Improve Health by Growing Community

Author: Brian Fisher

Brian Fisher spoke at the It's Our Community event organised by the Centre, in partnership with the Socialist Health Association and Opus Independents. The event is part of the Centre's work to outline a detailed progressive vision for social care in Sheffield alongside disability leaders in the city. 

Here Brian sets out the damaging impact of inequality, isolation and powerlessness and offers Sheffield a practical strategy to better health and care. 

Dear Sheffield

The pandemic has triggered change everywhere. Although I’m not a Sheffield resident, I know that your beautiful city is exploring new ways in which care and support can be found and offered. I want to suggest an evidence-based approach that could make significant improvements to health, to democracy and to services. It could be applied everywhere, but let’s make Sheffield a great example!

First some background, then some ideas on how to implement.

Income Inequality

Over the last 40 years, half of the UK’s population has barely shared in the growth of the economy at all. Between 1979 and 2012, only 10 per cent of overall income growth went to the bottom 50 per cent of the income distribution, and the bottom third gained almost nothing. Meanwhile, the richest 10 per cent took almost 40 per cent of the total.

One result is the long-term decline in the share of national income which has gone to wages and salaries. In the mid-1970s, the ‘labour share’ of national income was almost 70 per cent; today it is around 55 per cent. At the same time, a rising share of income goes to the owners of capital, as the returns on financial and real estate assets have consistently outpaced the rate of economic growth.

Inequalities of wealth are even larger than those of income. 44% of the UK’s wealth is owned by 10% of the population, while the richest 1 per cent are estimated to own 14 per cent of the nation’s wealth. By contrast, 15% of adults owe more than they own. Inequalities of income and wealth have particular impact on both social mobility and health: in the poorest areas of the UK, people live on average a startling 10 years less than those living in the richest areas.

14 million people (22% of the population) live on incomes below the poverty line after housing costs, making the UK one of the most unequal of western European countries. This includes 4 million children in poverty, nearly 1 in 3, and the number is rising. As the significant growth of homelessness and use of food banks attests, poverty has made life desperately hard for very large numbers of people.

Economic Inequality Weakens Social Cohesion

Higher levels of inequality raise levels of social anxiety and heighten psychological and social costs among the vast majority of the population. People feel a lack of control, they feel more mistrustful and envious. Inequality builds a politics and a society of division. Inequality affects social cohesion. Community life is weaker.

Countries with bigger income differences tend to have less social mobility. Segregation increases.

People and families in poverty are far more likely to experience early trauma which has very significant negative impacts on development and behaviour and well-being.

In addition, austerity weakens those civil institutions which support links between people: libraries, social care, youth work, community development.

Weaker Social Cohesion Results in Ill-Health and Health Inequalities

Bigger income differences increase the prevalence of almost all socially graded problems: health, homicide rates, teenage birth rates, poor educational performance, drug abuse, mental illness, child well-being, rates of imprisonment and obesity. Across the whole population, affecting even the well-off.

Mental illness is more common in inequal societies. Inequality damages social integration and our sense of ourselves in relation to each other.

When our broken social bonds are not replaced by new forms of connection, then we move towards tales of domination and victory.

“Let me right at the outset define what I mean by alienation. It is the cry of the men who feel themselves the victims of blind economic forces beyond their control. It is the frustration of ordinary people excluded from the processes of decision making. The feeling of despair and hopelessness that pervades people who feel with justification that they have no say in shaping or determining their own destinies.”

Jimmy Reid, Rector of Glasgow University (1972)

Health Inequalities Influence Health through Psychosocial Pathways¹

Unequal distribution of the social determinants of health, such as education, housing and employment, drives inequalities in physical and mental health. There is also extensive evidence that ‘psychosocial’ factors, such as work stress, influence health and wellbeing.

How psychosocial pathways impact on health

Psychosocial pathways directly impact on physical health outcomes. Stressors experienced repeatedly or over a long period of time, including stressful living and working conditions, are associated with high blood pressure, development of diabetes, and ischemic heart disease. Psychosocial pathways influence health-related behaviours, such as drinking alcohol, smoking, diet and physical activity. Stressors exert effects from early childhood, throughout life. The relationship between social, economic and environmental contexts and health is complex and non-linear.

The importance of protective factors 

Individual characteristics such as control, self-efficacy and resilience, as well as the social characteristics described as ‘social capital’, such as social networks, can protect health from the effects of stressors in some circumstances; and thus positively influence health outcomes.

