PLAIN TEXT - Well-Placed: The impact of Big Local on the health of communities

New Local is an independent think tank and network with a mission to transform public services and unlock community power.

Our health system is under extreme stress. Demand for health and care services is rising faster than their ability to respond. Years of underfunding and the impact of the COVID-19 pandemic are presenting immediate challenges manifesting in rising waiting lists and intolerable workforce pressures. But underlying this, systemic pressures due to our ageing population with ongoing, more complex care needs, and rising inequality are playing a big role.

This research sets out to understand more about the role of one particular community-led approach to health and wellbeing. The Big Local programme is focused on 150 ​‘hyperlocal’ neighbourhoods, which shared common characteristics of high levels of deprivation, low levels of social capital and lower than-average health outcomes.

Published December 2023.

This report is authored by Imran Hashmi, Senior Policy Researcher and Laura Charlesworth, former Head of Health Research at New Local. The authors are grateful for input from Jessica Studdert, Adam Lent and Joe Sarling at New Local, James Goodman and Lily Staunton-Howe at Local Trust and Margaret Hannah at the International Futures Forum for their advice and input throughout the project.

We would like to thank all the participants we worked with, particularly the Big Local partnerships, who gave their time, insight and experience so generously. Thanks also to the team at Local Trust for working with us to shape the research and this report.

Our health system is under extreme stress. Demand for health and care services is rising faster than their ability to respond. Years of underfunding and the impact of the COVID-19 pandemic are presenting immediate challenges manifesting in rising waiting lists and intolerable workforce pressures. But underlying this, systemic pressures due to our ageing population with ongoing, more complex care needs, and rising inequality are playing a big role.

Our traditional model of healthcare provision is hospital-based, clinically led and focused on managing treatment. There is widespread recognition that we need to shift the centre of gravity within our system of health and care towards prevention, and away from expensive acute reaction which is costly for public finances and worse for people’s experience and outcomes. This would mean addressing the social determinants of health outcomes – the range of physical, social and environmental factors which many experts agree are more important for good health than services alone.

Health inequalities present a further systemic challenge. These inequalities are significant, evident through the gap in life expectancy where women and men living in the most deprived areas of the country can expect to live eight and 9.4 years less respectively than people in the least deprived areas. While health inequalities are linked clearly to deprivation, there are also important connections between health inequalities and place which add further complexity to the policy response needed.

In this context, the role of communities is increasingly important. Although they exist outside the boundaries of formal healthcare institutions, there is evidence of improved health outcomes from a range of community-led initiatives. From the perspective of our highly pressurised healthcare system, they exist on the margins and are a neglected asset when it comes to formal planning, commissioning and resource allocation. But there are reasons to be optimistic that the formal system of healthcare provision is shifting in a direction that in principle is more able to recognise the value of community-led approaches. Integrated Care Systems (ICSs) were formalised in 2022 as partnerships bringing together NHS organisations, local authorities and other relevant bodies to take collective responsibility for planning services, improving health and reducing inequalities across places.

The ICSs cover large geographical areas, typically around one million people, but within each ICS footprint two smaller scales are formally recognised – ​‘place’ partnerships and ​‘neighbourhoods’. ICSs are underpinned by the principles of subsidiarity – which means they should consider whether decisions need to be taken at a system-wide level or if they can be taken more locally. As a result, some Integrated Care Boards (ICBs) have pioneered different ways of working with people and communities who face health barriers and unequal outcomes. However, in the context of extreme pressure on services and the workforce, there has not yet been a notable shift towards a different way of working within systems to further enable and value community-led approaches to health and wellbeing.

This research set out to understand more about the role of one particular community-led approach to health and wellbeing. The Big Local programme is focused on 150 ​‘hyperlocal’ neighbourhoods, which shared common characteristics of high levels of deprivation, low levels of social capital and lower-than-average health outcomes. Each were given £1 million to spend over the course of 10–15 years from 2010-12 onwards. By placing considerable resource and autonomy over decision-making in the hands of communities, the model offers a unique insight into how communities would understand, identify and pursue their own priorities.

For the wider health system, the Big Local model provides a unique source of evidence for the efficacy of community-led initiatives on improving health and wellbeing outcomes. The experience of Big Local areas is instructive for how emerging local health systems organised around places recognise, work with and support community-led initiatives for improved health and wellbeing. These initiatives could have significant impacts not just for individual experience and outcomes, but hold the potential to alleviate demand pressures on formal healthcare provision.

Our research identified a wide range of health-related activity being supported by Big Local partnerships, revealed through a review of literature and a series of interviews with those directly involved.

The diagram below summarises these key findings. We identify four core conditions that enabled Big Local partnerships to set up, fund and run health activities. We identified seven different themes for this activity, which address different aspects of health and wellbeing in those communities. The impact generated by this activity is observed through the framing of three key social determinants of health outcomes.

Diagram 1: Key social determinants of health outcomes.

Diagram shows three concentric circles, labelled ​‘Conditions’, ​‘Activity’ and ​‘Impact fanning out from a central circle labelled Big Local. The circles include the following:

Conditions:

• Agency and control.
• Community connections.
• Flexible funding.
• Long-term funding.

Activity:

• Physical activity.
• Mental health.
• Food and nutrition.
• Cost of living.
• Children and young people’s health.
• Upskilling citizens.
• Supporting existing services.

Impact:

• Ensure a healthy standard of living for all.
• Enable all children, young people and adults to maximise their capabilities and have control over their lives.
• Create and develop healthy and sustainable places and communities.

Core conditions for community-led initiatives that support health and wellbeing:

At the heart of the Big Local model are four core conditions that help enable community-led action on health and wellbeing. While each one of these conditions is important in its own right, together they provide the environment for communities to identify and lead initiatives that respond to and support residents’ health and wellbeing. The four identified conditions are:

1. Agency and control: Placing power and control in the hands of communities through resident-led decision making.
2. Community connections: Big Local partnerships are embedded within their communities and understand the unique challenges they face. They have therefore been able to more effectively design interventions that address local issues and reach the most in need groups of people.
3. Flexible funding: Flexibility of funding has proved responsive to communities’ identified priorities and circumstances, ensuring support meets needs rather than being restricted to a pre-determined theme, type of intervention or condition.
4. Long-term funding: A long-term funding approach has built community capacity and capability while designing effective interventions for the long term.

Seven areas of activity to support health and wellbeing:

The four conditions enabled Big Local partnerships to work with their communities to design and fund activities as they felt necessary. This is an important feature of the Big Local model – ensuring local communities can identify shared priorities and collectively agree what would support them meaningfully. Our research found a wide range of activities that we grouped into seven themes. Some meet general ongoing needs such as support for physical activity and good nutrition, and some are clearly shaped by circumstances as they have manifested over the last decade; responding to deteriorating mental wellbeing after the pandemic and the pressures of the cost-of-living crisis. These seven themes and the specific activity within each are presented on the table opposite:

Table 1: Key themes and specific activity addressing community health and wellbeing in Big Local areas.

Physical activity:

• Directly funding programmes and equipment for physical activity.
• Developing and refurbishing of spaces for exercise.
• Supporting healthy daily habits such as walking and cycling.

Mental health:

• Delivery of mindfulness classes, arts and culture classes and outdoor activity.
• Funding wellbeing bags, with a focus on self-care and stress reduction.
• Awareness raising, particularly amongst minority and marginalised communities.

Food and nutrition:

• Nutrition education and food advice through cooking classes, recipe books and budgeting/​shopping advice.
• Awareness raising of poor nutrition and resultant health issues.
• Financial support for ingredients, cooking equipment and community food shops.

Cost of living:

• Warm hub provision using community hubs and cafes.
• Funding winter warmer packs.

Children and young people’s health:

• Setting up and running youth clubs focused on sports and culture.
• Working with schools to raise awareness of mental health and encourage physical activity.
• Funding specific services within primary schools to support children’s wellbeing.

Upskilling citizens:

• Improving residents’ knowledge and understanding of their health.
• Delivering new parent peer learning mentor programmes.
• Funding community research projects focusing on health.
• Funding and running digital health clinics.

Support existing services:

• Funding, enhancing or sustaining existing services.
• Providing physical space for public services delivery.
• General support for council led initiative.

The impact of community-led initiatives on health and wellbeing:

Our research identified important impacts on health and wellbeing. In general, quantitative findings from the census indicate that over the decade of the programme’s operation, the health of residents in Big Local areas was stronger over this period than the rest of the population (1). There were statistically significant improvements in residents reporting greater than average increases in ​‘very good’ health compared to non-Big Local areas between 2011 and 2021. Other studies are also starting to show health impact, primarily through improvements in residents’ wellbeing.

Our research used the framing of three key social determinants of good health to explore the impact of the Big Local partnerships as observed and reported by members through our interviews. With the right conditions to address community defined priorities, Big Local partnerships designed activities that focused not on formal health outcomes but on a broader range of issues that improve health:

1. Enabling a healthier standard of living for all.
2. Enabling children and young people to maximise their capabilities and have control over their lives.
3. Creating and developing healthy and sustainable places for all.

Limiting factors facing community-led initiatives on health and wellbeing:

The activity and impact realised by Big Local partnerships on health and wellbeing has progressed despite facing a series of obstacles which limit the scale and impact of the activities. Our research found three main obstacles which limit the degree of impact from Big Local partnerships and their ability to reduce demand for formal health provision.

The three limiting factors we identified are:

1. Current funding models and sustained cuts to resources mean that short-term demand pressures are prioritised by the formal health system. This inhibits long-term opportunities for prevention, early intervention and self-management through community-led approaches.
2. The dominance of the formal, clinically driven system of healthcare results in a power imbalance where the value of informal, community-led activity is not sufficiently recognised and trust is lacking.
3. The capacity and expertise required to meaningfully engage with communities is inadequate and exacerbates flaws in the current system.

The report makes three recommendations for ICSs, and the wider formal healthcare system, if the impact of community-led initiatives on health outcomes and demand pressures is to be fully realised in the future.

• Recommendation 1: Health system partners at all levels should develop a deeper shared understanding of where and how hyperlocal deprivation manifests within their geographies.
• Recommendation 2: Health systems should aim to deepen and expand community-led approaches to health and wellbeing, adopting a ​‘test and learn’ approach to measure their impact on outcomes and demand.
• Recommendation 3: System partners should commit to shifting resource towards investment in community-led health and wellbeing initiatives, as part of a wider rebalancing of spend towards prevention.

This report makes two recommendations for Big Local partnerships to improve their chances of working effectively with the formal healthcare system, despite identified limiting factors:

• Recommendation 1: Consciously and methodically build local links and relationships with the full range of stakeholders that work in health and wellbeing.
• Recommendation 2: Demystify and clearly evidence the work and impact of Big Local groups.

Big Local partnerships have created the conditions for successful community-led health initiatives. Their unique position in understanding the community, placing power and control in the hands of the community, and providing long term and flexible funding enabled a wide range of community-led health activity that has had direct and indirect benefits for health outcomes.

This activity and corresponding impact have been delivered despite facing significant institutional barriers.

Given the challenges facing the formal health system, policy makers need to urgently recognise the sustainability, value and contribution that Big Local and hyperlocal initiatives can make on improving the health of the population.

Our health system is under extreme stress. Demand for health and care services is rising faster than the ability of our traditional model of service delivery to respond. As a result, waiting lists for elective care are rising – high before COVID-19 hit, they have rocketed since (2). The workforce is in crisis – with pay stagnating in real terms and deepening recruitment and retention challenges (3). And care quality is deteriorating, with the UK experiencing poor standards and worse outcomes across a range of indicators in comparison with peer countries (4).

The fact that funding is not keeping pace with this rising demand is undoubtedly a problem. But there is also widespread recognition that many of the underlying challenges of our health system are systemic.

Our population is ageing with growing complexity of health needs. More people are living longer but requiring greater levels of support to do so comfortably.

Health inequalities present a further systemic challenge. These inequalities are significant, with life expectancy closely related to socio-economic status. Women and men living in the most deprived areas of the country can expect to live eight and 9.4 years less respectively than women and men living in the least deprived areas (5). In addition to this, the gap in healthy life expectancy means that people in deprived areas, who already live shorter lives on average, can expect to spend a higher proportion of their life in poor health – up to 20 years – compared to those in the least deprived areas (6).

While health inequalities are linked clearly to deprivation, there are also important connections between health inequalities and place which add further complexity to the policy response needed. For example, research by Professor Sir Michael Marmot found that living in a deprived area of the North East of England is worse for your health than living in a similarly deprived area in London, with life expectancy nearly five years less in the North East (7).

Other research has highlighted how left-behind areas, defined by wider determinants such as social capital and infrastructure alongside deprivation in a ​‘community needs index’, have poorer health outcomes. Just under one in four people (24%) in these areas have a long-term illness, higher than across other deprived areas (20%) and England as a whole (18%) (8). There is also variance between hyperlocal areas in close proximity to each other. For example, the University of Manchester explored life expectancy along stops on Greater Manchester’s Metrolink and found the largest gap (highest to lowest life expectancy) to be 10 years (9). Significant variation in health outcomes across relatively small distances underlines the importance of hyperlocal perspective and approaches.

