Blogs

Alex McCraw, The Health Creation Alliance

Together, that is the key word here. This last year and a half with Covid-19 has been the toughest and most challenging in recent times for everyone. Covid-19 did not discriminate and everyone suffered. That being said not everything that happened was doom and gloom.

I witnessed, as many did around our country, a unification of people from all walks of life who banded together to help and support of each other address a common and universal problem.

The basis many small community groups start up is to solve a problem, or support others in similar situations, but this time the community came together to take action on a national or even global scale, albeit by many small groups all fighting the same battle.

This got me thinking about the bigger picture for all of us more than normal… Our services, our support networks, our communities. The borders that so often define separate entities suddenly became blurred, or removed completely in many cases. In my local community alone, I saw everyday people reaching out with offers of support to friends, family, neighbours and service providers. Activities ranged from helping ensure vulnerable people had food and medication, to making and supplying PPE to services, frontline workers and those in need. Some of the hardest to reach people were engaged, and engaged in helping. New projects started to support young families, some with scrapped together limited funding, and on a voluntary basis. I watched groups and people that never usually interacted together forgot about any differences and work together to support others.

All this got me thinking…

...why can´t it be like this all the time?

One of the main thoughts were of the hardest to reach and the real lines of contact within our communities and what was different now. I looked at myself to begin with, both in the present and in the past. I started to realise that there were many differences, but most importantly there were constant factors that had not changed from my isolation days to my more confident self of today. In fact they had vastly improved. The biggest improvement was my initial points of contact, friends or family and more so over time those who I have established connection with in my community or network of connections. Is this the same for most people, yes is the answer.

The importance of human connections was reinforced as I spoke with others about initial points of contact, regardless of location, background, status, gender and all the usual differences. I think COVID-19 brought this to a forefront due to the isolation of so many, and as people reached out for the first time to their initial contacts, while also offering support to them. This in turn led to them supporting contacts of their contacts, creating a natural evolving and expanding support community. This seemed to be mirrored in many places around the country with stories of kindness and support all around.

Just like clapping for the NHS, the levels of support spread round our nation was something exceptionally good occurring in such a bleak time.

We have our frontline in health, we all acknowledge that. But there seems to be something missing from this frontline to some degree and that is where my thoughts are. That missing link or bridge from a person to the frontline health services. That initial contact.

I think it is time to evolve what our current perception of the frontline is and bring in a new role to create that link between people and services. A role that can become that initial point of contact because they would be from the immediate community. A team who would know the language, the barriers and challenges, but most importantly would know the people. People are going to be more relaxed, trusting and open with people they can relate to. People who can talk to them at the same level. This could be sort of an evolution of what we currently think of a Community Champion. A community-service bridge (CSB) worker type role. These CSB workers being from the community, based in the community, for the community but with direct connections into services. With them being focused on the community as a whole, this would help establish them as a connector and thus beginning and strengthening them as an initial point of contact with the local people and a bridge into local services.

Similar has happened and is happening in area’s but typically more focused on specific people – I.E. Salford Dadz for my local area. A support group for Dads and their families that basically became a voluntary non-service service. Take away or broaden that specific focus and turn that into a locational community focus and this widens the reach to anyone. With partnership work with local services, key targets can be found where more attention could be placed, as and when needed, due to that flexibility of not being singularly focused.

I hear and read it being constantly said about the difficulty in reaching “harder to reach people” or those who are “isolated”. But, they both have their own points of contact or communities just like everyone else. If we want to reach them, we need to become part of their communities and be a point of contact where that trust, familiarity and to a degree friendship breaks down the current barriers that limit and restrict engagement. CSB workers would have the ability and be in a position to do exactly that. Break the barriers of social divide, trust and difference by uniting smaller communities of individuals or groups into larger locational communities helping develop confidence and control through these better and stronger lines of contact.

In conclusion I feel now is the time when communities are at their strongest and services have openings into those communities that we rethink what the frontline actually is. We know services frontline and people know their frontline – we need to bridge both those frontlines to create a new equally beneficial and partnership based frontline where we truly are building back together.

It has taken a pandemic for us to fully understand that the resources of our beloved NHS are finite. The usual tactic, to throw money at the problem, will never be able to resolve the combination of issues it now faces; an exhausted and traumatised workforce, the non-COVID-19 clinical backlog, the likely need for COVID-19 vaccine booster programmes and longstanding workforce development issues. Not to mention the increased burden linked to an aging population and the increasing health inequity, brutally exposed by COVID-19. The money is welcome, but investment must also be directed to other areas if the NHS is to be protected from becoming overwhelmed, even during ‘normal’ times.

It has also taken a pandemic for many health professionals to start to understand what communities are capable of. Some have noticed people’s desire to help, both formally and informally during the lockdown periods and the deft way that communities organised to keep everyone connected, fed, occupied and receiving the health management and medicines  they needed. As the realisation that doing more of the same is no longer going to cut it, no wonder there is a renewed interest in looking at what communities might be able to do, to fill some of the gaps.

One way of thinking about the overall ambition and the paradigm shift that needs to happen across the system, is to consider how health can be created; what it is that makes people and whole communities well and how can we create the conditions for this to happen? There is now widespread acknowledgement that being meaningfully connected to other people is good for our health, and that both individuals and communities need to become active participants in their health (and not just passive recipients). But what about the detail and the nuances of working with people and communities? What about connecting with and supporting other local partners who already have credibility with local people and who are addressing health inequalities and the wider determinants of health? And how does the health workforce grow to understand what’s involved in creating health and embed and mainstream new ways of working to such a high level that it routinely works and becomes business as usual?

