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02 Thome Ljpc5 1d2

02 Thome Ljpc5 1d2

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Published by Brian Fisher

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Published by: Brian Fisher on Jun 30, 2013
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Connected communities
Health and Wellbeing Boards for a newpublic health
David Colin-Thome´ 
Independent Healthcare Consultant and Visiting Professor, Manchester Business School, ManchesterUniversity, UK and School of Health, University of Durham, UK
Brian Fisher
GP and Patient and Public Involvement Lead, NHS Alliance, UK
Health and Wellbeing Boards (HWBs) are one of theinnovationsintheHealthandSocialCareActof2012.Theycouldheraldalongoverduenewpublichealthby harnessing community activity such as asset-basedcommunity development. Box 1 describes how HWBsare intended to span the worlds of public health andprimary care.
RH Tawney said, ‘The poor have remained belovedbytheGodsbeingaffordedexcellentopportunitiesfordying young’
This remains true today, despite thehuge improvements in the public’s health and inhealthcare.Theseimprovementshavedisproportionately benefited the more advantaged.
Narrowing theseinequalities should be a priority of HWBs. Can they deliver this when so many public health policies of thepast have not? We argue that they can, and they must.To do so, they must complement the current publichealth approach that is concerned with discrete inter-ventions targeted at individuals, with ongoing inter-ventions that help whole communities and families tohelp themselves.
Key message
If Health and Wellbeing Boards are to make a realand lasting impact on the health and resilience of the populations they serve, they must revitalise theprinciples of community-oriented primary care,with its values of health protection, social justiceand community development.
Why this matters to us
When I (Brian) started GP practice in 1976, I founda community-development programme a few stepsfrom the health centre in south-east London. It wasfounded on principles of social justice and values of co-operation andchallengingpower.Itchangedmy life (and I married the community worker...) and Ihave tried to put these values into operation acrossthe NHS ever since.When I (David) began GP practice in 1971 I wasgreatly influenced by Dr Julian Tudor Hart andDr Geoffrey Marsh who, as GPs, focused on theindividual and the population of patients. Later, Iwas influenced by my friend Professor John Ashtonas we explored the GP practice as a public healthorganisation, and further shaped by my work as alocal councillor.
We remind readers of the evidence that community empowerment is a cost-effective way to improvehealth, and also that the conditions now exist todevelop this approach in the UK, by facilitatingcollaboration between clusters of general practicesandmultipleotherorganisations.Wearguethatitisthe role of Health and Wellbeing Boards to makesure that this huge potential is realised.
: asset-based community development,community development, cost benefit, health pro-tection,HealthandWellbeingBoards,personalcareandpublichealth,socialjustice,socialnetworks,theregistered list
London Journal of Primary Care
2013 Royal College of General Practitioners
Health and Wellbeing Boards for a new public health
General practice has always had a population re-sponsibility(theregisteredlist)aswellasaresponsibility to individual patients. These twin responsibilities lieat the heart of what it means to be ‘family andcommunity-oriented’ concerned not only withtreating the diseases that a patient has, but also recog-nising the impact of their social context family relationships, jobs, crime and so on. Indeed, this isone of the main reasons why decentralised generalisthealthcare systems are more effective than centralisedspecialist-led systems. In the words of Berwick, ‘(gen-eral practice/primary care) is the soul of a proper,community oriented, health-preserving care system.’
In the words of Starfield, ‘The well known butunderappreciated secret of the value of primary careis its person and population, rather than disease,focus’.
Clinical Commissioning Groups (CCGs) now havetheir hands on the reins of the NHS. This presents anopportunity to meaningfullyspan the generalpracticeroleofpersonalcareandpublichealthincollaborationwith their local authorities through HWBs. Generalmedical practices are statutory members of CCGs andhave to work together to achieve the aims of CCGs toreduce costs and retain quality. As has been describedin recent papers in
, it is becoming increasingly common for clusters of 10–20 practices who servepopulations of about 50 000 to come together todevelop collaborative practice – to share the load of overwhelming demands, for mutual support and forimproved care. Different places have called themdifferent things – ‘Local Health Communities’, ‘HealthNetworks’, ‘Cells’ and ‘Hubs’.Thesenewclustersofgeneralpracticecouldprovideasharedspaceforcollaborationbetweenpublichealthand primary care. In these spaces, multiple agenciescouldworktogethertoprovideinourcitiesandtownswhat pioneers like Julian Tudor Hart in South Wales
achieved in small communities – improving wholecommunitycapacity andresilience,aswellaspersonalmedical care. They could translate to the 21st century the vision of Kark’s ‘community-oriented primary care’
and Ashton’s ‘New Public Health’.
HWBs could make this happen, by ensuring thatgeneral practice and community services plan and actin concert with public health, local authorities, schools,voluntary groups and many other organisations, tosynchronise their efforts for health improvement. Con-ventional individually focused approaches to healthpromotion(e.g.smokingcessation,healthyeatingandphysical activity) could be complemented with socialapproaches that harness the energy in communities(termed ‘asset-based community development’).
Thisapproach helps people to help themselves – moreeffective than imposed solutions. As Kretzmann says,‘healthy communities have never been built upon theirdeficiencies but have always depended upon mobil-ising the capacities and assets of people and place’.
