01.08.14
Ask, don’t tell: improving public health through community development
Source: National Health Executive July/Aug 2014
The NHS Alliance has launched its Community Development Charter for Health, urging a radically different approach to community development that will save public resources and improve health outcomes. NHE interviewed GP Dr Brian Fisherof the NHS Alliance executive, who also chairs HELP, the Health Empowerment Leverage Project.
The signatories to a new charter on community development are urging NHS England, CCGs and local authorities to pay attention to the results of pilot projects and research that show fantastic cost-benefit ratios and improved health outcomes.
At the core of the charter is a new model of community action, centred on the ‘C2’ model (Connecting Communities, based at the Peninsula Medical School, Exeter University).
Dr Brian Fisher of the NHS Alliance executive explained: “The usual public health model is to go to an identified community and say, ‘We know you smoke too much, drink too much, you’re too fat – now let’s talk about how we can improve that together’. But we want to start where the issues are for the community, which may not be those issues. They may be something completely different: anti-social behaviour, the need for a dentist on the estate, different things.
“If you start where the community are and support them to start ‘negotiations’ with statutory agencies, then they become more confident, and all sorts of changes start happening. Health improves. It’s quite an important difference in agenda.”
Substantial savings
The model has been tested in Devon, Solihull and London, while a separate trial in Lincoln, Brighton, Dewsbury Moor and Cleobury Mortimer in Shropshire found that for an investment of £233,655 in community development activity, the social return was about £3.5m (a 1:15 cost:benefit ratio).
Other studies suggest a more conservative ratio of perhaps 1:4, but this remains attention-grabbing. “It’s likely to be a substantially good investment – and it’s not very expensive, in the first instance,” Dr Fisher said.
The C2 model sees people as assets, not just as bearers of diseases or poor health or social problems. Involving them more directly in their own health, and focusing on their own ambitions rather than the public health community’s, seems to have a win-win impact.
Debbie Abrahams MP of Labour’s shadow health team was at the launch, characterised by Dr Fisher as “an optimistic event”. Abrahams said: “From my previous work in public health I see community empowerment as a core component of any strategy to improve health and reduce health inequalities.”
NHE editorial board members Dr Mike Dixon and Lord Victor Adebowale are also firm backers of the charter and were at its launch.
‘Just do it’
Dr Fisher said it is “straightforward” for a CCG or council interested in the approach to just push ahead with it.
It could mean, for example, investing £80,000 a year (split between health and the local authority) for two years in the most difficult estates in an area. That would train relevant workers and agencies (NHS, police and others), and pay for specialist community development workers.
“After this, the estate would be very, very different,” Dr Fisher suggested. “There would be dramatically more involvement of local people with the statutory agencies. There would be work going on – depending on the issues that matter to the estate – with police, housing, health, whatever is important to those communities.”
Dr Fisher admitted the idea is “radical” and said: “It does challenge the usual way of doing things.”
He suggested that many CCGs and councils like to think they already ‘do’ community development, which is sometimes true but more often a case of re-badging more traditional models of engagement.
“I don’t think there are many places that are really starting with the agenda of local communities. It’s a radical shift that the rhetoric talks about, but I don’t think many places are actually doing it,” Dr Fisher said.
“Part of the reason for that is that it is quite scary. It is a moderately open-ended commitment: you’re trusting a community and saying you’re going to offer them support to find solutions on the issues that matter to them. That’s not the traditional way of doing things in the NHS.”
The pilots where the local NHS has been most engaged have had the best results, he suggested, admitting that HELP’s work in Wandsworth has had a less lasting effect than that in Solihull or Devon.
There is also the age-old incentive problem: savings accruing to agencies other than the ones doing the spending. But wider budget-pooling and risk-sharing approaches can solve this.
Achieving the charter’s ambitions would also require “a fair amount” of investment in training existing staff. Dr Fisher said: “I’ve talked to Health Education England about this in principle. They understand the issue and are sympathetic, but haven’t made any decisions about it. I would like them to, because I think they could contribute.”
The 2014 context (health and wellbeing boards, the Social Value Act etc) offers the most fertile ground yet for co-operation between CCGs, councils and national organisations on community development.
“It’s about changing the mindset enough to make it happen,” Dr Fisher added. “The charter says ‘do it’, but we would like to see policy changes to make it even easier. I would like NHS England to embrace this in a coherent way. It would make a great deal of difference on the ground.”
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