Let’s talk about place, baby
Guest blog by Andrew Attfield
NHS Anchors: Place, Health Systems and Inequalities
Talk about place and health inequalities has not been the sexiest topic in the NHS in recent times. The transfer of public health to Local Authorities has been a factor in this, the reduced profile of the Foundation Trust agenda and the internal marketisation ideology of the 2012 Health and Social Care Act in England have also played a part. However over the last 12 months COVID-19 has exposed pre-existing health inequalities and brought into sharp focus geographical and societal disparities.To quote the Beyond the Data report:
“Data from the ONS and the PHE analysis confirmed the strong association between economic disadvantage and COVID-19 diagnoses, incidence and severe disease. Economic disadvantage is also strongly associated with the prevalence of smoking, obesity, diabetes, hypertension and their cardio-metabolic complications, which all increase the risk of disease severity.
Stakeholders felt that the disproportionate impact of COVID-19 on BAME groups presented an opportunity to create fast but sustainable change and mitigate further impact. Change needs to be large scale and transformative. Action is needed to change the structural and societal environments such as the homes, neighbourhoods, work places - not solely focusing on individuals. There is a legal duty and moral responsibility to reduce inequalities.”
Inequalities and ill health are about more than just healthcare
This trenchantly puts the case for linking wider determinants to health inequalities and, in speaking about homes, neighbourhoods and workplaces, demonstrate the intersections of population and place. Also highlighted in the report, and further elaborated on in the British Academy’s report on the society wide impact of the pandemic, is the differential impact of the pandemic on Black, Asian and minority ethnic groups, young people and people with disabilities. The Sutton Trust and the Resolution Foundation have further highlighted that school students from more deprived backgrounds have had generally more disrupted education than average which has the potential to worsen outcomes in this group. As we come out of the current wave of the pandemic it is highly likely that the economic impact will linger longest among lower income and socially excluded groups. In East London 1 in 4 young people aged 18-25 are unemployed, and areas such as Waltham Forest which have a high number of self-employed people, are reporting significant economic hardship. Sectors such as retail and hospitality have high proportions of BAME staff so these groups will be particularly vulnerable if these sectors are slower to recover.
The further knock on impacts on mental health are already being evident, and are concerning in relation to young people who experience sustained periods of unemployment. It may be too early to fully understand all differential impacts, but it can be said with confidence that the protected characteristics (including age, race and gender); socio-economic status and health vulnerability are all critical points of inquiry, and all need to be interpreted in the context of environment and place. It is also certain that as things stand, the pandemic is in the process of making existing inequalities wider.
How can NHS organisations move beyond healthcare
One approach that is being floated as part of the NHS in England’s response to these inequalities is for its components to develop as anchor institutions. This initiative arose before the rise of the pandemic and appeared as the very last paragraph of the last appendix to the NHS 10 Year Plan for England, launched in January 2019 and signalling a renewed emphasis on place based collaboration in health systems. The Plan noted that: “As an employer of 1.4 million people, with an annual budget of £114 billion in 2018/19, the health service creates social value in local communities” and commissioned the Health Foundation to develop the concept and gather evidence. Since then the Foundation has worked with NHS England and NHS Improvement to develop the Health Anchor Learning Network, which has been very active in bringing people together to develop this agenda.
The Health Foundation’s “Anchors in a storm” long read offers a report from how NHS bodies are responding to this agenda during COVID-19 and sets out helpful lessons on how this should be approached including gaining leadership commitment and developing metrics. The report sets out two guiding principles for this including co-production with communities and purposefully tackling inequalities. These seem like questions we may want to return to, but firstly it is worth thinking about these issues in the context of place, and existing policy and practice around this. Issues include the questions of how the anchor agenda has landed in terms of its interaction with other agendas relating to inequalities and how issues of place interact with business and service imperatives. Most of the illustrative examples given below come from provider NHS experience but as hospitals, along with universities, are the most often cited anchor organisations, this doesn’t seem inappropriate. They have the largest spend; biggest employment and most prominent spatial footprint in the system and so have the biggest opportunity to make a difference in these spheres. However this in itself raises questions as to how anchors may work in relation to regional Integrated Care Systems.
The anchor agenda brings dimensions of geographical inequality to a crowded field. Michael Marmot’s work has placed the spotlight on the wider determinants of health and how they affect health over the life course of individuals. As he wrote recently (in connection to the Sewell Report):
“There are health differences between races that are not fully explained by class, and so therefore racism must play some role. To put it simply, these two issues may overlap but they are not the same thing.”
