London Journal of Primary Care 2014;6:154–8

# 2014 Royal College of General Practitioners

Community-Oriented Integrated Care

Community development through health gain and service change – do it now! Brian Fisher MBBCh MSc MBE Lewisham Clinical Commissioning Group, London, UK

Key messages . . .

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Community development improves health. Community development is effective as community-driven service change. Community development can be of real benefit to general practices, clinical commissioning groups and local authorities. The NHS needs to harness it now, particularly in the current economic climate, which threatens community cohesion.

Why this matters to me I first came across community development (CD) when I began as a general practitioner in Peckham in 1976. There was a CD project in a small Victorian building that seemed to thrive in the ocean of estates

that was our catchment area. A brief conversation with the workers there and a light bulb switched on in my head. The power of community; the learning for all of us, professionals and residents; the changes to individuals and services that could take place. We set up a health project and, when I moved practice to Lewisham, the evidence and experience we had accumulated enabled us to set up a project that became borough wide and lasted for over 10 years. We now have evidence from all over the world and the UK of the benefits and risks of CD as it applies to health. It is a complex process that can challenge power, control and the status quo - that is why I think it is so important. It brings people together, it changes lives, and it is a political process. I want the NHS to see it as a routine approach to care and for policy to change to make that easier.

ABSTRACT This article explores the principles and practice of community development (CD) in health from a primary care perspective. CD is defined and examples are given. There are many misconceptions about the term and so we explain what CD is not: for instance, it is not social prescribing, nor is it conventional public health interventions. The benefits for practices, general practitioners and clinical commissioning groups are outlined, and the current evidence on cost–benefit is given. In essence, the benefits are health gain and effective

community-driven service change. Risks, side effects and complications are described. Finally, the Charter for Community Development in Health is a call to action for clinical commissioning groups and policy-makers. We have an approach that changes people’s lives for the better – let’s harness it!

Keywords: assessment of healthcare needs; healthcare inequalities; patient empowerment; patient engagement; social capital

Introduction It is a truth universally acknowledged, that community engagement is essential for clinical commissioning groups (CCGs) and their practices. We need to understand and respond to the communities we serve to improve services and outcomes. Often, how-

ever, it may seem that community participation is more rhetoric than reality. Community development (CD) may help. CD has a long history with more recent evidence of health gain and effective community influence over planning

Health gain and service change

across a wide range of services, in and outside health. This paper explores the principles and practice of CD as it applies to health.

What is community development? CD is a social intervention that usually involves specialist CD workers, although existing NHS staff can also be trained. Through working with communities in a variety of ways, CD enables people to organise to identify shared needs and aspirations; improve lives through joint activity; address imbalances in power; bring about change founded on social justice, equality and inclusion; and influence the agencies whose decisions affect their lives.1 An ‘asset-based’ strand builds on positives: leaders, skills, strengths of individuals and communities, rather than need – ‘build on the strong not on the wrong’.2 CD is usually geographically based, but can address communities of interest, for instance, people with diabetes or the disabled.3 In one form or another, CD projects facilitate a series of opportunities for local people to work together to improve their shared environment, for mutual advantage. In this respect, CD is aligned to the values of mutual organisations. Mills and Swarbrick described how Rochdale Boroughwide Housing, the UK’s first mutual social housing provider, aimed to: ‘embed the idea of collaborative working between tenants and employees in the very way in which the organisation is set up...’.4 CD is a broad church, with a number of techniques. One example is that of C2,5 begun in 1992 after many successful interventions and taken up by the Health Empowerment Leverage Project (HELP).6 A sevenstep process begins by involving residents in community meetings, usually leading to a resident-led partnership between active residents and public services which develops an increasing range of community activity that influences services.

What community development is not CD is an increasingly familiar concept, but can be easily misunderstood. CD is not social prescribing. Social prescribing is the process of a clinician referring a patient to a community group, such as MIND or BreathEasy. It offers an alternative and relevant response to patient need, but it may often not show any of the principles of

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CD: the patient may remain passive. The process is similar to a prescription or referral. CD does not begin with an agenda prescribed by health. It should not involve a CCG going into an area with a list of issues defined by epidemiological data: excessive smoking, obesity, alcohol consumption and then expecting to work with the community to tackle those issues. That approach is certainly a useful and important way of working – but the concept of enabling and supporting the community to define its own issues and agenda is vital to CD. It is the community’s definition of problems that drives work with statutory agencies. Patient participation groups are a key element to participation in primary care. They are usually a small self-selected group and are likely to focus on the needs of the practice. They may play a part in CD by working with the CD workers, but it is unlikely that they could initiate CD on their own. CD is also not work for general practitioners (GPs), on the whole. The work should be done by CD workers or other trained staff. Although practices would be expected to support the process, GPs would not be expected to do the work themselves.