These systemic challenges were not foreseen when the NHS was founded. Our core healthcare model was established in an immediate post-war era of much lower life expectancy and greater prevalence of communicable diseases. As such, the system was designed to focus largely on administering treatment within a clinical setting. 

Three quarters of a century after the NHS was founded, it is clear we will only be able to address the systemic challenges driving up demand for healthcare if we move from an ​‘illness service’ to a system focused on prevention and early intervention (10). In other words, we need an approach to health that is not simply reactive, but capable of supporting independence, encouraging health-seeking behaviours and self-management, and promoting ongoing wellbeing.

Such activity necessarily takes place outside the walls of formal healthcare settings – in people’s homes, workplaces and localities. Extensive research has revealed that health is determined by a complex interaction between individual characteristics, lifestyle, and the physical, social and economic environment (11). With this in mind, the collective role of communities as the space in which these social determinants manifest and interact to influence health and wellbeing is significant. There is agreement amongst most experts that these social determinants are more important than formal healthcare services in ensuring a healthy population (12). The health service will need to turn its focus to these social determinants if it is to become a genuine force for prevention, early intervention, and self-management, rather than just treatment.

Against this backdrop of service pressures and recognition of the causes of ill-health, the role communities play in health and wellbeing is of growing interest and focus. There is evidence of improved health outcomes from a range of local initiatives which have started with the community rather than the health service. 

For example, Healthier Fleetwood was an initiative led by general practitioners in a disadvantaged community. GPs set up community groups to increase physical activity and improve diet, key to preventing the onset of diabetes and other non-communicable diseases (13). The approach was anchored in a wider body of evidence that improving social connectivity among isolated people with long-term health needs builds confidence and self-efficacy, leading to improved health and other outcomes, improved service delivery and a reduction in healthcare costs (14). This non-clinical response to the health challenges of Fleetwood had a demonstrable impact on demand for formal services, as people improved their health and wellbeing and strengthened relationships between each other through growing networks of support, allowing the approach to embed across the locality (15).

There is evidence from longitudinal research that when communities are given more agency and control, this can lead to both better individual health outcomes and greater overall community wellbeing (16). For example, the Wigan Deal was an approach to local service prioritisation and the adoption of asset-based practices led by Wigan Council from 2011 onwards, with upfront investment in community groups and capacity building at its core (17). Evaluation of its impact has shown a range of positive health outcomes including around 50% increases in the proportion of adults who were physically active over a five-year period and statistically significant declines in early deaths from cardiovascular disease (27%) and cancer (12%) (18).

Some initiatives to tackle wider socio-economic determinants have been correlated with positive mental health and wellbeing outcomes. For example, community wealth building in Preston involved public and non-profit organisations taking a more proactive approach to their procurement spending to support local supply chains, improve employment practice and increase socially productive use of wealth and assets. A peer-reviewed study of population mental health and wellbeing found that the programme was associated with reductions in the prescribing of antidepressants and the prevalence of depression relative to other areas. There was also a 9% improvement in life satisfaction and 11% increase in median wages amongst the local population relative to expected trends (19).

But community-led approaches are not clinically based and by definition operate outside of and distinct from formal healthcare service provision. Communities are informal, loose constructs anchored in place. Their adaptive nature and networked form of relationships are a strength. As we saw during COVID-19 and the mutual aid phenomenon, communities are capable of responding in real time (20). But this feature can also make it more difficult to capture and fully evidence the broad value of community action in a way that the formal health sector would recognise. As a result, community-led approaches operate in parallel and are often bypassed by clinical provision. This means the formal healthcare system risks missing the potential for supporting good health and realising the wider benefits this might have indirectly on alleviating demand for formal services.

There are reasons to be optimistic that the formal system of healthcare provision is shifting in a direction that in principle is more able to recognise the value of community-led approaches. In recent years, a stronger geographical architecture has been established to bring together the range of provision across acute, primary, community and social care around local populations. ICSs were formalised in 2022 as partnerships bringing together NHS organisations, local authorities and other relevant bodies to take collective responsibility for planning services, improving health and reducing inequalities across geographical areas (21).

They have four key purposes set in statute: 

1. Improve outcomes in population health and healthcare.
2. Tackle inequalities in outcomes, experience, and access.
3. Enhance productivity and value for money.
4. Support broader social and economic development.

The 42 ICSs across England cover large geographical areas, typically around one million people, but within each ICS footprint two smaller scales are formally recognised – ​‘place’ partnerships and ​‘neighbourhoods’. These three tiers within ICSs are underpinned by the principles of subsidiarity – which means ICSs should consider whether decisions need to be taken at a system-wide level or if they can be taken more locally. The two smaller areas within ICSs are described in more detail below:

• Place partnerships are often but not always at the scale of a local authority (between 250,000 to 500,00 people). This is where partnerships between NHS bodies, local government, social care providers and the voluntary sector are responsible for integrating care, improving population health and tackling health inequalities.
• Neighbourhoods represent teams delivering services on smaller footprints still, with primary care networks operating as groups of GP practices at their core. The scale is small in NHS terms, with a minimum of 30,000 registered individuals, but larger than many actual places which might identify themselves as neighbourhoods (22).

This three-tiered model of neighbourhoods, places and systems in theory establishes a strong structure to realise the principle of subsidiarity. When ICSs were formalised in July 2022, NHS England issued statutory guidance for ICBs and NHS bodies, setting out the expectation that these bodies would work in close partnership with people and communities (23). As a result, some ICBs have pioneered different ways of working with communities that face health barriers and unequal outcomes. 

The North Central London ICB, for example, set out to understand how to shift to a more community-led preventative approach to health. Community Powered Edmonton is a collaboration between the council, NHS, the voluntary sector, and residents. Over a three-month period, partners engaged through a range of activities such as workshops, focus groups and creative activities to identify what matters to local people and to identify mechanisms to greater collaborative working (24).

Yet overall, in the context of extreme pressure on services and the workforce, there has not been a notable shift towards a different way of working within systems. The Hewitt Review, an independent, government-initiated inquiry into the progress of ICS reforms, found that although they held ​“enormous promise” this was not yet realised. It made a number of recommendations including the need to more proactively shift institutional energy and focus towards prevention and the role of subsidiarity in achieving this (25).

Evidence from within ICSs themselves confirms this gap between theory and practice but reveals a shared recognition of the direction of travel needed. A year on from becoming formal partnerships, a survey of ICS leaders found that amidst a challenging operating environment, they identified slow progress around plans and commitment to devolving functions and power within systems (26). The same survey found ​‘health inequalities’, ​‘prevention’, ​‘population’ and ​‘communities’ were the most referred to areas where leaders wanted to make progress.

It is in this context that our research set out to investigate the role of Big Local as a model of community-led activity in relation to a range of health and wellbeing outcomes. The Big Local programme places resource and complete autonomy of decision-making into the hands of communities experiencing high levels of deprivation and low levels of social capital (27). 

Between 2010 and 2012, 150 local areas were identified as having been overlooked for external funding and were in need of long-term change. Each area can be termed ​‘hyperlocal’, comprising approximately 7–8,000 people – for example an estate or neighbourhood. These Big Local areas were then allocated £1 million each to be spent collectively over a period of 10–15 years. There were limited restrictions on how this funding should be spent, beyond that the community was encouraged to go through a process of identifying priorities and making decisions collaboratively. To support this, Big Local areas were required to set up ​‘partnerships’ that consisted of at least eight people, the majority of whom (at least 51%) had to be residents of the Big Local area. Big Local was designed in this way to avoid ​‘doing to’ communities and to enable capacity building locally, leading to longer term change.

The core principle at the heart of Big Local is that: ​“Long term funding and support to build capacity gives residents in hyperlocal areas agency to take decisions and to act to create positive and lasting change” (28).

Figure 1: Summary of the Big Local programme.

Figure shows a central circle labelled ​‘Big Local’, and three sections around it, labelled ​‘Big Local Rep’, ​‘Worker’ and ​‘Locally Trusted Organisation’. The sections include the following:

Big Local:

• 150 Big Local partnerships decide how to use £1.5m to meet local needs.
• Must be at least 8 people and at least 51% residents.
• Policies, processes and structure decided by the group.
• Typically unconstituted.

Big Local Rep:

• Tailored support.
• Informs, connects and supports Big Local partnerships.
• Shares successes, challenges, and news with Local Trust.

Worker:

• Paid employee.
• Delivers workplan decided by Big Local partnership.
• May bring community development skills.
• Often lives nearby or is a resident.
• May be one part time worker or a small team.

Locally Trusted Organisation:

• Legal entity.
• Chosen by the partnership.
• Manages and administers local funding.
• Provides administrative services if needed.

Provides long-term, resident-led funding with almost no strings attached. Each Big Local area receives £1.1m and a programme of support over 10–15 years.

Source: Local Trust.

The Big Local model is entirely community-led and absent of the preconceptions or priorities of professionals seen in our formal system of service provision. The experience of Big Local areas therefore provides a unique insight into the impact of community-led practice. As the programme nears the end of its cycle, the activity of the areas is an important resource to contribute to our understanding of how communities understand and pursue their priorities when given the freedom and resource to do so.

The nature of Big Local partnerships has created a series of core conditions which are important for understanding how activity to support health and wellbeing can be genuinely community-led. 

This is important to establish at the outset, as it sets out how the role of communities is distinct from formal service provision. Services might contract with community organisations, connect into community resource through practices such as social prescribing, or run provision that is based in communities. But these features do not amount to being genuinely community-led. 

This section sets out four core conditions for community-led health and wellbeing initiatives. While each one of these conditions is important in its own right, together they provide the environment for communities to identify and lead initiatives that respond to and support residents’ health and wellbeing.

Placing power and control in communities through resident-led decision-making has been crucial to how Big Local partnerships operate. In each case, the community were initially connected by the financial asset, and were supported to go through a process of identifying their own priorities. There were no strings attached to the funding, meaning that there was complete autonomy to pursue these priorities, subject only to community agreement. This process of empowerment in itself has positive impacts. Residents have reported that opportunities to connect and build trust with each other foster a greater sense of place and collective control over decision-making, and had positively transformed their subjective wellbeing (29).

The activities pursued were entirely self-directed by communities themselves, who have led the decision-making process. This means interventions have been bespoke and tailored to address specific needs and circumstances. We heard from Big Local partnerships that this meant the community had much more trust in the services being offered by them relative to other public services which, in turn, enabled greater reach and participation. 

“Data is not always 100% accurate, especially data before the pandemic. So we carried out our own community audit and spoke to people in the community to understand and unearth the key health challenges around obesity, unemployment and access to their health information.” – HAVA Big Local

This agency and control meant that volunteers were going above and beyond, in many cases working on Big Local partnerships in addition to day jobs. This level of commitment was unlikely to occur without them having skin in the game, the agency to make decisions, set their own agenda, and feel that sense of ownership.

Big Local partnerships have focused heavily on what the formal system would recognise as prevention and early intervention — activities that are specific to local need; that are up-stream and responsive. People living in Big Local areas are diverse and have a range of resources, skills and experience to help shape bespoke interventions (30). When given the opportunity, residents in the community present solutions for what is needed for effective prevention and early intervention and have the motivation and ambition to see it through.

Big Local partnerships are embedded within communities and understand the unique challenges they face, the specific nuances or history of those issues, and the barriers in accessing public services (31). This means they have been able to more effectively design interventions that are suited to address local challenges and reach the most in-need groups.

“Most of the volunteers and those running the programme are local residents and are embedded in the community. So, they all understand the specific local issues and challenges around mental health, physical health and poor nutrition.” – Northwood Big Local

The strong relationships and legitimacy within Big Local partnerships meant that participation was high in the partnerships that we spoke to. Word of mouth and co-designing interventions meant that demand for these services was considerable and little additional investment was needed to market new activity. This meant that more investment could be focused on developing activities themselves.

Links to the formal health system were not common, often reliant on individuals’ connections, and didn’t recognise the value of Big Local initiatives. There are some rare examples of meaningful collaboration and links with the formal health system, mostly with GPs, pharmacists and chemists. The more long term approach to building community connection within the Big Local programme contrasts with formal public services where wider pressures and high staff turnover can create fragility when it comes to consistent community connection.

The non-prescriptive flexible nature of funding has meant Big Local partnerships have been able to ensure the design and delivery of activities that stand the best chance of meeting the challenges and priorities of the community rather than being restricted to a specific theme, type of intervention or condition.

“With the Big Local programme, we have had the flexibility to redirect funding on the fly to address changing needs of our residents over time, and design bespoke services that addresses the specific cultural requirements and preferences in our community.” – Greenmoor Big Local (Better Communities Bradford).

This flexibility has also meant that Big Local partnerships have been able to respond at speed to immediate challenges communities face such as COVID-19 and the cost-of-living crisis. There has been the freedom for existing interventions to adapt and reprioritise and for new interventions to quickly develop and launch. Big Local partnerships have also been able to pivot towards other investment and related activity in their area. 

“In our community there are lots of families who have experienced trauma from people passing away abroad, and due to lockdown restrictions, not being able to grieve. In response to this, we quicky developed and launched our Tree of Life project — a narrative approach to dealing with this trauma.” – W12 Together Big Local.

