PLAIN TEXT - Research report: People, places and health agencies: lessons from Big Local residents

People, places and health agencies: Lessons from Big Local residents — Research report December 2016.

Authorship and acknowledgements

This report has been written by Leila Baker, Helen Garforth, Marilyn Taylor and Katie Turner. It is based on research carried out by the authors together with Charlotte Hennessy.

We are grateful to all those Big Local areas that took part and to the individual residents who gave their time and ideas to help develop this research. The research has benefited from the resources and reports that Big Local areas have created, some of which are reproduced in this report.

Local Trust commissioned this research because health and wellbeing had been identified as a priority in many Big Local areas; and because the areas that were already working with health agencies said that this relationship was both rewarding and challenging.

The research addressed two questions:

• Do Big Local areas and health agencies have common goals?
• How can they develop workable relationships?

By ​‘health’ we mean health and wellbeing (e.g. housing, employment, transport, etc.). By ​‘health agencies’ we mean Clinical Commissioning Groups (CCGs), Healthwatch, GPs, NHS provider organisations, voluntary organisations and social enterprises as well as private provider organisations, and Public Health.

Residents identified six important ways that Big Local partnerships play a role in improving health and wellbeing locally.

• Structure and support provided by Local Trust and the Big Local programme to help residents get started and maintain momentum.
• Resources and time to shape local services, activities and facilities, ensuring Big Local partnerships have a tangible offer to bring to the table to encourage others to work with them.
• A fuller picture of local health and wellbeing by gathering local insights into experiences and perceptions of health services.
• Bringing people together to collectively discuss health issues in the community and come up with jointly produced (residents, health agencies and local decision makers) solutions.
• Test beds for new ideas and activities, able to take certain risks that health agencies may not be so free to take.
• Health promotion, ensuring that health messages and activities are delivered in a language and an approach that are locally appropriate.

We asked residents to tell us about the factors that had acted as ​‘door-openers’ for building relationships with health agencies, and the things that they had found particularly challenging when working on health.

Door-openers

Finding allies: It really helped to find an ally in one of the local health agencies who was part of the community and wanted to get involved with Big Local. 

Using other networks: Many of the Big Local partnerships were already linked in with other local networks, making it easier for them to bring together different agencies and different parts of the community to discuss and act on health issues. 

Finding common ground: In conversations with Big Local partnerships and health agencies, we found that residents and health agencies are often all striving for the same health outcomes but that sometimes this is simply couched in a different language or approach.

Explaining the Big Local health ​‘offer’: We found that Big Local can help to open doors to health agencies if the partnership can explain clearly what Big Local has to offer. 

Stepping outside the boundaries: To tackle local health and wellbeing may mean both Big Local areas and health agencies working with people, groups and organisations that lie outside or are larger than their area. 

Continuing challenges

Being recognised as a ​‘legitimate’ player: Some Big Local partnerships said that they struggled at times to get health agencies and residents to take the work that they are doing and the issues they are raising seriously.

Cuts, mergers and outsourcing: These have led to some partnerships having to take a different approach and build new relationships with agencies.

Shaping services: For many Big Local areas, supporting the commissioning of health services in their area has been a process of learning as they go along and managing residents’ expectations. In some cases, plans have not worked quite as expected, with collaborations falling through, or being delayed for example.

The balance between protecting services and plugging gaps: Big Local partnerships were very aware of and sympathetic towards the current realities of reductions and cuts to health services but were also clear about the fact that Big Local resources should not be seen as replacing provision by health agencies. 

For Big Local residents:

• Tackling health and wellbeing is hard work. It’s important to find the ​‘right time’ for your partnership to pick up health and consider the effort and resources needed – many areas have found they really need a Big Local worker’s time and help on this.
• Meanwhile, other activities, such as tidying up the local area or arranging social events for local people, will all help improve local health and wellbeing and help build links with local health agencies.
• Go where the energy is. Be open to chance meetings and find individuals and likely allies that understand what you offer and how you work.
• Don’t let geographical boundaries be a straitjacket, given that most health agencies will have a remit to work across a geographical area that’s wider than your Big Local area.

For health agencies:

• Working with a Big Local area can help you fulfil your responsibilities to the wider population as well as improve health and wellbeing and work on preventative measures in the Big Local area.
• Big Local can help you to take proactive steps to engage residents in discussions about local health services, both through more formal forums and by participating in resident-led groups and activities.
• Invest time in cultivating the relationship with your Big Local partnership in order to learn over time what you can do together.

For Local Trust:

• Local Trust will need to think strategically about whether and where to seek to influence health policy and practice locally or nationally. Residents involved in this research thought that there may be potential for Local Trust to raise issues that are prevalent across areas at a national level.
• The ​‘right time’ for Big Local partnerships to pick up health as an issue will be different in different areas. Clear messaging to areas about the time and resources required to work on health would help them with this decision.

This research looks at the role of Big Local in supporting and influencing resident-led health and wellbeing in England. It was carried out between January and October 2016.

Local Trust commissioned this research, first, because a number of Big Local areas were beginning to engage with local health agencies; and, second, because areas were also becoming interested in ways to work with public agencies more generally.

Local Trust wanted to find the answers to two main questions:

• Do Big Local areas and health agencies have common priorities?
• How can they develop workable relationships?

We adopted a broad interpretation of ​‘health’ to include health and wellbeing and the wider determinants of health (e.g. housing, employment, transport, etc.). We believed that this would reflect the wide variety of issues that Big Local residents might see as ​‘health’ and, indeed, our experience during the research bore this out. The areas we worked with generally took a holistic approach to looking at health, mental health and wellbeing as part of the wider challenge of tackling poverty and deprivation.

This holistic view of health and wellbeing is in tune with national policy, such as the 2014 Care Act, in which ​‘wellbeing’ is a core principle, and the Better Care Fund, which emphasises the importance of integrated care and care closer to home. It also reinforces the idea that, locally, communities as well as health providers and commissioners are all part of a local health ​‘system’ or local health economy. Recent government policy and guidance has emphasised community development approaches to tackling health issues.

By ​‘health agencies’ we mean Clinical Commissioning Groups (CCGs), Healthwatch, GPs, NHS provider organisations, voluntary organisations and social enterprises, as well as private provider organisations, and Public Health.

Patient Participation Groups and CCG forums also featured in the research. Our findings will often apply to these groups, as well as to other non-health agencies whose work affects local health.

Throughout this report we use the terms ​‘Big Local partnership’ and ​‘Big Local area’ interchangeably and provide a snapshot of activities in Big Local areas, most of which are ongoing and will continue to change over time.

The areas selected for this study were chosen because they had shown a particular interest in tackling health issues. For many of the areas, health and wellbeing was often bound up in their wider objectives, such as improving access to education, tackling unemployment and improving the local environment, rather than seen as a standalone goal.

The following gives a brief overview of the seven areas that we worked most closely with during this research:

Beechwood, Ballantyne and Bidstone Village is in the Wirral. It has a population of almost 40005. The area is physically cut off from other parts of the Wirral and is generally not well-served by public transport. 93% of the population live in the most deprived 20% of neighbourhoods in England. 44% of children live in ​‘out of work’ households. The area sees Big Local as an opportunity to promote improvements in physical, social and psychological health and wellbeing, education, literacy, digital and financial inclusion and strengthen anti-poverty initiatives.

East Cleveland lies between a heritage coastline and the North York Moors National Park. The area contains 11 rural communities and has a population of 13000. Because of limited transport links, the area is not a typical location for new commercial investment and suffers from restricted employment opportunities and isolated communities. The area sees Big Local as an opportunity to build on its local heritage and to attract jobs, local business and much more local activity for the benefit of the community.

