New research: Community-powered investment has positive impact on health

Our health system is in drastic need of a shift – away from a centralised reactive system, to a place-based approach focused on prevention. In our latest research, we explore the health and wellbeing impact of the Big Local programme – a hyperlocal community-led initiative. 

A health system under severe pressure 

Rocketing demand and years of chronic underfunding has created a health system at breaking point. But we will not solve its problems at the point of crisis. We need to shift the centre of gravity within our system of health and care towards prevention, and away from expensive acute reaction. It means recognising the important link between health inequalities and place. It means we need to address the social determinants of health outcomes – the range of physical, social and environmental factors which are more important for good health than services alone. 

New research: The impact of community power 

Our new report undercovers the ways that community power helps improve health, and could ultimately ease the pressure on the system. 

We analysed the effects of the Big Local programme. It’s a scheme that is  focused on 150 ‘hyperlocal’ neighbourhoods, which shared common characteristics of high levels of deprivation, low levels of social capital and lower-than-average health outcomes. Each was given £1 million to spend over the course of 10-15 years from 2010-12.

By placing resource and autonomy over decision-making in the hands of communities, the model offers a unique insight into how communities would understand, identify and pursue their own priorities. 

From activities to impact, we found improvement in health and wellbeing 

From the ‘Hug a Mug’ mental health and wellbeing focused café in Ewanrigg, Cumbria, to a new community hub in Par, Cornwall, we found that communities delivered a wide range of health activities.

This activity led to important impacts on health and wellbeing. We found that there was a notable improvement in their health in comparison to national trends and to other similarly deprived areas. Analysis of Census data reveals that between 2011 and 2021, there was a larger increase in people from Big Local areas reporting their health as ‘very good’, compared to England as a whole. In addition, there was a greater than average reduction in the share of residents reporting their health as ‘bad’ compared with national levels. 

Percentage point change in self-reported health of residents, 2011-2021  

Source: Office for National Statistics Census, 2011 and 2021 

We explored benefits qualitatively too, looking at three key social determinants of good health: 

1. Enabling a healthier standard of living for all. The projects directly supported healthier and more active living, and responded in real time to events that undermine healthy living standards. 
2. Enabling children and young people to maximise their capabilities and have control over their lives. The projects supported strong family relationships and fosteried direct ownership and control. 
3. Creating and developing healthy and sustainable places for all. The projects supported physical community infrastructure and assets, and bolstered  vibrant community networks and relationships. 

Four core conditions that enable community-led action 

But what are the key ingredients that has made the programme a success? At the heart of the Big Local model are four core conditions that help enable community-led action on health and wellbeing.

1. Agency and control. Power and control were placed directly into the hands of communities through resident-led decision making. We found that this process of empowerment itself has had positive wellbeing impacts through a greater sense of trust, connection, and collective control over their neighborhoods and decisions. 

2. Community connections. Big Local partnerships are embedded within their communities and understand the unique challenges they face. They have therefore been able to more effectively design interventions that address local issues and reach those people who need help the most. These strong relationships and legitimacy within the partnerships resulted in high participation in Big Local partnerships.. 

3. Flexible funding. The non-prescriptive, flexible nature of funding has meant Big Local partnerships have designed and delivered of activities that stand the best chance of meeting the specific challenges and priorities of the community, rather than being restricted to a specific theme, type of intervention or condition. They have been able to respond swiftly to immediate challenges communities face such as COVID-19 and the cost-of-living crisis, and have been able to adapt existing interventions and quickly develop and launch new ones. 

4. Long-term funding. A long-term funding approach has built community capacity and capability while designing effective interventions for the long term. It has enabled partnerships to be more confident in risk taking and build in learning feedback loops. The certainty of funding has been significant too – creating the space for communities to plan more strategically, explore options best suited to their needs, and focus on longer-term outcomes with no need to immediately demonstrate short term results to a third party. 

The health impact of Big Local 

Recommendations: How can health systems support hyperlocal approaches to health? 

These impacts have been realised despite a series of obstacles that has limited the degree of impact and the ability of Big Local partnerships to reduce demand on the formal health system. Our recommendations therefore focus on local health systems, particularly new Integrated Care Systems (ICS), exploring how these obstacles can be tackled and how to amplify the positive impacts we have found. 

1. Develop a deeper shared understanding of where and how hyperlocal deprivation manifests within geographies.
   There is a weak understanding of the relationship between neighborhood level deprivation, health outcomes, and patterns of service demand. Partners should therefore aim to develop a clear shared understanding of the spatial distribution of deprivation in their areas at a hyperlocal level, in combination with hyperlocal analysis of service demand, health outcomes and reduced social capital. This needs to be a combination of quantitative metrics and qualitative insight from communities themselves about their own health and wellbeing. Developing this shared analysis across partners is a critical precondition to informing a system-wide case for different ways of working, commissioning and investing in community-led health and wellbeing support. 
2. Deepen and expand community-led approaches to health and wellbeing, adopting a ‘test and learn’ approach to measure their impact on outcomes and demand.
   Once this shared hyperlocal understanding is in place, health systems need to deepen and expand community led approaches to health and wellbeing, adopting the core features of the Big Local model we have identified above. There should be a focus on capturing and evaluating the learning and impact within the system – a test and learn approach within places – to then inform future commissioning and identify join up opportunities within the health system. 
3. System partners should commit to shifting resources towards community-led health and wellbeing activity as part of a wider rebalancing of spend towards prevention.
   The Hewitt review set out an ambition to increase total NHS budgets at ICS level by 1% over the next five years for prevention activity. We support this direction of travel but suggest an increased commitment of 0.1% of their budgets on community led activity, and to increase this over time as test and learn approaches outlined above deepen the system and place level evidence base of impact.

Given that we’ve found that the Big Local programme shows that a relatively small, but long term and unrestricted funding can generate important returns on building social capital and addressing social determinants, a commitment to increasing this to just 0.5% of current spending over the next five years could significantly grow community led health and wellbeing activity, and begin to shift the capacity of communities to support their own health. 

Given the challenges we face around increased demand for health and care provision, lack of adequate funding, and systemic issues in our current formal health system, policy makers need to urgently rethink their models. Our recommendations reflect the need to fully recognise the sustainability, value, and contribution that Big Local and hyperlocal initiatives can make. Maximizing the benefits of community-led long-term approaches has the potential to alleviate some of the severe pressures our system faces today and gives the emerging shape of a more preventative system of health and wellbeing in the future. 

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