Flexibility also extended to programme monitoring as there were no formal requirements for specific performance metrics. This avoided predetermining Big Local area decisions and guarded against potential ​‘gaming’ of the system – in other words trying to showcase that Big Local partnerships were meeting funders’ desired priorities regardless of their own needs or effectiveness. Finding the balance between avoiding onerous metrics but encouraging review of the impact of activities by any means is a challenging one, but one that successful Big Local partnerships managed well.

“Everything we do is about health and wellbeing. To make a true difference we need 20–30 years really, but 10 years for Big Local has been fantastic to enable creativity, responsiveness and impact.” — Ewanrigg Big Local.

The long-term nature of the funding has been crucial to the impact of the Big Local partnerships. A patient approach is much more likely to build community capacity and capability and to design effective interventions. This has also enabled the partnerships to be more confident in taking risks and they have had time to build in feedback loops for learning. 

Long-term funding also meant that the programme has been able to accommodate vastly different starting points between communities. Areas with an already developed ecosystem of community groups, with fewer conflicts between them, have been able to progress quicker. In areas where this ecosystem is much less developed, and/​or with little culture of civic involvement, the Big Local approach has had to be built from scratch. Arguably, these are some of the areas which most need this type of hyperlocal, capacity building investment and support, which would not be possible without a long timeframe. In addition, a long-term approach to funding means there is time to learn and recover from inevitable challenges and mistakes.

As well as the timeframe, the certainty of funding has been significant. This has created the space for the communities to plan more strategically, exploring options best suited to their needs, and to focus on longer-term outcomes with no need to immediately demonstrate results to a third party. The guarantee of this long-term financial asset has also helped Big Local partnerships to connect with other local organisations with whom it has historically been difficult to collaborate. 

“The fact that we had funding in place meant we got a seat at the table of some organisations who we would not ordinarily have met with. The certainty of our funding was attractive for them and an incentive to meet us.” – W12 Together Big Local.

Confidence and capacity building in communities was crucial for this long-term success, but this could only be done effectively by giving Big Local partnerships control and power to make decisions and learn from their successes and failures.

The core conditions at the heart of the Big Local programme have enabled the partnerships and communities to set up and run a wide range of activities. Despite there being no official requirement to focus on health and wellbeing, it is a major theme across the Big Local partnerships. In fact, nearly 60% of Big Locals identified an intention to improve health and wellbeing and allocated funding for that purpose (32).

Some common themes emerged from Big Local partnerships during the course of this research. The focus on health and wellbeing was often particularly related to issues which can be described as the ​‘wider drivers’ or ​‘social determinants’ of health outcomes. They frequently described health in relation to diet and weight, mental health, and wellbeing and happiness. Wider still, they also spoke about the poor local environment, such as pollution, lack of transport options to access health services, and mobility barriers such as lack of access to green space or equipment for exercising.

This demonstrates how, unprompted, Big Local partnerships set out to run activities to improve the social determinants of health specific to their neighbourhood. This is particularly important given action on these social determinants is something the formal healthcare system currently finds challenging.

The seven themes of health activity supported by Big Local partnerships:

Big Local partnerships have worked with their communities to design and run a wide range of activities, many of which are either directly or indirectly aimed at improving health and wellbeing outcomes. These can be grouped into seven key types of health-related activities.

Table 1 opposite sets out the seven types of activities ordered by frequency of reference in interviews, and this section will explore each in turn.

Table 1: Key themes and specific activity addressing community health and wellbeing in Big Local areas.

Physical activity:

• Directly funding programmes and equipment for physical activity.
• Developing and refurbishing of spaces for exercise.
• Supporting healthy daily habits such as walking and cycling.

Mental health:

• Delivery of mindfulness classes, arts and culture classes and outdoor activity.
• Funding wellbeing bags, with a focus on self-care and stress reduction.
• Awareness raising, particularly amongst minority and marginalised communities.

Food and nutrition:

• Nutrition education and food advice through cooking classes, recipe books and budgeting/​shopping advice.
• Awareness raising of poor nutrition and resultant health issues.
• Financial support for ingredients, cooking equipment and community food shops.

Cost of living:

• Warm hub provision using community hubs and cafes.
• Funding winter warmer packs.

Children and young people’s health:

• Setting up and running youth clubs focused on sports and culture.
• Working with schools to raise awareness of mental health and encourage physical activity.
• Funding specific services within primary schools to support children’s wellbeing.

Upskilling citizens:

• Improving residents’ knowledge and understanding of their health.
• Delivering new parent peer learning mentor programmes.
• Funding community research projects focusing on health.
• Funding and running digital health clinics.

Support existing services:

• Funding, enhancing or sustaining existing services.
• Providing physical space for public services delivery.
• General support for council led initiative.

Big Local partnerships most frequently focused on activities to support people in their community to participate in more exercise. For some, this meant overcoming challenges around lack or provision or barriers to access by directly investing in facilities, equipment, and spaces for exercise. For example, 3 Together Big Local invested in a ​‘gym in a box’ which included purchasing gym equipment and a shipping container located on a local primary school field, and funding a local personal trainer to run classes for residents. Elmton, Creswell and Hodthorpe Big Local partnership also prioritised the development of new space to exercise through investing to establish a new health and wellbeing centre after a local swimming pool closed down. HAVA Big Local funded bikes for local schools as well as the development of an outdoor gym and skate park.

Other Big Local areas focused on supporting specific initiatives to encourage people within their community to get more active through walking groups, outdoor clubs and weight loss challenges. For example, Bradley Big Local funded women-only cardio and weight loss classes to provide a comfortable space for women to exercise together, whilst Leigh Neighbours developed and launched a daily mile challenge to encourage families and children to walk or cycle to and from their primary school.

Designing and running initiatives to support residents’ mental health was the second most reported area of Big Local activity. Most partnerships shared how they had seen a big increase in demand for support around mental health both during and after the pandemic. As a result, many have designed bespoke activities to address identified unmet need in their communities. This demonstrates how responsive hyperlocal approaches can be to emerging needs in real time, contributing to wider prevention and early intervention. 

Some partnerships focused on activities to help reduce anxiety, stress and trauma. For example, 3 Together Big Local ran mindfulness classes, while HAVA Big Local set up a mindfulness café. Others aimed to address this need through creative activities such as Par Bay’s community pottery class, Bradley Big Local’s Pocket Park community garden, and Leigh Neighbours funding of a play therapist and art-based therapy classes in a local school. Some partnerships focused on getting support resources out to people in communities — such as W12 Together, which funded wellbeing bags to promote self-care and stress reduction, including a specific children’s bag, which were given out at local GP surgeries and food banks. 

In some areas, there was a strong focus on awareness raising and reducing the stigma attached to seeking help for mental health challenges, particularly for marginalised and minority communities. For example, we heard from Greenmoor Big Local in Bradford on their work providing mental health support for women through a series of sewing classes they were already delivering. By providing this support through a participative and social approach and in a comfortable and familiar environment, the partnership was able to raise awareness in this community of the support available, and residents over time became much more willing to discuss their mental health challenges.

Many Big Local partnerships shared how it has been difficult for their communities to access and prioritise preparing nutritious food, a finding also identified through previous research on activities of Big Local (33). Partnerships have developed a range of activities to support their communities and encourage participation around improving food and nutrition. These activities are a combination of information and education alongside direct support, and they demonstrate the importance of understanding local needs and taking a responsive and flexible approach to meeting them.

Some partnerships have set up and run activities focused on nutrition education, preparing food on a budget and the links between diet and physical and mental health. For example, both Gannow Big Local and Scotlands and Bushbury Hill Big Local delivered cooking classes to residents. In Wolverhampton these sessions took place in a community shop, where participants were provided with recipe books on how to eat healthily on a budget. Other areas have sought to address more directly and explicitly the links between poor nutrition and wider health. Arches Local Fit and Fed programme aimed to raise awareness of the link between poor food choices and diabetes, obesity, and high cholesterol. Tang Hall Big Local’s food co-operative focused on the links between food nutrition and physical and mental health.

As a result of rising financial pressures on households and the cost-of-living crisis, a significant amount of activity on food and nutrition has also focused on simply meeting basic needs. Many Big Local partnerships have provided direct support to residents with ingredients and equipment. This includes the provision of free food, for example Cars Area Big Local and Gannow Big Local distributed free food packs and 

Ewanrigg’s Hug a Mug project free food and drinks. Big Venture and Tang Hall Big Local prioritised more affordable food from community shops and food co-operatives and some have funded cooking equipment, such as HAVA Big Local which donated slow cookers to residents.

Beyond the food-related needs that have become urgent for many families as a result of the cost-of-living crisis, Big Local partnerships increasingly found themselves focusing on wider activities to support communities facing financial hardship.

This particularly the case during the colder months, when many partnerships found innovative ways to help their communities in response to rocketing energy prices. For some, this involved transforming existing community spaces into warm hubs. For example, Par Bay took over and renovated a community hub, and used it to provide a warm space for the community. HAVA Big Local’s Heat and Meet project provided a warm space, warm food, and an opportunity to socialise for three hours every evening throughout the winter. Alongside this, they also put together winter warm packs including items like gloves, hats and electric blankets. These examples demonstrate how Big Local partnerships have quickly adapted to changing circumstances to best support their communities.

Big Local partnerships have set up and delivered a whole range of activities to help improve children and young people’s health and wellbeing. The involvement of children and young people in the design of these activities meant that they were bespoke to their area’s challenges and opportunities For example, Keighley and Cars Area Big Local partnerships both ran youth clubs – with Keighley focusing on tackling loneliness through movie and sports activities, and Cars Area supporting young people to do more exercise and get involved in sports. Others invested in equipment and the refurbishment of facilities that children could use for play exercise, including Gannow Big Local’s refurbishment of the local children’s playground and Bradley Big Local’s extension and refurbishment of the local play area.

Many Big Local partnerships have worked with schools as a way to engage with and support the children and young people in their communities. For example, Bradley Big Local is developing a 3G pitch and community centre which will be used by three local schools. On mental health and wellbeing, Windmill Hill Big Local held children’s session to discuss lockdown and their mental health during COVID-19, and Leigh Neighbours Big Local funded a play therapist and sensory worker in a school to support educational attainment and improve mental health and readiness for learning.

Underpinning many of the activities that Big Local partnerships have set up, funded or delivered is a common theme of empowering the community around health and wellbeing, through providing access to education, promoting knowledge sharing, and creating awareness-raising opportunities. Deep and detailed understanding of local challenges and knowledge gaps has allowed partnerships to design activities to best support community needs. 

Peer-support is a powerful feature of community-led approaches to developing and sharing skills and knowledge that a number of Big Local partnerships have fostered. For example, HAVA Big Local facilitated peer-learning sessions for parents with children with special education needs and disability to come together to share and learn from each other’s experiences. 3 Together designed a peer-mentoring programme between older and younger children in a local school to help them increase their confidence and leadership skills.

Having the means and confidence to access health information can help support and empower people around their own health and wellbeing. Big Local partnerships have looked for ways to support their communities to better access health information. For example, HAVA Big Local developed a digital health hub so residents could quickly and cheaply access their health information, and Northwood Big Local designed and delivered their Shapeshifter programme. This was a bespoke, six-month health and wellbeing lifestyle programme where residents had daily check-ins with an allocated team leader, to ensure that they were not having any issues and to encourage them to book classes, go for a swim or attend a group walking session.

Some Big Local partnerships innovatively used community research as a way to provide people with new skills, while also identifying ways to improve health and wellbeing in their area. For example, Arches Local carried out research projects with residents on air pollution and worked with the Nuffield Trust on the topic of proactive prevention in response to the report The State of the Nation’s Health and Wellbeing in 2023 (34). W12 Together developed the West London Hub for community research, where residents were trained to become community researchers and could decide on the priorities and questions for any research, with a particular focus on health, with expert guidance and support available.

Given the backdrop of the last decade of austerity and cuts to public services, much Big Local area activity has helped to fund, enhance or sustain services. One contribution Big Local Partnerships have made is through the provision of spaces for public service teams to work from. For example, Par Bay and Gannow Big Locals’ investment in their community hubs meant that the local frailty and diabetes teams, as well as social prescribing link workers, could continue to work closely in the community. These centres would have been closed or sold without Big Local funding. 

Sometimes this support has taken the form of raising awareness of statutory provision. Many advertised and signposted existing public services in their centres, hubs and food shops and included information in support packs distributed to communities. Some of the Big Local partnerships worked with local coordination teams and with social prescribers to refer residents to appropriate council and NHS services, and they also funded and delivered events that previously would have been run by the formal health system. For example, Tang Hall’s food, nutrition and physical activity event programme focused on raising awareness of food poverty and poor nutrition, encouraging exercise, and signposting residents to the range of support services available.

Many of the examples outlined in the above themes refer to Big Local partnerships stepping into the spaces vacated by public services. In many cases, Big Local partnerships have been able to fund support that would otherwise be closed down as funding has been withdrawn, despite continued community need. The responsiveness to increasing prevalence of poor mental health has been partly driven by the large backlog in mental health referrals within the formal system and the difficulties in accessing support for low-level conditions through the NHS. 

Big Local partnerships have demonstrated that with autonomy, funding and flexibility communities can spearhead a whole range of activities. The focus of the next chapter is to explore how this community-led activity has impacted on health.

