Commissioners still failing to tackle causes of ill health, says community development advocate

11 February 2019

One of the most eloquent passages in the Five Year Forward View urged the NHS to stop fixing health problems and to tap into society’s collective ability to avoid sickness in the first place. 

Too often, it said, the NHS adopted a remedial approach to health instead of helping to create the conditions to keep people well. 

“Sometimes the health service has been prone to operating a ‘factory’ model of care and repair, with limited engagement with the wider community, a shortsighted approach to partnerships, and underdeveloped advocacy and action on the broader influencers of health and wellbeing. 

“As a result we have not fully harnessed the renewable energy represented by patients and communities…” 

To use a motoring analogy, we spend most of our time fixing battered and broken vehicles instead of building safer roads and teaching people to be better drivers. 

Nearly half a decade later, commissioners and service providers still fail to grasp that individuals and communities hold the keys to better health and wellbeing. 

So says Cormac Russell, managing director of Nuture Development, who advises NHS organisations, local authorities and other public sector bodies on asset based community development (ABCD).

The ABCD approach rose to prominence during the early years of austerity. Public sector organisations – particularly local authorities – employed community coordinators to encourage individuals and small community groups to draw on their strengths and do more for themselves and others. 

Russell says: “This is not about a top down approach – whether you are talking about healthcare, economic solutions or community policing. The question is how to make change happen from the bottom up. Unlike in countries like Rwanda, in the UK we don’t talk about what strengths and resources the individual has and how they can be helped to use them to benefit themselves or others in their community. Instead, commissioners focus on what can be done to you or for you without spending very much money. 

“We need a less institutional approach. One of the problems with supporting people with long term conditions, for example, is that institutions don’t work with the individual to ask what a good life of inter-dependent relationships looks like. Instead, it is about professionals with salaries and service users who have hardly any responsibility for their own life.” Russell says many healthcare practitioners do want to follow the ABCD model and funders and commissioners “are slowly but steadily starting to change”. He points to Leeds City Council which he said “can now ethically balance their budget” after their adult social care department embraced ABCD. 

However Russell said that the failure to capture the strengths of local communities and reliance on traditional approaches is “still a massive issue”. One barrier, Russell says, is the rise of social prescribing, which he argues can be used as a poor substitute for real community development. 

“Some organisations just use it to tick the box. It bypasses the hard work of creating neighbourhoods. In five to ten years this will be a scandal because of the abject neglect of the grass roots. Health commissioners really need to think about using this quick fix when there is evidence that we should be building communities in our neighbourhoods, rather than health silos. For example, we are not calling people health champions.” 

Russell points to an evaluation of an ABCD project in Ayrshire which received more than £700,000 in 2014 – largely from the NHS Endowment Fund. The evaluation was funded by the Scottish government and carried out by an organisation named Social Marketing Gateway. 

A team of locally-based “community builders” worked in seven communities in Ayrshire from 2014, connecting local people and supporting them to share their skills and talents to improve their local communities. It was hoped that improving ”social connectedness” would improve the mental health and wellbeing of local people.  

The evaluation of the three and a half year project reported “a large and diverse mix of new community activity” thanks to the work of the community builders. 

It said: “This has coincided with a noticeable rise in social connectedness, a slight increase in overall social cohesion, an increase in self-reported health and quality of life, and (in North Ayr) a significant increase in the mental health and wellbeing.” 

The North Ayr finding was based on 200 interviews with members of the public. The evaluation team concluded: “Improving population health and wellbeing was the main goal of the project, so we can say with some confidence that this outcome has been achieved. 

We cannot be definitive about the exact contribution that…(the ABCD project) has made, but it would be reasonable to conclude that the community activity that the community builders have stimulated and the increase in social connectedness are related.”

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