is a group of people joined together by a common interest, characteristics or experience. The definition adopted by the National Institute for 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 also be used in other 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 help shape or provide services. The local voluntary and community sector often 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 people are born, live, work and socialise in have a significant influence on how healthy they are. Although estimates vary about how much influence, these factors have a much greater influence on health and wellbeing than health services.  
  • For example, we know that, under certain circumstances, social isolation and loneliness can be as bad for health as risk factors such as smoking.  
  • 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 they need 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 through both formal health services and other means. 

The approaches to communities and health set out below 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 health services. The focus of ‘communities and health’ is broader, and is about how people, bound by common experiences, characteristics 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 formal health and care services in the community.    

Public 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 2019, the NHS Long Term Plan set out ambitions for the health service, including the role the NHS can play as an anchor institution in supporting healthier communities and the move towards integrated care systems (ICSs). These ICSs are place-based systems of care that aim to bring services closer together across an area and improve population health. The government’s integration and innovation White Paper has now set out proposals for how ICSs will develop their approach. Since the scale of ICSs is relatively large, they are naturally quite distant from communities of place. To be successful they must therefore work with and devolve decision-making and power to more local places and neighbourhoods where connection to community is stronger. From an NHS perspective, this means an important role for primary care networks which should work closely with communities and others at the place and neighbourhood level, including the voluntary and community sector, local government including district and parish councils, and elected councillors. Working in partnership at local level will be key not only for meeting the ambitions of the NHS Long Term Plan, but also to addressing wider issues and inequalities.  

Across a number of sectors, there has been an increase in interest in and research on how investing in strengthening and improving the resilience of communities can lead to better health and wellbeing, and reduce inequalities. Examples and frameworks for understanding this include New Local’s work on ‘the community paradigm’, showing how and why public services need to work more strongly with communities; The Health Creation Alliance’s focus on ‘health creation’; the Royal Society for Public Health’s exploration of ‘community spirit’ and its links to health; and the learning from Public Health England’s work on community-centred whole-system approaches to public health. Each of these explores different aspects of this subject, but what they have in common is seeking to understand, support and strengthen communities and health, and wider wellbeing. Health and care systems need to engage effectively with these ideas and approaches to increase their impact on the wider determinants of health and to fulfil their contribution to population health.  

The Covid-19 pandemic has brought all this into even sharper focus including through the contribution of volunteers, community groups and individuals in the response. The pandemic has also led to more reflection on the future relationships between NHS services, people and communities. There is also learning from other disasters that shows investing in communities will have a key part to play in recovery, as The King’s Fund’s recent work on recovery from disasters has shown.  

Examples of community involvement in health

There are many ways to support communities to improve their health, and working with and through communities is an important aspect of how to effectively tackle health inequalities, as experiences from the Covid-19 pandemic have shown. 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 designing services and pathways of care by definition involves 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, as illustrated by work exploring the Wigan Deal, and the examples and frameworks mentioned above.  

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 supporting communities to build on their strengths so that they can improve the local health outcomes that matter most to them or improve the factors that affect their health. Community development often focuses on equality and inclusion, by promoting the voice of those communities that are less often heard. 

Examples

  • Asset-based models that focus on a community’s capabilities rather than its needs. The Health Foundation has detailed some case studies including Forever Manchester, where trained ‘community builders’ 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 and 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 becoming volunteers 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. Another example is The Health Creation Alliance, a national movement whose members aim to improve population health and wellbeing, tackle health inequalities and deliver sustainable change.   

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 Blackpool Citizens inquiries. These bring together groups within a community to share their experiences, identify challenges and produce recommendations. More broadly, several parts of the UK have set up fairness and poverty commissions; 10 of the latter are currently active across the UK and many, including the one in Morecambe Bay, have strong links to the health sector. These seek to involve citizens and communities more directly in strategic service direction and design that 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. Think Local Act Personal has developed resources to explain and support co-design and co-production in service design, and there are many case studies available, including a toolkit from The Point of Care Foundation. 

Community organisations in pathways of care

These approaches involve expanding the scope of services the health system provides, 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 leading to a number of benefits. 

  • Social prescribing, or community referral, which enables GPs, community link workers 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. For example, Somerset Open Mental Health is an alliance of  voluntary and community sector organisations, which works to deliver mental health care in partnership with the NHS.

  • 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 increasingly multidisciplinary approaches in general practice including access to Citizens Advice services.  

Our work and further resources

Healthier places and communities is one of the Fund’s strategic priorities for 2020–24. Work of particular relevance to this explainer includes:  

More information can be found on the introductory reading list from our Library Services. 

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Comments

Lee Adams

Position
Retired dph and loc gov ceo,
Comment date
24 May 2021

There was a cd and health movement in U.K. in 1980s much to learn from that . Your model misses out community participation and organisational development both crucial for more democratic health

Linda

Position
retired,
Comment date
17 May 2021

NICE in 2019 produced NG145, which did not at any point reflect the concerns of 100+ stakeholders.
I am pleased that focus is on communities and how they help one another and could be the start of being better prepared to continue helping into the future. But until the NHS and its myriad committees, and NICE, start being patient inclusive and centred, as they say they are, but aren't, we shall get no further.
I'm in a community and no-one in NICE or NHS is listening at all. We have tried very hard over the last 4 years.

Shaun

Comment date
05 March 2021

I completely agree with this. The societal shocks of 2020 have (again) brought into sharp focus the deficit (and at times the brilliance) of community infrastructure support (formal and informal support). Pre C19 without a different way health services would be unsustainable in x years time. Now is the time to build a new social contract with our communities. The starting point is building trust. The starting point of this is starting a conversation and humbly listening. Interesting article in the NEJM here: https://www.nejm.org/doi/full/10.1056/NEJMms2101220 about C19 vaccine hesitancy, in short vaccine hesitancy wont be resolved merely by more or better messaging on why you should have a vaccine. Before we attempt to persuade, we should try to understand.” “Getting the public to understand science may be insufficient, it’s also time for science to understand the public” .

Sithembiso Mabena

Position
Student,
Comment date
08 April 2020

This is very interesting, brilliant teaching, I have learned most of approaches, values, laws and more to develop and progress in my studies.

Michael Lingard

Position
Orthopath: Holistic Therapist,
Organisation
TotalHealthMatters!
Comment date
21 October 2018

We are catching up slowly........... The Prime Role of Family & Community as the foundation of health was the research outcome of The Peckham Experiment over eighty years ago; then drug therapy took over! Drs Scott-Williamson & Innes Pearce conducted this experiment involving over a thousand families in Peckham London to establish the aetiology of health. It was heralded as the most important health research of the day; every family improved their health by all medical tests over the duration of the experiment that started before the war and was closed down in the 1950's. They received no medical treatment at the centre only examination annually and advice plus good food.

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.

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.

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