Health as a Social movement: Theory into practice

The Health as a Social Movement project attempts to learn from the power of people working together to drive transformational change. This report takes as its starting point a double premise; the well-understood challenges to people’s wellbeing and to the care system that aims to support them, alongside a recognition that seeds of solutions are already out there in our communities.

By Sarah Arnold, Anna Coote, Tom Harrison, Emily Scurrah and Lucie Stephens

Foreword

The project is an attempt to flesh out what it means to focus on the role of communities and individuals, which is fundamental to the strategic direction of the NHS outlined in the Five Year Forward View. It looks at what we can do to move away from the ‘factory’ model of care to build a sustainable future based on a more personalised approach. It is an approach that recognises the aspirations and energy of individuals and shows the power that arises from people who are more connected with their wider communities.

The report makes clear that we cannot expect services to be solely responsible for the state of the nation’s health and acknowledges that it is counter-intuitive for institutions and systems to be leading social movements. And yet, the results of this report demonstrate that large organisations can be a catalyst for change if they build on the strengths and energy that are already there in a community.

This project does not offer a new revelation. It is part of a long history of community development, citizen participation and person-centred health and care. Neither does it offer a one-size fits all solution. It recognises that different activities work in different places, and aims to identify the common features which can send change rippling out across communities. The work builds on wider transformation taking place on the ground in six areas of England, and we are grateful to all who have participated in the work over the last three years, and in particular to the people in those areas who have participated.

The work reflected here stands as a testament to the energy of people both inside and outside the walls of our large organisations who are passionate about making life better for themselves, their families and their neighbours in community.

Nicola Kay

Deputy Director of Policy and Strategy

Personalised Care Group, NHS England

Nicola Kay is NHS England’s Deputy Director for Personalised Care Policy and Strategy. In this role, she develops and leads the approach to scaling up and mainstreaming personalised care, including embedding the relevant IT infrastructure, developing necessary skills across the NHS, identifying new legislative rights and strategic stakeholder engagement. She leads a team which work closely with local areas to embed new opportunities for personalised care (eg in areas such as substance misuse and neurodisability). Her team also includes a range of people who bring their own lived experience to the team’s work.
Prior to joining NHS England in 2016, Nicola worked for 10 years as a civil servant in a range of central government policy, strategy and finance roles. She led on health and social care spending at HM Treasury, including the commissioning reforms in the 2012 Health and Social Care Act, the Dilnot Commission and the 2010 Spending Review.

The Health as a Social Movement programme was commissioned by NHS England.

About the authors

Sarah Arnold, Researcher, the New Economics Foundation. Sarah is a researcher with a strong background in quantitative data analysis and econometrics. Her particular areas of interest are health inequalities and the social determinants of health. She is currently working on several projects to research the role of community action in the health system. She is an accredited SROI (Social Return on Investment) practitioner and expert in developing social value frameworks and other cost benefit methodologies.

Anna Coote, Principal Fellow, the New Economics Foundation. Anna is a leading analyst, writer and advocate in the field of social policy, she was Commissioner for Health with the UK Sustainable Development Commission from 2000–2009. She was Director of Health Policy at the King’s Fund from 1998–2004 before joining the Healthcare Commission to lead their work on engaging patients and the public (2005–8). She has written widely on sustainable development, public health policy, public involvement and democratic dialogue, gender and equality.

Tom Harrison, Public Services and Communities, the RSA. Tom’s research interests include mental health, health and social care devolution and service transformation. Tom coordinates the RSA’s contribution to the Health as a Social Movement programme and blogs regularly about the project. Prior to joining the RSA, Tom was Welfare Officer at Sheffield Students’ Union.

Emily Scurrah, has a background in campaigning, community work and qualitative and ethnographic research. She is currently working on a number of community-based health projects, giving practical and logistical support as well as supporting on research and evaluation.

Lucie Stephens, Head of Co-production, the New Economics Foundation.
Co-production is a way of working that brings together people’s lived experiences with professionals to design and deliver better services. This involves working with citizens, people using public services, service professionals, commissioners and policy makers.

This Programme Report culminates a two year partnership with NHS England, the New Economics Foundation and The Royal Society for the encouragement of Arts, Manufactures and Commerce (The RSA). This report was written by the New Economics Foundation and edited by the Health as a Social Movement team at The RSA.

Introduction

We hope to encourage and support citizens and workers engaged in health and care across the country — from local community-based organisations and local public services, to clinical commissioning groups (CCGs) and all those trying to transform the health and care system so that it is able to meet current and future needs.

The social and economic context which public and community services are operating in has often been described as the ‘perfect storm’; where higher demand and reduced resources frustrate attempts to support the prevention of ill-health and the encouragement of good health. Communities are mobilising across England to improve experiences of health and care services and the wellbeing of others through many different kinds of local action.

