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Shaping Places for Healthier Lives

Written by Jessie Johnson and Laura Malan.

The wider determinants of health are largely shaped by the social, economic, commercial and environmental conditions in which people live. These factors are diverse and interrelated, forming what’s known as a ‘complex system’ that shapes the health and wellbeing of people in a place. New approaches are needed to shape these systems in ways that promote good health for the whole population and reduce health inequalities. This is apparent now, more than ever.

There are stark differences in health outcomes across the UK — with a gap of almost 19 years in healthy life expectancy between the most and least deprived areas in England. Inequalities in power, money and resources at local and national levels can make people’s daily lives more challenging. Unless action is taken, the health inequalities that exist between the richest and poorest communities across the UK are set to widen.

The Health Foundation and Local Government Association are working in partnership to explore how coordinated system-wide action across the wider determinants of health can shape a place to help people to live healthier lives. The Shaping Places for Healthier Lives programme will support five projects to make sustainable changes within their local systems. These changes aim to improve population health and will be designed to have impact beyond the lifetime of the programme. The focus will be on promoting good health, building cross-sector partnerships and strengthening new ways of working across the system.

We are currently working with 32 council-led local partnerships that have been shortlisted as part of an open call for applications. Their projects focus on a wide range of themes. These include mental health, poverty, green space, and community connectedness and safety; as well as key determinants of health at different stages of life, including school readiness and childhood obesity, employment, and healthy ageing. What they have in common, is a uniquely broad perspective across the many diverse and interrelated factors that influence their chosen themes.

Taking a systemic design approach

Teams will use a collaborative approach to develop proposals that outline innovative and sustainable actions that shift the system in ways that promote better health of the local population.

At its heart systems thinking acknowledges that we all have a role to play in the world we live in and the world we want to shape whether in our personal or professional lives. As our Chief Design Officer outlines in her blog about systemic design “systems can be biological (a forest), social (a neighbourhood), organisational (the health system) or technological (a computer system).” At a very high level, systems are made up of different parts that are connected around a common challenge or goal.

Systems thinking embraces the complexity of societal challenges. Recognising that there are lots of different elements at play that need to be addressed in order to create positive change. Some of these include:

● Cause and effect: Digging into the root causes of issues to fully understand problems

● Micro and macro causes: Understanding individual experiences as well as seeing the wider context you are working within

● Stakeholder and community engagement: Working with others across the system to create value

● Seeing how things are connected: While being mindful of unintended consequences

● Creating a shared vision: Supporting and connecting work happening across the system.

While the programme was paused during the height of the COVID-19 pandemic, towards the end of July we brought together over 20 councils and their project teams to share experiences and learning from the pandemic over the previous few months.

When thinking about systems it is important to start with oneself, taking time to reflect on your own role within the system and from there, begin to build relationships with others to see how your experiences and motivations connect. Mapping the experiences with the councils and their partners, and wider changes they’ve noticed, has given valuable insight into the common challenges faced, as well as opportunities. These might also be relevant to others working in local government or public health.

Some of the personal emotional experiences — highs and lows — over the last few months

The pandemic has highlighted how now more than ever, taking a systemic approach to improving the health and wellbeing of our communities is key if we are to affect long-term change.

Here we summarise some of the challenge and opportunities that have been highlighted over the past few months:

Challenges

During the COVID-19 pandemic, health inequalities have been front and centre, with some communities disproportionately affected by the pandemic and the measures put in place to control the spread of the virus. There have been huge increases in support needs across communities, exacerbating existing inequalities and leaving new groups vulnerable.

“I was struck by the extent of vulnerability of communities. Much more than I would have expected…”

There were challenges in interpreting national guidance and maintaining clear messages to the public, and pressure from the huge increase in mental health challenges. This included increases in social isolation among the most vulnerable, new challenges for people shielding as well as concerns about people falling through the gaps or being ‘hidden’ when not accessing services.

“Many of our vulnerable people now fear or have concerns around getting outside again”

“How do we better reach out to under-represented groups (low income, Black, Asian and minority ethnic communities)…?”

Others experienced tension surrounding use of local green space — some people had less access to the natural environment during lockdown.

Some of the challenges teams noticed over the past few months. Those highlighted red represent the most commonly mentioned challenges while those in pink were noted less frequently.

Whilst some feared accessing in-person services; there was also tension in how to make sure that once those services shifted to be delivered digitally, they still reached those who weren’t online.

“How could we best support more vulnerable individuals without access to digital resources etc?”

As well as expected challenges around adapting existing work practices and working remotely; teams faced redundancies, projects being put on hold, which in some cases resulted in financial pressure. While balancing business as usual with crisis management and working in fast paced ways — “sometimes with a snip of chaos”, avoiding duplication became difficult.

“Some of our partners e.g. the police & NHS are totally consumed with COVID-19 response so can’t engage at the moment.”

