London Journal of Primary Care 2013;5:56–61

# 2013 Royal College of General Practitioners

Connected communities

Health and Wellbeing Boards for a new public health
´ David Colin-Thome
Independent Healthcare Consultant and Visiting Professor, Manchester Business School, Manchester University, UK and School of Health, University of Durham, UK

Brian Fisher
GP and Patient and Public Involvement Lead, NHS Alliance, UK

Key message
If Health and Wellbeing Boards are to make a real and lasting impact on the health and resilience of the populations they serve, they must revitalise the principles of community-oriented primary care, with its values of health protection, social justice and community development.

Why this matters to us
When I (Brian) started GP practice in 1976, I found a community-development programme a few steps from the health centre in south-east London. It was

founded on principles of social justice and values of co-operation and challenging power. It changed my life (and I married the community worker...) and I have tried to put these values into operation across the NHS ever since. When I (David) began GP practice in 1971 I was greatly influenced by Dr Julian Tudor Hart and Dr Geoffrey Marsh who, as GPs, focused on the individual and the population of patients. Later, I was influenced by my friend Professor John Ashton as we explored the GP practice as a public health organisation, and further shaped by my work as a local councillor.

We remind readers of the evidence that community empowerment is a cost-effective way to improve health, and also that the conditions now exist to develop this approach in the UK, by facilitating collaboration between clusters of general practices and multiple other organisations. We argue that it is the role of Health and Wellbeing Boards to make sure that this huge potential is realised. Keywords: asset-based community development, community development, cost benefit, health protection, Health and Wellbeing Boards, personal care and public health, social justice, social networks, the registered list

Health and Wellbeing Boards (HWBs) are one of the innovations in the Health and Social Care Act of 2012. They could herald a long overdue new public health by harnessing community activity such as asset-based community development. Box 1 describes how HWBs are intended to span the worlds of public health and primary care.1 RH Tawney said, ‘The poor have remained beloved by the Gods being afforded excellent opportunities for dying young’. This remains true today, despite the huge improvements in the public’s health and in

healthcare. These improvements have disproportionately benefited the more advantaged.2 Narrowing these inequalities should be a priority of HWBs. Can they deliver this when so many public health policies of the past have not? We argue that they can, and they must. To do so, they must complement the current public health approach that is concerned with discrete interventions targeted at individuals, with ongoing interventions that help whole communities and families to help themselves.

Health and Wellbeing Boards for a new public health


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 will collaborate to understand their local community’s needs, agree priorities and encourage commissioners to work 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 commissioning decisions alongside commissioners across health and social care. Boards will bring together clinical commissioning groups and councils to develop a shared understanding of the health and wellbeing needs of the community.

Through undertaking the Joint Strategic Needs Assessment (JSNA), the board will drive local commissioning of healthcare, social care and public health, bringing in other services such as housing and education provision.

General practice has always had a population responsibility (the registered list) as well as a responsibility to individual patients. These twin responsibilities lie at the heart of what it means to be ‘family and community-oriented’ – concerned not only with treating the diseases that a patient has, but also recognising the impact of their social context – family relationships, jobs, crime and so on. Indeed, this is one of the main reasons why decentralised generalist healthcare systems are more effective than centralised specialist-led systems. In the words of Berwick, ‘(general practice/primary care) is the soul of a proper, community oriented, health-preserving care system.’3 In the words of Starfield, ‘The well known but underappreciated secret of the value of primary care is its person and population, rather than disease, focus’.4 Clinical Commissioning Groups (CCGs) now have their hands on the reins of the NHS. This presents an opportunity to meaningfully span the general practice role of personal care and public health in collaboration with their local authorities through HWBs. General medical practices are statutory members of CCGs and have to work together to achieve the aims of CCGs to reduce costs and retain quality. As has been described in recent papers in LJPC, it is becoming increasingly common for clusters of 10–20 practices who serve populations of about 50 000 to come together to develop collaborative practice – to share the load of overwhelming demands, for mutual support and for improved care. Different places have called them different things – ‘Local Health Communities’, ‘Health Networks’, ‘Cells’ and ‘Hubs’. These new clusters of general practice could provide a shared space for collaboration between public health and primary care. In these spaces, multiple agencies could work together to provide in our cities and towns what pioneers like Julian Tudor Hart in South Wales5