Context: 

Greenmoor Big Local is made up of the neighbourhoods of Scholemoor and Lidget Green in Bradford. The two areas haven’t previously connected, with little interaction between residents and limited reason for residents to travel between. The area has experienced the effects of increased deprivation and a lack of regeneration over many years. Allocation of Big Local status and the investment that followed gave local people the chance to share their challenges and issues and have a say in how these were addressed using Big Local funds.

Greenmoor Big Local carried out a year-long community consultation which meant people who lived and worked in the area able to contribute to a community plan which informed how the Big Local investment was used. Like many areas experiencing deprivation, residents highlighted health issues as a priority. This included:

• Lack of spaces for physical activity, such as places to walk or access to a swimming pool.
• Frustrations about GP and dentist access as residents had to travel to a neighbouring area for these.
• The impact of housing issues on health — compared to national averages a significant proportion of residents in the area live without basic household amenities such as central heating or an indoor toilet.

Project Activity: 

Better Communities Bradford will be the legacy project from Greenmoor Big Local. Better Communities Bradford fund sewing classes focused on addressing loneliness and depression that was prevalent within the BAME and immigrant communities. Discussion in these classes highlighted the need for specialist mental health support. Better Communities Bradford now fund a mental health therapist for nine hours every week to attend the sewing classes and talk with attendees about their problems, feelings and mental health, as well as to signpost to and discuss potential solutions.

Project Impact: 

These classes are now oversubscribed, and there increasing demand for a similar type of support for men in the community. Attendees have reported reduced levels of loneliness and anxiety, having formed social connections and found a safe space to discuss their problems without fear of stigma.

The sewing classes have impacted significantly on individual residents in the community. One resident described struggling with poor health for three years previously. She had been out of work, losing friendships and confidence. Through the sewing class, she began to reconnect with other local people, and she identified a further opportunity to develop her skills. She is now a community digital champion, using her newfound confidence to help others.

Key Learnings: 

The flexible nature of the funding has been key to delivering this activity and its impact. Better Communities Bradford was able to be responsive to new demand discovered within the classes and was quickly able to pivot to fund a therapist, with few restrictions or barriers. This would undoubtedly have been much more difficult and time consuming if there were stringent conditions attached to the funding.

Relationships between local GPs and pharmacists have increased the signposting to community-led initiatives in the area. But greater engagement with health partners has been challenging due to capacity and resource.

Better Communities Bradford plans to continue the legacy beyond Greenmoor Big Local with a focus on developing accessible initiatives which are responsive to the needs of local residents.

Context: 

Bradley is a neighbourhood in Nelson, Lancashire, and is considered to be one of the most deprived areas in England for income, education, skills and training, and health and disability. To address these issues, Bradley Big Local set out on a mission to ​“make Bradley a place to call home”. At the core of this approach was a focus on understanding the challenges from residents’ point of view and working together to find solutions.

Bradley Big Local launched a community consultation process to understand what themes the partnership should prioritise. Response and engagement were high. Health and wellbeing emerged as a key priority across all age groups. Specifically, this included issues such as childhood obesity, malnutrition and diabetes. But residents also highlighted how issues around affordability and the rising costs of living were a barrier to improving health and wellbeing.

The next step was to identify how Bradley Big Local, the community, and partners could find ways to start addressing these challenges. Specific projects were proposed and prioritised based on demand from the community and unmet need from existing facilities. This process built trust with the community by ensuring their priorities went on to inform the development of new initiatives in their neighbourhood.

Project Activity: 

The result of this process was that Bradley Big Local set up, funded and supported a range of projects to help improve health and wellbeing. This included:

• Funding for a new outdoor play area – refurbishing the existing play area and adding outdoor gym equipment for all ages to use.
• Running summer camps where residents accessed two weeks of free football activities, working with Nelson Football club.
• Establishing a pocket park and community garden focused on improving health and wellbeing where residents could grow plants and vegetables and participate in classes. 
• Funding women-only cardio and weight loss classes in an existing gym – these sessions were developed in direct response to feedback from residents about being uncomfortable attending a mixed gym (for both personal and cultural reasons) and the barriers of this to exercising, with the knock-on effects to both physical and mental health.

Project Impact: 

The community enthusiastically participated in the range of activities on offer. This is evidenced by the demand for the various classes which have consistently reached capacity. In response to community demand, classes have continued for longer than initially anticipated.

The women-only physical activity classes have delivered a range of physical health benefits and have also become an opportunity for women in the community to connect, develop relationships and form healthy lifestyle habits together.

Off the back of this success, Bradley Big Local is now in the process of developing a state-of-the-art 3G football pitch and associated club facilities, working collaboratively with the local council, Lancashire Football Association, and Sport England.

Key Learnings: 

Listening to community priorities has been essential to the approach. Working with the community to respond to their concerns and prioritise activities has been important not only to the success of specific projects but also to developing a sense of trust and greater community connection.

Local collaborations have been key to the success of the activities. The partnership has worked alongside other community organisations and leisure facilities with shared priorities. It has also developed a good working relationship with the council and together they have identified some shared priorities including childhood obesity. Local health partners have also expressed some interest in the work of the partnership. Information sharing with the council and health partners has raised awareness about the work of Bradley Big Local, opening opportunities to connect residents to the partnership and the activities it offers.

Context: 

Northwood is a neighbourhood located in Kirkby, Merseyside. Northwood Big Local and residents developed a programme called ​‘Shape Shifters’, informed by the concerns and priorities of the community around mental health, physical health and nutrition, particularly since the COVID pandemic. The programme has also been informed by other barriers residents identified such as poor local transport to access services.

Project Activity: 

Shape Shifters is a bespoke, six-month health and wellbeing lifestyle programme that is open to local people. Residents apply for the programme and are interviewed by project board members and a personal trainer from a local gym. Programme participants are offered a free gym pass, weekly weigh-ins and talks about food preparation, nutrition, mental health and the menopause.

Each participant has a team leader, who checks in on them daily, checking that they are not having any issues and encouraging them to books classes, go for a swim or attend a group walking session. Participants access a Facebook page where they can identify who is going to what class, offer support and exchange recipes.

Project team leaders and the project manager meet every four weeks to check in on progress and offer support if required. At these meetings weight loss is discussed and if a participant is not losing weight or attending the gym, they may be asked to leave the project.

The project is in its fourth round and is now supported by Livv Housing Group and Volair Kirkby.

Project Impact: 

Shape Shifters has attracted a large amount of interest from local people, demonstrating that it is meeting the needs identified by residents. There has been measurable impact demonstrated by:

• Over 500lbs of collective weight loss from 24 participants.
• Reductions in cholesterol levels.
• Reduced risk of diabetes.
• Increased confidence.
• Reduced social isolation.

One participant described:

“Shape Shifters has changed my life. Not only have I lost weight and am eating healthier, but my mental health has vastly improved. My confidence is through the roof thanks to the support of the group and Northwood Together. I have met so many great people. I love coming to the gym in my own time now and I’m always sharing low fat recipes with the new group. It has also brought about other opportunities for me that I didn’t ever feel I would have the strength and courage to do.”

The increased confidence experienced by participants has resulted in several individuals exploring opportunities for employment, enrolling local education and skills courses, and becoming team leaders for future rounds of the project. A number have gone on to join the partnership board and one person has since become its new Chair. Social isolation has also been reduced longer term through tools to connect people such as WhatsApp and Facebook groups that cohorts have continued to use beyond the programme.

Key Learnings: 

The fact that Northwood Big Local staff and team leaders are residents in the community has been vital to its success. They had a critical understanding of the specific drivers of the local mental health issues – low self-esteem due to weight gain and poor physical health as a result of poor nutrition, inadequate housing conditions, challenging relationships, and existing health issues. This meant they could design a programme which is sensitive to the specifics of local challenges.

Northwood Together describe three reasons for their success with this project that might be helpful for others establishing community-led health initiatives.

1. Find the right people to engage and be involved in the project.
2. Listen to the community.
3. Be open and honest.

Existing relationships with local chemists and a GP have been valuable for the project as they have been able to undertake some of the health checks and promote the programme to residents.

Local NHS providers have heard about the project and given the demonstrable health impact there is interest in the model and are exploring this further

Context: 

Ewanrigg is a rural outer suburb of the town of Maryport in Cumberland, West Cumbria. Ewanrigg experiences high levels of deprivation, and as often experienced in rural areas, many people do not know what help and support is available to them. Ewanrigg Big Local investment created new opportunities to provide support to residents, focused on poor mental health, physical health, drug and alcohol use, and the health and wellbeing of young people.

“Everything we do at Ewanrigg Big Local is about health and wellbeing” — Ewanrigg Big Local Representative.

Project Activity: 

To support mental health of residents, Ewanrigg Big Local introduced ​‘Hug a Mug’ — an initiative where local people could attend a friendly place to connect with others in their community by having a hot drink and a chat with volunteers. All volunteers received communication and mental health awareness training to facilitate their conversations with residents and to help move them towards overcoming their issues and challenges.

In the spirit of Big Local, setting up Hug a Mug was a community endeavour. Renovating and preparing the physical space was completed by a group of local companies from West Cumbria and the partnership with Maryport medical services meant a free room was provided in a GP practice.

Project Impact: 

Hug a Mug was a popular initiative used by residents across the neighbourhood. The creation of a physical space for connection improved individuals’ mental health and reduced feelings of isolation. Moreover, access to volunteers meant that residents knew how to gain support for the challenges they were facing such as financial concerns or housing issues. It was not just about signposting to support, Hug a Mug helped with everything from creating a safe and warm space for people, to filling in forms to access DWP support.

The instant access without needing an appointment was valued by residents. Knowing you could just come in for a cup of tea was the start of much bigger change for some. Seeing the value of Hug a Mug meant that some local people decided to volunteer, creating a sense of purpose and greater community connection.

In a separate research project that set out to understand more about life in Maryport, Hug a Mug featured heavily. Residents praised Hug a Mug and said:

“Without Hug a Mug and the community centre, things would be far, far worse in Maryport.”

Key Learnings: 

Hug a Mug’s initial success was a result of excellent local collaborations between the Big Local partnership, ENTRA community care and Maryport Medical Services. Early engagement in the project was achieved through a breakfast networking event and through the employment of a business connector to spread the word about the initiative to raise awareness and generate interest.

Health providers were interested in the project and the partnership had a good relationship with a local GP who was an advocate for their work.

Unfortunately, Hug a Mug is no longer running and will not form part of the Ewanrigg Big Local legacy projects. There are a number of factors that contributed to this, including: 

• COVID-19 significantly impacted on the success of Hug a Mug. The social distancing requirements meant that the room was no longer functional nor appropriate and the team changed focus and tried to support residents using an online service. However, this change meant it lost the essence of the social connectivity of Hug a Mug and it was not as successful. 
• There was hope that a courtyard space in the GP practice would be used to create a Hug a Mug space. It would have formed part of the Ewanrigg Big Local legacy but due to increasing pressures on general practice, the GP surgery was no longer able to support the legacy project, meaning it will not be implemented. This is illustrative of how pressures in the formal health system can impact on community-led approaches to health.

Context: 

Par, in Cornwall, suffers from a range of socioeconomic issues and has poor levels of community cohesion and little cross-generation social contact. In the mid-1980s Par docks went into decline which eventually led to 200 job losses and a broader negative impact on the local economy. Since then, residents feel that the area has lacked opportunity and recovery has been slow and challenging.

In 2010, Par Bay Big Local was established as one of the first Big Local areas, supporting the communities of St Blazey, Par and Tywardreath in Cornwall. At the time, it was felt that the area faced significant health challenges. For example, the two GP surgeries are quite distant from the more heavily populated locations, no NHS dentist is available, people living locally have low incomes and lower life expectancy than the national average and they experience higher rates of teenage pregnancy. As a result, Par Bay Big Local set out to support local projects which would help overcome some of these difficulties in accessing health services and to encourage activities that could lead to improved health.

In 2015, Par Bay Big Local purchased an empty, two-story building with the intention of developing this into a community hub. The aim was to address a severe lack of affordable studio space for local creative entrepreneurs, plus restore ownership and pride in the community. The hub, known as ​‘Cornubia’, is a collaboration between by Par Bay Community Trust – a separate charity that will take ownership and provide a legacy for Par Bay Big Local — and local NHS providers and Cornwall Council.

Project Activity: 

There has been a wide range of initiatives in Par Bay. A defibrillator that was part funded by Par Bay Big Local was installed outside Cornubia in the autumn of 2018 and training was arranged for members of Par Bay and local businesses. Weekly health walks have been running since 2018 where walkers enjoy gentle exercise and fresh air whilst appreciating the beautiful scenery and nature to be found in the area.

A total of 13 food poverty projects have been undertaken and were of particular importance during the COVID-19 lockdowns. During this period Par Bay Big Local formed a partnership with the Community Larder, to set up several larders in the immediate and surrounding areas. Open to everyone, the community larders have collected surplus food from supermarkets.

Vulnerable and isolated residents have been supported through the provision of various activities available at Cornubia such as knitting, sewing, pottery painting, yoga, and fitness, helping them build contacts with whom they feel comfortable and confident.

Cornubia has been home to a number of tenants that have changed over the years to reflect demand and priorities in the community. Most recently Cornubia became home to the social prescribing service and NHS prediabetes clinics.

