Health inequalities: Why GPs should become involved in 'health creation'

The NHS needs to do more to prevent illness. Dr Brian Fisher explains how practices can become health creating and assesses the impact community action can have in improving health.

Dr Brian Fisher, vice chair, New NHS Alliance
Dr Brian Fisher, vice chair, New NHS Alliance

The NHS needs to go further in preventing illness. Practices concentrate on secondary prevention, but we also need to start upstream, helping to keep people well in the first place.

The Marmot review into health inequalities urges us to identify and respond to the ‘causes of the causes’ of disease and health inequalities. One of his evidence-based recommendations is for communities to become stronger and more resilient. Our health is socially determined not just dependent on our own actions.

The New NHS Alliance is committed to working across the NHS and with sectors such as housing, the fire service and local authorities to develop the principle and the practice of ‘health creation’.

Health creation is ‘the enhancement in health and wellbeing that occurs when individuals and communities achieve a sense of purpose, hope, mastery and control over their own lives and immediate environment’.1

Drawing on evidence and experience the Young Foundation concludes that our mental and physical health improves as we gain the ‘freedom to lead a life we value’. We need these 3Cs:

  • Control over the circumstances of our lives
  • Contact with others that is meaningful and constructive
  • Confidence to see ourselves as an asset, to be in a position to take actions and responsibility and to have a positive impact on those around us.   

Health-creating practices

Health creating practices enable people and communities to increase their levels of the 3Cs. When people are engaged in a way that appreciates and employs their strengths and skills, they start to take control of their own lives and environments, determine and articulate their own solutions and ambitions and participate in making them happen.

For practitioners and commissioners, this requires changes in culture and approach: to listen to the people and communities we serve, to start with the things that matter to them, to share power and control with them and to move away from the default choice of delivering more services.

Community action improves health - the evidence base

The Marmot Review sees community empowerment as key to tackling health inequalities2  through strengthening social networks - the connections we have with other people – friends, relations, acquaintances, colleagues. Areas with stronger social networks experience less crime, less delinquency, enhanced employment and employability.3 

Strong social networks appear to act protectively against cognitive decline over 65, and are associated with reduced morbidity and mortality.4 Social relationships can reduce the risk of depression. Low social integration and loneliness significantly increase mortality.5 

A meta-analysis shows 50% increased survival for people with stronger social relationships, comparable with reducing damaging health behaviours and consistent across age, sex and cause of death.6

Health creation is cost-effective, too.

Analysis suggests an NHS saving of £558,714 across three neighbourhoods over three years,7 based on cautious but evidence-based estimates of improvements in health factors by 5% annually as a result of increased community activity and social networks. This is a return of 1:3.8 on a £145,000 investment in community development, with additional savings through reductions in crime and anti-social behaviour of £96,448 a year per neighbourhood.

A more recent analysis of the Salford Dadz Project suggests as 1:14 return.8

These difficult calculations are similar to estimates obtained by others.9

How practices can get involved

In Fleetwood, practices are already becoming involved in such schemes.

Community action workers can offer practices insight and inroads into the communities they serve and enable a dialogue with local people and an impact on local social determinants of health.

At a 2014 London Journal of Primary Care workshop, GPs suggested ways to harness community development. Federations make it easier for existing community development projects to relate to all local practices. 

PPGs could be supported by community development workers to become more effective. There may be mutual interests faced by practices, their patients and local voluntary groups such as housing issues, education issues, or poor food outlets. Community development can help practices to contribute to campaigns to change these aspects of civic life. Collaboration for better services can be very powerful.

A recent community development project in Lewisham, based in public health and local practices, working with third sector groups, showed improvements to health, to trust in the community and to changes in GPs’ behaviour, leading to more BP and cancer reviews.

  • Dr Fisher is vice chair of the New NHS Alliance

References

  1. http://www.nhsalliance.org/wp-content/uploads/2016/07/Salix-New-NHS-Alliance-Health-Creation-PDF-1.pdf
  2. Fair Society, Healthy Lives Strategic Review of Health Inequalities in England post 2010. The Marmot Review, February 2010, p139.
  3. Peggy Clark and Steven L. Dawson, Jobs and the Urban Poor (Washington, D.C.: Aspen Institute, 1995).
  4. Fabrigoule C, Letenneur L, Dartigues J et al. Social and leisure activities and risk of dementia: A prospective longitudinal study. Journal of American Geriatric Society 1995; 43: 485-90;
  5. Bennett KM (2002) Low level social engagement as a precursor of mortality among people in later life. Age and Ageing 2002; 31: 165-168.
  6. Holt-Lunstadt J, Smith TB, Bradley Layton J. Social relationships and mortality risk: a meta-analytic review. Plos Medicine July 2010, Vol 7, Issue 7.
  7. Health Empowerment Leverage Project. Empowering Communities for Health: Business case and practice framework. November 2011.
  8. http://www.nhsalliance.org/salford-dadz-building-relationships-better-therapy/
  9. Catalysts for Community Action and Investment: A Social Return on Investment analysis of community development work based on a common outcomes framework October 2010

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