To celebrate and support this, the Health as a Social Movement (HASM) programme has worked in partnership with six vanguard sites across the country to:

• Understand and explore their aims and concerns about health and care in their area
• Encourage people to value and build on their assets and experience
• Enable people to get together, help each other, build knowledge, and develop a shared purpose
• Work out together what can support the improvement of the health and wellbeing of people living in their areas
• Build momentum for change in health and care, learning as we go

Alongside the sites, we are working to achieve the following changes:

• People take more control over health and care services
• People are better able help themselves and others to stay well and get ill less often and for shorter periods of time
• Communities build their capacity to meet health and care needs
• More people are able to lead good lives
• There is less acute demand for NHS and other services for avoidable treatment and care

The six vanguard sites all have taken up the opportunity to achieve transformational change in their communities differently. However, the sites have all demonstrated that different actions build on each other, so that momentum for change can keep growing and spreading over time.

In conjunction with a final paper containing the evaluations of the sites and recommendations for the health and care system published by the New Economics Foundation, this report looks at what has happened in practice across the sites, what local groups did and how their activities are continuing to help make change.

• We start by summarising briefly the why and the how of making these changes: what’s wrong with the way things are now, and what needs to be done differently?
• We then offer a picture of what success looks like, to help take stock of progress so far and guide future activities
• We describe what’s happening in six communities and draw on their experiences to show how they are trying to make change

This way, we hope to encourage and support citizens and workers engaged in health and care across the country — from local community based organisations and local public services, to clinical commissioning groups (CCGs) and all those trying to transform the health and care system so that it is able to meet current and future needs.

This report is aimed at helping people that are committed to improving health and care to take forward the principles that we have found underpin successful relationships with communities into their work.

Why make change?

We must shift away from the old ‘factory’ model of care and repair, towards a people-centred approach, rooted in communities, enriched by local knowledge and experience, and focused on shared activities to promote better health for all.

The NHS Constitution begins with the statement ‘The NHS Belongs to the People’ and at its best, the NHS is ‘of the people, by the people and for the people’. That is how it’s described by Simon Stevens, chief executive of NHS England. However, as he says, ‘sometimes the health service has been prone to operating a “factory” model of care and repair, with limited engagement with the wider community, a short-sighted approach to partnerships, and underdeveloped advocacy and action on the broader influencers of health and wellbeing.’

From ‘parkrun’ to the Adverse Childhood Experiences movement and the long campaign against tobacco, the health system is getting better at understanding that throughout the history of medicine, people who take action and challenge the status-quo have been at the forefront of improvement in care and treatment. We now have a great opportunity to shift power to people, places and communities to enhance their strengths to help prevent illness and improve health.

This greater appreciation of the power of movements for health comes at a time when pressures on health and care services are mounting steadily.

People are living longer, but too few are enjoying good health in later years. Since 2012, average life expectancy has stalled. The costs of care are increasing and it is more difficult to recruit and retain staff. Prevalence of chronic physical and mental ill health, such as diabetes, depression, dementia and loneliness are at unprecedented proportions. Health inequalities — where poorer people get ill more often and live less healthy lives than richer people — are widening. Up and down the country, the differences are striking, for example in Stockton-on-Tees, men in the most deprived wards die 17 years before their counterparts in the least deprived wards. Health and care services are a vital safety net when we are ill and vulnerable. However, there is a broad consensus that assets and capacity for social action in communities are part of the solution to preventing ill health.

Moreover there is an acknowledgment that we cannot continue to expect services, of which the NHS most often captures the public imagination in this respect, to be held solely accountable for the nation’s health. A recent Health Foundation report ‘Healthy Lives for people in the UK’ underlines this concluding that less than 10 percent of what affects our health and wellbeing comes from access to health care.

Our health and wellbeing is shaped by what happens in our daily lives — how we live, grow, work and play, and our homes, families, friendships and networks. That is why we must shift away from the old factory model of care and repair, towards a people-centred approach, rooted in communities, enriched by local knowledge and experience, and focused on shared activities to promote better health for all. This is not in order to replace existing health and care services, but to knit them together with community life so that they help and reinforce each other.

The need for this kind of change is now widely recognised. NHS England has declared its ambition to build a ‘social movement’ that will ‘help shift power to patients and citizens, strengthen communities, improve health and wellbeing and — as a by-product — help mitigate rising demands on the NHS.’ There are many examples of communities working with professionals to help realise this goal. Some of which has been captured in research like ‘Improving Experience of Care through people who use services’, the ‘Realising the Value’ programme, ‘Health and Wellbeing, A Guide to Community Centred Approaches’ and ‘Promoting Asset Based Approaches for Health and Wellbeing’. This research and report adds value to this work by exploring some of the examples emerging from the context of the six vanguard sites and by identifying the underpinning success factors of health as a social movement in local contexts.

How can change be achieved?

“There is a growing confidence in the direction of travel: people in communities engaging in local action to help themselves and others to stay well.”

There are plenty of theories about what social movements are in general and what kinds of social movements are best for meeting today’s health challenges. These are discussed in papers published recently by NESTA and the RSA.

Social movements for health are not simply spreading individual behaviour change initiatives. Evidence has shown that these approaches may make health inequalities worse since those who take up behavioural changes are those most able to and who already have better health and are already higher up the socio-economic ladder.

To bring about a radical transformation in our health system, as described in the previous section, we need true and widespread change: the whole system needs to work differently. We recognise that building a social movement for health is not something different from the ideas that lie behind a great variety of small and medium-scale initiatives already underway in a wide range of communities up and down the country. Many are inspired by approaches and activities that date back several decades — part of a long history of community development, citizen participation and person-centred health and care. More recently, this kind of activity has become more widely recognised and there is a growing confidence in the direction of travel: people in communities engaging in local action to help themselves and others to stay well.