achieved in small communities – improving whole community capacity and resilience, as well as personal medical care. They could translate to the 21st century the vision of Kark’s ‘community-oriented primary care’6 and Ashton’s ‘New Public Health’.7 HWBs could make this happen, by ensuring that general practice and community services plan and act in concert with public health, local authorities, schools, voluntary groups and many other organisations, to synchronise their efforts for health improvement. Conventional individually focused approaches to health promotion (e.g. smoking cessation, healthy eating and physical activity) could be complemented with social approaches that harness the energy in communities (termed ‘asset-based community development’).8 This approach helps people to help themselves – more effective than imposed solutions. As Kretzmann says, ‘healthy communities have never been built upon their deficiencies but have always depended upon mobilising the capacities and assets of people and place’.9 It means recognising that health is more than the sum of their medical diseases, and includes a sense of coherence that Antonovski calls salutogenesis10 and MacIntyre calls Narrative Unity.11 In this paper, we revisit the evidence that a social approach to health improvement is effective at improving health and that it is cost-effective. From this, we suggest what HWBs can do to shape a winning course.

A community-development approach improves health
Community development builds confidence to act for health improvements. For example, community-


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development work on the Beacon estate in Cornwall showed sustained improvements – when the community realised that they could make a difference by working together, their motivation to act increased and they caused sustained improvements in housing, education, health and crime.12 Similar results have been seen in Balsall Health.13 The key link is that community development extends and strengthens social networks. These are the links between people that shape their sense of identity – making them feel that they belong and capable of making an impact. Social networks are formed in thousands of everyday brief encounters – in pubs and shops, clubs and schools, for example. Social networks are good. A meta-analysis of data across 308 849 individuals, followed for an average of 7.5 years shows a 50% increased likelihood of survival for people with stronger social relationships. This is consistent across age, sex, cause of death and is comparable with risks such as smoking, alcohol, BMI and physical activity.14 Social networks and social participation also protect against cognitive decline and are associated with reduced morbidity and mortality.15 Low levels of social integration and loneliness significantly increase mortality.16 Social networks are weaker in more deprived areas and poor social participation is associated with mental ill health.17 Improving social networking and social relationships reduces the risk of depression.18 Those areas with stronger social networks experience less crime19 while enhancing employment and employability.20 Social cohesion and informal social control predict a community’s ability to come together and act in its own best interests and are derived, in part, from participation in local associations or organisations.19 There are a variety of models of different kinds of community development to examine, many of which have improved healthcare services. For example, the ‘Linkage plus’ programme developed and deepened social networks for older people while redesigning

health services with their participation. Significant improvements in health and independence resulted.21 Boxes 2 and 3 describe two other initiatives – the Health Empowerment Leverage Project (HELP) and the Connected Care Project. Both are examples of what has become to be termed ‘asset-based community development’.

Cost–benefit of communitydevelopment initiatives
The evidence above shows that community empowerment improves health, and there are good reasons why general practice should contribute to leadership of such community empowerment; also the contemporary clustering of general practices into geographic areas provides a new practical shared space for it to happen. Surely HWBs and CCGs must therefore ensure that it happens? But is it cost-effective? Studies show that community empowerment is cost-effective, not merely in deprived areas, but in all economic climates.22 When people in an area take charge of their destiny, they can better contribute to the design of cost-effective and humane services that improve quality and contain costs better than when they are unable to contribute. Making resources available to address the association between poor health and poor social networks and break the cycle of deprivation has been shown to decrease healthcare costs.23 Social Return on Investment19 is a social value approach to measuring an economic return on investment. It has been used to track the cost–benefit of a community-development worker in four local authorities, identifying, supporting and nurturing volunteers within their areas to take part in local groups and activities.

Box 2 The Health Empowerment Leverage Project, HELP HELP ( focuses on the creation of a long-term problem-solving neighbourhood partnership between residents and front-line services from health and other agencies. The partnership is led by residents, but generates parallel action and learning amongst agency staff, enhancing the development of confidence, skills and cooperation, and creating a cumulative momentum so that such developments are self-renewing and the whole atmosphere of the neighbourhood becomes more positive. HELP adopted a method known as ‘C2’ ( which displayed exceptional success over 15 years across six deprived rural and urban estates. A review of the longer term effects of a C2 project run on the Beacon Estate in Penwerris, Cornwall found improvements between 1995 and 2000 in education, health, employment and crime.18 HELP has developed an approach that can assist CCGs and HWBs to assess the social capital of their communities and track changes that have taken place as a result of intervention.