East Coseley is in the north-east corner of Dudley Metropolitan Borough. It has a population of 8300. In 2011, 58% of residents in the area were in full or part-time employment and 7% of residents were unemployed. There is a great deal of concern from residents about the difficulties faced by younger people and unemployed people seeking work. Residents want to use Big Local to improve the local environment and green spaces and generate more activities and employment opportunities within the local area.

Ewanrigg is a residential suburb within the town of Maryport on the West Coast of Cumbria. It has a population of about 1500. It has one of the highest Index of Multiple Deprivation (IMD) scores in the district, ward and country. Residents want to use Big Local to improve existing buildings and green spaces, develop facilities and activities, improve welfare and wellbeing and reduce crime and anti-social behaviour.

Hill Top and Caldwell is a neighbourhood located to the south of the market town of Nuneaton. It has a population of approximately 4000. Over 62% of working age people are classed as ​‘economically active,’ this is however lower than the Borough

average which is 71%. There are also nearly 100 young people not in post-16 education or employment. The area seeks to use Big Local as way to increase opportunities for employment and skills development, counteract poverty, and increase aspirations and community wellbeing.

PEACH (Custom House) is a district in the London Borough of Newham in London. It has a population of 13624. A listening exercise carried out by the Big Local partnership in 2012 found that some of the main issues affecting residents in the area are: the growth in zero-contract hours, unstable employment, and worries about what regeneration plans for the area will mean for local residents. There were also stories of people losing their children to street violence and the difficult relationship between some local residents and police. The area is full of people who love and are committed to the area and see Big Local as an opportunity to support improvements in employment, housing, safety and health in Custom House.

Wargrave is a district of Newton-le-Willows to the east of St Helens. It has a population of 5005. Over 60% of households in Wargrave are experiencing deprivation. Unemployment is a real issue with 10% of households having no adults in employment. The area sees Big Local as an opportunity to ​‘raise the ambition and aspirations of the people in Wargrave’ through a series of initiatives that will contribute to improving community safety, health, environment, employment and financial inclusion.

Towards the end of our research, we spoke to Big Local reps supporting four other Big Local partnerships that had also decided to focus on health and wellbeing. Speaking to these additional areas − Kirk Hallam, Lawrence Weston, Selby and Windmill Hill – helped us to check and test (‘triangulate’) our research findings.

Some writers are pessimistic about what can be achieved at local level, citing controlling cultures within the health professions, austerity, and that the key determinants of health lie way beyond the neighbourhood.6 They are critical of many community engagement programmes as being ​‘top-down’ in nature, co-opting residents in legitimising professional agendas or dependent on unrepresentative community leaders.

However, others argue that community engagement has a growing evidence base as a method of improving community health, alongside volunteering and expert patient models. Connecting Communities (C2), for example, is based on the belief that:

‘All dysfunctional communities inherently know what they need to heal themselves, and that by creating new ​‘listening’ relationships between residents and service providers, it is possible to transform a neighbourhood, with remarkable knock on health effects.’

There is a clear correlation between poverty, poor health and early death creating what Marmot calls a ​‘social health gradient’. Conversely, a range of studies has provided evidence on the positive links between social capital, the amount of control that people have over their lives, and health and wellbeing. There is a growing interest from health agencies in the role of communities in effective prevention and compliance, as well

as in tackling health inequalities and improving wellbeing (for example, in Scotland, the Healthy Communities: Meeting the Shared Challenge programme). Community

development offers an opportunity to listen to local people’s concerns and aspirations in relation to health, to increase their confidence and skills, to foster relationships between health professionals and local community groups, to develop community-based initiatives, to create opportunities for social interaction and to campaign against local conditions that negatively impact on health (for example, housing conditions, the preponderance of local shops selling cheap alcohol, etc.). There are many examples of local food initiatives and community gardens, Green Gyms and other exercise opportunities, as well as communities involved in managing Healthy Living Centres and similar initiatives.

There are of course challenges, familiar to all community programmes, of reaching the most marginalised populations; challenging professional mind-sets and predominantly medical models; austerity, short-term projects and programmes; combating the power of global corporations and so on. Not all of these can be met at a solely local level, but Big Local with its access to resources and support, and its relatively long-term timescale, offers an important opportunity to demonstrate what can be done.

We wanted this research to help Big Local partnerships make progress with health agencies as well as give us the information that we needed in order to report back to Local Trust. We took a ​‘participatory action research’ approach, which involved workshops with the partnerships and health agencies as a way of learning together about what could help them move forward.

The work was carried out in three steps: scoping, fieldwork, findings.

Step 1 – Scoping

Following a review of Local Trust reports and Big Local plans, we identified seven Big Local areas from those working with health agencies which were interested in sharing and building on that work as part of a research project. Before travelling to each area, we held telephone interviews with reps, workers and residents to understand more about health issues in each area and the ambitions of each Big Local area for health.

We also spoke to the School of Public Health Research (SPHR) to see if and where this research might contribute to or complement research they are conducting with different Big Local areas on behalf of Local Trust, looking at how collective control can impact on health and wellbeing.

Step 2 – Fieldwork

What we did in each area varied depending on what residents wanted to discuss and what they hoped to achieve next in their work with health agencies. Across the seven Big Local areas, the following took place:

• Focus group discussions with Big Local areas: We met either with whole partnerships or with health subgroups to hear about health and wellbeing locally and their ambitions for change through partnerships with health agencies. As well as collecting data to answer our research questions, we also: provided encouragement; reassured residents that their experience of working with health agencies – hard, slow to get going – was very common across Big Local; and gave residents concrete examples from other Big Local areas and beyond that we hoped would inspire confidence as well as introduce fresh ideas.
• Facilitated meetings between Big Local areas and their local health agencies: These included work on aligning values and managing expectations, as well as running action-orientated sessions looking at potential new ways of working together. Our role in these workshops varied. Some areas wanted us to be observers and reflectors, others wanted more ​‘hands-on’ support in building relationships and evaluating how current initiatives were working.
• Advice, information, resources and ideas: We offered bespoke advice, information and ideas on partnership formation, on the way local health economies work and on how practically to communicate with public agencies. We also provided advice on evaluating health and wellbeing initiatives and shared examples of how communities across the UK have worked with health agencies.

Step 3 – Findings

At the end of the fieldwork period, having done an initial analysis of the findings, we facilitated an event (with Local Trust and the Big Local areas that took part

in the research, including some of their health agency partners) to review and discuss the findings.

2. What are the issues?

When we asked Big Local partnerships what the health issues were in their area, these fell into two main groups: the prevalence of particular health and wellbeing problems; and access to services that could help tackle them.

In this section, we have set out the health and wellbeing issues in the Big Local areas we worked with as they were described and presented to us by residents in Big Local plans and during meetings and interviews. We did not see our role as checking or verifying these issues.

Most of the areas told us that multiple, long-term health conditions (such as obesity, diabetes, heart disease and smoking) were an issue in their area and that, as a result, health and wellbeing had been included as a priority in their Big Local plans. Big Local partnerships thought the high prevalence of long-term health conditions, such as diabetes and heart disease, might be linked to diet and lifestyle. When we asked them about this, they said that they thought more could be done to educate people about nutrition and about what constitutes a balanced diet. In some areas, partnerships knew of families with two or more generations that lacked this knowledge. As a result, for many residents these health issues have become the ​‘norm’ and as such they don’t recognise them as a problem.

Food poverty was mentioned as a major issue in three out of the seven areas. One partnership said that the number of residents seeking help from the food bank had increased to such an extent that it had been agreed that the food bank could support residents in the local area directly rather than acting as a distribution centre for the wider district. The same area thought that there were probably even more residents who would be entitled to use the food bank but were not doing so.

