The government's 'three shifts' – sickness to prevention, analogue to digital, hospital to community – will underpin the forthcoming 10 Year Health Plan and emerging new models of care, including neighbourhood health services. These shifts are not new, but actions to address them have often been side-lined in the face of extreme demands to address operational pressures – financial, workforce shortages and care backlogs.
Poverty and social inequities, such as poor housing and rising cost of living, increase demand for NHS services. The existing medical model holds the NHS in a paradigm of treating avoidable illness. Avoiding ill health in the first place is seen principally as the role of those outside of the NHS, such as local government or community services, even though demand for their services has also risen steeply. Addressing health inequity should be a shared endeavour between partners, who are focused on creating health in communities. This requires a healthy dynamic in the relationship between the NHS, local partners and communities.
Shifting from sickness to health creation
The Health Creation Alliance (THCA), defines health creation as 'the process through which people and communities gain a sense of purpose, hope, mastery and control over their lives and environments. When this happens, their health and wellbeing are enhanced'. We have set out 10 steps to achieving a whole system shift to health creation. This is underpinned by ground-up analysis, based on nine years of listening to and working with professionals from many sectors, community leaders and people with lived experience of poverty, trauma, discrimination – all of whom have experience in creating the conditions for health to be created and maximised.
The notion that health can and must be created as well as illness prevented and treated, is catching on. The Institute for Public Policy Research's Commission on Health and Economic Prosperity argues that 'better health will only be possible if we move from a sickness model of health policy to a health creation one'.
When you look through the community lens, the picture really starts to make sense. Much avoidable ill health is caused by an imbalance of power, at either a personal or a systemic level, or both. This 'poverty of agency' is correlated with social and health inequity and chronic stress which is a risk factor for many illnesses. At a systemic level, these imbalances can have exclusionary and isolating effects on people, resulting in difficulties accessing suitable and timely healthcare. The resulting health disparities show up in the data – higher than average levels of hypertension, mental illness, type 2 diabetes and higher maternal mortality rates for black women.
Meanwhile, communities ask for respect and reciprocity as partners in prevention and in creating their own health, but are rarely trusted, empowered or enabled to deliver the things they know will make the biggest difference. Community-led organisations keep many people well in difficult circumstances, at low cost, yet some systems are reducing their spend on the third sector.
The starting point of the antidote to disconnection is connection. Creating the conditions for people to become better connected – to themselves, to each other and to services – leads, over time, to increased confidence that enables people to take control of their lives and wider environment. The process through which people regain their collective and personal agency can support a shift in the power imbalance. Put simply in the 'three Cs of health creation' – 'Connections build Confidence to take Control'.
While this is, in part, the work of asset-based community development it must not stop there. There is also a case for a fourth policy shift, from national micromanagement to local empowerment because being trusted to get on with the job, together, wherever you are in the system, will drive coherence in the shift to new models of care, from the ground up.
What can trusts do?
THCA has a tried and tested asset-based framework that both enables health creation and underpins organisation and system change. Guided by it, we have helped: trusts working with minoritised communities to enhance breast cancer outcomes; local partners to redesign mental health pathways; and clinical and outreach services to reduce Hepatitis C among female street sex workers. NHS trusts wishing to embed the health creation approach, can use the framework to underpin and guide their work.
The 10 Year Health Plan provides an opportunity to re-focus efforts. Trusts should work with communities and local partners to make a shift to a health creating ecosystem capable of addressing their shared challenges; focusing on connections, creating the conditions that keep people as well as possible and actively removing the barriers to whole system change.
Feel like joining the movement for Health Creation? Become a member (for free): https://thehealthcreationalliance.org/members/
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