Some of it has been inspired by global movements such as Asset Based Community Development and home-grown approaches such as Community Champions. Some have a specific focus such as ‘parkrun’, while digital technologies have enabled people to connect and support each other, for example through online peer support.

Since 2015, the RSA, NESTA and the New Economics Foundation have been working with six ‘new care model vanguards’ that applied to be part of the Health as a Social Movement programme. We have been working with them to test out new approaches and with the aim to scale and spread their work across and beyond the health system. Drawing on previous publications by both NESTA and the RSA, we briefly describe:

• The different kinds of local action that are underway, both among the vanguards and more widely
• The outcomes they are most often trying to achieve
• The features of those actions that are commonly associated with positive outcomes

The important thing is that they are grounded in the assets and needs of the community where the action is taking place.

Different kinds of local action

Different kinds of local action range across a spectrum, where the balance of control shifts from professionals towards communities.

They can include formal volunteering, time credit and peer support schemes, advocacy and campaigning, co-production, community asset ownership, co-operatively owned services, community organising, and befriending and helping others.

They are often combined at local level and there need be no assumption that one kind of activity is better than another. What works in one context may not work in another, and in many contexts lots of different approaches could work. The important thing is that they are grounded in the assets and needs of the community where the action is taking place — i.e. they are led by the passions and potential of communities and professionals working together.

The outcomes

The outcomes that people are most commonly trying to achieve through these actions (directly or indirectly) are to reduce the risks of people becoming ill or stop them getting worse if they are already unwell. This is both to improve the quality of people’s lives and to reduce the costs of treating avoidable illness. They seek to build and share knowledge about health, bring people together so they can help each other inside and outside the system, and change attitudes and expectations amongst citizens and professionals.

This will ultimately enable people to adopt healthier lifestyles and support the whole system to tackle the underlying determinants of health, such as income, education, housing, diet, exercise, mobility and the quality of family and social relationships through acting in a holistic, person centred and flexible way.

So what are the features of local action that are most likely to lead to positive outcomes?

The most important distinguishing feature is that local action involves valuing and connecting into local assets and resources that are not part of the formal economy, such as lay knowledge and expertise, creativity, social networks and relationships, time and care.

Other features likely to lead to positive outcomes include:

• Actively engaging people who would not otherwise be involved

• Operating in ways that are open and inclusive

• Enabling those involved to feel a sense of ownership and control of local activities

• Encouraging a sense of shared responsibility for health and wellbeing, between residents, local voluntary and community groups, and those working in health and other public services

• Building local leadership, through individual champions and ‘anchor’ organisations

At the same time, if positive outcomes are to be sustained over time, it will be important to reach out continually to new people and groups and encourage them to participate; to keep on refreshing ideas and activities; and to respond to changing circumstances. Last but not least, an essential feature is to influence and change the way local services think and act, i.e. change the culture so that they become part.

What does success look like?

Drawing on what we have learned so far, we suggest there are eight signs of success. These would apply not only to the vanguard sites, but to all kinds of local action for better health and care. We would expect every initiative to be trying to make progress on all of these points and we show on pages 14–35 how each site is excelling in some of them.

The eight signs of success that we have identified are:

1 Acting early
Understand health holistically, addressing the wider determinants of health and tapping in to citizens’ concerns about health and care.

2 Shifting control
Enable people to have more access to, and more control over, the resources in their community that impact on health and wellbeing (including funding decisions, public buildings, local health and wellbeing strategies). Growing from

3 Bringing people together
Connect and mobilise citizens to build knowledge, help each other, develop a shared purpose and then take collective action in their communities to help each other stay well.

4 Collaborating widely
Join forces with local anchor institutions, local CVS organisations and other public services; gaining encouragement and support from the NHS.

5 Sharing power
Form partnerships between citizens and professionals, pooling different kinds of knowledge and experience to guide local action, taking a person-centred approach and co-producing action to enable people to act on their own health and wellbeing.

6 Changing culture
Work to change culture and practice within state and civil society organisations, so that they can provide effective and continuing support to citizens.

7 Growing from local
Make sure decisions and actions are rooted in local experience; address local needs and value; and build on the assets and experiences of the community.

8 Building momentum
Learn as you go and use every opportunity to spread good practice and make it sustainable.

How can public institutions work with local groups to build successful local action?

The following diagram illustrates the theory of change of the Health as a Social Movement programme.

The starting point, at the base of the diagram, is a desire to change the way health and care services are designed and delivered, so that human and social resources that are embedded in local communities are knitted together with the professional skills and public resources within existing health and care services. In a health and care context this is often motivated or initiated by personal experience and observations.

As we have seen throughout the Health as a Social Movement programme, the health and care system has a huge amount of potential to act as a catalyst, convener and enabler to bring local people and groups together, and to help them reach out and build connections. Individual champions for change are supported, and local anchor organisations often situated in the voluntary and public sector, are encouraged to come forward.

Building on the energy, commitment and creativity of local people and groups, momentum builds towards change — in the quality of local experience, in the capacity of local communities, in the way health and care issues are addressed locally, and in how professionals as well as local citizens think about health and care, relate to each other, take decisions and act.