Itmeansrecognisingthathealth ismore than the sumof theirmedicaldiseases,andincludesasenseofcoherencethat Antonovski calls salutogenesis
and MacIntyrecalls Narrative Unity.
In this paper, we revisit the evidence that a socialapproach to health improvement is effective at im-proving health and that it is cost-effective. From this,we suggest what HWBs can do to shape a winningcourse.
A community-developmentapproach improves health
Community development builds confidence to actfor health improvements. For example, community-
Box 1
The role of Health and Wellbeing Boards
Each top tier and unitary authority will have its own Health and Wellbeing Board. Board members willcollaborate to understand their local community’s needs, agree priorities and encourage commissioners towork in a more joined up way.
Health and Wellbeing Boards will have strategic influence over commissioning decisions across health,public health and social care, integrating services.
Boards will involve democratically elected representatives and patient representatives in commissioningdecisions alongside commissioners across health and social care.
Boardswillbringtogetherclinicalcommissioninggroupsandcouncilstodevelopasharedunderstandingof the health and wellbeing needs of the community.ThroughundertakingtheJointStrategicNeedsAssessment(JSNA),theboardwilldrivelocalcommissioningof healthcare, social care and public health, bringing in other services such as housing and educationprovision.healthandcare.dh.gov.uk/hwb-guide/
D Colin-Thome´and B Fisher
development work on the Beacon estate in Cornwallshowed sustained improvements – when the commu-nity realised that they could make a difference by working together, their motivation to act increasedand they caused sustained improvements in housing,education, health and crime.
Similar results havebeen seen in Balsall Health.
The key link is that community development ex-tends and strengthens social networks. These are thelinks between people that shape their sense of identity making them feel that they belong and capableof making an impact. Social networks are formed inthousands of everyday brief encounters – in pubs andshops,clubsandschools,forexample.Socialnetworksare good. A meta-analysis of data across 308 849individuals, followed for an averageof 7.5years showsa 50% increased likelihood of survival for people withstronger social relationships. This is consistent acrossage, sex, cause of death and is comparable with riskssuch as smoking, alcohol, BMI and physical activity.
Social networks and social participation also pro-tect against cognitive decline and are associated withreduced morbidity and mortality.
Low levels of social integration and loneliness significantly increasemortality.
Social networks are weaker in more de-privedareasandpoorsocialparticipationisassociatedwith mental ill health.
Improving social networkingand social relationships reduces the risk of depres-sion.
Those areas with stronger social networks experi-ence less crime
while enhancing employment andemployability.
Social cohesion and informal socialcontrol predict a community’s ability to come togetherand act in its own best interests and are derived, inpart, from participation in local associations or or-ganisations.
There are a variety of models of different kinds of community development to examine, many of whichhave improved healthcare services. For example, the‘Linkage plus’ programme developed and deepenedsocial networks for older people while redesigninghealth services with their participation. Significantimprovements in health and independence resulted.
Boxes 2 and 3 describe two other initiatives – theHealth Empowerment Leverage Project (HELP) andthe Connected Care Project. Both are examples of what has become to be termed ‘asset-based com-munity development’.
Cost–benefit of community-development initiatives
The evidence above shows that community em-powerment improves health, and there are goodreasons why general practice should contribute toleadership of such community empowerment; alsothe contemporary clustering of general practices intogeographicareasprovidesanewpracticalsharedspacefor it to happen. Surely HWBs and CCGs musttherefore ensure that it happens?But is it cost-effective?Studies show that community empowerment iscost-effective, not merely in deprived areas, but in alleconomic climates.
When people in an area takecharge of their destiny, they can better contribute tothe design of cost-effective and humane services thatimprove quality and contain costs better than whenthey are unable to contribute. Making resourcesavail-able to address the association between poor healthand poor social networks and break the cycle of deprivation has been shown to decrease healthcarecosts.
Social Return on Investment
is a social valueapproach to measuring an economic return on in-vestment. It has been used to track the cost–benefitof a community-development worker in four localauthorities, identifying, supporting and nurturingvolunteers within their areas to take part in localgroups and activities.
Box 2
The Health Empowerment Leverage Project, HELP
HELP (www.healthempowermentgroup.org.uk) focuses on the creation of a long-term problem-solvingneighbourhood partnership between residents and front-line services from health and other agencies. Thepartnershipisledbyresidents,butgeneratesparallelactionandlearningamongstagencystaff,enhancingthedevelopment of confidence, skills and cooperation, and creating a cumulative momentum so that suchdevelopments are self-renewing and the whole atmosphere of the neighbourhood becomes more positive.www.youtube.com/watch?v=Qj_W7QxPeM8&feature=youtu.beHELPadopted amethodknownas‘C2’(www.healthcomplexity.net) which displayed exceptionalsuccessover15yearsacrosssixdeprivedruralandurbanestates.AreviewofthelongertermeffectsofaC2projectrunon the Beacon Estate in Penwerris, Cornwall found improvements between 1995 and 2000 in education,health, employment and crime.
HELP has developed an approach that can assist CCGs and HWBs to assess the social capital of theircommunities and track changes that have taken place as a result of intervention.

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