Health and Wellbeing Boards for a new public health


Box 3 Connected Care in 11 sites since 2006 The Connected Care project (, part of the Turning Point organisation, set out to build on existing social capital and resilience to improve health and social care outcomes for local people in Owton ward in Hartlepool. Community researchers were recruited from the local community and supported by Turning Point and local agencies. Two hundred and fifty-one local residents participated in an audit via one-to-one interviews, focus groups and a community ‘have your say’ event. The results of the audit informed the development of the Connected Care service that is delivered through a local community social enterprise, incorporated as a Community Interest Company. The service includes navigators, a debt and benefits advice service, support for older people to stay in their own homes for longer, supported housing for young people as well as a gardening and handyman service. It also includes a Time Bank to utilise the skills of local residents and coordinate volunteering between local people. Connected Care is now managing 32 flats in Glamis Walk that are owned by Accent Foundation, who have now commissioned Connected Care to manage the whole estate. Connected Care is being rolled out across Hartlepool, building on the service delivered in Owton ward and community research activity across the town over the last 18 months. The programme in Hartlepool has expanded from 100 people receiving support to over 500 people benefiting from the range of services – including benefits and welfare advice, lunch clubs, social activities, gardening and handyman services, and meals on wheels. This service is expecting to triple again the number of people in the SAILS programme over the next year. On the back of this expansion, the council has awarded Connected Care the contract to provide lunch clubs and reablement support for elderly people leaving hospital. An investment of £233 655 in community-development activity was found to have created approximately £3.5 million in social return, a return of 15:1. The time invested by members of the community in running various groups and activities represented almost £6 of value for every £1 invested by a local authority. Lomas24 shows that harnessing social networks has an effect comparable with biomedical interventions. He estimates that for every 1000 people exposed to each ‘intervention’ per year:
. .

neighbourhoods of a local authority and £130 million across England. This represents a return of 1:9.

What should Health and Wellbeing Boards do?
It is understandable why there has been so little general practice leadership of community empowerment – medical training emphasises the treatment of discrete diseases and the science of collaboration and empowerment is largely absent from the curriculum. HWBs must act to reverse this, first at the postgraduate level, working with Health Education England to develop skills to lead this in the new clusters of general practices. It is understandable why there has been so little collaboration between general practice and public health practitioners to lead community empowerment – they operate in isolation from each other to different boundaries. Previously, attempts to systematically build community resilience and social cohesion have only been realistic in small communities where the shared boundaries are given by nature. In larger areas, the absence of shared boundaries fragments collaborative initiatives. HWBs must act to consolidate these new clusters of practices as a shared developmental space where local authorities, public health business and third sector organisations can contribute to a new public health.

social cohesion and networks of associations would prevent 2.9 fatal heart attacks medical care and cholesterol-lowering drugs would prevent 4.0 fatal heart attacks in screened males.

HELP was asked by the Department of Health to explore the cost–benefit of community development. Examining the HELP interventions in three neighbourhoods across England, it was estimated that serious medical events would be reduced by 5% per year – an NHS saving of £558 714 over three years on depression, obesity ad cardiovascular disease. This is as a result of local interventions such as exercise groups, dietary interventions and deepening of social networks.25 This is a return of 1:3.8 on a £145 000 investment in community development over the three years. Adding savings produced by reductions in crime and antisocial behaviour would produce a further saving of £96 448 a year per neighbourhood using directly age-standardised mortality rates per 100 000, £868 032 across the 20% most disadvantaged