Being an anchor is only half of the equation
However the danger of a hierarchy of inequality is clear, and from an anchor perspective there is a clear tension between locality and need. An example that is on my mind at present was the discussion that took place in the Social Value Group for the planned redevelopment of Whipps Cross hospital in Leytonstone, East London. The immediate thought of focusing on the “hyper local” locality of the hospital in Leytonstone and adjacent areas in Woodford and Wanstead ran aground when looking at local deprivation levels. Adjacent local wards in Redbridge ranked 533 and 590 out 633 in the London average Index of Multiple Deprivation (where (1) is the most deprived), and while the local wards in Waltham Forest ranked higher (219 to 355) they were by no means the most deprived areas in the Borough, with the most deprived ward in the Borough ranked 80th and the worst in Redbridge ranked 128th). In this case a distinction was drawn between addressing the environmental and nuisance issues at the hyper local level and looking at socio-economic benefits (such as local labour in construction) on a broader basis. Whilst deprivation was the key indicator used, there were clear links in the more deprived wards to child poverty and to high proportions of Black, Asian and minority ethnic populations.
A further tension is with the inclusion health agenda. Speaking of place to homeless people or Traveller communities may appear a cruel joke, or at least is perceived in different terms. From a provider NHS perspectives highly marginalised groups and/or those populations with substance or alcohol dependency loom large, due to their high needs and capacity to generate complex issues for the system, for example as frequent attenders in Emergency Departments.
The danger of piling issue on issue onto the anchor agenda is evident. To channel my inner Jonathan Van-Tam, if you hitch too many carriages to this train, it ain’t gonna move anywhere very fast.
Simplifying and making a start
To manage the competing agendas, the following diagram developed by the Local Government Association (LGA) is very helpful. The LGA model shows the interaction of social-economic groups; protected characteristics; Inclusion Health groups and geography. This schema shows the overlap between these different groups and potential for joint working.
Overlapping dimensions of health inequalities by the Local Government Association
What this diagram suggests, echoing Marmot, is that these dimensions should not be collapsed into each other, but there are significant overlaps. Clearly to make sense of this needs concerted needs analysis and a consistency of approach. For hospitals seeking to develop themselves as anchors, a clear idea of how they relate geographically to their area is important, and which parts within this they may want to concentrate on.
I recall from conversations with Leeds Beckett University, for example, that the anchor partnership there decided to focus on particularly deprived wards in Leeds. In areas of widespread deprivation, such as East London, this selection may prove invidious and other forms of prioritisation may be needed.
Nonetheless the LGA diagram does raise a question of what is meant by place. It was produced to provide an aide-memoire to support local areas to take a systematic and comprehensive approach to their planning and decision making around the pandemic, but I think it has wider application.
It will be seen that the geographical sphere is very limited in its description, covering broad categories such as rural, urban and coastal. Recently I had the opportunity to listen to the Suffolk and North East Essex Anchor board and this brought home the fact that this categorisation is helpful in an area that covers Ipswich, Bury St Edmunds, Colchester, Clacton, Haverhill, Sudbury and Felixstowe. This ICS (at the moment) includes quite affluent country towns but also highly deprived coastal areas such as Jaywick Sands. Nonetheless, this description feels a bit bald and not representative of all the attributes of a place. In the LGA schema, deprived areas are included in a socio-economic and deprivation sphere which again limits the full dimensions of place based work. Replacing geography with the new “Place” category allows for the inclusion of factors such as housing, air quality, travel and environment and it is strengthened by transferring “ areas of high deprivation” over from the social-economic sphere, leaving the more portable social-economic factors such as income or education in this domain.
Figure 1 Overlapping Dimensions of Health (amended)
Clearly there are nuances which cannot be captured in any schema but this amended version tries to strengthen the place aspect of inequalities and, in developing anchor frameworks, you can see how moving from place to the central overlapping categories means you can engage with the other dimension of health inequalities without obviating the need to consider areas of inclusion health and protected characteristics in their own right. This is particularly important in the acute NHS context given its emphasis on services for patient care rather than prevention or early intervention.
These considerations help respond to the Health Foundation’s imperative to “purposefully tackle health inequalities”, and an analysis that relates spatial deprivation and health inequalities is a good starting point, along with an analysis of groups by need and size of population. A number of locally informed judgements calls are needed here, but having the data helps inform these. Putting it simply this is about People and Place, and the relation between these factors.
To give a short and simple example, we know the smoking prevalence (England – reported 2020) is higher among routine and manual workers (23.4% are smokers) as against 9.3% for managerial and professional workers and 14.1% for intermediate roles. This represents a broad but not uniform gradient by income and the data indicates that the gap is widening between the manual group and the others. In thinking about the economic impact of COVID-19, we know that sectors such as hospitality and retail have been hard hit, and that BAME and young people are disproportionately represented in these areas. 29.1% of people with no qualifications are estimated as smokers opposed to 7.3% of those with a degree. 29.8% of council or Housing Association tenants are smokers as opposed to 10% of house holders with a mortgage.
