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Local Commissions tackle Social Determinants of Health

May 21, 2012

One of the risks of making something statutory is that times change and what seemed like a good idea becomes at best a distraction and at worst an impediment. I wonder if we are beginning to see this with Joint Strategic Needs Assessments.

I think that we are beginning to see a growing dissonance between on the one hand  Department of Health requirements to produce a Joint Strategic Needs Assessment, a Joint Health and Wellbeing Strategy, the various outcome frameworks and on the other hand approaches developed by local leaders to tackle tricky issues like health inequalities.

Ironically the big driver here is  governments promotion of localism and citizenship.

The problem with many JSNA is that they start from the premise that is possible to build plans upwards from a rational assessment of need. I think that this approach is mistaken – it ties up scarce and precious analytical resources in a sisyphean task – and produces a product that is often still too siloed in health, is too complex for most to connect with and is by its nature too often reduced to a set of rather bland statements that have little impact on commissioning.

The JSNA problem

  • Starts from the assumption that we need a complete picture of what a place looks like first in order to make rational decisions about investment. Leading to rather bland statements about action.
  • Engagement is weak – usually starting with technical data experts then inviting others to comment on their work
  • Siloed – struggling to adequately connect health and wellbeing to the wider determinants

Unsuprisingly agencies and organisations on the front line in particular find it hard to engage with this technical process of dubious impact.

Tackling the Social Determinants – the Commission Model

Increasingly local authorities are developing new models to drive commissioning that incorporate evidence, intelligence and citizens voice in ways that bring genuine challenge. one of the most promising are “Commissions”.

The approach here is different. The starting point is usually one where local politicians have made a decision to investigate a pressing and wicked issue and have asked for evidence and ideas about how to address this. Commissions recognise that the answers and evidence are just as likely to come from the front line and citizens as from ‘experts’. Indeed successful actions depend on all stakeholders being involved in problem solving.

Characteristics of a good commission approach include:

  • Engagement of leaders and communities from the beginning – its interesing that commissions are able to engage a much wider group of stakeholders than health and wellbeing boards – have a look at the core membership of the York Commission and also at the broader group of stakeholders who are involved.
  • A recognition from the outset of a key strategic challenge – a wicked issue – that needs addressing – by going public on the issue local leaders expose themselves to debate about whether they have chosen the right area and area and are able to engage local press and the public about why they have prioritised this.
  • Clarity about the key questions that need to be addressed and an inclusive approach to capturing quantitative and qualitative data – see the table below for examples.
  • Time limited and quick
  • They locate Health Inequalities in a wider determinants agenda. None of the commissions set out to reduce health inequalities as the core objective – they are built around a broader notion of fairness and equity. This feels the right way round – and the connection with other social determinants feels more natural and powerful.

There are already a number of examples of these and it is not suprising that one of the key players is the Equality Trust – the organisation established following publication of the Spirit Level.

Here are 4 Commissions that I am aware of:

Islington – Fairness Commission

Wakefield – Poverty and Prosperity Commission

York – Fairness Commission

Sheffield – Fairness Commission

Strategic Questions

Here are some examples of the sort of questions that the commissions are asking – the grouping is mine – you may disagree


The commission approach feels the right way round with:

  • Leaders taking responsibility for the problem and setting out a vision.
  • Valuing different perspectives and views – and using a variety of evidence
  • Multilayered opportunities for engagement and debate
  • Generating an informed view across different stakeholders of actions that need to happen

What do you think?

4 Comments leave one →
  1. June 26, 2012 12:19

    Hi Mark,

    Great post! The idea of rational policy-making has permeated Chilean municipalities too and they spent hours and hours of valuable resources in developing strategic plans that are only partly -and poorly- implemented.

    Establishing more dynamic structures that allow intersectoral collaboration, such as commissions, are interesting approaches. You need to keep in mind, though, that there is a risk of the commission turning also into a useless exercise if the commission doesn’t have a clear goal, deadlines and budget to implement the decisions.


    • June 29, 2012 19:40

      Thanks Sebastian – very helpful response – I agree that Commissions do not guarantee good quality outcomes but I do think that they can help place decision making into the public sphere – and therefore increase the likelihood of accountability and challenge. Best wishes Mark


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