Two areas said that drug use was a significant issue. In one area, a local GP had spoken to members of the Big Local partnership, aware that they were closer to the community, and informally asked them for information to help him gain a better understanding of the scale of the issue and also to help spread the word about the support available to drug users.

Some areas said that social isolation was a common issue. Some thought this was partly linked to an ageing population – in one area, half the population lives alone – but it was also related to broader social issues in the younger population such as high unemployment. The need for more specialist services such as dementia care was also prevalent in areas with an ageing population.

Some areas also cited a high incidence of mental health issues. In one area these were thought to be massively underreported, and another said that improving mental wellbeing was the single biggest health priority reported by both residents and health providers.

At least three areas had taken a conscious decision to tackle entrenched deprivation and poverty head on as they were the root of a range of problems including health and wellbeing. There was an example in one area of a school where 73% of children were on the ​‘at risk’ register, and the partnership identified that tackling health issues without looking at social deprivation was meaningless. While Big Local partnerships are well placed to tackle health and wellbeing holistically, we found that health agencies were not always set up to work in this way.

Key points:

• Access to services is an increasing problem as local delivery points are being closed or centralised.
• The GP surgery has an important role to play.
• Partnerships can help by publicising services/​activities and getting people interested in health and wellbeing.

In all of the areas involved in the study, access to health services is cited as one of the biggest challenges to the improvement, or prevention of decline, of healthcare outcomes in the area. Residents gave examples of local health services being closed down or at risk of closure, with services being centralised or outsourced to nearby villages and towns. In one area, residents were aware of the planned closure of a cottage hospital located within their community. The Big Local partnership disagreed with the health trust’s assessment that the hospital and the palliative care it provided was not financially viable and had been able to obtain evidence which supported their argument.

Although many health services have taken measures to run certain basic health checks and tests regularly and to ensure they are more easily available to residents (for example, running informal clinics at events or at the local café) poor access to public transport and low car ownership in many of the areas means accessing other health services is still a major challenge.

Many Big Local areas are heavily reliant upon their GP surgery, as the most accessible means of obtaining healthcare treatment and information. Several areas said that,

due to a lack of other healthcare services in the area, and the additional strain placed on GP surgeries, it is hard to get appointments and there are long waiting times for prescriptions. Some GP surgeries have been working very closely with residents and Big Local partnerships to jointly identify ways to improve access to health services but this is often dependent on one GP and his or her relationship with residents. We learned from the research that even if a GP is supportive, it can be hard for that GP to act alone in the wider local health economy.

Several areas thought that the Big Local partnership could play a role in helping to publicise existing health and wellbeing services and activities in the area. Some Big Local partnerships were already doing this, for example, by publicising locally available fitness activities through their local newsletter. Health services are not

always advertised or publicised in the best ways for local people. For example, many services rely on social media but people who may want to access these services do not necessarily have access to or regularly use social media.

In several areas, attracting residents’ attention to local health issues and making them aware of the health and wellbeing services that are available to them had been a major challenge. Big Local partnership members said that many residents don’t consider themselves to be unhealthy or make a connection between how they are feeling and diet. Where residents do want to address health and wellbeing in their local area, Big Local partnership members (who had seen local health statistics) thought that most residents were not aware of the full extent of local health issues. However, one area reported that a combination of the health outreach support provided by their local community hospital and community centre, along with the availability of local wellbeing courses provided by Adult Community Learning and Wellbeing CIC (Community Interest Company), meant that ​‘local people know stuff’, about health and wellbeing needs in their area and where to go for support.

Key points: 

• Big Local provides a structure and support to help partnerships start work with health agencies.
• The money and time available to Big Local partnerships mean that they have something tangible to ​‘bring to the table’ when they are trying to form new relationships with health agencies.
• Partnerships are also able to give agencies a clear picture of local health issues as residents experience them.
• They can provide a space where health agencies and residents can come together.
• They can act as a test bed for new ideas or for attracting new services and facilities into the area.
• And they can promote new initiatives with local residents.

This section is based on what Big Local partnerships told us about their experience of working with health agencies and on our experiences of working alongside them to develop some of those relationships further. Our research confirms that Big Local areas can make important contributions to health and wellbeing. In this section, we set out what those are and provide examples of where this is already taking place using the following headings:

• Structure
• Resources to help shape local services, activities and facilities
• A fuller picture of health and wellbeing
• Bringing people together
• Test beds for new ideas and activities
• Health promotion

Structure

We learned that working with health agencies is tough to begin with – and some areas found progress slower and more likely to get ​‘stuck’ compared to when tackling other priorities. But we also learned that health and wellbeing is important to people living locally and appears to attract small groups of passionate individuals who really want to do something about it.

Big Local provides a structure and support to help residents get started and maintain momentum. Specifically, the Big Local rep and worker were both instrumental in providing encouragement and jointly navigating the local health economy (mainly they were on a learning journey themselves). Having paid workers also provides someone who is a dedicated resource to take on day-to-day administrative tasks, leaving residents to focus on the more interesting tasks, making them more inclined to want to stay engaged in Big Local activities. Most areas also had a subgroup of residents who wanted to focus on health and wellbeing. Those that had attracted someone from a health agency to sit on a subgroup benefited greatly from their presence. Big Local partnerships that were successful in engaging health agency representatives had managed to do so by identifying a particular individual who shared some or all of their own objectives. These individuals joined the Big Local partnership as non-voting members, used their professional networks to help the partnership pursue its aims, and became involved in Big Local activities.

Resources to shape local services, activities and facilities

Big Local partnerships felt that having money and time on their side provides them with a very tangible resource to bring to the table to encourage others to work with them.

One partnership even said that they think there has been general increased interest and investment in their area since the arrival of Big Local, as it makes a statement that the area is worth investing in.

Big Local Partnerships have (financial) resources behind them and the time to research and understand the needs within their community before making any decisions about spending. This has enabled resources to be invested wisely:

‘It’s OUR money, and we will be careful about how we use it, maximise it, use it to lever in other services already part funded, and all the time holding on to what Big Local is about.’

In some cases, Big Local partnerships have used these resources to provide services directly linked to health and wellbeing. For example, East Cleveland Big Local had bought and helped to run the local minibus service that provides transport for individuals to get to and from hospital appointments, after this had been decommissioned by local health agencies due to cost. In other cases, partnerships have used Big Local money as seed funding to help kick-start an initiative or service. On speaking to Big Local partnerships about their decisions to directly fund services that had previously been state funded, they said that they were doing so because there was still a clearly identified local need but that this did not negate the possibility that they may argue for state funding to be reinstated in the future. Some partnerships also felt that by continuing to provide these services it also proved the point that there was still a need. In addition, they had often adapted these services to fulfil a wider purpose. For example, the minibus was also being used to take residents on day trips and contribute to tackling the issue of social isolation in the area.

Other partnerships see their long-term role as helping to prioritise and validate ideas rather than becoming involved in delivery. They help to shape how things are done and manage or support other local organisations (such as local community groups/​voluntary sector organisations or statutory agencies) to deliver the services.

Hill Top and Caldwell (HTC) Big Local have commissioned their local Healthy Living Network (HLN) to conduct free health-checks in the area. They have also worked with the HLN to set up a range of health initiatives within the local community centre including a breakfast club, Zumba classes and a Super Kitchen. The Super Kitchen uses waste food to cook healthy meals at the same time as teaching participants how to cook. HTC are keen to identify ways in which more health services could be brought into the community and encourage more community members to engage with these services.’

