Building healthier places

When we talk about health, we often talk about health services. However, if we want healthier communities, we need to look at the issue through a wider lens. Health is shaped by the places we live in, the strength of our communities, the jobs and opportunities available to us, and the people who have the power to shape our environment.

This was one of the central messages from Professor Kate Ardern, the former Director of Public Health and Chief Emergency Planning Officer at Wigan Council, during her talk at the International Longevity Centre’s annual Greengross lecture.

For those of us interested in devolution and public service reform, there is an important conversation to have here in the value of taking a place-based, whole-systems approach to public health.

Health beyond a service

A focus on prevention means thinking about health before someone needs a GP surgery appointment or hospital visit. The experience of our daily lives, from the houses we live in, to the jobs we work, and the transport available to us all impact our health.

As the landmark Marmot Review highlighted in 2010, reducing health inequalities requires action across all social determinants of health. This means health should not be treated as the responsibility of one department. To move our focus upstream and reduce demand on acute services, health needs to be a part of how we think about the whole place. Last year we published ‘A Place Toolkit for Improving Health through Economic Development’, which is intended to support places to deliver health outcomes through local economic development projects and programmes.

There are already examples of prevention work happening at a regional level. For example, Greater Manchester’s Live Well initiative takes a preventative approach focused on creating conditions for people to thrive by tackling health, social, and economic inequalities.

The new statutory health duty in the English Devolution and Community Empowerment Bill acknowledges that Strategic Authorities (SAs) have a major impact on many of the fundamental components of health. There is an increasing expectation that improving health and reducing inequalities should be taken into consideration alongside broader goals of inclusive growth and public sector reform, especially due to the close relationship between health, productivity, and economic growth. The West Midlands Combined authority has put together a package of resources to support SAs in responding to the new Health Duty.

The role of community voice

A place-based approach requires understanding the perspective of residents who live there. Administrative boundaries, policies, and programmes may make sense to institutions, but they do not always reflect how residents understand their own neighbourhood. The neighbourhood they identify with may not fit neatly into a council boundary, and the problems they face may not fit into rigid departmental structures. This makes community participation fundamental to understanding what a place really needs and how to deliver that change.

One example of a place taking the time to understand health issues through the eyes of the community is Wigan Council. The council created short public health films, as an accessible alternative to traditional annual public health reports. The films bring together the voices of residents, young people, schools, charities, and businesses around an annual theme. Importantly, this enables communities to have a role in deciding how to tell the story of their place.

Starting with the strengths of a place

The ‘Wigan Deal’ is an example of asset-based or strengths-based working, where a place builds on their strengths to improve outcomes. In 2011, like many local authorities, Wigan Council were facing major financial pressures which required them to explore alternative approaches to delivering public services. Rather than starting with what people or places are struggling with, it focuses on recognising and building on the strengths that exist. This approach began in social care but became a wider way of working across the council and local organisations.

In an evaluation by the King’s Fund, published in 2019, they note that at a time Wigan council had significant budget cuts, and lost around a fifth of its workforce, it also saw improvements in healthy life expectancy, improved quality of social care services, and improved staff engagement. However, this approach is not a quick-fix and requires deep, embedded cultural change that needs time, consistency, and strong leadership.

Workforce and capacity-building

There can be a risk of getting so carried away with what needs to be changed, that understanding the foundations that need to be in place to make that change possible is overlooked. Place-based working depends on people who understand their communities, have productive relationships across organisations, and a workforce with the right skills and culture. Importantly, the approach must not solely rely on individual leadership. It needs to be truly embedded so that it has long-term sustainability, even when leaders move on.

This is why devolving powers over workforce, education and skills are relevant. A place-based workforce needs to go beyond understanding their profession, to understand the place where they operate and the system they are a part of. Arden described her ambition as, for example, not having doctors just proud to be a doctor in the NHS, but proud to be a doctor in the NHS in Wigan. This results in a workforce that sees itself as part of a place and requires local and regional government to have power over their skills, education, and employment planning.

What does this mean for devolution?

The main takeaway is that if we want healthier places, we need to give those places the power and capacity to shape their futures. To achieve this, key lessons include:

• Local and strategic authorities need greater powers around health, skills and workforce planning to effectively develop the skills, capacity, and relationships required for a place-based approach.
• Local residents and communities need to be given genuine power in how their place is shaped, and the story that is told about it.
• Health, wealth, and place are inextricably linked and a whole-system approach needs to be taken when developing policy on prevention.
• The foundations needed for devolution to work must be invested in. This requires building better relationships between organisations, leadership, workforce capacity, and community infrastructure.