Project Impact: 

The long-term nature of Big Local funding meant that Par Bay Community Trust has been able to plan for the long-term benefit of the area, rather than focusing solely on short term reactive interventions. They were able to strategically plan the purchase and refurbishment of the asset and co-design activities in Cornubia knowing that it will be an asset to the community for years to come.

One participant described: ​“I am eternally grateful to Carolyn, Sonia, Sally, and the rest of the Cornubia Team for taking me on and giving me the opportunities, I needed to become the confident, productive and hardworking person, I am today.”

The range activities delivered at Cornubia and through the Par Bay Big Local support and enable early intervention, so issues are tackled before more serious care is required. Activities encourage self-management within the community and the development of agency and autonomy. Cornubia has created spaces for activities which support community connectedness and reduced social isolation, as well as increased pride in the area, which benefits residents’ mental health and wellbeing.

“The Group met in St Blazey and allowed locals and those from surrounding areas to meet and share interests and problems, reducing isolation and improving mental health” – Par Bay Big Local Representative.

Local NHS services are continuing to value provision of services in the community hub and will be exploring the introduction of a pain clinic in addition to their existing use of the space.

Key Learnings: 

Members of Par Bay Big Local and Par Bay Community Trust are all local residents meaning they have insight into the community and recognise that communities grow organically. It is felt that this was a critical component of the community-led approach, as there was a good understanding of how things worked and how to get things done from the outset.

Building partnerships has been key and this has been achieved by creating a sense of community ownership. An engaging approach and attitude to working with partners has been vital, focusing on inclusivity, being good listeners, and being flexible to change.

Big Local partnership activity is by definition community-led and self-directed. Given there were no predetermined outcomes to be achieved or stipulations over how the funding allocated should be spent, activity took many different forms and progressed in a wide range of directions. There was no requirement to report back in the way statutory public investment often dictates, so there are no set evaluative methods for capturing impact in comparable ways, which the formal health system tends to require. This is a common feature of community-led approaches, which tend to have subjective, qualitative value that is hard to prove within our traditional policy and delivery model that requires evidence of direct impact often measured by quantitative metrics (35).

Despite these constraints, it is possible to demonstrate the impact of Big Local activity on community health and wellbeing in two substantive ways: through secondary longitudinal research and through primary evidence gathered through our research. The first provides an insight into the long-term impact of Big Local, and the second adopts the framework of social determinants of health outcomes to explore self-reported impact of activity.

Using data from the Census, over a ten-year period reflecting the operation of the programme, residents in Big Local areas report better health compared to England as a whole and to other similar non-Big-Local areas (36). As Figure 3 shows, between 2011 and 2021, there has been a greater than average increase in the proportion of residents in Big Local areas that report their health as ​‘very good’ compared to nationally and to other similar areas. In addition, there has been a greater than average reduction in the share of residents reporting their health as ​’bad‘ compared to national levels. 

Figure 3: Change in self-reported health of residents, 2011–2021.

Bar chart shows the percentage point change in ​‘Big Local areas’, ​‘Comparator areas’ and ​‘England’. 

• Big Local area residents self-reporting very good health: around 2.0% increase.
• Comparator area residents self-reporting very good health: around 1.75% increase.
• England residents self-reporting very good health health: around 1.4% increase.
• Big Local area residents self-reporting bad health: around 0.4% decrease.
• Comparator area residents self-reporting bad health: around 0.5% decrease.
• England residents self-reporting bad health: around 0.1% decrease.

Source: Office for National Statistics Census, 2011 and 2021.

This is a significant finding and implies a measurable contribution by Big Local areas to reducing inequalities, given their focus on areas of high levels of deprivation and low levels of social capital, where outcomes might be expected to be worse than the national average. Especially over a decade that has involved a prolonged period of austerity and the COVID-19 pandemic, this suggests a stronger degree of resilience amongst Big Local communities to weather these storms. Although further statistical analysis might be required, the findings from Census data provides a long-term measurable indication as to the positive impact Big Local activity could be contributing to health. 

Given the nature of Big Local partnerships, anchored in communities where physical, economic, social and environmental factors coalesce around individual and family factors, adopting the lens of social determinants of health outcomes enables significant insights into the impact of activity in the round. 

The social determinants are the broad social and economic circumstances that impact on health across the life course (37). Michael Marmot identifies five categories of social determinants set out in his seminal Marmot Review published in 2010 (38). Our analysis indicates that Big Local partnerships have introduced activities relating to all five determinants:

1. Ensure a healthy standard of living for all.
2. Enable all children, young people and adults to maximise their capabilities and have control over their lives.
3. Create and develop healthy and sustainable places and communities.
4. Give every child the best start in life.
5. Creating fair employment and good work for all.

For the purposes of this analysis, we focused on the first three social determinants, which are most clearly met through Big Local partnership activity. The remaining two are addressed in significant ways through Big Local partnerships, evidenced most strongly through previous research. For example, in relation to give every child the best start in life, Big Local partnerships have been shown to have supported childcare and creche opportunities and provided support for parents (39). In relation to creating fair employment and good work for all, Big Local activity has resulted in resident skill development and increased employment (40). However, the impact on health and wellbeing can be attributed most strongly to the three key determinants listed below.

1. Ensure a healthy living standard for all.

Big Local areas are by definition those which are experiencing relatively high levels of deprivation and low levels of social capital, so have a weaker starting point than average when it comes to ensuring a healthy standard of living for community members. To live a healthy life, individuals require access to basic resources, including but not limited to food, housing and access to transport and wider economic participation. There are two key respects in which Big Local activity has contributed to ensuring a healthy standard of living where their partnerships operate.

Direct support for healthier and more active living, through widening access to nutrition and exercise:

Big Local partnerships invested extensively in addressing community need related to food poverty, with a focus on trying to develop more sustainable solutions to enable families to prepare healthy and cost-efficient meals. Over time, this is likely to lead to improvements in health outcomes and reduced formal service demand associated with poor diet and nutrition.

“Through the work we have been doing in our food co-operative, people in our community have started to realise the link between levels of obesity/​poor nutrition and mental health. As they have developed healthy eating habits, their self-esteem and mental health have shot up.” – Tang Hall Big Local.

“Our fit and fed programme means around 70 to 100 young people are immersed in a world of physical and creative activities during half terms and their summer and winter breaks. Over a four-day period they play a range of sports and games, and our community chef provides them with a hot delicious nutritious lunch.” — Arches Local Big Local.

Active travel was important to communities, built on the desire to improve fitness levels and address air pollution concerns in their area. Walking and cycling decrease congestion and reduce air and noise pollution which are both linked to health and economic benefits. There are also known physical and mental health benefits of increased active travel with reduced risk of cancer, cardiovascular disease, and obesity and protecting against anxiety and depression (41).

“Our gym in a box addresses the lack of any gym or leisure facilities nearby for our community. Alongside our community cycling hub, which has had fantastic take up, we are contributing to more active lifestyles and regular exercise for our community” – 3 Together Big Local.

“To reduce the impact of car pollution on our communities, we ​‘ve encouraged school children to walk and cycle more through a daily mile challenge and the donation of bikes so they can cycle to school. Not only has this reduced pollution around the schools, but we are setting the kids up for good habits and a future active travel lifestyle” – Leigh Neighbours Big Local.

Responding in real time to events that undermine healthy living standards:

Across all Big Local partnerships, there was significant evidence of responsiveness to external shocks which impacted communities, notably the COVID-19 pandemic and the cost-of-living crisis. Much of the support for mental health was noted as a direct consequence of emerging need following lockdowns and lack of formal provision stepping in to meet the demand. Similarly, when basic needs for food and warmth have been increasingly identified as unmet, activity has shifted to fill the gaps – directly increasing access to food and warm spaces for community members.

“We funded and delivered our heat and meet project to combat the really high energy costs our community faced. We provided warm space, warm food and good company for three hours every evening through the winter. They were really well attended and its popularity led to the development of our mindfulness café.” — HAVA Big Local.

“We modified our community wellbeing bags in response to the stress and loneliness some of our residents were experiencing in lockdown. We added in practical tips and contact details for people to talk to about their mental health and anxiety. We created a children’s version too specifically to help them deal with being away from school.” — W12 Together Big Local.

“Because we’ve renovated and taken over the Hub, we were able to host a warm hub right in the heart of our community during the winter. This is important because we have a large proportion of elderly people in our community, so they were able to come, stay warm and socialise whilst energy costs were spiralling.” – Par Bay Big Local.

2. Enable all children, young people and adults to maximise their capabilities and have control over their lives.

With empowerment and agency core features of the Big Local approach, there are important ways in which activity has supported people across the life course to maximise their capabilities and control over their lives. We identified two core respects in which this has taken form through the community-led approaches: supporting strong family relationships and fostering opportunities for direct ownership and control.

Supporting strong family relationships:

The role of strong, positive family relationships is important for a range of outcomes. For adults, these provide mechanisms for coping with stressors that would otherwise impact on wellbeing (42). Where relationships are strained, the ability to cope with stress is reduced and the resultant impact can lead to effects on mental and physical health (43). For children, exposure to positive relationships early in life supports healthy development (44). In particular their experience of the first 1,000 days of life can have lasting impacts on their future health (45).

Big Local partnerships have set up, funded or run a wide range of activities to support families. This includes activities to support pregnant women and new parents as well as a range of activities to support the whole family. These initiatives are important for supporting mothers’ and parents’ health and wellbeing as well as early childhood development. 

“It has been a very good community learning experience and, as an added bonus, the children and adults enjoyed it very much – great fun! There have been requests for more exercise to music sessions to help improve health, fitness and general wellbeing, both for children and adults” — Local Residents’ Association in Par Bay Big Local.

“For our We will Youth mental health campaign, young people rewrote the rulebook! We saw them taking a leadership role in campaigning their skills and leading it with creativity. We want them to do it their way and they did. It was complicated but beautiful — their skills and confidence have improved incredibly.” – Ewanrigg Big Local.

Activities focused on bringing families together around sport and exercise have been a way for Big Local partnerships to encourage families to get active and provided opportunities for role modelling of healthy behaviours by adults to children. This can cement healthy behaviours later in life and creates greater opportunities for familial bonding through physical activity.

“We have supported a bike library where residents can learn to ride a bike or borrow a bike for the summer. One mum brought her 6‑year-old, she asked for a bike for her husband too, the scheme is strengthening connections with families, and the same family have returned for bikes three years in a row.” – Leigh Neighbours Big Local.

One important aspect of Big Local partnership support has been on providing specialist support for young children, particularly those with sensory issues, autism or ADHD. Some Big Local-funded initiatives described the important role play therapists and sensory workers had in enabling young children to engage more consistently and remain in education. This is significant in light of evidence regarding the correlation between health and educational attainment (46), and because children with ADHD are reported to be more than 100 times at greater risk of being permanently excluded from school than other children (47).

“The impact of having a play therapist, sensory worker and an arts-based therapy project has been huge and would not have happened without Big Local. These roles had a positive impact on children’s readiness to engage with education in the classroom and reduced the number of children removed from school.” — Primary school located in Leigh Neighbours Big Local.

Fostering direct ownership and control:

Feelings of greater agency and control are important for wellbeing, on an individual and community level (48). A common theme across Big Local partnerships was the direct support for community connection and a sense of agency which individuals noted as a result of activity. Often, the approach adopted was not the form of traditional service delivery or compulsion, but encouragement, advice and awareness which supported people to take early steps towards exerting more control over their lives. 

“Anyone in the community can be a researcher in our community hub. This gives them agency in the decisions that are being made around and about them, and ultimately gives them ownership of their health.”- W12 Together Big Local.

“We know that mental health, physical health, and poor nutrition are all linked, so a project to tackle all three has really helped our residents’ wellbeing and confidence.” — Northwood Big Local.

“We’ve helped 24 people lose 500lbs in total from our Shapeshifter project. Regularly attending the gym and weekly check ins about their health and nutrition kept them accountable and supported them to develop healthy daily habits.” — Northwood Big Local.

One important feature of community-led activity is the fact it is accessible to all. Unlike formal services which can be hard to access or complicated to navigate, often creating a significant barrier to entry, community-led activity is open to all residents. This creates a lower barrier to starting off that first conversation about taking on more control and putting in place measures to support health and wellbeing, which is much more efficacious to the individuals than navigating a formal system of entitlements and referrals.

“Our community shop has 850 members, who all get regular access to affordable healthy food, cooking classes and recipe books so they can learn to cook healthy and nutritious meals for their families.” – Scotlands and Bushbury Hill Big Local.

“We’ve delivered over 7,180 volunteer hours, and awarded over £137,000 in grants to local residents, organised groups, services and business so they can have ownership of their area.” – Keighley Big Local.

3. Create and develop healthy and sustainable places and communities.

There is growing recognition of the importance of place in shaping people’s health outcomes (49). Evidence from the nature of Big Local partnerships demonstrates how activity is contributing to creating and developing healthy and sustainable places and communities. This can be identified across two core domains: supporting physical community infrastructure and assets, and supporting vibrant and community networks. 