The changes that are envisaged include increased social connectedness between individuals and groups, and increased control, resourcefulness and resilience in local communities. People become more confident that they can influence change in their lives and communities; they gain more knowledge and skills that enable them to make the changes they want, and they increasingly influence how the health and care system operates.

These changes in turn help to generate improvements in the wider determinants of health and wellbeing, and in the culture and practice of local health and care services. As momentum builds, people start to lead healthier and happier lives, and the old factory model of care and repair gives way to a health system that is genuinely preventative and sustainable.

How are local vanguard sites contributing to change?

In this section we describe the activities that are underway in six NHS vanguards that are part of the Health as a Social Movement programme.

We have picked out examples of where they show signs of success as well as certain challenges that have been identified by some of the sites. We identify key learning points from each vanguard.

Airedale Social Movement

Context

Activities in care homes can be routine and residents are often treated as one homogeneous group rather than people with diverse personal interests. All too often the strengths and histories residents have to contribute are overlooked. At the same time, care homes themselves are often overlooked within their communities. Care homes can feel remote from the community: people rarely visit unless they have a specific purpose such as for work or to visit a relative.

The aim of the Airedale Social Movement, led by the Alzheimer’s Society, is to work with the community to put true person-centred care into action by “bringing the community into the care home”. By connecting residents with local groups that share their interests and making care homes hubs for the surrounding community, they aim to reduce loneliness amongst people living in care homes and increase understanding of old age and dementia amongst people in the community.

Local aims

The programme has led a process of asset mapping to understand both the interests, skills and aspirations of care home residents, and the groups, activities and projects that exist in the area surrounding the homes. Initially this was done through desk research, walking the local patch and asking the advice of local councillors. Staff also attended community meetings. Research was followed up by an event in the care homes, drawing together local people who might be interested in offering activities in the home, hosting resident outings to local groups and events, or spending time with residents.

Local people helped add to the asset maps and made suggestions of how they could become involved in the social movement. Plans were created with nine care homes to engage people and groups in their local communities and use this to:

• Create a community within the care home setting where residents enjoy each other’s company and outside visitors are always welcomed.

• Encourage the outside community to be a part of care home activities and residents’ day-to-day lives, participating in activities that are led by care home residents’ own passions and interests.

• Deliver Dementia Friends information sessions run by volunteers to discuss what it is like to live with dementia and how people can help to create dementia friendly communities, with community groups, organisations, family members and care home staff.

Practical progress on the eight signs of success

Growing from local

The programme has listened to residents and learned a lot about their diverse passions and interests; from photography and baking to fishing. They then encouraged activities that draw upon residents’ interests rather than standardised or homogenising activities. The aim is to bring out residents’ personalities and trigger memories to overcome boredom and build enjoyment in life. For example, one home has found a dance instructor who hosts a resident and staff dance class once every three weeks. In another home, weekly boccia (indoor bowls) sessions are now hosted, led by two women from the local bowls club and a resident who used to play bowls as a member. Key learning has also been to think about skills and assets more broadly — not just in terms of groups and activities — in order to tap into informal networks as well as formal ones.

Collaborating widely

The Alzheimer’s Society has embarked on multiple new partnerships with local institutions compiling their learning into a community engagement toolkit for care homes across Leeds to use. In one home, the programme has hosted events to uncover potential new links into the community. The local groups engaged include the embroiders’ guild, soroptimists (the local club of a worldwide volunteer movement focused on improving the lives of women and girls), a GP surgery and a youth charity. The programme has developed significant partnerships with a local Pupil Referral Unit (PRU) and students visit a home regularly to work on their gardens as part of their BTEC qualifications. They have also engaged community projects; for example one care home has been visited by an expert from the Age UK Bradford and district’s Veterans’ Project, who presented a slideshow based on the Yorkshire Film Archive and hosted a reminiscence session about World War, because there are several veterans of the army and women’s land army in the care home.

Changing culture

Airedale Social Movement soon realised the importance of engaging care home managers, staff and carers in asset mapping processes. They have recognised that it’s important to involve home managers and carers in identifying local assets and co-designing the approach from the start. This means they are more likely to buy into the social movement approach and make it sustainable. Key to changing culture is to win over staff and managers by breaking down the separation between staff and residents and changing some staff’s expectations about residents’ willingness and ability to get involved.

What’s challenging?

For residents, two barriers are prominent: firstly, that the care home is not a natural community, and secondly, that several residents are used to self-excluding from activities and external engagement. Airedale Social Movement is seeking to make care homes more like communities and to build on local connections between the home and the surrounding area. In some cases this is not entirely natural; residents may not come from the local area and do not necessarily find that geography is a point of connection. In many instances decisions about location are made not by residents but family members, based on where they are living. This barrier can be overcome and indeed residents may appreciate building more of a connection to local place, but it cannot be assumed.

For care home staff, the key challenge is time pressure. As much as they commended the Airedale Social Movement and saw the benefits, staff struggled to find the time to respond to emails from the programme manager, network with community members and participate in activities.

Many staff saw this way of working as a nice ‘add on’ rather than a fundamental shift in how they work.

Key lessons from the sites

• Start with building relationships of understanding with staff — change will not occur unless those working with residents on a daily basis change their practices and buy in to new ways of working.