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It is understandable why there is not more evidence of the huge untapped potential of community empowerment to improve health. Databases in the NHS are focused on individuals with individual diseases. HWBs must ensure that Commissioning Support Units routinely gather data of the effect of these clusters on things like unscheduled admissions to hospital, place of care for those who are dying, and a breadth of other indices that will be affected by the large number of small acts of kindness that happen in empowered communities. They must provide reports of these data on a regular (monthly) basis so local people can witness the effects of their actions. HWBs should also support pilot projects within these clusters, and create mechanisms for results to be fed back to CCGs so others can learn and change. HWBs should encourage such long-term capacitycreating interventions as an antidote to the usual old-fashioned projects that have short-term focus. They should work with universities to support evaluation of these initiatives. The literature about asset-based community development is particularly worth reviewing. This involves residents identifying local skills and experience, then discovering what they care enough about to change, then creating mechanisms to act together to achieve those goals. HELP and Connected Care use this approach (Boxes 2 and 3). If HWBs perceive their roles narrowly they will chart a traditional course with two or three key priorities (probably medically perceived). And they will fail. But if they claim a wider role (and they should), they could position themselves as enablers of a new public health that provides the training, the conditions and the evidence that community empowerment produces better health at lower cost.

These are the personal opinions of the authors drawing on published papers so ethical committee approval is not needed.
REFERENCES 1 2 kings-fund-report-aug2012.pdf 3 Berwick DM. A transatlantic review of the NHS at 60. BMJ 2008;337:a838 4 Starfield B, Shi L and Macinko J. Contribution of primary health care to health systems ... quality of care in England. New England Journal of Medicine 2009; 361(4): 368–78 5 Hart J. A New Kind of Doctor: the general practitioner’s part in the health of the community. London: Merlin Press, 1988.

6 Gillanders WR. Community-oriented primary care: the legacy of Sidney Kark. American Journal of Public Health 1993;83:946–7. 7 Ashton J and Seymour H. The New Public Health. Milton Keynes: Open University Press, 1988. 8 Morgan M and Ziglio E. Revitalising the public health evidence base: an asset model. In: Morgan A and Ziglio E (eds) Health Assets in a Global Context: theory, methods, action. New York: Springer, 2010. 9 Kretzman JP and McKnight JL. Building Communities From the Inside Out: a path toward finding and mobilizing a community’s assets. Evanston, IL: ABCD Institute, 1993. 10 Antonovsky, A. Unraveling The Mystery of Health – how people manage stress and stay well. San Francisco: JosseyBass, 1987. 11 MacIntyre A. After Virtue. London: Duckworth, 2000. 12 Stuteley H and Cohen C. Developing Sustainable Social Capital in Cornwall: a community partnership for health and well-being (The Falmouth Beacon Project). Redruth, UK: Cornwall Business School, 2004. 13 Atkinson D. Civil Renewal. Studley, UK: Brewin Books, 2004. 14 Holt-Lunstadt J, Smith TB and Layton JB. Social relationships and mortality risk: a meta-analytic review. Plos Medicine 2010;7(7). doi: 10.1371/journal.pmed.1000316 15 Jenkins R, Meltzer H, Jones P, Brugha T and Bebbington P. Mental Health and Ill Health Challenge. London: Foresight, 2008. 16 Bennett K. Low level social engagement as a precursor of mortality among people in later life. Age and Ageing 2002;31:165–8. 17 Berkman LF and Kawachi I. A historical framework for social epidemiology. In: Berkman LF and Kawachi I (eds) Social Epidemiology. Oxford: Oxford University Press, 2000. 18 Morgan E and Swann C. Social Capital for Health: Issues of definition, measurement and links to health. London: Health Development Agency, 2004. 19 Fulbright-Anderson K and Auspos P (eds). Fear of Crime and Neighbourhood Change. Community change: theories, practice, and evidence. Queenstown: The Aspen Institute, 1986. 20 Clark P and Dawson S. Jobs and the Urban Poor. Washington, DC: Aspen Institute, 1995. 21 Willis M and Dalziel R. LinkAge Plus: Capacity building – enabling and empowering older people as independent and active citizens. Department for Work and Pensions Research Report No 571, 2009. asd/asd5/rports2009-2010/rrep572.pdf 22 Knack S. Social Capital, Growth and Poverty; a survey of cross-country evidence. Social Capital Initiative, Working Paper No. 7. Washington, DC: World Bank, 1999. 23 The Marmot Review. Fair Society, Healthy Lives Strategic Review of Health Inequalities in England Post 2010, p. 139. The Marmot Review, February 2010, ISBN 978–0– 9564870–0–1. 24

Health and Wellbeing Boards for a new public health


25 2012/11/Townstal-Community-Partnership-baselineindicators-final-sept-12.pdf


´ David Colin-Thome Email: Accepted 18/3/2013

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