There is much work to be done to build a new sort of health and care system; one in which communities play significant roles and NHS and non-NHS sectors work seamlessly together with everyone playing to their strengths around the same essential goal – Health Creation. Knowledge and experience of how to create the conditions for people to become and to stay well has been growing and maturing over the last 25+ years, much longer if you count the evolution of community development and ethanography upon which Health Creation is based. Much of the best innovation and practice has taken place outside the NHS on tiny and precarious budgets which makes it is easy to sideline.

In an effort to uncover and raise the status and profile of health creating practices, The Health Creation Alliance (formerly New NHS Alliance) worked with its community and lived experience members to develop a ‘Framework for Health Creation’ around five years ago (it can be found here: Health Creation | The Health Creation Alliance) and we have continued to develop tools and insight to guide practitioners through the maze as they develop their skills and approaches. Ideally, the skill-set involved in creating health would become core to everyone’s job alongside the specific skill-set relating to their professional role; making it universal is one way to ensure that systems are designed for Health Creation.

In the wake of the COVID-19 pandemic, our Call to Action is to ‘Build Back Together’. Because experience tells us that when the people who live in a place and the people who work in the place are working together on equal terms, and playing to their everyone’s strengths, those are the optimal conditions for lasting Health Creation to take place, particularly in the most disadvantaged neighbourhoods. When you have trusting and productive relationships in place – between professionals and communities as well as between local partners – and are listening to what matters to communities, then a lot of new solutions can emerge.

We are calling on Government, Integrated Care Systems, Local Authorities, Primary Care Networks and everyone who works within the wider health and social care system to play their part in delivering against ten key messages that emerged from our most recent reports.^1,2,3,4 They are:   

1. Help local people gain control
2. Prioritise Health Creation
3. Build trust with communities
4. Support community-led activity
5. Fund communities to create health
6. Value and build relationships
7. Include communities within governance
8. Support community development
9. Develop new recovery pathways
10. Share anonymised data.

As we move towards the goal of creating health, there is a lot of learning to be done and a lot that could go wrong. Learning from successes and failures is part of the process but being aware of some of the common pitfalls and solutions to these will help to speed up progress.   

Here are five pointers, pitfalls and solutions to consider as you move forward into the brave new health creating world:

• Health Creation is not something that can be ‘rolled out’ like other NHS programmes because it is not, in fact, a programme at all. It is an entirely new way of thinking about health and how best to address health inequalities. It requires a high-level commitment to enabling bottom-up, community-led, initiatives to flourish, and a new paradigm for how the NHS works, learns, commissions and develops. It is an ongoing process that never ends.

• Health Creation requires a commitment to build trusting relationships with communities and local partners. This is not currently costed into the NHS model at any level. However, increasing numbers are recognising the value of it and, by finding the resources to build those relationships from within their own systems, are starting to reap the rewards.  

• The things that make the biggest difference to people’s health and wellbeing tend to be ’hidden’ or ‘intangible’. Being listened to and taken seriously, being treated with dignity and not talked down to, having the opportunity to learn and progress, being meaningfully connected to others, having a purpose in life and something to look forward to, however small. The NHS’s tendency to over-medicalise mean that the small non-medical matters are easily overlooked and opportunities to create health missed.

• Communities in the most disadvantaged places need intensive support to help build the social infrastructure and connections that enable Health Creation. Having a dedicated community-facing community development presence is critical. The NHS can help in many ways: by actively supporting new small community-led initiatives to emerge and strengthen (eg. through offering small amounts of funding); by making a case for employing community development specialists locally; by providing suitable and inexpensive safe spaces for different communities to come together around a common interest; by providing apprenticeship, training and jobs for local people.

• It’s crucial to avoid ‘lifestyle drift’ whereby policies, practices and initiatives start with the intention of creating health but revert back to addressing lifestyle issues such as smoking, drinking and exercise. It’s easy to see why this happens given the evidenced links between these and health outcomes, but the implicit blame and judgement can be crushing and is often the antithesis of Health Creation. The ‘inverse evidence law’ in which the real solutions to health inequalities remain hugely under-researched, coupled with the greater and more sustained effort required to properly address health inequalities, keeps progress largely out of reach.

Whatever your role and position within the wider health system, you can play your part. You can take note of what it is that creates health and work out how to adopt the right attitudes, practices and systems – and avoid the pitfalls. You can help your colleagues around you to learn about and adopt the five features of health creating practices. And you can challenge your system when it reverts to more traditional medical or lifestyle approaches.   

Let’s stop looking to government for all the answers and work together, with our communities and local partners, to move beyond healthcare to a model that is principally focused on how all partners, the NHS, communities and other local partners create health together.

The ten key messages are drawn from the following The Health Creation Alliance reports:

1. Health Creation: How can Primary Care Networks succeed in reducing health inequalities?
2. Primary Care Networks and place-based working: addressing health inequalities in a COVID-19 world. A partners’ perspective
3. Learning from the community response to COVID-19; how the NHS can support communities to keep people well  
4. Digging Deeper, Going Further: creating health in communities. What works in community development?

For more information and how to join the Movement for Health Creation: Members | The Health Creation Alliance