• The programme has been most successful when time has been invested into supporting someone who can continue the work, most often this is an activities coordinator. This person should record and pass on the information about the members so that connections are not lost when that staff member leaves.

• Think about skills and assets more broadly — not just in terms of groups and activities. Informal networks are as important as formal ones. Volunteers must always feel welcome by having a member of staff allocated to look after them, to help and gather residents together for activities.

Wellbeing Erewash

Context

Wellbeing Erewash is one of NHS England’s vanguard multi-specialty community providers (MCPs) and has a strong focus on community and personal resilience. It aims to shift investment and energy ‘upstream’ to encourage thriving communities, where people feel confident and supported to choose healthier lifestyles, stay well and know how to get help and

person-centred support when needed. They define wellbeing as ‘‘feeling as well as you can be, physically and mentally, with the confidence and support you need to choose a healthy lifestyle and to get help when you need it’’.

Local aims

The ultimate goals are to contribute to improved wellbeing and health (as defined by the community) and to reduce demand for services. To achieve this, those involved in the vanguard are working to ensure that local people are more empowered, resourceful and resilient. Under the umbrella of Wellbeing Erewash, they are bringing together local support services (statutory and voluntary) to build an interdependent system. Wellbeing Erewash promotes a shared culture and set of values that include working with communities where they are, not just in the places that belong to local services.

There are three interventions that form the basis of activity for the health as a social movement programme:

• Brilliant Erewash has been co-commissioned by public health and Wellbeing Erewash. The programme works with Year 7 pupils across all the secondary schools in Erewash, to raise aspirations, self-esteem, confidence and resilience, and to promote good mental health. Young people are supported to recognise the difference that their approach and attitude has on others within their school, home and community, and encourages them to take action to promote a positive outlook among school staff, and other young people and local residents.

• Community connectors have been recruited to help make the most of the existing assets and opportunities for support in Erewash. The connectors talk to people, find out what is important to them and what they need, and connect them to local groups and other community-based assets.

The project is supported by a community connector development worker employed by Erewash Voluntary Action.

• The Petersham Project is an asset-based physical activity programme that works with several partners including the Community Sports Trust. It reduces social isolation and increases physical activity by supporting people in Long Eaton to get to know each other through activities that they themselves have helped to design and deliver.

Practical progress on the eight signs of success

The Brilliant Erewash project focuses on working across six local secondary schools to support young people to think about their own wellbeing and identify ways to take action to improve or maintain it. This is a preventative approach that promotes positive psychology and good mental health, rather than waiting for young people to reach a mental health crisis before intervening. By supporting young people to take action in their communities they are sharing positive wellbeing messages with families and friends.

Collaborating widely

Wellbeing Erewash is a partnership between NHS Erewash Clinical Commissioning Group (CCG), Derbyshire Community Health Services NHS Foundation Trust, Derbyshire Health United, Derbyshire Healthcare NHS Foundation Trust and Erewash Health. They have a strong partnership with Erewash Voluntary Action (a local anchor organisation), the voluntary sector forum, the Erewash Time Bank, the University of the Third Age, The Community Sports Trust and the local education team.

Changing culture

Wellbeing Erewash has spent time working collaboratively with its partners to identify a clear set of values and definitions. They have also invested in training for local statutory and voluntary sector organisations in person-centred approaches, to improve skills and build a common set of working methods.

What’s challenging?

At the outset, people were using similar language to describe asset based, personalised and co-produced activities. When practical activities started to take place in communities it became clear that there were different interpretations of putting these ideas into practice.

Key lessons from the sites

• There are many new words and phrases being used by the statutory and community sector (personalisation, co-production, person centred, wellbeing). Organisations can adopt new words but it is harder to shift culture and practice as this is about changing deeply rooted power imbalances and socially conditioned assumptions and behaviours. Paying attention to the methods that people use and the ways in which they work can build understanding of how far different approaches genuinely engage local people.

• Taking a strength-based community building approach has enabled Wellbeing Erewash to identify a wide range of community organisations and activities that are already supporting local people’s health and wellbeing. They were then in a position to enable local people to contact and use these opportunities.

Greater Manchester Cancer Vanguard Innovation

Context

Cancer Research UK estimate that 1 in 2 people currently alive will develop cancer at some time in their lives. Greater Manchester has some of the highest rates of premature deaths from cancer, clearly linked to late identification and referral of patients.

Local aims

Greater Manchester Cancer Vanguard Innovation’s programme aims to contribute to a decrease in the prevalence of cancer, to improvements in the population’s health and wellbeing, and to an increase in individual/ community control, resourcefulness and resilience. The vision has been to catalyse and connect a grassroots, citizen-led social movement for cancer prevention by working through the voluntary sector, aiming to engage groups, networks and existing campaigns and support them to develop their own activity and take collective action.

The programme has:

• Targeted cancer-focused voluntary sector groups and networks, bringing them together to identify current cancer prevention activity, and co-design the focus of the movement, in order to identify ways to connect, support and scale it up.

• Recruited a network of cancer champions, and supporting organisations, who share awareness raising information (ranging from behaviour change to cancer symptoms and screening) with family and friends in their communities, and feedback information about barriers to change and access to services in the health system.

