We hope our latest edition of Health Matters – on the subject of “Community-centred approaches for health and wellbeing” – will help you and other professionals by compiling key facts, figures and evidence of effective interventions.
Placing communities at the heart of the public’s health can empower people, create connected and resilient communities, engage those most at risk of poor health and reduce health inequalities. Our latest edition of Health Matters focuses on community assets and the Family of Community-Centred Approaches, a framework developed to represent some of the practical and evidence-based options that can be used to improve community health and wellbeing.
In this blog we’ve published the answers to a number of Health Matters questions we received from professionals across the UK at the recent launch teleconference.
Our Q&A panel are Dr Ann Marie Connolly, Deputy Director, Health Equity and Mental Health, PHE, Professor Jane South, National Adviser, Healthy Communities, PHE and Leeds Beckett University, Jude Stansfield, National Adviser, Public Mental Health, PHE and Terry Blair-Stevens, Public Health Consultant in Health and Wellbeing, PHE South East.
Question 1 (How do we make the case for the cost effectiveness of community-centred approaches?)
We are doing a lot of work around community-centred and person-centred approaches. We invest in this work a lot and I am very conscious that we are squeezing the budget. What is the panel's approach to ensure that we are putting money in the right places?
It's a very important question because the temptation at this time is to squeeze the sort of investment in how you engage with communities and supporting communities to be more self-sustaining. We do have evidence on the positive benefits and the positive outcomes, the social value and the economic value of engaging communities. The evidence around volunteering is very strong here, and also peer support. It's challenging because the ways to calculate costs and the sort of wider benefits that can be felt when service models shift, is more challenging to evaluate. But we do have the trends and evidence that tends to show that it brings economic and social value, but we will be looking for where areas are trying to redesign their services, and hoping that good evaluations will be able to provide some of those answers around service redesign and investment in prevention.
Question 2 (Demonstrating cost-effectiveness for the health and social care system)
I am a commissioner for these community-centred approaches and I have lots of evidence of impact on the person. Our finance department also understands the impact on the person. But what they want to measure is the impact on the system, showing how this intervention (or basket of interventions) changes behaviour or usage or makes people more resilient and able to use the health and social care system appropriately. What I am struggling with is how do you show prevention, the thing that never happened?
You raise some useful points and familiar ones in health improvement where the goals are long-term and ultimately about improving outcomes in good health and wellbeing, which we've been addressing in our work here. The first challenge is perhaps that commissioners should value health and wellbeing outcomes as legitimate goals to commission services and interventions. That is, good health in the population is the endpoint, using some of the community outcomes we mentioned such as social capital, wellbeing, participation, social connectedness - all things that can be measured. There is good evidence that these outcomes are also protective factors for health that impact on behaviours and illness. There is evidence for this in the Marmot Review and also in PHE's recently commissioned work from the Marmot team on psychosocial pathways for health outcomes.
This shows the causal pathway that can help illustrate a logic model approach - if we achieve x it is likely to impact on y. The second challenge is perhaps to use the existing evidence to model local impact. Lastly, the challenge is to have the capacity to evaluate impacts on the system. Some local initiatives do this by joining up different parts of the system in their evaluation framework e.g. monitoring use of services. The Realising the Value programme produced some useful resources for commissioners. Partnerships with local academics can be fruitful and there are funds available for evaluating local public health practice. NHS England is supporting social prescribing and this will hopefully provide some system impact data.
Question 3 (How do we sustain a project that is already running?)
We run a health champion project, which is very successful in the community, where we work from community centres, job centres and libraries. It’s about sustainability of the project and we are capturing evidence that we are making an impact. How are we able to continue this service? Because it's limited in regards to funding. And I just want to know the panel's ideas of supporting ongoing work.