In this case there is a clear link between the prevalence of smoking, income and occupation and this has an impact in terms of place and population if we are to design stop smoking services. Public health teams need to be looking at deprived areas with high numbers in council or Registered Social Landlord tenure, as well as populations with higher smoking prevalence such as men and some ethnic/national groups. Action on Smoking and Health (ASH) has reported smoking prevalence of 77% among homeless people, which may be an indicator of this health behaviour in the inclusion health field. From an anchor institution’s point of view, this data can help steer an organisation’s work with its own workforce and make it think about how it can help reduce inequalities in its wider environment, and among its service users. Hospitals are already expected to identify smokers and signpost them towards quitting (where offered and accepted), but this imperative to focus on inequalities can and should strengthen collaborative efforts. This needs assessment approach will help with the assessment of impact as well, and this is important in considering how place fits with the NHS structures and priorities
Working with NHS functions and business imperatives
The outline of overlapping inequalities above is based on the premise that the NHS wants to play a key role in combatting inequalities, which of course is correct. However it will have competing priorities, not least of all restoring services to pre-pandemic levels, and handling the huge backlog of procedures and tests. NHS staff need support in recovery and recuperation as well, so any additional pressures need to be taken into account.
Developing a systematic approach to working as a local Anchor
This context is important as the anchor agenda cuts to the heart of how the NHS functions as an organisation and performs its role as a healthcare provider. Its role as employer and purchaser are key offers to the community. At Barts Health we have along-established local employment practice which is built into standard operating procedures for recruitment. As a big employer (17,000 plus), normal turnover generates over 300 vacancies per annum at entry level which are accessible to the East London community. The Community Works for Health programme identifies vacancies such as healthcare support workers, receptionist and medical laboratory assistants and offers these to a talent pool of local candidates which is filled by regular open days run with Local Authority and RSL support. Candidates are assessed for English and maths and where possible provided with pre-employment advice and work placements. East London has residents with low or non-existent qualifications (or have English as a second language) so many fail the functional skills test. These are offered support through Adult Learning and Further Education provision. Once in the pool, talent pool members are treated as internal candidates and get first shot at the relevant vacancies. Over 100 vacancies a year are filled through this route which demonstrates the anchor principles of localism, targeted support and cross organisational working. Since the scheme started over 1,000 local people have progressed into NHS roles, making a significant contribution to the 42% of staff who live in the hospital group’s footprint. For a central London NHS Trust this is a significant proportion.
The business advantages of local recruitment is that it increases the chances of retention (as local staff are already based in the area and have fewer transport costs, and more likely to live in affordable accommodation) and in a diverse area can offer cultural and linguistic capacities. The Community Works programme is complemented by specialist employment programmes for people with learning disabilities (Project Search) and Women into Health (a London Borough of Tower Hamlets scheme aimed at reducing the deficit in female employment in the borough). Further discussion is taking place on supporting care experienced young people. Again you can see the overlaps between the different dimensions of health inequality.
In 2018, the Trust secured external charity funding (including the hospital’s charity, Barts Charity) to extend this local approach to schools and colleges. This was an area based widening participation scheme called Healthcare Horizons which works with 37 schools and Colleges with Sixth Forms, offering a range of careers events (72 delivered) and advice to over 1,200 school students. The outcomes include 10 cohorts of pre-apprenticeship training and 80 young people progressing to apprenticeships or jobs. We expect over 100 students to be successful with entry to health related degrees by the time summer clearing is over. The benefits of this are obviously related to workforce development, but as significantly this scheme offers a good deal of social value. It is an excellent calling card for the Trust with local communities and engages staff on a range of mentoring, work experience and demonstration activity.
Other priorities in the Trust’s anchor programme include work to increase the social value achieved through its procurement of goods and services. This is looking at measuring tendering in social value terms, introducing KPIs to measure delivery and developing a consistent social value set of metrics. This programme will be supercharged by the redevelopment of the Whipps Cross Hospital (part of the Barts Health group), planned to start in 2021.
This sketch is designed not just to show what a hospital can be and do as an anchor institution but to illustrate the challenges and opportunities that are in play with practical implementation. There is a lot of grey in this. Programmes such as the ones described certainly can help with business imperatives but to do this at scale and sustainability needs internal drivers and leadership, as well as an understanding that helping community members join the NHS workforce requires ladders and bridges over barriers they may face, and groups with bigger challenges inevitably need more help.