Supporting physical community infrastructure and assets:

Activity supported by Big Local partnerships has contributed to healthy and sustainable places through investing in and widening access to physical assets within the community. This has a range of practical expressions, from obtaining equipment to enable exercise, to supporting buildings and spaces for community use or removing barriers to accessing facilities faced by residents as a result of cost or lack of transport. 

Many Big Local partnerships have directly purchased buildings within their communities, often bringing communities together to refurbish and launch their shared community spaces. These assets have been used for wide ranging Big Local activities, from financial support to Zumba classes. Increasingly, these spaces are becoming anchors for wider public services, from which a range of formal provision can be carried out, accessed by communities in a trusted local space. 

“We have refurbished and invested in a play area that hadn’t been touched for 20 years. We funded new outdoor gym equipment and play facilities, and it’s now really busy and heavily used by families exercising and playing together. ” — Bradley Big Local.

“Local government funding cuts meant our local community centre was earmarked to close. Councillors and the community didn’t want it closing though, so we’ve invested heavily to keep it running. It’s now a valuable base for the local health and wellbeing team and the social prescribing link workers, improving the wellbeing of our residents.” – Gannow Big Local.

These findings are supported by prior research into the Big Local programme where improved green spaces, new outdoor amenities, and public realm improvements improved health through opportunities for more physical activity and reduced environmental stressors (50). 

Supporting vibrant community networks and relationships:

Evidence from this research highlights how Big Local partnerships are contributing to a core aspect of healthy communities – supporting strong networks and relationships, which promote belonging and mitigate against isolation. The existence of strong mutual support from networks and support between people within a community are key elements of social capital (51). 

There is increasing awareness, particularly in light of the pandemic after-effects, of the prevalence of social isolation and the knock-on effects on ill health. Having a sense of belonging to a neighbourhood is known to help protect from the effects of loneliness (52). Big Local partnerships addressed the causes of social isolation through much of their activity around supporting community relationships, based around residents coming together to lead initiatives or participate in funded group activity in different ways.

“Our investment in the community centre means we have been able to rent out spaces to a range of community organisations, who run a variety of services. It’s been really great to see the diversity of activities and community coming together in one place.” — Gannow Big Local.

“Café Eden was designed as space for parents and carers for someone who is autistic to come together, talk and learn from each other. We heard from our community that it can be quite lonely and isolating for them, and we’ve worked really closely with AWARE and Keighley College to make the café an open and welcoming place.” — Keighley Big Local.

“We have seen from the people who volunteer, particularly with our Fit and Fed programme, that they are more likely to feel they belong in their area and those who take part in activities are more likely to enjoy stronger social links with other people.” – Arches Local Big Local.

“Weekly football sessions for the Bradford Syrian Community Welfare Association gave the young people a sense of togetherness and increased friendship. Families attended the weekly sessions, and shared their experiences of the traumatic journeys they had taken as refugees, helping them overcome trauma, reduce stress and make friends.” – Greenmoor Big Local (Better Communities Bradford).

There are also important ways in which Big Local partnerships have filled a space between residents and formal services, created by lack of trust or difficulties in accessing mainstream services. This shows the role informal activity can play both directly in supporting communities and indirectly in supporting formal provision to be more effective.

“Our community distrust people with a lanyard, half of them don’t have access to transport, and with different services located in so many different places, there are so many barriers to accessing support. By having a GP surgery located next to our Hug a Mug scheme, it really helped build connections between the community and GP, and increase the effectiveness and speed of the support they needed.” – Ewanrigg Big Local.

“Mental health support can be really challenging to access for a whole range of reasons, including knowing where to go to, who to speak to, not to mention the stigma that can be associated with it in some communities. By locating this support in an environment where our community are already going to and feel comfortable, we have been able to deliver more support to more people.” — Greenmoor Big Local.

The impact set out in this section demonstrates the wide range of activities alongside the interconnectedness of impact. There are clear and important links between individuals’ health and wellbeing and individual agency, confidence, wider social fabric and a sense of belonging. Crucially, all of these factors are of recognised high value to communities but sit outside the objectives of the formal health system which has a primary mandate to treat ill health. 

The Big Local programme has improved the health and wellbeing of communities, despite facing a number of unexpected challenges such as the COVID-19 pandemic and the cost-of-living crisis. Our research found that the wide-ranging health-related activities, and the resultant impact on the social determinants of health, occurred despite the absence of alignment and links to the formal health system. We identified a number of factors that provide some explanation for this disconnect that inhibit the impact and scale of community-led approaches to health and wellbeing from reaching their full potential. The final section of this report sets out a series of recommendations for how the formal health system might better understand, nurture, and invest in community-led initiatives which support good health in the context of a wider shift towards prevention.

Big Local partnerships have supported a wide and dynamic range of activities that positively affect residents’ health. These activities are important in and of themselves, because communities are demonstrating that they understand the issues they face and can play a leading role in overcoming challenges in order to improve their health outcomes. They are extremely well placed to balance the competing pressures of the need for immediate assistance and creating the conditions for long-term improvement to health.

This activity should also play a more significant and recognised role within the formal health sector – notably the new ICSs, which comprise NHS bodies, primary and community-based care and local authorities. Greater and stronger links between community-based health activity and the formal health system could support improved health outcomes. However, as this research has shown, these links are few and far between, particularly within those most deprived areas that face the greatest health inequalities. The value of community-based health activity is not fully recognised within the formal health system, despite ICS objectives to tackle health inequalities and the wider recognised need to shift towards more prevention (53).

In exploring the link between community-based activities and the formal health system, this research has found significant institutional constraints that if removed could help scale up the impact of community-led activity like that seen in Big Local areas. These limiting factors centre on: 

1. Short-term funding models and priorities of the formal health system.
2. The power imbalance between the formal health system and community-based activity.
3. The lack of skills and expertise within the formal health system to meaningfully engage with communities.

This section will now explore each in turn, before the final section of the report sets out recommendations to overcome them.

Chronic underfunding of public health alongside real-terms cuts to wider local government activity mean that essential services are frequently not being provided. In addition, although superficially it appears that NHS budgets have been protected, the rising cost of inflation, years of austerity, and increasing demand have resulted in a large financial deficit (54). This has created an extreme short-termist culture within the NHS, establishing an aversion to risk-taking and a focus on short-term planning and prioritisation of immediate demand pressures (55).

“Statutory health organisations don’t understand that community organisations rely on external funding as a lifeline. We can’t wait for the wheels of bureaucracy in order to deliver projects. We just don’t work in the same way or pace, and we can’t afford to wait.” – Big Local partnership.

“There is no dedicated health resource in the council. With restrictions in funding, it is hard to meaningfully progress things that aren’t going to be sustainable.” — Participant from research workshop.

The health system’s emphasis on short-term demand, treating ill health, reducing waiting lists and meeting centrally driven key performance indicators fail to align with Big Local partnerships’ focus on longer term solutions, holistic approaches to health and wellbeing, and listening and responding to community need. This is frustrating because support for the longer-term solutions within a community could help shift the dial on demand in the medium-term. 

“You need time and money built in to be able to fail and test ideas. Needing to prove that something has worked within one year is impossible.” — Participant from research workshop.

“So many cuts and need for mid-term savings is creating silos. It’s creating a situation where you’re not even working with your internal partners as effectively as you want.” — Participant from research workshop.

“We need communities to be considered equal where clinical commissioners are as much guided by long term as they are short term.“– Participant from research workshop.

Opportunities to maximise prevention, early intervention and long-term-management through community-led approaches to health are inhibited by the formal health system’s lack of investment and engagement. Funding for community-led preventive activity remains disproportionate to acute response and treatment (56).

Where funding is made available it is often allocated in short cycles and small quantities. This creates competition in the voluntary, community and social enterprise (VCSE) sector and results in a disproportionate amount of time and effort spent completing administrative processes rather than working with communities and improving health and wellbeing. In both the formal health system and the VCSE sector, financial pressures and the complexity of funding stifles innovation, ultimately inhibiting the impact of collaborative working for the health and wellbeing benefits of communities.

The power imbalance between the formal health system and community-led activity leads to a concentration of siloed decision making within the health system which does not fully incorporate or recognise wider benefits of activities at the community level. This power imbalance manifests within three key areas: spatial scale; expertise and system knowledge; and communication and recognising value.

Spatial scale:

“Communities need to be trusted – there’s so much going on, there are so many skills and so much knowledge in places but at a strategic policy level this isn’t acknowledged.” — Participant from research workshop.

The power imbalance and associated disconnect between the formal health system and community-based activities arises from working across different spatial scales. Big Local partnerships operate at a hyperlocal level, at a much smaller scale of approximately 8,000 residents, much less than the health system definition of ​‘neighbourhood’ as anything between 30,000 and 50,000 registered patients. This scale difference and associated funding models inevitably leads to different strategic perspectives meaning the formal system is frequently unable to recognise the value in smaller-scale grassroots activity.

Expertise and system knowledge:

“We have people in the council and NHS who are telling them what services they need. These people don’t know the area, haven’t lived here or visited. They haven’t made the connections like we have – they haven’t made real world connections, everyone thinks it is someone else’s job to lead. People listen to me as chair of a Big Local, but they don’t listen to me as a resident.” — Participant from research workshop.

“The NHS and health and care landscape is so complex — I don’t know who or where to go to start a working relationship.” – Big Local partnership.

Residents and community organisations have reflected that not only does the formal health system hold much of the strategic and financial power but that it is concentrated on specific individuals within those institutions. Residents and community organisations find it difficult to navigate complex formal systems and to identify and influence decision makers. Even with the financial foundations Big Local partnerships have, this is still a challenge. Where this has happened, it has been driven by the initiative of individual community leaders rather than the formal system.

Communication and recognising value:

“There is a total disconnect between GP surgeries/​pharmacies and community organisations. They have no connection to the community, with high turnover of temporary locum staff who have no incentive to meaningfully engage with us. They are very much focused on short term clinical treatment.” – Big Local partnership.

There are significant problems of communication and mutual understanding between Big Local partnerships and local health systems which makes deep collaboration around shared community health priorities very difficult. At the heart of this is lack of trust or strong relationships but it is also about a lack of shared learning and exchange of perspectives. This disconnect means that opportunities to expand the new forms of engagement, collaboration, and direct decision-making championed by Big Local areas are dramatically reduced. Exacerbating the communication issues is a lack of joined up research, insight and information shared across organisations. The formal health system has the power and legal authority to share information and start meaningful conversations with communities, but this does not happen in a systematic way. Without this, perspectives cannot be understood and new ways of working cannot be forged.

Residents and community organisations reflected that individuals with power frequently do not have direct experience of what it is like to be a resident in their area. Communities are well placed to identify the key challenges they face and can play a key role in developing local solutions but they are often sidelined from this opportunity (57).

As community knowledge and ideas are chronically undervalued and under-recognised within the formal health system, decisions are infrequently influenced or informed by the people who are affected by them. The formal health system is used to making decisions on behalf of communities and are often removed from their realities leading to significant missed opportunities for improvement of health outcomes.

“We have found it challenging to engage with GPs and the NHS due to a lack of capacity and resource from them.” – Big Local partnership.

“There is an enormous gulf now between public services and communities – this worries me. There are conversations about finetuning coproduction, but its bigger than that. Cash is reducing, their ability to engage is going down not up! Many volunteers are getting burnout.” — Participant from research workshop.

There are significant opportunities for the formal health system and community-led groups to come together and share learning, perspectives, ideas, and competing pressures. But this must start with people in the formal health system acknowledging that they hold disproportionate power when compared to people in communities, which can be a barrier to collaboration. 

Big Local partnerships add value by viewing health as a contextual or community matter requiring collective responses. However, many Big Local partnerships reflected that health professionals are rarely aware of the assets and opportunities that are located within communities that could improve health outcomes. This means both that those assets are underutilised and that Big Local partnerships find it difficult to persuade health systems of the value of their work and hence promote collaboration.

“Their [local health services] funding is stretched so they are focused on their primary day-to-day responsibilities rather than the work we do.” – Big Local partnership.

“We need to flip the system so council directors are asking what they can do to enable you rather than having to lobby for their time. If we weren’t a Big Local partnership with a million pounds no one would listen at all.” — Participant from research workshop.

Without the necessary time, tools and skills to hear communities discuss their needs, meaningful engagement and delivering successful outcomes will be low. We found that there was a lack of capacity within the health system to collaborate, particularly as Big Local activity was viewed as something outside of the day-to-day delivery or ​‘business as usual’ role of the formal health system. 

“Despite link workers co-locating with us, they just don’t get how we work or understand the benefits of what we do.” – Big Local partnership.

This lack of capacity is compounded by the opaque nature of health institutions. Big Local partnerships reported that they found it very difficult to navigate the complex structures and interwoven bureaucracy of NHS bodies and councils. This militated against collaboration or, more basically, day-to-day interaction. This situation was exacerbated by the fact that the institutional focus and mindset of health system bodies meant they often lacked the right skills or outlook to support engagement activity by Big Local partnerships. Notably, Big Local partnerships often felt that health bodies interacted with them in a purely transactional form, seeking some institutional benefit for themselves rather than a meaningful collaboration based on shared strategic goals. 

The next section of this report will consider how to overcome these limiting factors in the recommendations.