• Connected individual cancer champions, voluntary sector partners and supporting organisations, groups and networks through the use of digital technology.

Practical progress on the eight signs of success

Acting early

Cancer champions commit to a variety of actions, to increase knowledge and support for behaviour change and access to services, and to increase preventative behaviour as well as early screening and detection of cancer.

Bringing people together

There is already a strong base of cancer champions in Greater Manchester. The social movement programme has been able to generate the additional value of collective action and bringing people together to design and shape the campaign to generate ownership. Exploring the use of digital technology, including a new website as a convening hub and Facebook promotion campaigns, has been a valuable part of this work.

What’s challenging?

This project co-designed a set of cancer pledges for people to sign up to, but shaping these pledges took longer than the creation of the initial recruitment website, which was launched without these pledges listed.

This missed an opportunity to capitalise on the immediate motivation to take action of those who first signed up. The new, full website that was subsequently developed did address this however.

Key lessons from the sites

• There is an appetite for people to talk to their family and friends about how to be healthier.

• Connecting existing activity, particularly that in the voluntary sector, is a crucial way of galvanising further action and generating buy-in. Mapping local community assets is important to identify what is already in place in order to build on strengths and grassroots intelligence.

• It may be helpful to ‘start small’ and focus on something winnable in the beginning to build momentum.

• Digital technology is a tool like any other — it can be a help or a hindrance and depends on a range of factors including expertise, approach, timing and understanding of the audience/user needs and experience.

Better Care Together

Context

Better Care Together is an integrated primary and acute care systems (PACS) vanguard — joining up GP, hospital, community and mental health services. Better Care Together has strong communities that residents identify with and a strong voluntary sector. Better Care Together encompasses two sites that the Health as a Social Movement programme have been working with; Morecambe Bay and Barrow. These are areas with high levels of deprivation and a greater demand for health services, with communities that have not always been effectively engaged by the health system.

Local aims

The programme in Morecambe Bay is implemented by the Better Care Together vanguard, a partnership of 10 health organisations in north Lancashire and south Cumbria. Their vision is for community-based services to be the first port of call for most people. Better Care Together has three goals for this programme: to contribute to an improvement in population health and wellbeing in Morecambe Bay and Barrow, to reduce health inequalities, and to create more co-produced and responsive services.

They are doing this by:

• Organising community conversations about health and wellbeing and how to improve it.

• Hosting events and training to act on community ideas to improve health and wellbeing.

• Developing communities of practice to assist sustainability of the initiatives kicked off because of community involvement.

Practical progress on the eight signs of success

Collaborating widely

Alongside Cumbria County Council, general practice surgeries, such as Burnett Edgar Medical Centre, have collaborated with volunteers from the local area. Together they have engaged the community in refurbishing a centre so that it can be used for Wellness Days, weekly yoga sessions and more — these are also being rolled out in other wards. Individual GP champions within surgeries have built partnerships between local authority public health workers, the voluntary sector, school leaders and other GPs, to host conversations about issues identified by the community as important to them.

Sharing power

In Morecambe Bay, change is being galvanised and supported by GPs and colleagues from the voluntary, community and faith sector working closely with the local community. They are using a number of techniques including the Art of Hosting, a participatory leadership approach that uses dialogue to encourage collaboration through storytelling and appreciative inquiry techniques, among others. This approach harnesses the collective wisdom and self-organising capacity of groups, acknowledging the experience and assets of all involved. All GPs and the partners involved in these initiatives believe that talking to communities is energising and exciting.

Building momentum

In Morecambe Bay there is optimism about change, and involved leads report a ripple effect and a feeling that innovation and doing things differently is possible. The Art of Hosting trainings have proved very popular.

What’s challenging?

In order to collaborate across institutions and organisations with different expectations and ways of working, it is important to ‘find the right people’. Leads in this project describe that in many cases it has taken a long time to find the person in an organisation who ‘gets it’ and is willing to devote the time and energy to spread the message.

Changing culture is hard, takes time and can be challenging. Avoiding individual burnout is very important. The project leads recommended celebrating the small victories; for example, where Art of Hosting training has allowed GPs to understand better about the social determinants of health.

Key lessons from the sites

•Find the people with energy to work with — just keep talking to people until you do.

• Avoid burnout by holding on to the small victories and practising self-care.

• Energetic individual champions with a mission can drive change but need to engage other like-minded people to sustain and scale the efforts.

• There are challenges to innovation and changing culture from inside the health and care system — but seek and you will find partners.

• Remember to let the community decide what works for them: “do with” rather than “do to”.

The Royal Free London NHS Foundation Trust

Context

Like many NHS sites, the Royal Free London NHS Foundation Trust has staff who report feeling over stretched and stressed. The trust understands the power of the NHS as an employer to radically improve the health and wellbeing of staff. The Five Year Forward View calls for the NHS to make improving staff health and wellbeing a top priority and for staff to act as ‘health ambassadors’ in their local communities. Prior to joining the Health as a Social Movement programme, the trust was running a health and wellbeing programme called ‘Fit at the Free’ for staff but found that this was predominantly used by staff in higher pay grades, whilst some of the lowest paid staff — employed in bands 1 to 3 — tended not to participate.