Wargrave Big Local are also in discussions with the Local Authority Health Improvement Team and other health agencies about how they can work together to provide health and wellbeing activities that are tailored to the needs of residents in Wargrave, in particular those who are most in need of support.

A fuller picture of local health and wellbeing

Many of the residents involved in Big Local partnerships have been directly affected by changes to local health services because they or people they know have experienced poor health. They have insight into residents’ experiences and perceptions of health services and into the ​‘in addition’ problems that, for some people, can make their health problems worse but that often go unreported. As a result, Big Local partnerships can provide residents and health agencies with a fuller picture of local health issues.

‘They [residents] tell me things they won’t tell you [health agencies].’

This particular partnership member is part of an informal network of residents who support local families. She explained that the local GP taps into this informal network and asks her and others to encourage residents to seek help with health and wellbeing issues, such as the need for support around healthy eating for a family with an obese child.

Although it has proved to be a challenging process at times, contributing to the gathering and dissemination of data on local health issues is something tangible that Big Local partnerships are well positioned to take forwards and it can help them to forge new relationships and partnerships in the process.

One CCG representative who had met the Big Local partnership in the early days of starting her role said that she had really welcomed the opportunity, through engaging with the Big Local partnership, to familiarise herself with the local community and its health issues:

‘We [CCG staff] are expected to hit the ground running. We don’t get the chance to go back to basics … And you, Big Locals, are going back to basics.’

She said that this was not something she would have otherwise had the opportunity to do during her induction. Big Local partnerships could potentially find a place in these kinds of under-used and mutually beneficial opportunities, like health agency staff inductions, to engage with health professionals.

PEACH Health Group’s focus to date has been on improving access to the local GP surgery and gathering evidence on the problems experienced by local residents. Group members conducted a story gathering exercise, asking residents to describe how they had personally been affected by poor access to health services. Based on the evidence gathered they produced a report and leaflet that explains the issues and describes what PEACH Health Group has achieved so far. The stories highlight the human impact of what is going on and why it matters. They also provided an opportunity for residents who were unable to attend the formal meetings to still have a voice.

In Beechwood, Ballantyne and Bidstone Village, partnership members said that being able to provide residents with the raw, very local data, presenting it visually and breaking it down by theme ​‘really helped residents understand the situation they are in’. They also hired video pods and put them in local schools to encourage residents to come and record what they thought about the priorities identified in the initial consultation.

During the time we were carrying out this research, Wargrave Big Local was in the process of carrying out surveys of residents to find out more about how they see the health issues in their community.

East Cleveland has worked closely with Loftus Accord, a forum for Chairs and officers of various faith, resident, community and business groups, to take a joint approach to tackling local issues, including health and wellbeing. Together they have conducted a health needs survey and supported NHS England to conduct a survey about dentists.

Bringing people together

Building on the Big Local ethos of bringing people together, Big Local partnerships are providing the opportunities for residents, health agencies and other local decision-makers to come together to discuss and tackle health issues in their local area. Often this is done through informal spaces, such as the CHAT (Community Health & Transport) group set up by the East Cleveland Big Local.

We came across similar initiatives in all the Big Local areas, such as the ​‘Make Maryport Smile’ campaign in Ewanrigg, and various local fun fairs and events that had been organised by Big Local partnerships. The focus of these activities and events was always first and foremost on bringing people in the community together and providing them with a fun day out, but they were then used as a dual opportunity to signpost the residents to health and nutrition services and information in a very light touch way. Because health providers are also taking part, coming along to provide free health checks or run stalls, these events provide them with an informal opportunity to find out more about people’s experiences of and views on health services in the area, as well as a chance for local voluntary sector organisations and health agencies to talk to each other. One Big Local area made the point that events like this can also demonstrate to residents that the voluntary sector and health agencies are working together in a joined-up way.

East Cleveland Big Local’s CHAT group is a weekly residents’ group that meets up over coffee and cake to decide on destinations for minibus outings to local attractions and beauty spots. The partnership also uses these meetings as an opportunity to gather information on community needs and access to services. Health professionals are sometimes invited to these sessions and are given a twenty-minute slot to talk to residents about a particular health issue or initiative. One resident said of this group in terms of its impact on her own and other residents’ wellbeing: ​‘It’s one of the best things that has happened in Loftus’.

Test beds for new ideas and activities

Several Big Local areas have acted as test beds for local programmes, able to take certain risks that health agencies may not be so free to take. Partnerships have also linked to existing local health and wellbeing schemes, while, in some cases, local councils have asked a Big Local partnership to help them pilot a new scheme.

Wargrave Big Local partnership members commented that although what they are able to pilot at this point is not anything over and above the basic services, what was important from their point of view was that these services were on offer in and tailored to their local area. 

In East Cleveland, the Big Local partnership had already set up a local walking group and the local authority provided training for walk leaders (19 local people are now trained) so that the initiative could be scaled up and offer a range of walks, which served the additional purpose of helping to attract more local tourism.

In Beechwood, Ballantyne and Bidstone Village, the Big Local partnership purchased 26 leisure passes that were then handed out free (on a first come, first served basis) to people who went to the health centre for a health check and agreed a health action plan.

Health promotion

Big Local partnerships know that in order to interest residents in health issues and encourage them to take action, health messages and activities have to be delivered in a language and approach that is locally appropriate. In Ewanrigg, the Big Local partnership had plans to launch ​‘How’s your fettle?’ – informal health checks for local residents that would also be a symbolic way of having more of a health presence in the community and that would gently encourage more engagement, particularly for those residents who might not take the first step of going to the GP surgery. Several Big Local partnerships said that by taking a more community-based approach to health messaging and approaches, residents are more likely to engage:

‘If we put a stall up to say Advice Available, or Health MOT – there’s not exactly a rush to engage! But using a more community-based approach, HLN have managed to access people who would be put off or not engage normally.’

Big Local partnerships can also help health agencies to identify the most appropriate response for engaging residents in health issues. Wargrave Big Local described this role as being able to reconcile people’s personal knowledge with what the data says and asking health providers: ​‘How can you work with us to do something about it [the local situation in relation to health and wellbeing]?’ Big Local partnerships have already been putting this principle into practice in their own approaches to engaging residents in health and wellbeing issues and activities. Some take a ​‘health by stealth’ approach, incorporating health messaging into other activities and events, while others prefer to use shock tactics, gathering statistics on local health issues in order to present the scale of the issues to local residents. In each case, their approach depends on their prior knowledge and understanding of residents and the underlying issues in the area and using this to help design an approach they feel residents will be most likely to respond to. We also saw a number of examples where health agencies have already begun working with Big Local partnerships to help embed health plans within the community. For example, the Public Health Team in one area has worked with the Big Local partnership to address the issue of smoking cessation, consulting it on locally appropriate solutions, e.g. controlled smoking zones, underage restrictions, etc., and working with it to look at how these plans could best be introduced at a local level.

Several Big Local areas are also proactively seeking ways to engage more volunteers within the community, with the dual purpose of helping to support Big Local activities and resident engagement but also as a way of tackling issues such as social isolation within the community.

Key points:

• Partnerships have found that finding allies within the health system, having good networks generally and demonstrating common aspirations can all help to build relationships.
• Both Big Local partnerships and health agencies could explain more clearly to one another what they can offer or how they can contribute to health improvement.
• Big Local partnerships need to be willing to step outside their area boundaries when this can benefit local residents.
• However, establishing their legitimacy within the wider health system can still be a challenge for Big Local partnerships.
• Cuts and changes to health structures also present a challenge for existing work and relationships and to sustainability.