The exploration of Big Local partnerships’ activities has demonstrated that hyperlocal and community-based projects can have a positive impact on residents’ physical and mental health. This finding is important in and of itself: communities should be given the tools, resource, and support to be able to develop meaningful solutions to the particular needs they recognise. These frequently relate to the wider determinants of health, which is an important dimension of a preventative approach to health and wellbeing, in contrast to the treatment focus of the formal health system.

There is an opportunity here to ensure the impact and reach of these community-based activities is increased. The relationship and interface between the formal health system and community-based activities should be better. For a variety of reasons, the formal health system is overwhelmingly focused on short-term, acute issues, while community-based activities are typically focused on longer-term issues. If the connection and recognition of value were greater, the synergy between the two could be impactful.

The reasons behind this lack of synergy were the limiting factors set out in the previous section. These indicate the need for a systemwide shift in how finance flows, how we recognise and measure value and how staff are supported to engage with communities to draw their insight into decision-making. Overcoming these limiting factors could unlock new ways of working, better ways of communicating and sharing insight, and a recognition that positive activity in one area could help alleviate problems in another.

This final section explores the potential solutions to overcoming those limiting factors. It focuses heavily on ways in which local health systems can break down these barriers and realise the benefits of a different type of health activity, and ends with some recommendations for existing hyper-local groups trying to influence the current formal health system.

The Big Local model demonstrates how hyperlocal community-led initiatives can generate progress on a range of health and wellbeing indicators. The approach has particular significance for deprived neighbourhoods, where there are spatial concentrations of poor health outcomes (58). This provides learning for the formal system of health provision, which is facing high demand pressures to which a primarily service-led response is struggling to respond. 

Community-led approaches are extremely beneficial in this regard as they are inherently preventative. In other words, by supporting healthy activity, positive health behaviours and wider physical and mental wellbeing, there is greater likelihood of postponing the onset of poor health, and when it does occur spotting it early to mitigate deterioration. To realise the benefits community-led health and wellbeing initiatives can have, our recommendations focus on how local health systems can create enabling environments for community-led activity to grow. 

ICSs have four core purposes, of which two are most relevant in this context:

• Tackling inequalities in health outcomes
• Supporting broader social and economic development 

Across the new local health system architecture, at system, place and neighbourhood level, there needs to be greater recognition of the role of hyperlocal community-led health and wellbeing initiatives as a core route to meeting these purposes. In terms of tackling health inequalities, the focus on Big Local areas has shown how adopting an approach which starts with communities can support the health and wellbeing of hyperlocal areas where high levels of deprivation are concentrated and existing social capital is low. These areas are likely at greater risk of poor health outcomes amongst residents. In terms of supporting broader social and economic development, supporting community-led initiatives is a way of tackling the social determinants of health outside formal healthcare settings. 

Below are three core recommendations which aim to progress this understanding within the formal health system so that it can support community-led activity. These are intended to overcome the disconnect between formal clinical reactive provision and informal community-led preventative approaches. The insights of Big Local areas supporting the health and wellbeing of their residents indicate a feature of an emergent, more sustainable system of health and wellbeing support. This would be one which operates beyond the boundaries of formal health institutions and is anchored in places where the social determinants of health outcomes manifest. 

Recommendation 1: Health system partners at all levels should develop a deeper shared understanding of where and how hyperlocal deprivation manifests within their geographies.

There is at present a relatively weak understanding within the formal healthcare system of the relationship between neighbourhood deprivation on both health outcomes and patterns of service demand. ICSs have brought together all partners involved in health, wellbeing and care across a large geography. This architecture, which was put on a statutory footing in 2022, holds the promise of developing better place-and neighbourhood-level approaches to improving health outcomes within each of the 42 systems. 

To progress this, partners at all levels should develop a clear shared understanding of the spatial distribution of deprivation in their areas. This should then inform the identification at a hyperlocal level (middle layer super output area) (59) where there are significant concentrations of deprivation.

Once these have been identified, place partners should lead a deeper analysis of both patterns of service demand and health outcomes at this hyperlocal neighbourhood level. Such analysis would consider several health data sources and measures pertinent to the social determinants for example, housing, employment and measures of community safety. Quantitative metrics interpreted solely by professionals will not provide a full picture – this data should be supplemented with qualitative insights from communities themselves about their experience of health and wellbeing. A greater focus on strengths and connections within communities might also be beneficial to inform a more sophisticated system-level evidence base on the population need at a hyperlocal level. 

Taking lessons from the Big Local model, wider health inequalities strategies should include an analysis of hyperlocal areas experiencing deprivation and depleted social capital, and understand the consequences of this for poor health outcomes. There is a core role here for both primary care networks (60) and other partners within the system including councils and the local voluntary sector. Their combined understanding of their areas, for example within large estates or small neighbourhoods, is crucial local intelligence to inform wider system planning.

Developing this shared data analysis across partners is an important precondition to informing a system-wide case for different ways of working, commissioning and investing in community-led health and wellbeing support. 

Recommendation 2: Health systems should aim to deepen and expand community-led approaches to health and wellbeing, adopting a test and learn approach to measure their impact on outcomes and demand.

Once local health systems have developed their understanding of hyperlocal deprivation across their geographies, the next step should be to deepen existing and expand new community-led activity on health and wellbeing. Where community-led approaches already exist such as in Big Local areas, these should be supported and clear routes into the formal system identified, for example through primary care networks. 

More generally, the learning from Big Local partnerships highlights core features of community-led approaches to health and wellbeing which could be deployed within systems in areas with high levels of deprivation and low levels of social capital. On the basis of a fuller evidence base and shared understanding of where communities might benefit from a different approach, new community-led health and wellbeing initiatives should be progressed in key identified areas, with learning captured and fed back into the system. 

These should adopt core features of the Big Local model. This means that activity should be informed by community priorities, not those of the service or wider system targets; giving communities direct agency and decision-making power should be a key feature. This should be based on the system recognising that genuine participation enhances health because it builds trust and improves the quality of relationships. Relatively small levels of upfront funding with no strings attached should be invested where communities identify there is a need. The seven areas of activity identified in this research indicate what this might involve. The investment should be over a long timeframe and not subject to in-year requirements for outcomes which is a feature of funding and reporting within the current system. 

A crucial aspect of this will be capturing and evaluating the learning and impact within the system. One barrier to mainstreaming support for informal community-led activity within a wider formal clinically-led system is that it is hard to prioritise prevention with longer-term impacts over immediate demand pressures, even if the former could contribute to easing the latter. At system and place level, there is the prospect of developing trusted relationships across organisations and a shared evidence-informed understanding of population health and patterns of demand. It is in this context that the impact of community-led approaches can be both tracked, and crucially the implications of shifts can then inform future commissioning. 

It might be that several communities are pioneers of this test-and learn approach within each place, and once established there are opportunities for better join up with the existing health system. For example, social prescribing is a recognised bridge between the formal health system and community-based assets, but it tends to operate through more formal programmes and VCSE organisations. In addition, social prescribing tends to prioritise clinically defined activity with immediate results on ill-health, rather than that which impacts social determinants that might promote good health over the longer term. As primary care networks mature and build deeper links with community assets and opportunities outside clinical settings, there are opportunities for existing social prescribing practice to broaden and thus deepen its impact. Over time, this could develop into a longer-term funding source for community health and wellbeing initiatives.

In particular, areas of high deprivation and low social capital could benefit from association with more informal community-led activity and building links into broader community-initiated priorities. This will require a more flexible approach to working with community-led organisations which operate at a more grassroots level than the larger, more professionalised VCSE organisations with which health systems tend to work.

Local actors need consistency from national bodies, and the UK Government in particular needs to recognise the challenges of operating in the context of sometimes contradictory messages from different departments. The UK Government and other national governments should learn from the example of the Wellbeing of Future Generations Act in Wales, which has achieved a level of consistency that all public bodies, and the partners and communities they work with, can plan around. 

Recommendation 3: System partners should commit to shifting resource towards investment in community-led health and wellbeing initiatives, as part of a wider rebalancing of spend towards prevention.

Based on the development of a shared understanding of neighbourhoods experiencing hyperlocal deprivation, and learning within each system through testing, systems should commit to shifting an agreed level of resource towards community-led health and wellbeing activity over time. The Hewitt Review set out a clear ambition to increase the total of NHS budgets at ICS level going towards prevention by at least 1% over the next five years (61). We support this broad direction of travel, and suggest a further commitment to investing in community-led prevention activity that would build on this. 

ICSs should commit to a target of spending 0.1% of their budgets on community-led health and wellbeing activities and to increasing this over time as test-and-learn approaches deepen the system and place level evidence base for impact. This is a very small proportion of overall budgets — £1 million for every £1 billion of health and care spend. But the experience of the Big Local programme shows that relatively small, but long term and unrestricted funding can generate important returns in building social capital and addressing social determinants. A modest growth to 0.5% of current spending (£5 million for every £1 billion in ICS budgets) over the next five years could expand and sustain such community-led health and wellbeing activity and begin to shift the capacity of communities to support their own health in ways which shift outcomes and patterns of demand.

There are risks associated with formal healthcare systems investing in community-led activity. Initiatives developed, shaped and owned by communities should not become subservient to the priorities of the system, nor forced to generate a narrow set of results on the terms of formal services. This is why an ongoing test-and-learn approach will be so fundamental – this shouldn’t be a case of the health system contracting out to communities. Community insights should reflect back into the health system to inform more effective planning, design and delivery. 

To enable this, there is an important role for national health bodies, in particular NHS England, to promote awareness of community-led health and wellbeing activities which address the social determinants. Guidance is an important permissive signal and should ensure systems and places are supported to pioneer new approaches to invest small sums in community-led practice and effective evaluation. 

Beyond issuing guidance, NHS England should also recognise it has a deeper enabling role. This includes permitting more flexible funding models and longer financial cycles to account for long-term investment. It will also require fewer centrally issued performance targets, which dominate the energy of the system and can create perverse incentives to suppress new approaches and ways of working outside service boundaries. ICSs should be supported and enabled to shift the locus of power through raised awareness of the need to shift from a paternalistic and transactional mindset to an open and collaborative culture.

Whilst the recommendations in this section predominantly focus on the implications for the formal health system, our research has found two key lessons that are important for other Big Local partnerships and those leading hyperlocal community initiatives. 

Understanding the pressures and priorities of organisations and persevering with building individual connections might be important to develop relationships. Our research found that relationships tend to be strong between Big Local partnerships and other local VCSE organisations but significantly less so for NHS organisations, councils and public health teams. Those working with a hyperlocal focus could look to forge these connections wherever possible to ensure buy-in to any work and to build in capacity and capability from those organisations. 

The research has found that, where these links have been strong, they are dependent on individual relationships between Big Local partnerships and councils, local GP surgeries or pharmacies. Hyperlocal initiatives should look to identify individuals and champions of preventative approaches within the formal health system and work through how each other’s activity could be mutually beneficial, complementary, and effective at achieving short-term and long-term goals.

Second, hyperlocal organisations and associated funders and think tanks should focus on demystifying community-led activity and work more proactively to communicate impact to potential partners in the health system. Community-led activities are configured around a different set of value patterns where results are predominantly subjective and are felt and experienced by participants themselves. Sharing stories, examples, and case studies are all important activities for hyperlocal initiatives in forging greater links with the formal health system. A particular emphasis on using this information to create the link between the formal health system’s short-term goals and the long-term benefits of a hyperlocal approach will demonstrate how activity in the latter could help alleviate excessive demand in the former.

With the resources and freedom to set priorities and improve their own community, Big Local partnerships have delivered a wide range of health activity that has had direct and indirect benefits for health outcomes. Big Local partnerships have addressed three core social determinants of health, and improved residents’ self-reported health and wellbeing.

This activity and corresponding impact have been delivered despite facing significant institutional blockers to maximising the potential of their approaches. Barriers exist within the formal health system which are hindering both these areas and wider hyperlocal activities. These need to be overcome in order that more hyperlocal, community-led activity can happen across the country and allow their value to be established as a common feature within our system.

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

New Local undertook this project, commissioned by Local Trust and in partnership with the International Futures Forum, to explore whether and how Big Local partnerships responded to health challenges in their local area and the impact of this community-led decision-making on health outcomes.

The research questions were:

1. How do communities understand health and what approaches do they take to improving health in their community?
2. What role do community approaches to health have in the wider health system and health system transformation?
3. What support and conditions are needed for communities to successfully engage with local health and health systems transformation?
4. What support and conditions are needed for healthcare providers to engage with community-led approaches?

We undertook this research in four distinct phases as described below:

Research phases:

1. Design phase.
2. Collection and analysis of existing evidence and desktop review.
3. Collection and analysis of data through one to one interviews/​focus groups.
4. Production of final report and workshop delivery.

In the design phase, we worked in partnership with Local Trust and the International Futures Forum to confirm the research questions, methodology and specific requirements for the project report, interviews and any further output or dissemination opportunities.

As part of Phase 2, we conducted a desk-based review of a range of background sources on the Big Local programme, including background documents and material provided by Local Trust, as well as previous research publications about the Big Local programme and other hyperlocal and community led initiatives.

In Phase 3, we carried out 18 interviews with Big Local partnerships. Local Trust invited Big Local partnerships to be part of this research. We then contacted those who indicated that they would be happy to speak to us. Whilst we aimed to get a representative geographical spread, in reality our approach was to ensure we spoke to as many Big Local partnerships as possible. All interviews were undertaken online.

