The source of Community-Centred Health and well-being is the NHS Executive itself. Public Health England is an agency of the Department of Health. Signatories to their report published in 2015, are Duncan Selble who is the Chief executive of PHE and Simon Stevens, Chief executive of the NHS (England). [PHE publications gateway number: 2014711]
The essence of Community-Centred Health is a programme of slow privatisation and it masks the process by alluding to development of the NHS through outsourcing services. The need to take on the ideas of development through expansion of existing services is presented as an, ‘either or’ rather than an ‘and’. It uses this eclectic presentation and advocates the pragmatic notion of a new system of working, in counter-position to an integrated notion of a Health Service.
To understand the notion it demands looking at the underlying ideological framework. We need pull out of their report their intentions.
They forwardly propose creating the conditions for community assets to thrive and stimulating partnerships. These partnerships are outlined for their perceived potential; the assets within communities, such as skills and knowledge, social networks and community organisations, are building blocks. Many people in England contribute to community life through volunteering.
Collaborations and partnerships are therefore based on communal sentiment juxtaposed with the notion of being a predatory asset. They even advocate that there is a substantial body of evidence on community participation and empowerment on the health benefits of volunteering. Yet they still have no cost evidence but they speculate that community capacity building and volunteering will bring a positive return on investment.
Not only do they say that, but advocate a shift also to more community-centred ways of working in public health and healthcare, but also they do not say that preservation of the back-up existing structures, the NHS as a system, should remain.
They want to develop volunteering as the bedrock of community action and move to a new health system of local government. They are alluding to a whole society approach. This is closely related and follows the Depart for Communities and local Government strategy for its particular brand of localism. They have developed their theoretical standpoint and want to, and in some cases have (Ventnor on the Isle of Wight being such a case), move to a conceptual framework for working with communities.
The executives of NHS England describe community participation as a tenet; this comes directly from the World Health Organisation (WHO). They have taken the idea of democracy to create its own model around ‘giving people a voice’ and empowering individuals and communities making it an issue of choice and control over their own lives. This notion is based on people having to decide to do this because there will be no other provision if they do not. In other words fending for oneselves without the responsibility of Government and an NHS to society. This can only be seen as a formula for eventual abrogation.
In this way they point to the need for a new wave of public health based on the active participation of the population as a whole. In this fashion they speak of working together but in reality it says that people at the bottom solve the problem by freedom of the individual and only then if it becomes private and profitable.
They give reasons why the current situation needs to change and primarily these are assets within communities. Outreach is the issue moving away from the NHS centre and out there where it matters. The lonely people can support themselves because they are in the same boat despite mortality and morbidity and only you can intervene to ensure survival at the local level not help from above and you should take responsibility to manage and tailor your own solutions. The new local government and clinical commissioning groups now have the freedom to sanction such moves.
In the current period of austerity, the Wanless review’s conclusion is that high levels of public engagement are needed in order to keep people well and manage rising demand.
All communities have assets. Apart from private businesses they include local groups and organisations. These are the building blocks. There is a growing interest in the UK in asset-based approaches that identify and mobilise the assets of individuals, communities and organisations to enhance individual and community capabilities.
Resilience and evidence are linked to self-preservation under adversity. They say that it frees people to work together to shape their decisions that influence their lives, giving people ‘self-esteem’, ‘self-efficacy’ and solve all of the problems themselves without relying on the state. The notion of freedom being the neo-liberal idea.
Volunteering is said to be a form of participation and an important part of the social fabric in England. Levels are high, The Citizenship survey for 2012-13, shows that 49% volunteered either formally through clubs and organisations or informally assisting friends and neighbours once a month. 72% of people volunteer once a year. In the health and social care sector in England, the King’s Fund estimates that around three million people currently volunteer, compared to an NHS paid workforce of 1.4 million.
These people in this report, Community-Centred Health and well-being, say that participation in volunteering actually itself gives better health, gives satisfaction and decreases depression so citizens should do it more. It is acting upon peoples’ pro-social nature and sentiment towards giving back to the community. They say that even if there are still important roles for local government and the NHS, It is out of the remit of formal public health programmes, the NHS proper, what makes us healthy.
The Marmot strategic Review recommended that public and third sectors adopt new roles where individuals take control. The ‘Think Local Act Personal’ partnership, shows exactly where its interests lie. It brings together an emphasis on community self help with co-production of services to support the further personalisation (individualisation) of health and social care.