Finding allies

All the Big Local areas in this study found it hard to know which health agencies to talk to, who to talk to within them, and how to go about this. Having some assistance with identifying likely allies, working out who to contact and some help with understanding local health agencies’ priorities made a big difference. In some cases, IVAR assisted directly in this process, helping Big Local partnerships to identify or prioritise the most relevant health agency representatives and facilitating discussion. Individual areas had also identified their own tactics, such as appointing a health lead; one Big Local area told how one of their members who has great ​‘personality and charm’ had been successful in getting past some challenging relationships in order to win over staff at the local GP surgery.

The most likely health agencies for partnership working were Public Health (local authority) and service delivery teams in the public or social enterprise sectors. All the Big Local areas wanted a relationship with local GP surgeries because of their role in addressing health and wellbeing and because they can reach so many residents (in some areas they had the highest footfall of any local organisation).

Individual relationships and the identification of key allies within healthcare agencies, who understand what Big Local is about and the importance of connecting with residents, have often proved fundamental to Big Local partnerships’ ability to engage in and influence local healthcare agendas. Finding healthcare professionals who are part of and understand the community and who have perhaps been independently looking for ways to engage local residents in healthcare solutions was often down to luck and serendipity rather than something that could be planned for. However, several Big Local partnerships had often found natural allies within health structures. For example, in several areas the local GP – sometimes the whole surgery but often just one individual – has gone to great lengths to work with the Big Local partnership to improve the availability and quality of services in the local area. One partnership member, who is also part of a Public Health team, said that her boss really ​‘gets’ the importance of resident engagement and supports her to work with Big Local as part of their health promotion work. Another Big Local partnership said that involving Public Health had brought borough-wide experience to the group and helped them to align the groups’ health priorities within the Big Local plan. Big Local partnerships can also be a welcome ally to individuals within the health service who feel they are isolated in wanting to bring about change from within.

In one area, the CCG has appointed a Link Development Officer whose role is to link up voluntary and community sector bodies and health agencies to identify joined-up solutions to health issues. Although CCGs in other areas had also been pro-active in reaching out to residents, such as attending Big Local meetings or running public information forums, some CCGs felt that they were not always the most appropriate health agency for Big Local areas to engage with directly as they were not able to take the kind of localised approach to change that Big Local areas or Public Health teams were able to do.

We came across very little engagement between Big Local partnerships and Patient Participation Groups (PPGs) although two areas that had not worked with their PPG in the past had both been advised by health agencies to do so. This was for two reasons. First, to be seen to engage with the structures that exist; and, second, to explore whether or not there were opportunities to work together. One area had followed this advice and had contributed to a meeting of their PPG. Their reservation was that while they were listened to, it was not made clear to them how their points would be taken forward. Another area had struggled as, in order to join a PPG, you have to be a patient of the GP surgery affiliated with it and most of their members attended a surgery outside of the immediate area.

While the identification of key individuals within health agencies, who act as allies and messengers for both sides, has helped Big Local areas to navigate the current complexity of healthcare structures, the reliance upon individual relationships and access to the right networks can mean that those Big Local areas that do not have access to such individuals are at a disadvantage. One area commented that the lack of engagement of their local GP has been a real barrier. It means that it has taken Big Local partnership members much longer to get their heads around the complex set-up of health structures and agencies in their area:

‘If we could actually, in partnership with the CCG Link Development Officer, make some headway with the GP in the area that would really make a difference, but at the moment it’s a bit flat.’

The Big Local group, PEACH, pointed out that finding allies might also be about going beyond health agencies into the wider community who also have a vested interest in championing the same health issues. Such allies can add strength in numbers to Big Local partnerships and help to advocate on their behalf. This partnership gave the example of building alliances with the local schools and churches in its area.

In Ewanrigg, the Big Local partnerships and residents came together through the ​‘Save Our Beds’ campaign to prevent the closure of the local cottage hospital. As a result of the campaign they now have the support of the whole GP surgery and huge numbers of residents. But it was also because they had managed to secure a health expert on their partnership, who provided them with information suggesting that the hospital’s closure would not lead to valid cost-savings, that they were able to take this view and launch a public campaign to save the hospital.

Big Local’s existing networks

Many of the Big Local partnerships that had chosen to work on health were already linked to other local networks and resident-led schemes, or held existing roles in the community, such as youth worker, Brownie leader, community policy officer, teacher, vicar, etc. These networks enhance the Big Local partnership’s ability to engage and bring together different agencies and demographics within the community to discuss and act on health issues.

Through these networks and partnerships, Big Local areas can strengthen resident engagement in tackling health issues. Several areas said that engaging residents beyond those involved in the Big Local partnership itself is often challenging but that they are often better placed than health and other service agencies to understand and find ways to try and overcome these challenges. Big Local partnerships are using their individual networks, their presence on social media, newsletters and sometimes even door-to-door leafleting to help publicise existing local health initiatives and activities.

In East Cleveland, the Big Local partnership put on a panto, ​‘Snow White and the Seven Doofers (they ​‘do for others’)’ which they took to 11 venues across eight of the 11 villages that they support. The panto helped to spread the message about Big Local and the East Cleveland community and weaved in messages about health and wellbeing.

East Coseley Big Local are working in partnership with other voluntary sector organisations, private companies (Network Rail & London Midland), local schools and the Council to improve the infrastructure of the local area, encourage more use of green spaces and improve the health and wellbeing of local residents. These include:

• Canal towpaths clear-up (in partnership with the Canal and River Trust)
• Coseley Railway Station clear-up and flower bed planting
• Green Gym installation
• Allotment project
• Skittles tournament (around 100 people take part, four times a year)

All of these initiatives, even if they were not directly conceived as public health initiatives, help to improve health and wellbeing in the area and bring the community together. One resident said ​‘success breeds success’ because, even though it had been hard work at times to convince local partners and residents to get on board with the different initiatives, once they had seen them in action, people really got behind them.

Residents and health agencies want the same thing

In conversations with Big Local partnerships and health agencies, we found that residents and health agencies are often all striving for the same health outcomes but sometimes these are simply expressed in a different language or approach. So it helps when Big Local areas and health agencies can find common ground and work on those issues together.

This is not to say that alignment was always easy to find. Big Local partnerships acknowledged that it may only be later down the line working on a particular health issue that people realise how they can work together and counselled others not to lose heart if common priorities are not immediately apparent. In some Big Local areas, it was much harder to find common priorities or get health agencies to see them as legitimate groups. In such cases, the relative autonomy of Big Local partnerships was an important factor in enabling them to challenge health authorities on certain issues that they felt it was the health agencies’ responsibility to resolve.

In Beechwood, Ballantyne and Bidstone Village, the Big Local partnership wanted to tackle the high level of smoking. As there was already a local smoking cessation service that was trying to recruit people onto its books, the partnership invited this service to join in on the door knocking that it was already doing to introduce Big Local and find out about health issues in the community. The smoking cessation service was able to ask an additional question about smoking and offer support. A mutual respect for each other’s knowledge, experience and networks, helped by the fact that the cessation service had already been working on the estate so was also known there, and a willingness to share access to residents, made for a successful collaboration.

Explaining well what Big Local brings to the table

We found that Big Local can help to open doors to health agencies if the partnership can explain clearly what Big Local is about and has to offer. This wasn’t always easy and most areas said that explaining what they do was ​‘a work in progress’. CCGs and others were often surprised to hear that there was money attached to Big Local, and about Big Local being a long-term initiative. During this research, Big Local areas were thinking about:

• How to word invitations to community events in a way that would attract health agencies to come along.
• What kind of logo and other visuals would help people understand the Big Local offer.
• How to convey to a surgery, which might be reluctant to engage with residents, that Big Local can be a part of the solution to local health and wellbeing issues.

