Primary Care, Neighbourhoods and Health Inequalities
NHSE in their recent report “Promoting Equality and Tackling Health Inequalities” note that “inequalities in both health outcome and service experience have endured over time despite substantial investment in healthcare” I 
think that the reasons are fairly well established – the root causes of health inequalities are fundamentally to do with the social determinants of health – and as the NHSE report says only…
“15 to 20% of the life expectancy gap can be directly influenced by healthcare interventions”
As a CCG non exec I know that there are front line GPs who have a long history of working hard to improve the health and wellbeing of the communities they serve. They are frustrated by the limited range of interventions they can offer – many of which assume that people are in good housing, have stable incomes and have had access to a good education.
We know that there is no magic wand here, many of the people experiencing the greatest health inequalities are under the cosh, even more so at the moment as they are hit from all sides by government policies.
Yet there is more that we can do. There are tremendous long standing examples of good practice which are built around peoples own relationships and communities, they build on their strengths as well as addressing their needs.
One of the best examples in my view are neighbourhood organisations (sometimes referred to as community anchors) that:
- Provide a range of services and therefore respond holistically to peoples needs
- Have a history and experience of working with people as assets – as volunteers, employees, trustees
- Are independent and accountable to local communities
The relationship that these organisations have with some of the most excluded communities is so much more coherent than the transactional one that health service providers find themselves forced to adopt.
The example that is often cited is Bromley by Bow Healthy Living Centre, but there are plenty of other longstanding neighbourhood based community organisations. Many of these are members of Locality – which is the umbrella body for these. Locality was formed through a merger of the British Association of Settlements and Local Action Centres (BASSAC) and the Development Trust Assocation.
…and yet these organisations rarely appear on the radar of health and wellbeing boards and Clinical Commissioning Groups as agencies that are a key part of the solution to addressing health inequalities.
At Leeds Metropolitan University Health Together we did a piece of work with a small number of Locality Members. working with them to capture their views about how local commissioning can better support them in their work. The full report “Strengthening the Voice of neighbourhoods” is available here – its not very long!
Some of the issues that emerged from this work and subsequent discussions at the 2013 Locality Convention included:
The tyranny of public health evidence – There is very narrow view of the evidence which ignores peoples experience as a whole and focusses too much on measurement of clinical conditions and the evidence for clinical solutions. We at Leeds Metropolitan University recently organised a national conference on this topic – and there is more information including speakers videos here.
The commissioning delusion – there is an assumption that most health services need to be commissioned at ‘place level’ (local authority or CCG) rather than at neighbourhood level. I know that many Local Authorities have ambitions to push budgets out to neighbourhoods through Area Committees, Area Panels etc but in my experience they have struggled to gain interest and the amount of funding they have available is usually trivial.
There are a number of options here, some of these are spelled out in ideas from the project we did with Locality members which include:
- A greater focus on the contribution of neighbourhood structures – not just area committees and panels – but the role of Parish and Town Councils
- A need for more work at a national level to support good practice guidance on neighbourhood led commissioning
- A great emphasis on joint/integrated commissioning across CCGs and Local Government
- More visits to and presentations from grass roots community organisations by health and wellbeing boards and other governance structures.
There are real possibilities to be generated through formal alliances between General Practitioners and their local community neighbourhood organisation – usually a Locality Member or a neighbourhood based health living centre. As well as providing the opportunity to tailor services directly to particular communities it also starts to develop a service model which may help the sustainability of not just small community based organisations but also of independent primary care.
All of these ideas have a fit with continued government interest in Whole Place and Community Budgets. The always excellent House of Commons Library has a useful summary report on these here.
What do you think?
Mark,
I don’t disagree with you as such but i think the real challenge in implementing much of what you say is the restrictions and reductions in investment in commissioners. As we reduce the capacity of commissioners the net effect will be bigger commissions – making neighbourhood level commissioning even more unlikely than ever.
Somehow we need to marry up the obvious benefits of localism with the actuality of limited resources. This will need a radical rethink and greater budgetary power to localities which may mean challenging all our thinking: i.e. how do we have a National Health Service if we commission everything more local and different areas have radically different priorities? How do you live in a world of post code lotteries which we naturally produce?
More questions than answers as usual i am afraid!
Great to hear a voice from across the Pennines Richard – yes agree – cuts are making things very unpleasant and reducing room for manoeuvre. While local community organisations with health funding are experiencing cuts the situation is so much worse for those who rely on local authority funding streams – many of these focus much more on the social determinants of health. Nonetheless I do think that there is a real appetite to develop radical service models that might persuade existing providers to change how services are provided with current funding. While I take the point about postcode lotteries I for one have never been that convinced that the ‘National’ Health Service approach has really protected us from these…… I would rather deal with local politicians at least I can talk to them.
Individuals, families and communities live and have their being at a neighbourhood level. Public services have to organise operationally at a level above this to make sense. Their frontline workers can and do work at neighbourhood level. It is possible to create a framework that joins these together in a coherent framework of action and planning. It takes some local government and partner public services nerve and imagination to see the possibility. Bradford did it once!