The intention was to then interview local health system colleagues in Big Local areas. However, during interviews with Big Local partnerships, it became apparent that relationships with local health colleagues in the areas we spoke to were early in their formation or not yet established. We adapted our approach and instead spoke with health colleagues working in national roles. We obtained their views through completion of a short online questionnaire. 

Following these interviews and online survey, we carried out thematic analysis of the interview findings, which involved coding the findings to establish themes, pull out quotes for evidence of impact and barriers, as well as to identify case studies for this report.

We shared our research insights at a New Local workshop where over 80 attendees joined to hear early research findings. This workshop supplemented our research findings through testing of the three barriers to maximising the impact of the Big Local partnerships on health and wellbeing. We used detailed notes taken during breakout sessions to develop our understanding of the barriers, these are reflected in the final report and are supported by participant quotes.

A list and map of all interviewees is set out below:

• 3 Together Big Local.
• Arches Local (Central Chatham, Luton Arches).
• Bradley Big Local.
• Cars Area, Smith’s Wood, Solihull.
• Elmton, Creswell and Hodthorpe.
• Ewanrigg Big Local.
• Gannow Big Local.
• Greenmoor Big Local (Better Communities Bradford).
• Hawksworth Wood Estate, the Abbeydales and the Vespers (HAVA) Big Local.
• Keighley Big Local.
• St Oswald and Netherton (L30s Million Project).
• Leigh West (Leigh Neighbours Big Local).
• Northwood (Northwood Together Big Local) = Par Bay Big Local.
• Scotlands and Bushbury Hill Big Local (Big Venture)Tang Hall Big Local.
• W12 Together Big Local.
• Windmill Hill Big Local.

Figure 4: Map of Big Local partnerships.

Figure shows a map of all Big Local partnerships with those interviewed highlighted in pink.

Source: New Local Analysis.

1. Office for National Statistics (2021) General health by age, sex and deprivation, England Wales: Census 2021. Accessed here: ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandwellbeing/articles/generalhealthbyagesexanddeprivationenglandandwales/census2021.
2. The King’s Fund (2023) Waiting times for elective (non-urgent) treatment: referral to treatment (RTT).
3. The King’s Fund (2023) NHS Workforce. Accessed here: kingsfund.org.uk/projects/ nhs-in-a-nutshell/nhs-workforce.
4. The King’s Fund (2023) How does the NHS compare to the health care systems of other countries? Accessed here: kingsfund.org.uk/publications/nhs-compare-health-care-systems-other-countries.
5. The King’s Fund (2022) What are health inequalities? Accessed here: kingsfund.org.uk/insight-and-analysis/long-reads/what-are-health-inequalities.
6. Ibid.
7. Marmot, M. et al (2020) Health Equity in England: The Marmot Review 10 years on. The Health Foundation. Accessed here: health.org.uk/publications/reports/the-marmot-review-10-years-on.
8. Local Trust and OCSI (2019) Left behind? Understanding communities on the edge.
9. The University of Manchester (2016) Life on the line? Greater Manchester’s Metrolink used to map life expectancy. Accessed here: policy.manchester.ac.uk/posts/2016/10/life-on-the-line-life-expectancy-and-where-we-live.
10. Curtis, P., Glover, B. and O’Brien, A. (2023). The Preventative State: Rebuilding our Local, Social and Civic Foundations. Demos. Accessed here: demos.co.uk/wp-content/uploads/2023/04/the-preventative-state.pdf.
11. Marmot, M. (2010) Fair Society, Healthy Lives – The Marmot Review. Accessed here: parliament.uk/globalassets/documents/fair-society-healthy-lives-full-report.pdf.
12. See The King’s Fund (2013) Broader Determinants of Health: Future Trends. Available here: kingsfund.org.uk/projects/time-think-differently/trends-broader-determinants-health.
13. Spencer, M, ​‘Healthier Fleetwood’: Creating healthier communities via improved social networking in a disadvantaged area of the UK, British Journal of Diabetes 2017. bjd-abcd. com/index.php/bjd/article/view/240/421
14. Ibid.
15. New Local (2021) ​‘Folks have lost a third of their body weight by singing‘: The GP doing things differently. Accessed here: newlocal.org.uk/articles/gp-mark-spencer/.
16. See Pollard, G., Studdert, J. and Tiratelli, L. (2021) Community Power: The Evidence. New Local. Available here: newlocal.org.uk/publications/community-power-the-evidence/.
17. The King’s Fund (2019) A citizen-led approach to health and care: Lessons from the Wigan Deal. Accessed here: kingsfund.org.uk/publications/wigan-deal.
18. Cunliffe, K. and Ardern K (undated) Asset-based approaches in local authorities: the Wigan experience. Local Government Association. Accessed here: local.gov.uk/asset-based-approaches-local-authorities-wigan-experience.
19. Rose, T. C., Konstantinos, D., Manley, J., McKeown, M., Halliday, E., Lloyd Goodwin, T., Hollingsworth,B. and Baar, B. (2023) ​‘The mental health and wellbeing impact of a Community Wealth Building programme in England: a difference-in-differences study’. The Lancet. Accessed here: thelancet.com/journals/lanpub/article/PIIS2468-2667(23)00059–2/fulltext.
20. Kaye, S. and Tiratelli, L. (2021) Communities Vs Coronavirus: The Rise of Mutual Aid. New Local. Accessed here: newlocal.org.uk/publications/communities-vs-coronavirus-the-rise-of-mutual-aid/.
21. Each ICS comprises an Integrated Care Board (ICB) composed of NHS bodies and an Integrated Care Partnership (ICP) which draws in a wider group of stakeholders. See The King’s Fund (2022) Integrated Care Systems Explained. Available here: kingsfund.org.uk/publications/integrated-care-systems-explained.
22. These definitions are taken from Integrated Care Systems Explained, The King’s Fund. As noted there, they are a simplification of a more complex system in practice, which is variable between different areas. Accessed here: kingsfund.org.uk/publications/integrated-care-systems-explained.
23. NHS England (2022) Working in partnership with people and communities: statutory guidance. Accessed here: england.nhs.uk/publication/working-in-partnership-with-people-and-communities-statutory-guidance/.
24. Healthwatch Enfield (2022) Community Powered Edmonton: Using community powered collaboration to improve services and reduce inequalities. Accessed here: healthwatchenfield.co.uk/report/2022–12-20/community-powered-edmonton-report.
25. Hewitt, P. (2023) The Hewitt Review: An Independent Review of Integrated Care Systems. Department of Health and Social Care. Accessed here: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1148568/the-hewitt-review.pdf.
26. NHS Confederation (2023) The state of integrated care systems 2022/23: Riding the storm. Accessed here: nhsconfed.org/publications/state-integrated-care-systems-202223
27. Local Trust (2019) About Big Local. (Web page no longer available).
28. Local Trust (2020) ​‘Our Bigger Story’ evaluation of Big Local. Available at: ourbiggerstory.com.
29. McGowan V. J. et al (2022) Collective control, social cohesion and health and well-being: baseline survey results from the communities in control study in England. Journal of Public Health, 44, 2, 378–386.
30. Local Trust (2019) The Halfway Point. Reflections on Big Local. (Web page no longer available).
31. The criteria was that there should be at least eight members of a Big Local partnership, over half of whom should be residents of the Big Local area boundary, while not representing any other organisation.
32. Local Trust (2020) Power in our hands: An inquiry into positive and lasting change in the Big Local programme. Accessed here: https://www.learningfrombigloc….
33. Food, Farming and Countryside Commission (2021) Food builds community: From crisis to transformation. Accessed here: ffcc-uk.files.svdcdn.com/production/assets/downloads/FFCC-LT-Food-Builds-Community-July-2021.pdf?dm=1652696568.
34. Nuffield Trust (2023) The State of the Nation’s Health and Wellbeing in 2023. Accessed here: nuffieldhealth.com/downloads/healthier-nation-index-report-2023#:~:text=This%20year’s%20Healthier%20Nation%20Index,that%20requires%20a%20national%20response.
35. See Studdert, J. (2021) ​‘Escaping the Community Power Evidence Paradox’. New Local. Available here: newlocal.org.uk/articles/evidence-paradox/.
36. Based on analysis of the average Index of Multiple Deprivation Score for Big Local areas and then identifying 25 local authorities with a similar score.
37. Public Health England (2017) Chapter 6: social determinants of health. Accessed here: gov.uk/government/publications/health-profile-for-england/chapter-6-social-determinants-of-health.
38. For a seminal exploration of this, see Marmot, M. (2010) Fair Society, Healthy Lives – The Marmot Review; and see also Marmot, M. et al (2020) Health Equity in England: The Marmot Review 10 years on. The Health Foundation. Available here: health.org.uk/publications/reports/the-marmot-review-10-years-on.
39. Local Trust (2022) Big Local relationships with public agencies. Accessed here: https://www.learningfrombigloc…
40. Local Trust (2019). Working on Big Local: a survey of paid workers. Accessed here: https://www.learningfrombigloc… and Local Trust (2023) Big Local and civic participation. Accessed here: https://www.learningfrombigloc….
41. Department for Transport (2022) Active Travel: Local Authority Toolkit. Accessed here: gov.uk/government/publications/active-travel-local-authority-toolkit/active-travel-local-authority-toolkit
42. Thoits, P. A. (2010) Stress and health: Major findings and policy implications. Journal of Health and Social Behavior, 51, S41– S53.
43. Reczek, C. et al (2014) Diet and exercise in parenthood: A social control perspective. Journal of Marriage and Family, 76, 1047–1062.
44. Parent-Infant Foundation (2023) Early relationships shape babies’ social and emotional development and influence many key outcomes. Accessed here: parentinfantfoundation.org.uk/why-we-do-it/why-relationships-matter/.
45. For example, exposure to stress and adversity can impact on the development of the immune system and the likelihood of developing diseases later in life. See 1,000 Days (2022) Building Health. Available here: thousanddays.org/why-1000-days/building-health/
46. The King’s Fund (2017) Healthy Schools and Pupils. Accessed here: kingsfund.org. uk/projects/improving-publics-health/healthy-schools-and-pupils.
47. O’Regan, F. (2009) Persistent disruptive behaviour and exclusion. ADHD in Practice, 1, 8–11.
48. Charlesworth, L. and Hashmi I. (2023) Rapid Review of Community Agency and Control as final outcomes, or enablers of place-based interventions to improve community wellbeing. Accessed here: newlocal.org.uk/publications/community-wellbeing/.
49. Belon, A. P. et al (2014) How Community Environment Shapes Physical Activity: Perceptions Revealed Through the PhotoVoice Method. Social Science and Medicine. 116, 10–21.
50. McGowan, V.J. et al (2022) Collective control, social cohesion and health and well-being: baseline survey results from the communities in control study in England. Journal of Public Health, 44, 2, 378- 386.
51. Hey, N., Martin, S., Musella, M. and Bignall-Donnelly, R. (2022) What works social capital evidence review: Belonging, cohesion and social support. What Works Centre for Wellbeing. Accessed here: whatworkswellbeing.org/wp-content/uploads/2022/10/What-works-social-capital-evidence-review-Belonging-cohesion-and-social-support.pdf.
52. Bignall-Donnelly, R. et al (2023) Social Isolation Over Time. What Works Centre for Wellbeing. Accessed here: whatworkswellbeing.org/wp-content/uploads/2023/06/WWW-Social-Isolation-A4-FINAL.pdf.
53. Hewitt, P. (2023) The Hewitt Review: An Independent Review of Integrated Care Systems. Department of Health and Social Care. Accessed here: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1148568/the-hewitt-review.pdf.
54. The King’s Fund (2022) NHS funding: our position. (Web page no longer available).
55. Nuffield Trust (2023) ​“Addiction to short-termism” puts NHS future at risk, warn think-tanks. Accessed here: nuffieldtrust.org.uk/news-item/addiction-to-short-termism-puts-nhs-future-at-risk-warn-think-tanks.
56. Martin, S., Lomas, J. and Claxton, K. (2020) Is an ounce of prevention worth a pound of cure? A cross-sectional study of the impact of English public health grant on mortality and morbidity. BMJ Open.
57. Pollard, G., Studdert, J. and Tiratelli, L. (2021) Community Power: The Evidence. New Local. Accessed here: newlocal.org.uk/publications/community-power-the-evidence/.
58. Williams, E. et al (2022) What are health inequalities? The King’s Fund. Accessed here: kingsfund.org.uk/publications/what-are-health-inequalities.
59. As defined by the Office for National Statistics, middle layer Super Output Areas (MSOAs) comprise between 2,000 and 6,000 households and have a usually resident population between 5,000 and 15,000 persons. See: Office for National Statistics (2021) UK geographies. Available here: ons.gov.uk/methodology/geography/ukgeographies/.
60. Primary Care Networks operate at a ​‘neighbourhood’ level within places and systems, albeit with a population size of a minimum of 30,000 registered patients which is a larger scale than the neighbourhood level of the Big Local model.
61. Hewitt, P. (2023) The Hewitt Review: An Independent Review of Integrated Care Systems. Department of Health and Social Care. Accessed here: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1148568/the-hewitt-review.pdf.