How do you hone your approach to tackling big health challenges? Test with others
Walk between two streets in Lambeth or Southwark and you’re liable to pass between two different worlds. The same is true of many, if not most, inner-city environments.
These worlds differ in housing, employment and wealth. And while the causes of these differences are complex, the consequences are clear. If you live in an urban and deprived area you are more likely to have poorer health, lower life expectancy and a greater proportion of your life lived unwell.
This, for Guy’s and St Thomas’ Charity, is our motivating factor. How can we better understand the health inequalities of urban, deprived and diverse areas? And more than that, how do we reduce them — not just in London, but beyond?
A ten-year journey
Earlier this year, we set out in a new and exciting direction. Our strategy, broadly, is to focus on deeper understanding of complex urban health challenges; to layer up interventions tackling these issues; and over time to share what we learn with other similar cities.
And while we’re only at the start of this journey, we thought it might be of interest to share some of what we’ve learnt so far and what we’re up to next.
The first of our learnings — which I wrote about in March — is that when dealing with urban health issues, context matters. Health improvements have a better chance of succeeding when rooted in a richer understanding of people’s lives: from the streets they avoid, to the shops they buy from, to the local services they use or ignore because of who ‘they feel they are for’.
The second — which we wrote about in June — is that work is needed to fill out the evidence base on urban health. While we know the effectiveness of some things, there are still major gaps in understanding. Our work needs to be both evidence-led and evidence creating as there isn’t a simple playbook to draw from.
The third — which is the subject of this post — is that successful approaches need to embrace complexity. The major health challenges of urban environments are emergent, in that they can’t be explained by one thing; and adaptive, in that they often interact in unpredictable ways. As a result, they need to be approached as a system, with interventions coordinated, tested and adapted.
To get going, we’ve focused on two complex urban health issues — childhood obesity and multiple long-term conditions — and spent the year working with academic experts, civic society, the statutory sector and businesses to identify how best to proceed.
On childhood obesity, this has led us towards targeting the environments children pass through (home, school and streets) and the behaviours — both eating and activity-related — that can lead to healthier lives.
On multiple long-term conditions, a much less understood issue, this has focused our energies towards identifying those most at risk of developing several chronic conditions, and intervening early to slow down progression.
Of course, on complex issues the bottom is often deeper than you think, and we still have much to learn on both areas. That said, there are common themes across the two.
One is that they cut across many aspects of life — health issues that are clearly broader than healthcare. Another is the considerable impact of scarcity on healthy decision-making, and the need for the right thing to be the easy thing to do. A third is that it is often the same families that are affected by both health issues. Indeed, for a Charity like ours, is a childhood obesity programme just an upstream approach to a long-term conditions one?
Learning through doing
We are now in a development phase, where we are testing out smaller elements of our planned programmes. We’re doing this both to check how evidence from elsewhere plays out in practice and to get some first-hand experience of a new way of working for the Charity.
For example, we’re testing the value of combining initiatives in Faraday, an area in Southwark that has high rates of childhood obesity. Here, we’ve partnered with small organisations like Alexandra Rose (who provide vouchers that young families can spend on fruit and vegetables) and Bags of Taste (a local charity than runs cooking classes for those on very low budgets), as well as larger ones like Sustrans (a national body who promote activity through building cycle lanes). We plan to learn from the process of setting up this collective effort for how best to replicate the model elsewhere.
We’re also testing different models of engaging communities. For example, in Lambeth one in six residents speaks Portuguese. This community has high rates of diabetes and other chronic conditions. As a result, we’ve been working with local GP surgery The Grantham Practice and a coalition of community leaders in the area to identify how best to engage this group — including through embedding health workers in community events. We plan to learn from this for how we engage with other cultural ethnic groups across our two boroughs.
A final illustration is using rapid prototyping to see what works. For example, while we know that physical space affects eating and activity decisions, evidence around what actually has an impact — especially in urban environments — is limited. So we’ve partnered with the Behaviourial Insights Team to test different behavioural nudges in a local home, school and retail setting. We plan to use evidence from these experiments to influence the design of our future programme.
Moving to delivering
Hopefully through all of this, you can see a pattern emerging to our work — one motivated by reducing health inequalities, focusing on urban health, and intent on sharing what we learn. The pattern is a systems-approach to our activities, embracing context, uncertainty and complexity; with the Charity actively identifying what we think will lead to success; and working through partnerships to achieve this, testing and reframing as we go.
Next year we plan to share early details of the shape of our long-term programmes. If you’re motivated by the work we are doing, and believe you can add to it in a meaningful way, then do please get in touch.