Sustainable development has a similarly complex picture. Many of the gains from sustainability are a no brainer. Reducing energy costs can be combined with using greener sources (such as CHP plants) and help meet carbon reduction targets. But a big redevelopment such as Whipps Cross, which is linked to residential development in later phases, has large environmental impacts which cannot all be mitigated. The sustainable development agenda necessarily is a key part of the place approach and there are huge potential benefits with partnership approaches on this, such as improving air quality, where the NHS role is important but not central to programmes to reduce NO2 and PM2 pollution.
A conclusion here is that the NHS clearly can make a focussed contribution to reducing health inequalities, but this is not zero sum benefit. It needs the right infrastructure and partnership to do so and for this agenda to be embedded in its workforce, procurement and estates functions. A return on investment analysis would be useful, along with a consistent set of outcomes measured if we are to get to a consensus over measuring achievement.
Anchors as a social movement
The second imperative set by the Health Foundation for the anchor agenda is community co-production. Clearly much of this thinking is in play in relation to individual patient care and working with service users, but what does this mean in relation to the anchor concept? As with the discussion above, this doesn’t come out of nowhere. The NHS has a history of collecting data on patient experience and from Community Health Councils to Foundation Hospitals' membership forums there are historic examples of formal engagement with the community. Organisations such as Healthwatch as well as patient panels have worked to articulate community concerns and deal with complaints. Barts Health set up a vibrant inter-faith forum to deal with concerns over COVID- 19 and vaccine hesitancy. But this agenda demands a bit from the anchor concept.
As suggested in the heading, it requires that local engagement becomes a social movement, or putting it another way that the voluntary efforts of healthcare and other professionals to engage with their communities is acknowledged, facilitated and encouraged. This is not without risks. The NHS is a public body (or set of bodies) that cannot simply adopt the corporate calculations of the private sector (i.e. Corporate Social Responsibility), as its whole purpose is generating public good. Many initiatives may stem from hyper-local interests, either in locality, healthcare or personal interest terms. Letting a thousand flowers bloom is easier said than done (and didn’t end well in Mao’s China, as I recall).
I found the features of good practice in community co-production listed on the Social Care Institute for Excellence website (taken from work by the New Economics Foundation) useful in unpacking the concept. These include:
defining people who use services as assets with skills
breaking down the barriers between people who use services and professionals
building on people’s existing capabilities
including reciprocity (where people get something back for having done something for others) and mutuality (people working together to achieve their shared interests)
working with peer and personal support networks alongside professional networks
facilitating services by helping organisations to become agents for change rather than just being service providers
These appear good principles to look at, and I can think of examples from my own Trust of hospitals reaching out, and the work with young people seems particularly productive. Work with violence reduction, NHS Cadets, promoting healthy living as well as the careers work cited earlier are good examples showing at least some of these features, as is the inter-faith forum.
However turning this work into a systematic approach needs a bit more thought and investment. A common assumption in the acute sector has been that community engagement in general (never mind community co-production) is something done at primary care level. As with the issue of overlapping inequalities there needs to be an understanding of what communities are being considered, what community and voluntary sector organisations are engaged in and what are the gaps. Keeping objectives and outcomes real, such as measuring equity of access, looking to address digital exclusion and finding ways to support staff engagement with communities is going to be key, along with open and consistent communications and access to data.
This ethics based approach seems to me crucial to the idea of anchor institutions treating their stakeholder communities as assets and participants in co-production of local healthcare, including being potential employees, business partners and neighbours. For secondary NHS bodies this ethos, which necessarily will engage staff and services across a range of disciplines and roles, has the opportunity to embed the anchor approach and avoid the NHS disease of short lived initiatives, with learning lying untended.
Back to the key question
Having considered some issues relating how a place based approach intersects with the wide range of health inequalities, we may be better placed to pose the research question - can anchor institutions help reduce inequalities? The answer is of course yes it can, but work programmes need to be clear on the inequalities they are seeking to address and their intersectionality. Looking at the examples made above also hopefully shows the challenges and opportunities of incorporating anchor principles into the functions of a big hospital, and the opportunity to sustain this work and align it with NHS business imperatives. It is also good not oversell the impact even of large hospitals on inequalities; how anchor partnerships take shape in the context of the new integrated health and care system landscape, and inter relate with national approaches to skills, levelling up and regional development in a bumpy period for the economy is going to be crucial to maximising impact on inequalities. Remembering that all this takes place in real places not organograms is something that anchor partnerships can help with.
A second way of framing this research question could be: can being an anchor institution improve healthcare outcomes? Certainly it can have an impact on the wider determinants of health, and thereby improve life chances, but as the Health Foundation identified in “Anchors in a Storm”, the promise is a bit more than this. It is about how health systems, hospitals, primary care, mental and community health services, with partners in social care and education can work more equally with their communities and genuinely co-produce good health.
Andrew Attfield is Associate Director for Public Health at Barts Health NHS Trust.
Follow him on @AAttfield.