In Wargrave, the Big Local partnership’s health sub-group hosted an introductory meeting to talk to health agencies about Wargrave Big Local and make them aware of the energy/​people, time and resources available to Big Local areas and identify possible shared priorities. It was important to keep reiterating key messages about Big Local – ethos, timeframe and money – so that when partnership members or health agency personnel change, this knowledge isn’t lost.

Where Big Local areas have developed a clear health ​‘offer,’ they have something tangible that they can present to health agencies to help kick-start their initial engagement. As the example from Beechwood, Ballantyne and Bidstone Village below shows, it helps if Big Local partnerships have been able to time these engagements to coincide with emerging opportunities within the wider health sector.

Being able to drill down to a very local level is an important part of the Big Local offer. Although Big Local areas have gathered strong anecdotal data on health issues in their area, they also recognise the importance of building on this through more formal data collection in order to present a clearer and more compelling case to health agencies, whose own remit tends to be borough-wide. In Beechwood, Ballantyne and Bidstone Village, the partnership said that better data collection during and after its free leisure passes project would have helped with needs identification during the project and might have also helped them to demonstrate the longer-term impact on people’s health and their levels of activity.

In Beechwood, Ballantyne and Bidstone Village, changes to the Joint Social Needs Assessment process locally provided new opportunities for consultation on health issues which the Big Local partnership was able to engage in. The partnership used this as an opportunity to work with the Joint Strategic Needs Assessment Intelligence (JSNAI) team and a local housing association to obtain health-related data on the Big Local area. The JSNAI’s contribution made a huge impact as the team used their time, skills and information to drill down into health statistics that were specific to the Big Local area. Engaging in this process and sharing the data that Big Local had collated on local health issues also helped to give the Big Local partnership authority and status in the local area, with the findings from their research also being shared on the CCG and local council’s Health and Wellbeing websites.

Stepping outside the boundaries

In order to grapple with the local health economy both Big Local partnerships and health agencies may need to work with people, groups and organisations that lie outside or are larger than the Big Local partnership’s or a particular health agency’s area.

One area, where it had proved very difficult to engage the only health provider actually located in the Big Local area, was advised by Public Health and the CCG to align itself with district-wide structures that would be broadly supportive of their ambitions. Interestingly, another Big Local partnership commented that it had been easier to engage with the County Council, as the Big Local area was on the Council’s ​‘high health needs’ list, whereas the Town Council seemed to struggle with the fact that the Big Local partnership did not cover the whole area. These examples highlight the need to sometimes look beyond the most obvious allies and to consider working with agencies that are located outside the area and/​or that have responsibilities that are wider than health and wellbeing.

Ewanrigg backs on to estates which share similar health challenges and community assets. The Big Local partnership is concerned that if it focuses only on the Ewanrigg area it is at risk of increasing inequality and creating artificial boundaries, so it is trying to integrate its local work with initiatives that ripple out across the wider area. It is working with Maryport Health Centre to set up a new entity, the Maryport Health Assets Group (MHAG), which has been an informal partnership until now. This will cover the wider geographical Maryport area, allowing Big Local Ewanrigg to maintain its focus on the Big Local area as required and ensure Big Local funding is focused there, but also work in partnership to effect change in a wider geographical area – an area that makes more sense in terms of service transformation. MHAG continues to go from strength to strength, adapting its structure to jointly agree on independent organisations that work alongside Ewanrigg Big Local.

Being recognised as a legitimate player

Although many Big Local partnerships have formed positive relationships with local health agencies, several of them said that they still struggled at times to get health agencies and residents to see them as legitimate groups. Members of one Big Local partnership said that when they had taken certain issues within the community to the statutory bodies they had been told: ​‘We’re dealing with it’, but it didn’t seem to them as though any action was being taken. They said that sometimes statutory bodies’ insistence on going through the right channels can create barriers and hinder progress and be quite demotivating. Another group gave an example where it had worked hard to get issues raised by residents onto the agenda of the Patient Participation Group meeting and had spent time practising its negotiations but, when it came to the meeting, the discussion was ​‘hijacked’ by a focus on over-use of inhaler prescriptions.

Cuts and changes to public services

Cuts, mergers and outsourcing have led to some partnerships having to start afresh and build new relationships with agencies, including local authorities and others outside the formal health system. These have taken time to establish. One Big Local partnership had the support of a very proactive local GP but, due to a merger of two local surgeries, this GP was no longer able to participate as fully on the partnership. Cuts have also placed an increased burden on some of the health professionals that are willing to engage, and their participation is often reliant upon them putting in large amounts of time and capacity outside their day job. In one Big Local area, the relationships the partnership had built up with a local health team were lost when the team’s work was outsourced to a social enterprise. Another area that was advised to work with its Healthwatch found that the Healthwatch contract was being retendered. While this was going on there was no one for them to work with. Reflecting on why they were still struggling to identify and build relationships with health agencies, one area thought that this was perhaps because as there were so few services left within the community, there was no one to form these alliances with.

Shaping services – the highs and lows

For many Big Local areas, supporting the commissioning of health services in their area has been a process of learning as they go along and managing residents’ expectations.

There was also a barrier for some areas in sorting paperwork between the Locally Trusted Organisation and the service provider they wanted to work with, and the commissioning and procurement process sometimes led to delays in initiatives being started. These sorts of delays could sometimes be quite demotivating for Big Local partnerships and could create difficulties when managing residents’ expectations.

One Big Local area commented that the siloed ways of working within some public agencies were at odds with their own approaches and the needs within the community. They gave the example of the local education team’s approach to getting kids to school. The education team saw their role as increasing attendance by getting children into uniform and to school. They were not prepared to work with the Big Local partnership and residents to help tackle the underlying causes, linked to poverty and deprivation, that were affecting children’s attendance in school.

With Beechwood, Ballantyne and Bidstone Village Big Local’s leisure pass project, the partnership was able to give people the opportunity of leisure passes for four months but it couldn’t offer them anything afterwards. The partnership had hoped, following talks with the local council, that the council would offer some form of further discount for using the services, but the council was under such financial pressure, it couldn’t. So, although the project was a success whilst the partnership was able to fund it, residents were unable to afford the cost of the passes once they were no longer free and so stopped attending. This suggests that Big Local activities need to be linked to wider health priorities and funding plans if they are to be sustainable.

In East Cleveland, the Big Local partnership had made the decision to take over the local minibus service, previously funded and run by the local GP surgery when it was part of the Primary Care Trust. It was aware that ​‘We, the community, are saving services money’, but took the view that it was still better to be able to fund the service for an additional year or two than for it not to exist at all. However, at the same time it was lobbying for improved public transport links to the local area. The local Healthwatch has been working very closely with the Big Local partnership to do this, including taking the residents’ stories of access to health services to the Clinical Commissioning Group. So, the Big Local partnership has been able to make use of its Big Local resources to provide a service that would otherwise have been cut, but was simultaneously working with health agencies to look for more sustainable solutions to the issue.

The balance between protecting services and plugging gaps

Whilst Big Local partnerships were very aware of and sympathetic towards the current realities of reductions and cuts to health services, they were also clear that Big Local resources must be protected and should not be seen as replacing provision by health agencies. Local Trust guidance also states that Big Local money ​‘should not simply replace statutory funding that meets a statutory obligation.’ This means that Big Local funding needs to be ​‘additional’ to public funding (things national and local government should fund). However, what we learnt from the areas that we worked with is that, in reality, it is often hard to define statutory obligations when many public services are being restructured or cut.