It is important that we measure outcomes of projects and are able to check out the local evidence base about why a project is needed, what sort of outcomes result and the communities that are involved in that project. So, if you’ve got a champions project where you’ll be reaching parts of the communities that much more traditional services don’t manage to, then that’s part of your case for further funding. It’s the responsibility of people involved in practice to engage in evaluation, as you have done, and get the evidence. At the same time, there is a role for commissioners to try and put in place systems to gather that evidence appropriately and to understand what's needed in their local area.
They should also use some of the evidence based on large research programmes, such as through the National Institute for Health Research (NIHR). Hopefully you are well engaged with your local GPs and your CCGs to be able to continue to promote the value that you are already offering them, and to help them understand even better what you are actually delivering and providing on their behalf – communicating that this is a helpful complementary service to other clinical-based services. In the NHS, we tend to find clinical solutions whereas sometimes the solutions are right there within our local communities. There are many approaches to resilience in terms of funding and the crucial element is really relationships, both with the commissioners who are funding the work, demonstrating the strength of the impact of the work that you are doing and the benefits for the audience that you are working with, and having those relationships with your allies. NICE guidance states that this work needs long-term and sustainable approaches and that needs reflecting within local commissioning plans.
Question 4 (What scalable initiatives are there?)
I’m a director of environment in a London borough and we are aligning some of our health and environmental services priorities. Health in terms of getting communities more engaged in their area, but we’re envisaging it would have the benefits that we can retract services by passing over the control and the ownership of services to people. What evidence do we have for particular initiatives that are particularly productive in terms of health as well as in terms of getting people engaged, and that are scalable across a wide area to make a big impact?
The answer on one level is that there is no one intervention and that’s what the family of community approaches aims to show - that a range of practical models are needed. In terms of some of them that have got quite a long history, there are projects such as the C2 Connecting Communities model, which is about neighbourhood community development, some of the scalable models around time banking that come under different guises, participatory budgeting and some of the health promotion planning models that have been around a long time. The key thing is that in some ways it doesn’t really matter where you start and what you start with, it’s about the relationships that you build over time in the community.
We know from a lot of evidence that it’s the length of time that’s needed to build those relationships, and that’s what is really critical. So, take something from the family and have a go and let us know what has happened, because we’d be interested. You would also want to be looking for strong local support from the communities themselves as you were choosing what you were going to do. Ask your community involved, your community members and community workers, see what they feel would work best and involve them in deciding that and delivering it and measuring it. It is important to have a local champion, perhaps in the local authority. Local authority members are champions of the communities they represent and they’re often the best people within a council to advocate for the assets within a community, because they know their communities well. Success breeds success as well, so the tension is always between starting small and scaling up. Sometimes you can’t do community-based grassroots bottom up at scale until you have started at the grassroots and built that trust and relationships and community development over a period of time.
Question 5 (How to engage with communities)
Firstly I just wanted to make a statement. Everybody talks about engagement with communities, but actually that is a very skilled activity, and I don’t think that’s always appreciated. When we go into communities, they don’t want a tick-box exercise and I think they really get fed up with different stakeholders coming in, asking them for their opinion, and they never see that individual back again. So, I think those sort of issues at a very ground level have got to be realised by commissioners and services. They must understand the importance of a very skilled engagement activity with the communities in order to get people on board.
My question is this: When we’re working with communities and certainly for a health promotion event where we go to the communities, for example with the bowel cancer screening programme, what's the evidence for actually incentivising communities to come and attend a workshop or an event?
To your first point about the nature of engagement, at PHE we have been looking at workforce development, looking at what are the knowledge and skills needed within public health to work actively with communities, to work across different sectors and to look at the required competencies of people that are in those roles. Working across sectors and taking a place-based approach to engagement and empowerment is what’s needed. So public health aren’t doing their own thing without working with social care, police and crime, NHS, because all agencies are wanting to do more of that engagement and we need to do that in a skilled way. It is also important to understand the health literacy levels of the community. We need to avoid tokenistic engagement and using jargon. We've got to use the right word, the right language and words that people understand, when we really want to try and get buy in. Understanding the community language is vital and as commissioners and service providers, we really need to get it right.