Local aims

The Royal Free London NHS Foundation Trust aims to support facilities staff to take action on health and wellbeing as part of a social movement. Within the facilities team, the project is particularly working with domestics, porters and security, who are typically employed in the lowest pay bands in the hospital. Staff helped co-design a programme of events including cooking classes, walking days outside London, organised trips to climb Mount Snowdon and family social events.

The aims are to:

• Deliver a series of programs to be designed with staff, not just for staff

• Encourage and develop sustained lifestyle change within Facilities’ team

• Empower staff to take responsibility for their own health and wellbeing

• Support staff to take community/ widespread action to become healthier and more active

• Put the staff at the centre of change through wide-scale and ongoing engagement

• Engage the Facilities Team in large scale change to benefit the entire team

Practical progress on the eight signs of success

Growing from local

The first year of the programme was spent engaging with staff, building their trust and understanding their interests and circumstances. This was achieved in a number of ways. The staff work across all areas of the hospital, so engaging with them in a range of settings was important, whether that be in their staff room or on their clinical ward. Attending large staff meetings provided a key opportunity to address large audiences.

A key aspect of the preparatory work was to identify what the barriers were that prevented or discouraged the staff from attending existing events, and identifying what kind of health and wellbeing events they would like to see developed. A key finding was that the shift patterns of facilities staff meant that the current times of existing activities were not convenient and many staff were working two jobs, or had caring responsibilities, and therefore could not attend. This insight enabled the project team to co-design activities for staff that met their needs and acknowledged their personal circumstances, for example by setting up weekend events for staff and events that started at the end of their shifts; for example at 3.30pm.

Building momentum

The programme built up trust and interest as it developed. The project managers started by initially hosting a health and wellbeing event, a light-hearted learning event, where staff participated in health checks and in small fitness challenges. It also worked as a platform to discuss ideas with staff and establish interest in forthcoming events. One of the ideas that came from this was a weekend walking group. Twenty-eight volunteers signed up allowing the project team to take a small group on the first walk, the event was photographed and the photos from both events were shared with all staff to get further sign ups, which allowed the team to quickly gather momentum and a large number of new ideas from staff members. Participation on the walks is not limited to facilities staff, those from across the hospital are also able to attend which has allowed the facilities team to make friends and develop relationships not only with each other but also with other members of staff from across the hospital. This is now a regular monthly event, with at least 30 attendees at each. Additionally staff have started an ‘end of shift’ walk on a Thursday which is also very well attended.

What’s challenging?

Hospitals have a hierarchical culture, and it has taken a while to build trust given staff have a history of feeling overlooked. In addition, many of the staff work throughout the hospital; many domestics change wards from week to week and the porters are frequently on their feet moving patients around. Therefore, it is time-consuming to engage with them and trust takes time to build up. Secondly, many of the staff do not currently have the confidence to lead activities. Some activities in particular require a high degree of administration given their health and safety implications. The project staff are currently designing hand-over initiatives to promote sustainability, for example tapering support over the next year.

Key lessons from the sites

• Growing leadership and building confidence, particularly with staff at lower levels of the hospital hierarchy, can take time and patience. Consideration should also be given to English being a second language for some staff.

• Getting out of the hospital environment can be a good way to break down hierarchies and develop team relationships.

• Understanding the legal and health and safety implications of staff leading activities is important. This should be approached in a way that removes barriers for staff and may require existing policies to be reviewed. This issue reflects the sometimes conflicting priorities and needs between formal system activity and informal community building activities.

• Planning for sustainability needs to be embedded from the very beginning of any intervention. Incorporating activities that grow leadership and confidence among the staff taking part is vital to enable this work to continue.

Stockport, Oldham and Tameside

Context

The Greater Manchester Population Health Plan highlights the role of social and community support structures, the harmful effects of social isolation, and the importance of people as positive role models and motivators.20

Loneliness and social isolation is an issue across the whole population of the three areas. The aims of the programme are therefore not restricted to any particular group.

Stockport Together, working in partnership with the boroughs of Oldham and Tameside has allowed the programme to reach across the newly formed Greater Manchester Health and Social Care partnership.

Local aims

The programme chose to focus on exploring the potential for social movements to tackle loneliness and social isolation. The programme had two main phases:

An exploratory phase

Movement building-type activity was possible in three specific contexts — arts, food and micro-grants.

• Arts

The programme worked with the existing Live Well Make Art network to help stimulate and resource a project that highlighted the benefits of people connecting with creative activities in their communities; and as a consequence, increasing their health and wellbeing.

•Food

They worked with a GP surgery, a community cafe and the Kindling Trust (a social enterprise which uses food as a catalyst for social change) to connect people at risk of social isolation through growing and cooking together.

• A micro-grants programme

Forty-seven projects, existing or newly formed groups, were awarded small amounts (£500- £2,500) to support their development or implement new ideas for tackling social isolation and loneliness.

A mobilisation phase

Initiated through a call to action event where people involved in phase one came together to share learning and shape further action. The focus has been on developing the organising and leadership skills of these activists.

A series of stewardship skills/skill sharing workshops have been organised to reflect the learning and development needs of participants. Examples include: story-telling, short film-making, community organising, peer research methodology and learning visits to an enterprising GP practice.