A range of benefits There is now good evidence that CD can improve health protection, help tackle health inequalities, improve health behaviours and assist in enabling local people to influence planning of local health and other statutory services.7 The basis for this benefit appears to be the confidence and strength engendered by building the number and strength of our face-to-face social networks. That is, simply the connections we have with others: friends, family, colleagues, acquaintances. The term social capital is often used to describe the accumulation of these networks and their effect.8 It is these community connections that underpin increased community cohesion and resilience. And it is these shifts that enable communities to take more control over their areas and be strengthened to engage in dialogue with their local statutory agencies. In the face of evidence of disillusion with voting, politics and engagement with the state, CD has shown time and again that local people can be lit up by local issues. The energy and engagement that can be fired by CD and other social movements can be powerful. CD has a significant impact on participatory democracy. At a time when austerity threatens many aspects of civic society, weakening employment and thinning out social capital, CD may offer some counterbalance. It increases community resilience and supports associational life.

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What’s in it for GPs and our practices? CD can offer a practice an insight and an inroad into the communities it serves. CD can enable a practice to have some impact on the social determinants of health. It can help a practice begin and hold a dialogue with local people, and there are opportunities for practices to work with CD to offer facilities and ideas for local people that could, at little cost, make a big difference to some groups. In Lewisham, for instance, a CD project helped a practice solve some difficult ethical and practical conundrums by opening up a dialogue with local groups. These included whether to charge immigrant patients and how to deal more effectively with the housing department. By working with young people and the council, the project created a whole new service that operated out of hours in the surgery, bringing young people and health services together in new ways. The project also helped the practice see itself through others’ eyes. Feedback was enhanced and understood – and acted upon. Offering premises to local groups can make a significant difference to the viability, effectiveness and reach of local groups and practices, and hospitals should consider this as a routine offer, if space is available. The simplest benefit of a strong local CD presence is the ease with which a practice can learn more about relevant third sector groups – and more easily refer to them. Improved relationships can also make it easier for practices to have groups working and offering services in the practice.

How general practice can realise these benefits At a 2014 LJPC workshop, GPs suggested a range of ways to harness the benefits of CD. By clustering practices into geographic localities of about 50 000 people it makes it easier for existing CD projects to relate to all local practices; it is just too difficult for CD projects to link with every practice without a structural arrangement like this. Such clustering also provides a way for general practices to support the application for funds for CD projects, potentially increasing their number. Within such clusters, a practice could identify patients with complex problems and the CD worker could work with them to identify social aspects of care that could be harnessed for their benefit. Patient

participation groups could be supported by CD workers to become more effective. There may be mutual interests faced by practices, their patients and local voluntary groups such as housing issues, education issues or poor food outlets. CD can help practices to contribute to campaigns to change these aspects of civic life. Collaboration for better services can be very powerful.

What’s in it for the CCG? CD helps communities agree local priorities for change that matter to them. CD helps them build local consensus and local structures, such as residentled partnerships, that support a dialogue between the community and the CCG and other statutory agencies as appropriate. Representatives of health, education and the police can find themselves together in a room with residents solving problems spanning a range of issues. Often they have never met the other agencies before. Experience suggests that changes towards these local priorities can be rapid. CD can be a powerful way of implementing the CCG’s responsibilities for participation. Seeing the NHS, education and housing as common contributors to locality health becomes in effect a way of integrating services and attitudes from the grassroots. The national movements bringing social care and health together can begin in localities. CD can also assist CCGs in their responsibility for improving health inequalities. Marmot is clear that community cohesion is a prerequisite for tackling health inequalities.9 There is some evidence that healthy behaviours can be enhanced through CD, or at least through peer support which CD can promote.10 Health and wellbeing boards can contribute greatly to the power and significance of CD, as they have similar coordinating responsibilities.11 We see that joint commissioning through the local authority and CCG is one route to sustained and more or less reproducible community health development.

Costs and side effects There is now increasing information about cost– benefit in financial terms. The HELP experience suggests an effective community development project costs about £80 000 a year per neighbourhood. Two years’ work should leave a self-renewing resident group, supported by existing front-line workers. The Beacon project is 15 years old.

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An internal HELP analysis12 suggested an NHS saving of £558 714 across three neighbourhoods over three years, based on cautious but evidence-based estimates of improvements in health factors by 5% annually as a result of increased community activity and social networks (SNs): a return of 1:3.8 on a £145 000 investment in CD, with additional savings through reductions in crime and antisocial behaviour of £96 448 a year per neighbourhood. These calculations are difficult and open to criticism. However, the results are similar to estimates obtained by others.13 There are other side effects. The work is complex and difficult, even for trained CD workers. The process may benefit from or be thwarted by strong personalities in the community. Public agencies may not listen, or may impose solutions fitting organisational convenience rather than residents’ concerns. CD workers need to persuade agencies to involve their front-line workers, learning to see local residents as sources of solutions, not merely as presenting needs. This can challenge traditional NHS ways of working. The NHS, in general, and primary care, in particular, may sometimes be only peripherally involved. Statutory agencies worry about the unpredictability of outcomes, as the key issues for the community are largely unknown at the beginning. In addition, funding may come from one agency and benefits accrue to another. For instance, if the NHS were to fund a CD project, residents may want to focus on antisocial behaviour, in which case the police may be the most immediate beneficiaries. Community budgets may, therefore, be particularly useful, through which local funding may be shared.14 CD is in essence about power: sharing power or shifting power. Agencies like the NHS may find challenges of this sort uncomfortable. Councillors can also feel that their democratic status is under threat if local movements appear that were not initiated by them.