In answer to your question, we haven’t got much evidence around incentives around community engagement, but what we do have evidence for is the importance of making it easy for people to take part and also the fact that there are a number of costs associated with taking part in things. We shouldn’t make assumptions that people are just going to turn up and give everything for free and possibly spend an afternoon having a discussion without recognising that there needs to be some reciprocity. Different communities will approach that in different ways, but people’s costs should be taken into account in terms of getting there. That’s really important. And also they should get something out of events for themselves. They’re not going to engage again if it’s just a chore.
Question 6 (Involving communities in defining outcomes)
I think one of the common stumbling blocks in engaging communities is that we are trying to fulfil our own agendas rather than the community’s. Are there any guidelines or any evidence around how that changes the relationship and are you working towards outcomes that are defined by the community? As an adjunct to that, when we are speaking to communities we find that it's not only about being connected to services that are important to them, but also about the kind of opportunities to participate and opportunities to make a contribution to the local community. Is there any evidence or examples of that in the work that you have concluded?
It's an incredibly important point. As far as guidance on this, well we have got the NICE guidance and particularly the NICE quality standards on community engagement, which were published in 2017. There are only four quality standards and these are things that are expected of the wider health system and one of them is that communities should be engaged in evaluation. What they mean is that communities should be involved in deciding what are the important things to measure in a local project, what the goals are and what the outcomes should be. So that is a valuable quality standard and you can use that as a bit of ammunition for making a case. Practically speaking, there’ll often be a mix of outcomes, things that sometimes the health system want and things that communities want, but we need to put both together, so that we can see the link between why someone who is feeling better connected leads to them being more likely to take on healthier behaviours.
A community-centred approach is actually asking a lot of professionals who are not normally involved in this to change quite a lot about the way they think, about how to approach their job, and so it's a reframing of our approaches and actually starting from where local people in communities are coming from. Participation in design and decision making is a critical part of this engagement because that is what will help you understand what are the measures that are important and what will help people understand when success has been achieved. And then the next time around when you want to talk about a new health service programme, the community is going to be more receptive if they have seen you deliver the first time around.
Question 7 (Mapping local assets)
When we’re looking at a project across the system, how do we best improve communication across the system and effectively map the assets that there are in order to reduce replication?
This has come up frequently, particularly in relation to issues like social prescribing. The first step is in knowing who your community is in all its richness and diversity. So stepping in, mapping what the community is and the positive assets that it holds in terms of the knowledge, the skills, the facilities that they have available to them locally, is a great starting point. This shouldn't be undertaken by one partner in the system on their own. With public health being based in local authorities, the default position might be that local authorities are seen to be leading on this, but really if we are trying to improve health and wellbeing for our communities, asset mapping needs to be shared across all the partners in the system. This includes the NHS partners and it should be done in partnership with those communities who are part of that wider system. There are many examples across the country of how others have done this. Some are using digital technology and digital mapping processes to map the community assets. Some are set up to enable communities to put in their own resources and what they have to offer on those digital mapping sites.
PHE has its own Strategic Health Assets, Planning and Evaluation tool (SHAPE), so that we can map assets more rigorously. One of the things that the National Information Board and others are working on is a taxonomy for these assets, because how one person describes an asset may be very different from someone else. There is some scope to develop a common language around how we describe assets, so that people know what they are and how we can find them. From a community engagement and empowerment perspective, one might say an asset is only an asset if the community says it is. And certainly when we are talking about the community assets of knowledge, interest and passion in networks, it's the community that might decide where they are and what they are. In the Call to action section in this edition of Health Matters, we've got some information about the use of the SHAPE tool. We also have examples from Wakefield where they used SHAPE to do an integrated asset map to support alcohol reduction and one that Macmillan used to support people living with cancer. So those are some examples and it would be good to hear from elsewhere as well if people have done asset mapping and it’s worked.
If you have any further questions, the Healthy Communities team here at PHE will be pleased to answer them. So please send your question by email to firstname.lastname@example.org.
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