Making decisions with communities for senior ICS decision-makers

Who, What, When, Where, Why?

By Merron Simpson, Chief Executive, The Health Creation Alliance

Imagine a traditional decision-making scenario. Senior ‘qualified’ people in formal positions, making decisions about finances, strategies, service delivery or some such ‘high level’ issue. It will almost certainly be at one of a planned sequence of diarised board meetings and taking place in a board room in a formal institution. The decisions they make are critical for the smooth running of the health service they are in charge of.

Now think about the communities you work with, particularly those with the worst health outcomes. What does decision-making mean for them? It is very unlikely to look like decision-making in the NHS and it will always be about communities being heard and about solutions that work for communities.  

How will you go about the who, what, when, where, why? How will it differ from traditional decision-making?

WHO – are you making decisions with?  

Increasingly, the NHS is looking to data to lead it to particular communities that have the poorest health outcomes, and to provide some insight into what is wrong for specific cohorts. Population Health Management and Core20PLUS5 both use mainly quantitative data to focus on specific communities.

But these data-led programmes don’t tell you why they have the worst health outcomes nor do they tell you what solutions will work for those communities.

Solutions that work are surely what we’re striving for? They come from many places. While the data leads you down a narrow, increasingly focused path to identify what needs fixing, we need to employ the opposite skill – to think broadly, be open-minded and prepared to grow new solutions in conversation with people.

You actually need to talk to those communities about the things that matter to them and make decisions with them. Not being prepared to do so is a very common mistake and lies behind a long-term lack of trust between communities and services.

WHAT – are you making decisions about?

Are you making decisions about things that the system believes are important? Or about something the community you’re trying to work with believes is important? People are far more likely to engage with you if you’re prepared to talk to them about something that matters to them and if you’re prepared to understand why.

Community insight is valuable qualitative data…and it needs to be given the same status as quantitative data. In one place THCA worked recently, sophisticated community insight had been generated by the VCSE sector but this was not being taken into account by the NHS despite their best efforts. That needs to change.

WHEN – should you be making decisions?

Good decision-making with communities needs to be understood as an ongoing conversation with decisions being made as-and-when, not in a moment in time.

Some decisions can be made by communities themselves; some at the frontline between communities and frontline staff. Decision-making should be devolved to this level wherever possible.

Communities should have access to small amounts of funding to help oil the wheels of new solutions. Because community-led activity is often the most impactful; it gives communities the most control and can lead to the best outcomes; it is health creating.

Where systems need to make bigger decisions – ones that are expensive or require operational changes – this should also involve conversations with communities. Senior decision-makers need to be prepared to engage communities in conversations that lead up to the big decisions and to respond to the matters that are emerging from the ground-up. This is sometimes called ‘deliberative democracy’.

WHERE – should you be making the decisions?

Here’s a call to action for all Integrated Care Boards; if you do this it will make a big difference:

• Hold your ICB meetings and ICP meetings in community venues

• In the month preceding the meeting, organise for every member of the Board to do a one-to-one 1.5 hour walkabout, partnered with a member from that community

When very senior people spend time getting to know people in their community setting, this sends a very powerful message to that community…having someone so senior talk to them as an equal about their life in their community means that they can feel heard and respected.

Hearing people´s stories first hand is one way of ‘digging deeper’; it can help your senior board to better understand the nuances of community and to appreciate why community-led solutions work. Also, by doing this you should increasingly be able to identify community leaders who can represent their community at the most senior level on your formal board.

The Health Creation Alliance has found system-unwillingness to do this as being the biggest barrier – both to community Health Creation and to system transformation.

WHY – should you make decisions with communities?

Why would you go to all this trouble?

Because people will make their own decisions anyway. They weigh things up, decide whether something is worth the effort, make their own judgements.

If a service doesn’t meet their needs and they decide not to use it, they may be labelled ‘hard-to-reach’ or told they need to ‘take more responsibility for their health’. But they are probably simply making a good decision based on their circumstances, past experiences and information they have at the time.

Making decisions with communities means being prepared to work as equal partners with local people on the things that matter to them and to find solutions together that draw on their strengths and redesigning services accordingly. This is what Health Creation is…The Health Creation Alliance can help you to have impact through changing the way you make decisions with communities.