Some areas felt that more could be done to engage residents in helping to come up with potential solutions to cuts in services – solutions that could address this reality but still respond appropriately to residents’ needs. Several Big Local partnerships are helping health agencies to find more creative and inclusive ways to encourage residents to become involved in local issues. Examples include encouraging health agencies to run stalls at local events, or providing health checks in more informal spaces such as the local café.

Our study has shown that health and wellbeing issues are important to Big Local partnerships, and that much has already been learned about what opens doors to health agencies but that this is a process that may take time to get started. Progress can be slow and frustrating but can be boosted by chance as well as design. Even small gains are important because these will help to build a relationship with health agencies and pave the way to bigger changes.

The Big Local areas that took part in this research were already contributing to health and wellbeing locally. They had:

• Provided new services to local residents
• Gathered new information to inform local health services
• Influenced the way existing services are provided to tailor them more closely to local needs and preferences
• Promoted strong health messages to residents

We were asked to address two main questions. In this section, we set out our preliminary answers to those questions based on the data we have collected and then set out five themes that emerged as important.

QUESTION 1: Do Big Local areas and health agencies have common goals?

Yes, they do but often they are articulated and experienced differently. This means that sometimes they don’t realise that they do have common priorities. It helps to bring people together and give them ​‘permission’ to be frank about their priorities and what they want. Get it out on the table that everyone in the room actually wants better health and wellbeing outcomes for residents but have different ways of talking about it and different specific requirements, obligations, accountabilities and focuses. Health agencies can help Big Local partnerships to access other health agencies and fit their actions into wider strategies.

QUESTION 2: How can Big Local areas and health agencies develop workable relationships?

Accept that it takes time and patience to build relationships. Understand that relationship building is a task in itself. For example, it could involve persuading someone from Public Health to spend time with the Big Local worker or sit with commissioners explaining what the Big Local ​‘offer’ is. Breaking into whole health agencies is really tough and finding an ally in a health agency can be a good place to start.

Below we talk in more depth about how Big Local areas and health agencies can draw closer in their efforts to improve residents’ health and wellbeing.

THEME 1: Mutual understanding – getting across the Big Local offer and the ask

For both parties to be able to see the bigger picture – see below – they need to understand one another. There are barriers on both sides that can be broken down by identifying common aims. Health agencies and Big Local areas should be clear and transparent about why they want to collaborate with each other, what their own interests are, and then work together on a joint plan of action. But the first step is being in touch and it does need Big Local areas to get better at saying what they have to offer and also what they want. Big Local areas found this hard. From our research with areas, we have created a visual summary of what Big Local can bring to the table (the ​‘offer’). Areas can use their Big Local plan to help them articulate what they are looking for (the ​‘ask’). Big Local reps can help with the ​‘ask’ by supporting partnerships to ask questions and think things through when deciding whether to get involved with a health agency’s activities.

Messages that health agencies needed to hear included:

‘We’re here, we are passionate and have time and energy; we are residents and can connect you to communities; we can help you meet your statutory obligations to engage with people and communities; we’ve got a significant amount of flexible money that we can use to try new things; we want the same as you for local residents’ health; we are up for partnering you; we’re in it for the long term.’

Key message for residents: You need to explain to health agencies what you bring to the table and what you want. And you will need to keep explaining it to help them understand why they might want to work with you. You also need to keep explaining how they can work with you so that you maintain control over your resources and ensure that all your activities continue to be resident-led.

Key message for health agencies: It can be really hard for resident groups to know which health agencies to talk to, and how to go about this. Health agencies can help by taking proactive steps to engage residents in discussions about local health services, both through more formal forums such as Patient Participation Groups but also by participating in resident-led groups and activities.

THEME 2: Your local knowledge – a fuller picture of local health and wellbeing

Some Big Local areas had produced reports about local health and wellbeing. These married local people’s knowledge and experience with statistics and research (while accepting that these will not be precisely the same as Big Local). Big Local partnerships used these reports to challenge norms that affect local health and wellbeing and to shape services, activities and facilities to what local people need and want.

Big Local partnerships needed the skills, knowledge and contacts to collect information from residents and agencies, and then to compile and present it in ways that were accessible to residents.

Local Trust can help with data: Local Trust can also help with drilling down to very local data and presenting statistics. It has weighted data for all of the Big Local areas, based on the 2010 census, which could help provide a useful starting point. It can also put you in touch with other areas who have had successful relationships with universities or colleges to work with research students.

Key message for residents: Health agencies have data that Big Local needs, but Big Local also has access to information, data, and experience that complements the health agency data and makes it real. It’s worth getting help to build skills and knowledge about data and how to present it if you want to work on health.

Key message for health agencies: Residents’ experiences and opinions about health and wellbeing locally matter. If you put them together with local statistics, then you have a strong picture of local issues that you can use with residents to shape services and convince other residents about the importance of tackling health issues in the community.

THEME 3: Allies – finding people who want to be part of the bigger Big Local picture

The best relationships are ones where health agencies actually want to get involved in the whole of Big Local. They are interested in the ethos, plans and ideas. They see the point of turning up to community events and understand how their particular health promotion ambitions fit into this bigger picture. Big Local areas similarly are interested in how their ambitions can be reflected in the responsibilities of health agencies and are interested in how they can help.

It is important to identify allies who see health as part of a wider picture and are prepared to look at tackling it holistically – and looking at what assets they and Big Local can bring to the party. Some of those allies may in turn be looking for support outside the system to help them drive change from within. Allies can also be helpful if they are interested in connecting efforts on health to other issues, like transport, that can help or hinder progress. But finding and holding onto allies isn’t always easy – people move on – and even if allies are supportive, it can be hard for them to act alone in the wider local health economy. Where there are very few services left in a community, it makes it very difficult for Big Local partnerships to find individuals who they can form the necessary relationships with.

Key message for residents: Go where the energy is. Be open to chance meetings and find individuals that get what you offer and how you work. But be aware that these individual allies will need leaders ​‘further up the system’ who back them up. And once you have your ally ask them to help you build a relationship with their organisation so that if they move on you don’t have to start from scratch. It may be that you can also form a collaboration with other voluntary organisations who have more traction with health agencies locally and piggy-back on their relationships and events.

Key message for health agencies: Health agency representatives already working with Big Local partnerships can help them to form relationships with a wider network of health professionals. This could be done through helping them to look for mutually beneficial collaborations, for example, Big Local partnerships inducting new health agency members on the demographics and issues within their local community.

THEME 4: Boundaries – they needn’t get in the way

Big Local partnerships have a remit to work within specific, usually quite small, area boundaries for the good of the people that live there. Most health agencies cover much larger geographical areas and have a responsibility for much larger populations. We learned from Big Local areas and health agencies, first, that health and wellbeing 

problems and their solutions do not fit neatly into these geographical or administrative boundaries; and, second, that it is sometimes essential to work beyond area or administrative boundaries in order to address residents’ health and wellbeing, especially in the long term.

Although Big Local’s remit is to work for the good of residents who live in a particular area, neither they nor the health agencies that work with them think that this needs to be a barrier to working together. Big Local partnerships can work without their area if it meets the Big Local outcomes of transforming the Big Local area.

For example, the Big Local areas and health agencies we talked to told us that:

• Health agencies have benefited from the opportunity to gather detailed information on local needs and to talk directly with local residents.
• It sometimes makes sense to tap into a borough-wide initiative to tackle a particular health and wellbeing issue that has been identified by residents, rather than trying to tackle it alone.

So, while working together creates challenges in relation to geographical and administrative boundaries, our research found that, where both parties wanted to collaborate, they were able to get over these difficulties without too much trouble.

