How can the contribution of small community-led agencies and associations be recognised and maximised in the new local systems of health and care?
This was part of a series of events to explore what can be done to reduce health inequalities and improve social care, in our communities, and nationwide.
Lara Rufus-Fayemi, our thought leader on the theme of ‘joining forces’, opened the discussion by pointing out that many organisations claim that they bring about positive social change, but the truth is that most social change is complex and challenging and cannot be achieved by a single organisation on its own. We need to build a practice that goes beyond organisational self-interest, she said, combining with others to make a real and enduring impact.
She gave the example of Tower Hamlets Together, a coalition of statutory and voluntary organisations in East London, which is setting up a new health inequalities fund, aiming to bring about a culture change with a focus on preventative activity by voluntary and community organisations able to operate on the ground, with better integration into the wider system.
Anne Bowers, Newham Council’s strategic lead on community engagement in public health, then spoke about the critical importance of continuing to build mutually respectful and open partnerships and relationships, of the kind that happened early in the Covid pandemic. The pressures we now face, with cost of living for example, are unequally distributed, and are already creating challenges for health outcomes.
To address the ‘social determinants of health’ we need to support communities, which we are all part of, to be health-promoting and health-enabling. And when people are not healthy, they need services which are accessible, relevant and trusted. For all this to happen, the relationships with voluntary organisations and with community associations are critical, she believes.
In some cases, where the voluntary sector organisations really understand the problems and hold the relationships, e.g. with people with no recourse to public funds, the council needs to respect this, and its role may be convene and to channel resources, and advocate for policy or practice change, but not to try to control everything itself.
Anne gave an example of commissioning some insight-gathering via a local organisation, which works with new mothers from Black and Asian backgrounds. Here the council has taken care not to be prescriptive about the method or set targets for number and types of people to be contacted. All this has been left to the organisation, on the basis that they know best how to approach the task, they are best placed to cultivate the relationships that are needed to produce the real insights.
Anne explained that the council’s overall aim is to encourage, enable and enhance ways in which residents can take action to promote their health. Methods include small grants and a participatory budgeting programme. The council is also able to use its convening power, bringing people together, understanding that in doing so it can’t always predict what will happen. It is reviewing its strategy, including how best to build internal and external capacity, and how to establish shared governance and oversight, and make it possible to better assess whether the various activities are achieving the outcomes which are collectively wanted.
When is enough, enough? she asked. Statutory services, more and more, are relying on community champions, those able to convince others in their communities of the value of a particular health intervention, e.g. the Covid vaccine. But the failure to engage lies with the statutory system. Are we putting our problem on other people to solve? It is implicit in the language we use, she suggested, that it’s the responsibility of communities to keep themselves healthy, or heal themselves, yet often the responsibility truly lies with decisions taken in the statutory system, often at national level. It's hard to create partnerships and trusted relationships when people feel that a huge burden of responsibility has been placed, unfairly, on them.
Sometimes the council needs to share a problem, in an open way. For example, cost of living and access to food is a shared problem, which belongs to everyone in a community. The council has some capabilities, but so too do communities and community groups. We need to let go of the idea that the council is fully responsible for the solution, and act on the basis of shared responsibility and mutual respect.
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Here are some of the points that emerged from the subsequent breakout and plenary discussion:
Many of the policy statements from the NHS and local councils are excellent, it was felt. But practice is lagging far behind.
Budgets are not being devolved in a significant way. Attempts to do things differently, for example through social prescribing, are undermined by under-investment in community organisations.
Where there is funding for small community organisations and associations, a much lighter-touch approach is needed from statutory agencies and large charities. There are good examples of this, e.g. in place-based work in Cambridgeshire.
People are tired of being asked for their expertise with no financial recompense – ‘we are not here to service large organisations and make them look good,’ one said. But we know it is possible to work with people in a more positive way. We heard about a university/voluntary sector collaboration in Bristol, where a research project is using arts and community development methods to establish a respectful, not exploitative set of relationships with people from a local community.
If the formal institutions want to engage well with people in their communities they need to establish a reciprocal relationship, with reward and recognition - offering something of value in the here and now: money, or support, or a change of practice.
Fundamentally, we need to shift the perspective that the leadership that’s is needed to bring about a more healthy society comes from above, ‘it can come from all around you’ as someone pointed out.