EXECUTIVE SUMMARY

  1.  The Healthy Communities Collaborative run by the Improvement Foundation is a proven method of addressing health inequalities. It focuses on small populations with the greatest need. Members of the public are not simply consulted but constructively engaged and empowered to actively lead and drive improvement in their own community's health and well-being. Health, local authority and other agencies, including the voluntary sector, are then orientated around the population in order to support the required changes. Remarkable successes have already been achieved in reducing falls in older people and improving access to a healthy diet and work is already being undertaken to identify people at risk of cardio-vascular disease and people with symptoms suggestive of cancer. It is an approach that could easily be applied to any topic but obesity, alcohol misuse and access to primary care would be ideal.

THE IMPROVEMENT FOUNDATION

  2.  The Improvement Foundation (IF) is a not-for-profit organisation working across the NHS and other public services to support service improvement. We have been running successful improvement programmes since 2000, forging a credible reputation with primary care and other service providers, and working with local community members. Successes include improving access and chronic disease management in primary care, and the management of patients with more complex, multiple conditions especially in older people. We have enhanced practices' abilities to maximize the benefits of practice based commissioning and helped people living in deprived communities, with high levels of morbidity and mortality, to improve the health of their community. We have the devolved structure necessary, with our 10 regional IF Centres, to work locally, regionally and nationally with front-line staff to develop capacity and capability for improvement.

  3.  Our method is to bring together experts and those achieving good results in a given topic area to tease out the characteristics of their systems that produce a better outcome. From that, we identify the key change principles (which if replicated by others will result in similar good practice) and monthly measures that participants report on. We are very focused on measurement as we see it as a key part of the process, without which we will never know if there has been an improvement. The next step is to expose people working in the field to the examples of good practice, the change principles and the measures and help them implement and measure change in their own working environment. We teach them a variety of quality improvement techniques, and we roll-out and spread the improvement across the entire country via our ten IF Centres.

  4.  We think it would be helpful to describe one of our specific programmes, the IF Healthy Communities Collaborative, which was set up to help the NHS to achieve a reduction in health inequalities and relates to the issues you are examining.

THE INEQUALITIES CONTEXT

  5.  Strategies to address health inequalities have recognised in recent years the need for partnership working which is vital in addressing some of the social, economic and environmental factors which contribute to poor health. In many of these existing partnerships, however, an important element is missing—that of the community as a significant partner. There are well recognised barriers to involving local people, some of these emanate from the professionals involved and some from the community itself. These barriers in the community become apparent when attempting to engage people who are not "the usual suspects" in public and patient involvement, people who may well lack the confidence and self esteem to get involved.

COMMUNITY ENGAGEMENT AND TACKLING INEQUALITIES: IF HEALTHY COMMUNITIES COLLABORATIVE RESULTS

  6.  The Improvement Foundation (IF) Healthy Communities programme has won national awards for its innovative work and results, and has become internationally recognised as leading the field in the area of involving deprived communities in the improvement of their own health and wellbeing.

  7.  In a recent NICE review of the use of community engagement, the IF Healthy Communities work was identified not only as successful in improving health outcomes but also one of the few national programmes that could identify the cost effectiveness of community engagement through a focus and attention to measurement of results.

  8.  The results of what local people can achieve when working in partnership with a range of agencies has been staggering.

  9.  For example, the initial focus of the programme was Falls Reduction in Elderly People. In just three sites covering a population of 150,000 there has been a 32% reduction in falls (730 fewer falls over 2 years). This amounts to reduction in hospital costs of £1.2 million pounds, ambulance costs of £120,000 and residential social care of £2.75 million pounds. This gives a total £4 million over two years or £2 million a year saved just for these small populations.

SOCIAL CAPITAL RESULTS

  10.  IF Healthy Communities also produces a gain in social capital within the overall community in which the improvement activity takes place. In the general population for Wave 1 sites (falls) following the work of the programme there was:

—  12% increase in people's perception of whether their area was a good place to live

—  12% increase in people's perception of whether individuals show concern for each other.

—  22% increase in the number of people who knew where to get advice about falls

—  In participants active in the programme there was a 48% increase in the number of people who thought they could change and improve things in their communities.

  11.  Subsequent work addressed "Improving Access to a Healthy Diet". A few of the many examples of success stories are illustrated below as case studies.

  12.  We are now testing the Healthy Communities approach with two new topics, promoting early presentation of cancer symptoms and early assessment of the risk of cardiovascular disease in deprived communities in spearhead PCTs with deprived communities.

  13.  Dealing with minor ailments and improving primary care access and responsiveness for black and minority ethnic groups could easily be tackled with this approach, as well as addressing obesity, alcohol and other public health issues.