3 Harness the interventions that have the best evidence and are most reproducible. These include community development or community building or community transformation. Community development can be mainstreamed to a much wider group of agencies than ever before. Initiatives often coalesce into resident-led partnerships. 4 Develop, through community building, communityled neighbourhood partnerships of residents and service providers. These can: a play a key role in improving health and wellbeing in local communities; b reduce silo thinking; c improve services and make them more accountable to local people; d bring the whole system of residents, services and elected representatives to bear on complex issues and problems; e encourage a greater level of accountability between residents and services. 5 Active communities need expert support. CD workers could play a key co-ordinating/senior practitioner role in supporting other public sector staff to work as effective partners alongside communities.

The Charter for community development in health15

REFERENCES

HELP and other organisations launched the Charter in July 2014. It summarises the principles of CD and urges CCGs to commit to the following: 1 Inspire residents to become key players in developing their own health and well-being. 2 Be prepared to listen, respond and begin to work in new ways. This can be turbulent but is highly productive both for communities and the agencies that serve them.

Conclusions CD has a lot to offer CCGs, public health, practices and communities. As with all complex interventions, outcomes are not guaranteed and the journey can be bumpy. There are tried and tested techniques that appear to have good outcomes and that should be disseminated and encouraged. However, there is much that needs to be done to support the NHS and public health to routinely harness this kind of approach. The Charter for Community Development in Health suggests policy changes across the NHS. We hope that this can be the start of a dialogue for change.

1 www.lluk.org/documents/cdw_nos.pdf 2 Asset-based Community Development Institute. www.abcdinstitute.org 3 Altogther Better (Date) www.altogetherbetter.org.uk/ altogether-better-diabetes 4 Mills C and Swarbrick G (2014) Going with the grain: organising for a purpose. London Journal of Primary Care 6: 3–7. www.radcliffehealth.com/sites/radcliffe health.com/files/ljpc_articles/02_mills_ljpc_6–1.pdf 5 Durie R, Wyatt K and Stuteley H (2004) Community regeneration and complexity. In Kernick D (ed) Complexity and Healthcare Organization: a view from the street. Radcliffe Medical Press: Oxford.

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6 Health Empowerment Leverage Project (2011) Empowering Communities for health: business case and practice framework. www.healthempowerment.co.uk/ wp-content/uploads/2012/11/ DH_report_Nov_2011.pdf 7 Health Empowerment Leverage Project (2012) Community Development in Health – a literature review. www.healthempowerment.co.uk/wp-content/uploads/ 2012/11/HELP-Literature-Review.pdf 8 Brodie E, Cowling E and Nissen N (2009) Understanding Participation – a literature review. NCVO, IVR and Involve: London. 9 Marmot M (2010) Fair Society, Healthy Lives. Strategic review of health inequalities in England post 2010 (The Marmot Review). www.instituteofhealthequity.org/ projects/fair-society-healthy-lives-the-marmot-review 10 National Institute for Health and Care Excellence (2008) Community Engagement. NICE public health guidance 9. www.nice.org.uk/guidance/ph9/resources/guidancecommunity-engagement-pdf 11 Fisher B (2013) Health and Wellbeing Boards for a new public health. London Journal of Primary Care 5: 56–61. 12 Health Empowerment Leverage Project (2011) Measuring Impact & Cost Benefits. www.health empowerment.co.uk/ measuring-impact-cost-benefits

13 Community Development Foundation (2010) Catalysts for Community Action and Investment: A Social Return on Investment analysis of community development work based on a common outcomes framework. Community Development Foundation: London. cdf.org.uk/wp-content/uploads/2011/12/SROI-Report-FINAL1.pdf 14 Whole Place Community Budgets: rewiring public services around people. http://communitybudgets.org.uk 15 NHS Alliance (2014) A Charter for Community Development in Health. www.nhsalliance.org/wp-content/ uploads/2014/08/NHSA-CD-Charter-FINAL.pdf

ADDRESS FOR CORRESPONDENCE

Brian Fisher MBBCh MSc MBE 100 Erlanger Rd London SE14 5TH UK Tel.: +44 (0)7949 595349 Email: brianfi[email protected] Submitted July 2014; revised September 2014; accepted November 2014

Community development through health gain and service change - do it now!

This article explores the principles and practice of community development (CD) in health from a primary care perspective. CD is defined and examples ...
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