Practical progress on the eight signs of success

Growing from local

The programme has grown from the local by closely aligning and integrating with Action Together, a local voluntary sector infrastructure organisation, and local system leaders involved in growing community capacity.

The programme has identified the strength and power of building personal relationship between people united in their passion to address the crisis of loneliness and social isolation.

Shifting control

The resourcing of activity was flexible in its approach and aimed not to be prescriptive in the ways that funded projects took action. Key to this was transferring the responsibility for awarding, administering the funding, and supporting grantees to Action Together — an organisation experienced in championing people-led approaches.

Building momentum

The programme has maintained and built momentum in a number of ways. People have continued to connect and share skills through ongoing stewardship circles. Connections have also been strengthened through social media channels; and through a dedicated resource at Action Together which shares information/learning and maintains personal contact with key people.

There have been challenges in building common cause amongst diverse projects where people are under pressure to cope with funding challenges and ever-changing public service priorities.

Key lessons from the sites

• The idea of the NHS leading social movements is counterintuitive; learning indicates that systems need to recognise that they can give space for movements to flourish with a view to responding positively to their demands.

• There is a huge value in activists in communities working alongside voluntary sector support organisations with their wealth of experience of supporting citizens and groups in engaging with policy makers/public services.

• The added creativity that projects involved in arts and food bring in amplifying issues and co-designing local responses to health has been hugely beneficial.

• The value of having people involved who have the skills to build relationships between systems and communities.

• A recognition that social movements ebb and flow and that future movement building activity may change in ways that cannot be controlled or even anticipated.

Learning from local practice

Who to work with

• Start by recognising and building on energy, assets and activities that already exist in the locality, wherever possible making different groups and organisations aware of each other and enabling them to work more closely together. For example see Stockport, Oldham and Tameside and Wellbeing Erewash.

• Social movements are often started by one or more champions who will drive the change from the start. This can be a challenging role with many barriers along the way. It is important that the champions look after themselves, find support from allies and reach out and engage with other like-minded individuals. For example, see Better Care Together.

• Keep reaching out beyond those who are already involved in local action; make sure marginalised minority groups are engaged on terms that make sense to them; encourage and enable people to talk to friends and family about health and care issues. For example see Greater Manchester Cancer Vanguard Innovation.

• Focus on local health and care staff as well as residents in the locality; value them and help them to adapt the way they think and act to the new direction of travel. For example, see The Royal Free London NHS Foundation Trust and Airedale Social Movement.

How to work

• Always use accessible language and forms of communication; remember that digital technologies can sometimes be a barrier to wider engagement, and sometime be a help. As with any communication tool, it is important to understand the audience. For example see Greater Manchester Cancer Vanguard Innovation.

• Pay attention to what is really happening and the methods people are using to pursue local goals, not just to words and phrases that are being used. Providing training to build skills in new ways of working can help grow local capacity and support shared values. For example see Stockport, Oldham and Tameside.

• Take account of unequal power relations between different people at local level and make sure as far as possible that these do not get in the way of positive change. For example see The Royal Free London NHS Foundation Trust.

• Be patient and persistent. It takes time for people to build the skills and confidence that enable them to engage and act effectively; recognise when people are at risk of overload and burn-out and try to make sure that everyone, especially those who take on leadership roles, are well supported. For example see Better Care Together.

What to do

• Plan activities, including skill sharing and training, with those who are likely to be involved in them, so that the activities respond to local interests and needs. Providing training for ‘staff’ and ‘citizens’ together will help to grow local understanding and a culture of co-operation. For example see Wellbeing Erewash.

• Be prepared to learn, adapt and change ways of working as you go along. For example see Airedale Social Movement and Better Care Together.

• Plan from the start to maintain and continue the progress you are making beyond the lifetime of this programme. Take active steps to build and grow leadership throughout the project. For example see The Royal Free London NHS Foundation Trust.

What happens next?

The National Partners, the New Economics Foundation and the RSA are continuing to work with NHS England and each site to:

• Generate further evidence highlighting the impact of this programme and ways of working in each site — using methodologies including network mapping and peer research.

• Understand the business case and potential local impact on services

• Continue to spread the learning from each site nationally, through blogging, publications and events.

Get in touch if you would like to learn more

Key contacts for each location:

Airedale Social Movement
Website: alzheimers.org.uk
Email: laura.cope@alzheimers.org.uk
@alzheimerssoc

Wellbeing Erewash
Wellbeing Erewash website: wellbeingerewash.org.uk
Email: wellbeing.erewash@erewashccg.nhs.uk
Email: sara.bains@nhs.net (Community and Personal Resilience Lead)
@WellErewash

Greater Manchester Cancer Vanguard Innovation
Website: icangm.co.uk/become-a-cancer-champion
Email: elizabeth.benbow@nhs.net
@GMCancerChamps

Better Care Together
Website: mbht.nhs.uk
Email: jacqui.thompson@morecambebayccg.nhs.uk
@BCTMorecambeBay

The Royal Free London NHS Foundation Trust
Website: royalfree.nhs.uk
Email: angela.bartley@nhs.net
@RoyalFreeNHS

Stockport, Tameside and Oldham
Contact: Dr Donna Sagar, Deputy Director of Public Health, Stockport Metropolitan Borough Council
@Stockport2gther