THE IMPORTANCE OF COMMUNITY MEMBERS AS A RESOURCE

  14.  The IF Healthy Communities programme recognises that people need to be encouraged and supported to contribute and to feel valued as contributors. When they are, their contributions to solving problems are imaginative and innovative, and often very simple. They have a way of looking at solutions from the receiving end. An early lesson for us was learned after a meeting to recruit members of a community. One evaluation form came back with the following quote :"I haven't been to school for 60 years. How can I be of any use here?" That person had a wealth of knowledge and experience, not least about his own small community, as well as ideas about how things might be done differently to achieve more responsive service delivery.

  15.  Below is a quotation from a community member of an IF Healthy Communities Team describing how her confidence has grown as a result of taking part.

  16.  Joining the Healthy Communities Collaborative

"As from July my confidence was about to take a huge leap. I became involved with the Cancer Awareness, this is something that I have taken a real interest in, and it has really opened my eyes to the problems that many people have to face. I'm finding it very rewarding and worthwhile; it has given me confidence I never thought I had. . . . The contributions I make to the collaborative are appreciated. I honestly feel that the more I give, the more I receive back. I know I am part of a great team where your ideas, thoughts and opinions are considered. We get on very well and when at meetings or conferences we work hard and after the important things have a good laugh. As you may of noticed my confidence is growing and I would like to thank all the team for helping me . . . "—Community Member (Name can be supplied) Birtley Team, November 2007.

  17.  We actively support people with their personal development, bringing their confidence to levels where they are no longer afraid to speak up in groups, and can articulate their ideas and proposals in front of a range of professionals. We do this by teaching them some basic tools. Top of the list of these is the improvement methodology, but before this can be applied effectively, people have to understand their communities. They need to identify current service provision and the systems which operate (and which sometimes seem to be having an adverse effect on their expectations). We help community members to identify and understand the barriers to care.To help with this we teach community mapping techniques, participatory appraisal and process mapping.

  18.  We also get the local people to present their findings in public, describing how they have addressed some of the gaps in service provision. This is done very much in partnership with the professionals who support the community members in their drive to improve health and well being.

  19.  In one example, a team member living alone had never left the country or owned a passport. During her first year as a community team member, she instigated a phenomenal amount of work to improve elderly care provision in her area, and was invited by IF to present this work to an international conference in Copenhagen. She successfully described to the international audience the power unleashed in her community by the Healthy Communities approach in a single year. It was her first time in an aeroplane and she was 81 years old.

  20.  Another area which is addressed by the Healthy Communities approach is that of raising expectations—of life in general, life expectancy and quality of primary and secondary care provision. We start by pointing out the stark difference between the deprived areas we are targeting and the national average. We then go on to show how big the difference is when compared to the best communities in England. We create anxiety in these communities about their health status, using this as a spur for them to find their own solutions. For many people, this is the first time they have been made aware of their community's situation in a way which is understandable. The population sizes we work with (8-10000) make the statistics a reality for them. We can then begin to make them want to improve things which will lead to better health and well-being.

HOW THE HEALTHY COMMUNITIES COLLABORATIVE RECRUITS COMMUNITY MEMBERS

  21.  The recruitment of community members does not happen without preparation and forward planning. The partner organizations, having been identified beforehand by IF, meet to develop a profile of their local populations, using small area data on age, sex, ethnicity and socio-economic features and incorporating local knowledge. The profiling is matched to the subject matter. Our strategy is to identify the groups which would yield possible members. For example, if the subject for intervention is of particular relevance to older people, we would begin by targeting the networks and support groups, both statutory and voluntary, which serve older people. We then enlist the organizations who are the stakeholders to invite 50 or more people to an orientation event.

  22.  Invited participants are given the information they need to decide whether they would be interested in joining, but at the same time we give them the reasons why their particular areas have been selected, and present their local poor health statistics in comparison with the average and the best. This raises their anxieties and motivates them into wanting to be part of the changes.

HEALTHY COMMUNITIES SUSTAINABILITY

  23.  What keeps the people involved is just as important. It is made clear that no one organization or individual is more important than another. This is not the usual volunteering scenario. The volunteers are valued for their contribution, and at the same time it is made clear that local people will take the lead in the work, which is supported throughout by professionals. They feel that they have some control over finding solutions to long standing problems.

  24.  Their gains include enhanced social networks, increased confidence and new skills and knowledge which in some cases can lead to opportunities for employment or further study

  25.  Since the first sites were chosen in 2002, there have been 18 IF healthy communities programmes, all in different areas of England and three in Scotland, working either on falls, widening access to a healthier diet or both. Only one of these 21 sites has failed to sustain the work in one form or another.

  26.  The value of the HCC model has been recognised by the stakeholders in the participating sites in addressing both the topics of falls and healthy eating, and in the wider social exclusion agenda.

  27.  In most areas, the initial topic for engagement has developed and widened. One common area for development has been in drawing up strategies for older people's health and well-being, but the model adds value and substance to the implementation of local and national strategies and policies.