Many were struggling to balance their preventative work versus the crisis work streams or getting partners to see the long term when “all their consciousness is focused on emergency responses”.

“Short-termism in decision making in some areas. Maybe a less proactive mindset?”

Partners’ priorities or capacity changed, or providers were furloughed which meant that the commissioning of services was challenging. Some experienced difficulties such as having vital commissioning work paused or having to stop face-to-face services and pivot to remote ways of working.

“Commissioning has been difficult; the pandemic is changing all the time. In terms of commissioning services. What do they look like? What are the transitions?”

Opportunities

Despite these challenges teams recognised that the increased focus on health inequalities has placed a much needed emphasis on tackling health inequalities now and in the future “It’s raised profile of public health x2”.

Emergency measures from the pandemic have sparked debate about what’s needed in the long term for everyone to lead long and healthy lives including increased media interest and awareness around the role of public health more broadly. Highlighting the huge inequalities that impact health has renewed the focus on addressing them.

“There’s been more media interest in what we already know, about the wider determinants of health. This will hopefully spill into our work…”

Some of the opportunities faced by teams over the last few months. Those highlighted turquoise represent the most commonly mentioned opportunities while those in purple were noted less frequently.

It also shone a light on marginalised communities and groups who have been hit hardest by the pandemic. Some found that it allowed them to gather a better picture of vulnerable families and individuals and how best to support them.

“It has brought to light existing inequalities, something that we have been trying to raise for years e.g. inequalities in our Black, Asian and minority ethnic communities…”

“It’s led to unexpected better understanding of social isolation and impacts and what we need to do”

Teams have noticed their communities valuing each other more. The increase in community activity has helped to demonstrate to everyone that “there are people who care”. They’ve built stronger connections with the Mutual Aid and other community groups and new people have become involved in community engagement work. It also highlighted the vital role that key workers play to “keep the country going”.

“Social connection and cohesion — some people are getting to know their neighbours and volunteering in their local community for the first time”

They’ve seen increases in walking, cycling and in people visiting green spaces, especially by those who don’t usually access these spaces as well as a greater understanding of the role nature plays in our health. Simultaneously there’s been a recognition that those living in deprived areas and those from Black, Asian and minority ethnic backgrounds often have less access to green spaces. There are signs of partners being more open to suggestions for new innovations and ideas or people introducing their own ideas around use of green space. The pandemic has created more visibility around the digital divide, pathing the way for new online and offline ways of sharing.

“We’ve seen people running their own activities in parks when we had planned to commission them…!”

“We’ve seen great participation by the community on digital programmes for example virtual stop smoking sessions!”

The teams have made new connections and partnerships and have seen better relationships through working with a wider set of colleagues across local authorities, voluntary, social enterprise and other sectors. Some have noticed that the trust in local councils has increased, or that it’s been a time for council staff to step up and develop new skills and practices.

“We had good partnerships before but across public health these have been enhanced — we’re working with Black, Asian and minority ethnic communities more systematically — Mosques, care homes and voluntary and community sector organisations…”

Other teams shared positive moments and stories like local food support on offer for vulnerable families, local housing associations distributing sewing machines to local residents, Mosques supporting international students and projects encouraging people to cook from scratch and grow their own food.

“We set up a mental health task group which has developed and reacted quickly to covid e.g. and produced grief and bereavement guides, partnerships etc.”

“It revealed the hidden strengths in our voluntary, community and social enterprise sector. Our first challenge was Personal Protective Equipment (PPE) in the wrong places; but our veterans community stepped up (they’re good at logistics, can drive, follow the rules!). They drove 100s of miles picking up PPE from dentists and vets to GPs”

There’s been an overwhelming experience of people working more collaboratively together, removing boundaries quickly, and more solution focused partnership working. Decisions have had to be made quicker and there’s been an ability to get stuff up and running in ‘double quick time’.

“The public sector learned it CAN work quickly and innovatively — there’s risk appetite!”

“Commissioning — it has moved conversations that were initially in that ‘too hard to move box’ It has pushed us to think about taking a whole life approach to opportunities”

The pandemic has dramatically highlighted the importance of systemic approaches and the capability of the system to collaborate around a shared vision. It shifted the focus to more partnership working and the recognition that we need collective efforts in order to tackle systemic challenges — health inequalities and others — and showed the potential for creative thinking in addressing these.

“We need to stop thinking ‘we’ need to facilitate the solutions, and think more about the collective ‘WE’ and how we support communities to do it for themselves by resourcing it better”

“There’s a huge amount of creativity across the systems, people thinking outside the box. We need to embrace it”

As a programme we’re continuing to reflect and capture our learnings, and we’ll be sharing more as the programme progresses. For more information please visit www.local.gov.uk/shaping-places-healthier-lives or sign up to our mailing list.

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Jessie Johnson

Jessie Johnson

Programme manager at Design Council. Passionate about scaling design and innovation across the public sector.

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