A review of the role of community in health and social care policy
The answer is community. What’s the question?
Kate Linsky from the National Development Team for Inclusion (NDTi) reflects on the work she has undertaken on behalf of TLAP to trace how the role of ‘community’ in shaping policy, legislation and practice in health and social care has grown in recent years. Whilst they have different origins, there is a great deal of commonality. There is a good case for consolidating some of the thinking and practice in this area into the development of the Asset-Based Area, which has been advanced by TLAP.
In response to the “tumultuous year of 2020’, the makers of Monopoly are updating all their Community Chest cards for the first time in over 85 years. Winning beauty contests and paying life insurance are out. Instead, there are rewards for spending time with an elderly neighbour and volunteering as well as penalties for not shopping locally. According to Hasbro, the changes reflect the fact that “community has taken on a whole new meaning”.
This article explores the gathering policy interest in the role of communities in care and health. For many, TLAP and NDTi included, communities have always been a central source of support to the health and wellbeing of local populations. People who live and/or work there have the skills, knowledge, connections and potential to help themselves and others live a good life. There is mutual gain. The relationship is not transactional. It is not about giving and receiving, purchasing and providing but the benefits to all of taking part.
Communities have always been a central source of support to the health and wellbeing of local populations. People who live and/or work there have the skills, knowledge, connections and potential to help themselves and others live a good life.Community approaches
A growing number of local authorities have already followed principles of community involvement and are looking to find ways of sharing power and decision making with local people and groups. Somerset, Wigan and Thurrock have adopted place-based approaches by working with their communities and collaborating with their many and varied partners, as highlighted in Reimagining Social Care.
Over the past decade Community Catalysts work has worked with a growing number of councils to help people use their talents to start and run small enterprises and community businesses that support and care for other local people, helping them to stay connected with and contributing to their community, as well as creating local jobs.
Similarly, around 30 statutory organisations across England, Scotland and Wales are part of the NDTi’s Community Led Support programme, which explores difference ways of working to maximise the strengths and community connections of people in local areas.
The experience of Covid-19 has only accelerated this trend, with many more councils having a closer connection with the communities they serve and a much better understanding of assets and needs at a neighbourhood level. Examples of these approaches are documented in TLAP’s recently published report, The 3 R’s of social care reform.
The White Paper on working together to improve health and social care for all sets out the legislative intention for a Health and Social Care Bill. It builds on work already taking place across the country, and also draws on the different ways of working that took place at pace to tackle the issues presented by Covid-19.
The reduction in bureaucracy and use of innovation seen across the country are cited as guiding examples of the clear need for health and social care to continue to work better together with the placing of Integrated Care Systems on a statutory footing seen as an integral to achieving this ambition.
The White Paper also touches on the role of Health and Wellbeing Boards in achieving this aim, not just between health and social care partners, but also other relevant statutory and non-statutory organisations. Many will be hopeful that the Boards are given executive powers for decision-making rather than remain partnership forums, with variable performance and effectiveness. Regardless of that outcome, as the Boards are based on local authority footprints, they will be key in supporting the development of locally rooted community based approaches to care and health.
This ‘place based’ approach will be especially important in areas where the Integrated Care System covers several local authority boundaries. As well as setting a clear direction for the role of place and neighbourhood, the White Paper establishes a reciprocal duty to collaborate.
Back to the future
The Care Act set the direction of travel for social care in 2014, when it provided statutory guidance on the “wellbeing principle” that formed the new core of adult care and support; designed to help people achieve the outcomes that mattered to them. Promoting universal wellbeing, with work, education, training or recreation and an individual’s contribution to society taken into account, meant working together with local community-based partners. Co-production was regarded as vital and needed to be considered at every stage of the commissioning process – as was mapping community assets. When needed, personalised care would deliver more bespoke solutions that fit the needs and interests of the person, beyond meeting basic needs only, through support that helps keep the person connected and taking part in their communities for as long as possible. The vision and ambition is as relevant today as ever.
The role of the community in supporting health and wellbeing as well as care and support is not just the province of social care. Public Health England has advocated the need for place-based approaches to reduce health inequalities in the framework they have developed, “Community-centred public health: taking a whole system approach” (Pg 4) This quote from the framework makes the point crystal clear.
“Community life, the places where people live, and having social connections and a voice in local decisions, are all factors that make a vital contribution to health and wellbeing and help buffer against disease…. Evidence supports the case for a shift to more person and community-centred approaches to health and wellbeing”.
The diagram summarises the approaches Public Health England believe are needed to achieve a whole system approach, based on 11 elements.
It’s good to see co-production there as one of the key principles required to deliver change in communities. It’s difficult to see how change can be delivered without it.
The NHS Long Term Plan (Jan 2019) and the subsequent implementation framework do not explicitly focus on co-production as a driver for change, instead relying on patient and public involvement, which often feels a much lower rung on TLAP’s ladder of co-production. That said, the NHS Long Term Plan’s priority area of personalised care relies on being able to increase a person’s choice and control over the care they receive.
One of the major changes within the plan is the NHS Universal Personalised Care: Implementing the Comprehensive Model (Jan 2019). Social prescribing, personalised care and support planning and personal health budgets are key vehicles for widening and diversifying the support options available. The intention is that they will be increasingly funded and supported by local partnerships enabled through Primary Care Networks and at neighbourhood level. The Primary Care
Networks, covering populations of between 250,000 and 500,000 people, and ‘Neighbourhoods’ of between 30,000 to 50,000 population are seen by the NHS as key geographies for developing local approaches to health and care that can draw on the ‘assets’ of their communities.
The personalised care model recognises the contribution of communities and the voluntary, community and social enterprise sector (VCSE) in supporting people and to help build resilience. As is the value of mapping communities and their assets, including the identification of gaps. Link workers are recommended to connect people into community-based support, building on what matters to individuals and making the most of community and informal support, including peer support.
The ultimate success of this personalised agenda, widespread through current NHS policy directives, will rely on the availability and access to ‘assets’ within the local community, alongside collaborative commissioning with partners, to include those with lived experience. These are relationships that will need to be nurtured rather than simply purchased.
The expectation of collaboration across health and social care commissioners and providers is a key strand of the Mental Health Community Framework (CMHF) for Adults and Older Adults (Sept 2019), as is the need to build effective links with community assets, such as libraries, leisure, social activities and faith groups, employment, education and training services. The framework suggests using social prescribing to act as community connectors to support and enable more people to become more embedded in their community, and to use these assets to support their mental health. Again, the role of Primary Care Networks is set out, working alongside local authorities, VCSE and people with lived experience and their carers.
How to pass Go
TLAP’s paper, the Asset Based Area (2018), set out ten steps that every area can take to find and value the skills, knowledge, caring capacity and potential within the community. Achieving an Asset-Based Area rests on co-production, adopting a strategic approach to wellbeing and diversifying the workforce to grow more person centred forms of support at the local level.
The ten steps redress the balance between meeting needs and nurturing strengths. The framework has been updated to include a description of the behaviours needed between people, workers and volunteers in order to make further progress.
The origins and focus of the different policies described in this article differ, but they do share the common thread that support should be provided in or close to where people live. They also promote the view that communities, with all they have to offer, can be a key source for providing that support and improving the health and wellbeing of local people. It may be helpful therefore, for those working in the field, to draw together and align these policies when developing the idea and practice of the Asset Based Area.
In summary, policy and guidance across health and social care is pointing towards the role of the community. In recovering from Covid-19 and building on the surge of community response, surely now is the time for statutory organisations to follow Monopoly’s lead and take a closer look at what’s in their own local Community Chests?