Communities and health

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.  

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.    

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.  

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.  

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 

• Community-based participatory research (CBPR), in which members of a community are recruited and trained to carry out research into the community’s needs, and to develop possible solutions. The Centre for Social Justice and Community Action has developed a series of toolkits for and case studies on developing community-based projects, and case studies from Policy Link include examples of community involvement in reducing diesel bus pollution and tackling food insecurity. 

• Community planning and decision-making, which involve communities in the process of understanding needs, priority setting and agreeing solutions. Similarly, in community or participatory budgeting, members of a community decide how resources are allocated, and help scrutinise the decisions afterwards. For example, some local authorities have consulted local residents on where to make budget savings and how to spend local budgets.   

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.  

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

• our work on social prescribing 
• our report, Reimagining community services: making the most of our assets 
• our report on lessons from the Wigan Deal 
• case studies from Volunteering in general practice: opportunities and insights 
• our exploration of commissioner perspectives on working with the voluntary, community and social enterprise sector 
• ongoing support for the GSK IMPACT Awards 
• the Healthy communities together programme 
• our work on developing a vision for the public health system, which includes a strong communities focus. 

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