Making the case for place

In the US, politicians will say of political campaigns, ‘that all politics is local’. Certainly, in a previous life when I served as a councillor and then an MP, local really mattered.  

You could say that ‘place’ was at the heart of everything I did. Back then, as is the case today, people spoke to me mostly about their street, hospital, school or town centre.  

I can count on the fingers of one hand the number of times someone came to one of my surgeries to talk to me about how exercised they were about regional or subregional NHS structures. Most people see the world through the prism of place – not remote ‘systems’. 

People define their community in a way that most makes sense to them. That might be identification with a local football team, it could be the school your children attend, it might be the street where you live.  

That sense of connection with a place matters.

Significance of place

Why does it matter? It matters because there is a growing consensus that we can only hope to address the population health challenges we face if the NHS looks beyond its front and backdoors out into the community.

This means reaching out to work with local government, housing providers, the community and voluntary sector, employers and many others in place. As argued in last month’s updated Marmot Review:

“We need to focus on place - on small areas and on influencing the environment and social and economic conditions of places in order to improve the health of residents.”

This is not the first attempt at working this way. The Five Year Forward View spoke of the need to tap into the “renewable energy” of communities, with mixed results. Before that Total Place tried to capture the spirit of collaborating and organisations around a place.  

So what needs to be different this time?

First, it needs a shared vision, a set of guiding principles and agreed rules to support shared decision-making at every level: integrated care system, place and neighbourhood. Knowing what happens where is critical to determining who must be involved in decision-making and what governance arrangements are most appropriate.

It matters because there is a growing consensus that we can only hope to address the population health challenges we face if the NHS looks beyond its front and backdoors out into the community

Local leaders of place, elected councillors, people who use services, and the voluntary sector, need to be at the heart of shaping this. 

Second, it means health and care leaders developing place-based plans which mobilise the assets and social networks within communities. With more and more evidence pointing to the potential of asset-based approaches to reduce social isolation, promote people’s wellbeing and increase people’s control over their health and lives.

Robin Tuddenham, chief executive of Calderdale Council, who Social Care Institute for Excellence interviewed for the research, told us: “We are beginning to use bottom up, strengths-based approaches to address complex local issues, such as placing work advisers in GP practices to address worklessness.”

Third, rather than a ‘system by default’ approach we need ‘partnership by default’ with local government at the heart of decision making. As we implement local system plans, it would be counter productive if local government were given the impression they were seen as junior partners to the NHS.

Rooted in local communities, and responsible for broad range of public services that have an influence on people’s health and wellbeing, local government play a vital role in health creation. 

Litmus test

Finally, we need to place citizens at the heart of this. It is not sufficient to see a person’s health status as the sum total of their lifestyle choices; as the Marmot report demonstrates it is much more complex than that.  

But by enlisting citizens in designing services informed by their lived experience and circumstances we can remove the barriers and create the conditions in which there is equity of access and outcomes.

Today sustainability and transformation partnerships, and integrated care systems, are in most cases remote and little understood by the public. As these nascent structures or ecosystems take on more power and authority, how they engage with the public will become a litmus test for their legitimacy.  

One example of a place-based approach to engaging with the population is the Camden Health and Care Assembly, a citizens’ assembly that uses the principles of deliberative democracy to shape priorities for local communities.

The assembly first addressed environmental issues and is now addressing the future of health and social care. We need more initiatives like this.

The Marmot report is a wake-up call to us all that as well as making progress – on technology for instance – we can also go backwards, on health inequalities. But we don’t have to stall or go backwards.

This is what excites me about the potential of the ICS journey and why coordinated action and commitment, at the level of place, is more important than ever.