Module six: communities as assets in health
In this module, leaders explored how to start thinking about wellness rather than illness, and how to genuinely engage with communities to co-create outcomes.
With rising demand and the reactive care models we are having to employ in primary care, we know that we need to go upstream to make a difference to patients and our communities. The traditional model of general practice is evolving to look at root causes, including the social determinants of health. The Marmot review (2020) proposed an evidence-based strategy to address the social determinants of health; the conditions in which people are born, grow, live, work and age and which can lead to health inequalities. In order to do this, we need the help of our communities to understand what matters to them, using a bottom-up approach as outlined by the National Voices insights report, The NHS at 75.
In this module, south east PCN leaders explored how we can start thinking about wellness rather than illness, how we can genuinely engage with our communities to co-create outcomes, and the impact of using different models such as social prescribers. All with the aim of identifying effective contributions to help us tackle inequalities and improve overall population health; a major factor in helping to de-medicalise conditions. In a focus group, one PCN clinical director reflected:
“One of the chief learnings was that for most people to live a healthy and happy life, they often don't need their GP or any medical input. They need support from their community, a safe place to live, financial support if needed, and food. The aim is that we as a PCN and as primary care, need to recognise that we can't support everything and we do not hold all aspects of people's health and wellbeing.”
Engaging with our communities
Some of our leaders shared how they have found engaging with communities particularly tricky. One participant admitted to not knowing where to start, after coming to a realisation of how important co-creating with the community is for his PCN:
“Working with our communities as assets so is something we should be better at ... we have the small city communities all around us and we know our little groupings. We don't use the communities and that is something that is more of a realisation thing.”
To truly engage meaningfully, our participants learned that we need to break up the traditional hierarchal view that is felt within our healthcare system, and ensure that everyone is treated and approached as equal. We reflected on how going out into the community brings trust and encourages different conversations and perspectives than having the same conversations at the surgery. For example, starting with what matters to people and what they care about and joining in with community events shows that we ourselves are members of the community. This is a different approach for many, as one participant reflected that:
"…we feel that we've lost the ability to reach out into communities and we need to switch our mindset."
We need to reframe what we put our time and effort into as work, and the importance of distributed leadership:
“We have learned that if you reach out to people, they don't expect you to do it, they will work with you … that's really stayed in my head that actually some of this is doable. You just need to break it down into small bitesize chunks rather try and solve everything. As [PCN] leaders we think that we have to take it all on, and part of leadership is actually the delegation and finding the best person to take things forward.”
The PCN as part of the community
Discussing examples of what works best demonstrated that the answers will come from the communities themselves, it just requires us to approach work differently. This sentiment is not new, we have great learning from the Wigan deal, which highlighted how giving people a voice leads to genuine co-production. Regarding really getting to know people, one participant said:
“…with my own primary care community, I call them my friends and we're all part of the same community system.”
Our PCN leaders have appeared more optimistic about the future, one participant reflected:
“There are many, many volunteers and interested parties that are available if we ask for help, and sometimes it's very difficult in primary care and particularly as a GP that people come to you to help. But now we work in partnership and the future is brighter together. And part of this programme allows me to address this.”
The gems of PCN peer-to-peer advice that I am taking away with me are that if at first, people do not respond to you, keep persevering, use your networks to build momentum and keep expanding these networks. Be adaptive, don’t fix too early and own what you create.
In terms of changes implemented in my PCN, our population health management data shows a lower prevalence of depression coding in our black population, so we have been trying to increase engagement. We are looking at ways in which we could become more approachable, with the help of our council, faith and voluntary sector. We are continuing to persevere with this project as we would like to recruit community champions. We understand that we need to value the time of our community in helping us move forward and we need to keep expanding our network of networks.
The role of social prescribers in asset-based health
“When it comes to mental health, there needs to be a shift from responding to mental health crises, to preventing people from getting into crisis.” Christina Melam, CEO, National Association of Link Workers
Social prescribing link workers were introduced into the PCN DES contract in year 1 (2019) as part of the NHS Long Term Plan. The intention of the role is to provide people personalised care to meet practical, social and emotional needs that affect their health and wellbeing. This is achieved by connecting people to what is available through community-based support, activities and services, which includes statutory services such as housing, financial and welfare advice.[1]
This model is underpinned by the rationale to take a proactive approach to address and work with the root cause factors (determinants) of poor mental health before a crisis or decline occurs. This is achieved by creating a sustainable support infrastructure around the person within the community, that allows the person to have agency and choice in how they engage with it. We explored the power of this approach and found the case study from Stort Valley and Villages PCN using social prescribing to improve the mental health of children and young people inspiring.
There is a societal view that health problems need to be fixed with medication. An example of this view is still held regarding antibiotics by some, as referenced by Atul Gawande where infection rates were already falling due to public health interventions such as clean water, education and the wider determinants of health, not wholly due to the introduction of penicillin, however we often hold a different narrative. The asset-based health inquiry tells us:
‘approaches to healthcare other than the prescribing of medicines can be incredibly effective. At its best, social prescribing can give people a purpose in life, a reason for living. It can make people genuinely happy.’
Even though there is some strong evidence for the impact of social prescribing there is, however, a variation in how these link workers are being integrated. The King’s Fund paper on integrating ARRS workers into PCNs (2022) discussed the specific challenges for Social Prescribing link workers as feeling isolated in their roles (often more so if subcontracted from the voluntary sector), a misunderstanding of the purpose of their role, difficulty accessing IT systems, plugging the gaps into mental health services and often having to deal with a high level of mental health complexity which is beyond their training.
The safe spaces that we created as a collective allowed us to the opportunity to challenge ourselves in terms of how we as senior leaders have worked with integration of social prescribers (as well as wider ARRS roles), and think about what next. We want to hear more examples of best practice, using the social prescribing lens - not only of the successes, but also what has not worked well, at system, regional and national levels.
PCN leaders are keen to look at social prescribing schemes at scale, using the resources of the community, the voluntary and faith sectors and the councils, with ideas for change coming from the communities themselves with us acting as their enablers.
Dr Rupa Joshi is a GP and clinical director for Wokingham North Primary Care Network and deputy chair of Berkshire West Primary Care Alliance; clinical adviser for NHS England’s Primary Care Transformation team; chair of the Workforce and Estates Design Group at NHS Confederation’s Primary Care Network; and clinical adviser for learning and development for the South East PCN Development Programme.