  28.  Critical Success Factors in Sustainability:

—  When the collaborative programme has run its course, continuation costs are minimal, and in the main consist of funding for a project manager.

—  The collaborative method ensures a legacy of knowledge and experience in the participating communities in the subject areas, specifically, but also in community development and social inclusion. Given the right nurturing environment, this becomes a formidable resource.

—  The programme concentrates on bringing together individuals and organisations, which form new and strong networks with experience of working together.

—  Local people develop new found confidence to continue and expand in areas of importance to their health and social welfare.

—  The methodology taught to the teams gives them a tool which they can apply to any topic for improvement.

—  There are quickly demonstrable outcomes which confirm the value of the work to individuals, organisations and likely commissioners.

—  The template for joint working which is at the heart of the Healthy Communities Collaborative approach, allows for efficient and effective use of resources.

STRATEGIC DEVELOPMENT

  29.  Where a Healthy Communities programme has become well established and its value recognised, it has become a model for service delivery through Local Area Agreements. There are excellent examples of this in Northampton, Gateshead, Sunderland and Salford. In other areas funding from various sources has been identified for the continuation and expansion of the work. Current work strands which are focused on cardio-vascular disease and cancer awareness, are already being planned into sites' strategies at the start so they will continue after the IF Programme has ceased.

CONCLUSION

  30.  The IF Healthy Communities Collaborative has worked with people in the most disadvantaged areas in England and successfully engaged residents in these areas to work alongside service providers and the voluntary sector. We believe that health is everyone's business and that there are untapped and unrecognised resources in every community. We ensure by our approach that these come to the fore in the battle against health inequalities.

31.   Improvement Foundation Healthy Communities Case Studies

Targeting Young Families, Easington HCC

  The Healthy Communities Team in Haswell, County Durham were aware that many mums with young families did not know how to shop for, prepare and cook meals with fresh produce. They also were aware that people in the area live on very low incomes. Trying a new meal therefore involves a considerable amount of risk, as if it is not liked the family go hungry.

  They tackled this risk by organising a free 8 week course for mothers in the area to learn how to make a healthy meal. This was done in conjunction with a local butcher who could supply fresh meat for the course and give advice on cooking it. The Primary Care Trust agreed to cover his costs through a voucher scheme and to provide the other ingredients. This pre-empted the Healthy Start voucher scheme, due to be introduced nationally in the following year.

  The team contacted the mums 9 weeks after the course to monitor the outcomes and offer further advice and support. They were delighted to discover that all but one of the participants were using their new skills and continuing to patronise the local butcher and food co-op.

Grow Active Allotment Scheme, Blackburn with Darwen HCC

  There's nothing like growing your own fruit and vegetables to understand food. The Healthy Communities Team in Blackburn with Darwen has put this into practice with the Grow Active Allotment Scheme.

  Following a successful allotment initiative led by the local authority the teams have helped develop a new plot on Bangor Street. The plot was cleared, a large shed erected, paths cleared and raised beds built in order to provide easy access for a broad range of people. Seeding, growing and sharing the produce has improved participants access to and knowledge of fresh food. In addition, it has helped bridge boundaries between different age groups and communities. It does this in a peaceful, colourful setting, in which team member's hard work is rewarded with satisfaction of growing your own food.

  From this project, the community was spurred on to continue with its improvements in lifestyle and integration. The teams went on to apply for lottery funding to revive and bring up to standard, an outdoor bowling green. The membership is focused on involving different racial and cultural groups and on involving young people in this form of exercise.

Before and After School Club in Gateshead

  This initiative took place in an ex-mining village, counted as one of the 20% most deprived communities in England, in a pre-school nursery which provides a breakfast club and after school facilities for children from age 3.

  The Healthy Communities teams decided to target this group with the aim of improving the general nutrition of the children attending the nursery. A significant proportion are children in need or at risk, according to social services criteria.The staff provide both a breakfast club and an after school facility where snacks are served. These were mostly fizzy drinks, crisps, chocolate and sweets. There was never a direct intention to affect the behaviour of the children at the nursery, but to improve their nutritional intake. The concern was greater because, for many of the children, the after school snack was the last food they were offered in the day.

  The work began by introducing fruit as an alternative to sweets, and the team bought a smoothie maker to enable nursery staff to replace the fizzy drinks on offer. The children quickly became fans of smoothies, and then began to accept raw vegetables with dips as snack foods. The school staff noticed (without prompting) a difference in the children's behaviour. The head teacher remarked on how much calmer the children were becoming as the consumption of junk food lessened.

  At the AGM the decision was taken that confectionery products should not be available at all at the after school club for 2 out of 5 days a week. Some parents were asking for a complete ban, because of the improvement in the behaviour of their children.

  At the same time, the nursery introduced breakfasts of fresh fruit, yoghurt and wholemeal toast. There was a noticeable difference in the levels of fatigue and alertness in the children at the start of the school day.

January 2008