The focus is on practical, evidence-based models that local government; NHS and third sector can use to work with communities to achieve health goals. Time banking is a volunteer model that involves both community capacity building and access to community resources. Time banking is a specific community capacity and social networks based on the assets and time that people can share as volunteers. It involves reciprocity where people exchange services and labour time. It is based on the idea of ‘time credits’ to meet social or health needs. Labour time is homogenised where added value is not skill differentiated but the price replaces money exchange by labour time expended. The reciprocity leads to a growth of social capital.
Health trainers and champions make up an important part of the wider public health workforce in England. Community health champions, themselves, are volunteers. The Big Lottery Well-Being programme supports a range of portfolios and volunteers.
It is becoming clear how the community health is looking towards the US model of health car. Some US lay advisor models have specific ‘inreach’ elements to ensure community experiences are fed into planning more equitable services.
It promotes volunteering as a pathway to education, employment or other roles.
Partnerships involve working with communities to improve planning, service design and delivery. It goes on community-professional partnerships. Community academic researchers have looked at European case studies, California and Sao Paulo.
Participatory budgeting is a devolved form of decision-making, usually place based groups and service providers coming together to decide allocation of resources. Total Place Pilots, Whole Place Community Budgets and Neighbourhood Community Budgets are all initiatives. In 2014, the British Academy recommended using participatory budgeting to increase mental capital in communities.
To gain access to community resources it requires tapping into the assets of voluntary and community organisations, which already exist. Even food banks and resistive welfare advice in primary care, is considered fair game. Community referral will take place signposting and connecting to local organisations. Befriending organisations is a way in with staff with knowledge of local organisations tapping in or engaging. Community hubs layer health into an existing community resource, such as faith settings (Churches, mosques and temples) or libraries. Community based commissioning is a move to partner and tap into knowledge of the third sector.
It is now seen as vital that local government and the NHS obtain economic and social value from the services that are commissioned and delivered. Traditional ways of looking at value have tended to ignore what people and communities can bring to services. Community involvement and volunteering are not free. Training, volunteer co-ordination, project management, set-up costs and expenses are seen as legitimate costs. A proportion of volunteers become employed and paid. It saves the public purse. In 2011 figures, the Cabinet Office calculated the monetary value to the well being of the volunteers as £13,500 per person per year.
The London School of Economics undertook an economic analysis of community capacity building using three interventions: time banking, community navigators and befriending. All three were found to deliver a net economic benefit when costs and value were calculated. For example, time banking had an estimated net value of £667 per person per year, extending to £1312 if improvements in quality of life were included in the analysis. This goes a way to explaining the transferable value as a proportion of added value in the equation.
A return of £2.16 for each pound invested and the value of volunteers running activities was almost £6 to a pound invested to employ a community development worker. York Economics consortium found a positive return on investment from £0.78p to £111 per pound invested. This capital growth provides a nice little earner resource available for future full blown selling off and privatisation later.
Community capacity building and volunteering, potentially offer a significant return on investment. Variability in the economic value and potential exploitation will have to contend with poor retention, high turnover and low levels of community ownership later. Low uptake would force up costs so financial incentives will most likely be required with people also not given much choice but to participate through some kind of workfare or pressured labour to support the engagement needed.
Initially though, it will have to, and is, exploring options for commissioning that do not require any ‘forced labour’. It takes on board the need to build the community/volunteer workforce as agents of change. It also should celebrate, support and develop both formal and informal volunteering as the bedrock of community action. Increase capacity, provide some initial grants and training and of course there must be some essential ‘marketing’.
The family of community-centred approaches was developed as part of the ‘Working with communities: empowerment, evidence and learning’ project. It has been adopted as the neo-liberal basis of change towards an American based health system right at the heart of the NHS England.
A scope review was undertaken by Leeds Beckett University and a major review of community engagement and inequalities led by the Institute of Education. An initial ‘family’ was developed around four basic strands. Three closely based on theories for change and a fourth added on connections with community resources, broadened to look at UK practice in place already.
Stakeholders have tested at national level but particularly in Nottingham where discussions took place and a workshop in Manchester at the festival of public health.
It has since been adopted as policy.
The Report source:
Community-Centred Health and Well-Being
2015, [PHE publications gateway number: 2014711]