Key message for residents: Look at the most appropriate boundaries for you on a case- by-case basis and be prepared to go beyond them where that is necessary for you to address local issues. Don’t let them be a straitjacket, given that most health agencies will have a remit to work across a wider geographical area.

Key messages for health agencies: Working with a Big Local area can help you fulfil your responsibilities to the wider population as well as improve health and wellbeing in the Big Local area. Solutions to problems in one small area will often be applicable elsewhere and the experience of Big Local area residents can inform your wider work.

THEME 5: Time and timing

Big Local partnerships will pick up health as an issue at different points in their development and the ​‘right time’ will be different in different areas. Meanwhile, they may find that other activities that they are doing, such as tidying up the local area, arranging social events for local people, are still contributing to health and wellbeing and relationship building.

We know that it takes time to build relationships and gain trust, and this is particularly tricky when working on a complex issue like health. We found that Big Local areas did a considerable amount of work to pave the way to working with health agencies:

relationship building, researching health and wellbeing and, in some cases, recruiting a worker to take on some of the tasks involved. This meant that, when the time was right, or the opportunity arose to take action on health, they were ready. This was the case in two of the areas we worked with:

• Spotting when the time is right to make your move: A Big Local area that had been unable to build a relationship with the GP surgery discovered that there was a change in Practice Manager. The Big Local group already had their research on local health and wellbeing ready, they spotted their chance to make a breakthrough and grabbed it with both hands.
• Being alert to who else is out there and what they are thinking about: A Big Local area had been talking publicly about their asset-based community development approach at the same time as the local GP was researching asset-based approaches to health – they heard each other speak and realised they were thinking along the same lines and could work together.

Key message for residents: Tackling health and wellbeing is intensive work so consider buying in extra help in the form of a worker or recruiting volunteers who can concentrate on health. Try and find a quiet period in your Big Local schedule to begin to tackle some of the trickier issues like health. You can also begin by doing your preparatory work, such as having your research on health issues in the local area done and ready for when you decide to take action.

Key message for health agencies: It may not be immediately apparent what you and Big Local partnerships can do together, but it’s worth cultivating the relationship and giving it time to emerge. Big Local partnerships have at least 10 years meaning that they offer a chance to think and plan with communities for the medium and long term.

Representing your data

How to present health inequality data in a striking, easy to understand format.
This resource is an example from Beechwood, Ballantyne and Bidston Village Big Local who worked with local health and housing agencies to gather data about their area.

In a ​‘nutshell’ Beechwood, Ballantyne and Bidston Village

Population: There are 3,950 people living in BBBV. 66% of people have access to the internet.

Education and skills: 39% of people have no qualifications (22% nationally). By Year 1, there is a 5% shortfall in achievement by pupils against national average.

Housing: 2% of households lack central heating (3% nationally). 58% of people live in social housing (18% nationally).

Economy: The largest employment sector in the area is health and social work. The % of people on JSA is double the national average. There are 17 claimants per job (three claimants per job nationally).

Vulnerable Groups: 44% of children live in ​‘out of work’ households. People claiming mental health- related benefits is more than double the national average.

Deprivation: 3,687 (93%) people live in the most deprived 20% of neighbourhoods in England. 52% of children live in poverty (22% nationally). The number of pension credit claimants is 2.5 times the national average.

Crime: Reported crime is lower than the national average. The reported violent crime rate is below national average. 26% increase in alcohol-related crime since 2008.

Access and transport: 46% of households have no car (26% nationally). 71% of pensioners have no access to a car (59% nationally).

Health and wellbeing: 29% of people have a limiting long-term illness (20% nationally). Life expectancy is five years less than the national average. 41% of people smoke (22% for England).

Communities and environment: The percentage of people ​‘satisfied with their neighbourhood’ is higher than the national average.

Representing your experiences

How to collect and present residents’ stories about health and wellbeing.

This resource builds on work by the Big Local group, PEACH, which is based in Custom House, Newham.

Gathering residents’ stories about their experiences of using local health services can be a great way to show the impact (good and bad) that these services have on residents’ day to day lives. It also provides an opportunity for residents who are not able to attend formal partnership meetings to still have their say.

The following gives an example of the sort of data you might find it useful to collect when gathering stories from residents about their experiences of using local health services.

• Name: It is usually best practice to anonymise responses and discuss this with the person giving you their story but you might want to keep a reference for your own records of which person said what.
• An experience or problem that you have had at (add the name of surgery/​health care facility).
• How did you feel?
• How did/​does this affect your health or other healthcare arrangements?

Once you have gathered stories from residents about their experiences of using local healthcare services, think about who you want to share these stories with and how you are going to present them. For example, PEACH Big Local presented the stories they gathered in a short report and leaflet that explain the issues they uncovered including positives as well as problems. Below is the template that PEACH Big Local used and which you may want to adapt for your own use.

Stories

Summarise whose stories are being told here, i.e. which local residents, and why. For example, in the case of PEACH Big Local Partnership, they wanted to give people who felt too ill to come to many meetings a chance to say how the issues were affecting them and wanted to show the human impact of healthcare.

Issues

Summarise what the common issues appear to be from across all the stories. For example, the common issues identified by PEACH through residents’ stories were:

• Direct effect of worse health and more pain.
• Additional stress and impact on employment, education etc.
• Feeling frustrated, angry or upset and losing trust in the service.

Representing what you bring to the table

How to describe and explain the role your Big Local partnership can play. This visual resource builds on ideas that were shared with us by Big Local Ewanrigg.

• STRUCTURE AND SUPPORT: Helping residents get started and maintain momentum. 
• RESOURCES AND TIME: At least £1m worth of funding and ten years or more to spend it.
• BRINGING PEOPLE TOGETHER: Providing opportunities for residents, health agencies and local decision-makers to come together.
• LOCAL DATA ON HEALTH ISSUES: Gathering insights into experiences and perceptions of health services.
• HEALTH PROMOTION: Delivering health messages and activities that are right for locals.
• COMMUNITY ACTION: Working with health agencies to try out new health and wellbeing activities.

1. Care Act 2014. Available at: legislation.gov.uk/ukpga/2014/23/contents/enacted/data.htm.
2. NHS England (undated) ​‘Better Care Fund’. Available at: england.nhs.uk/ourwork/part-rel/transformation-fund/bcf-plan/ See, for example, NHS Five Year Forward View and the guidelines emerging on Clinical Commissioning Groups’ (CCGs) Sustainable Transformation Plans (with the Six Principles of Social Action in Health recently promoted through the NHS Alliance, and taken up in National Voices’ Six Principles of Community Engagement).
3. Profiles have been taken from Big Local areas’ original Big Local Action Plans.
4. Population figures provided by the School of Public Health Research (SPHR).
5. Somerville, P. (2016) Understanding community: Politics, policy and practice, 2nd edition, Bristol: Policy Press.
6. For a summary of the evidence see Gilchrist and Taylor (2016) The short guide to community development, 2nd edition, Bristol: Policy Press.
7. Stuteley, H. and Parish, R. (2010) The emergence of the H.E.L.P practice model: From apathy to anger to positive energy, London: Health Empowerment Leverage Project.
8. Wilkinson, R. and Pickett, K (2009) The spirit level: why equality is better for everyone, London: Penguin.
9. Marmot, M. (2010) The health gap: The challenge of an unequal world, London: Bloomsbury.
10. South, J., Stansfield, J. and Mehta, P. (2015) A guide to community centred approaches for health and well- being, London: Public Health England.
11. Scottish Community Development Centre (SCDC) (undated) ​‘Community Health Exchange (CHEX)’. Available at: scdc.org.uk/what/community-ledhealth/