Local areas can use their powers to improve the built, natural and social environment, that are inclusive and encourage empowerment, social cohesion, sense of belonging, social relationships and social capital.

Rebuilding Community Through Community Action Creates Health

If alienation is the point at which our crises converge, belonging is the means by which we can address them. Revive community, and by anchoring ourselves, our politics and parts of our economy in the life of this community, we can work with communities to mobilise change and create health. This benefits not only the people involved but also the majority of the community, even if they are involved only to a small degree.

We know that social action to build community has many benefits:

• Protects health
• Improves individual health behaviours
• Helps institutions to become more responsive to the populations they serve
• Helps fight health inequalities
• Is a good investment

We can help create a more participatory culture that increases the 3Cs: contact, builds confidence and supports people and communities to take more control over their lives and places.

It is the increase in control that is health creative.

We want this participatory democracy to work in collaboration with the state, with the NHS, with housing and with local authorities. The erosion of the state has contributed to this atomisation. We do not want this process contributing further to the shrinkage of the state.

“The success of an economy and of a society cannot be separated from the lives that the members of the society are able to lead... we not only value living well and satisfactorily, but also appreciate having control over our lives.”

Amartya Sen, Development as Freedom (1999)

Rebuilding Economic Justice

Although this kind of community action has an important impact on people’s health, it is only a small part of what needs to be done to challenge inequalities nationally. Many other changes are needed.

A broader definition of what prosperity means: the quality and security of work as well as income; time with family and community as well as money; and the common good as well as individual wellbeing.

A fairer economy generates greater prosperity, with stronger and more stable growth and lower social costs. Everyone – from top to bottom – is better off when the economy’s rewards are more fairly shared.

Redistribution. The IMF is now clear that inequality is bad for growth and redistribution is not damaging to growth.

Economic justice – suggestions from IPPR

• No-one living in absolute poverty
• Everyone should be treated with dignity in their economic life – no exploitation
• No group in society should be systematically or institutionally excluded from economic reward. The large gender and race pay gaps which characterise our economy, and the discrimination and exclusion widely experienced by women, ethnic minorities, people with disabilities and others, are evidence of structural injustice
• Narrowing inequalities of wealth, income and power over time
• No places should be left behind. The inequalities of income and opportunity between the richest areas of the country and the poorest have grown far too wide.
• Looking after the future as well as the present. Today, our environmental impacts place the welfare of future generations at risk. We want to see sustainable development

Responding to Ethnic Inequalities in Health²

Here are recommendations from the Marmot Team:

• Data collection, analysis and reporting: Gaps in data collection must be filled and there must be more consistent analysis and reporting of data on ethnicity, health and healthcare so that there is adequate understanding of local needs and the extent to which they are being met by policies and services 
• Action on the wider social and economic determinants of health may exacerbate ethnic health inequalities unless it adequately takes into account the ethnic patterning in residential, income, educational and occupational profiles 
• Tackling racism and ethnic discrimination: the central role of racism must be acknowledged, understood and addressed. There is an urgent need to build the evidence base around effective action 
• Commissioning of culturally sensitive health promotion interventions: Interventions need to work with cultural and religious understandings and values while recognising intra-group diversity and avoiding stereotyping 
• Improving access, experiences and outcomes of health services: Actions at organisational level include: regular equity audits; integration of equality into quality systems; good representation of black and minority ethnic communities among staff; sustained workforce development; trust-building dialogue with service users 
• Engagement with minority ethnic groups: Across all areas of activity, the meaningful engagement and involvement of minority ethnic communities, patients, clinical staff and people is central to understanding needs and producing appropriate and effective Local action on health inequalities: Understanding and reducing ethnic inequalities in health 49 responses or shaping services. A concerted effort is required by public and private sector employers and service providers 
• Making use of evidence: The evidence base to inform policy and practice remains limited but more can be done to mobilise the available evidence and to document and evaluate promising local practice both locally and nationally

A Health Creating Programme in the UK

Here is an example from The Health Creation Alliance:

1. Develop incentives and levers that support the practice and development of Health Creation and coproduction with communities across all professions.
2. Create new outcome measures based on the 3Cs, focusing on what matters to people. Community capital may be useful.
3. Every PCN area to use an evidence-based community building model – for instance community development or local coordination. 
4. Every local authority to expand local community-based options. Tools already in the Care Act should be in use to deliver more localised community capacity. 
5. Invest in ‘Community Health Creators’ – people with a track record in successful asset-based community development – particularly in places with no or little existing social infrastructure. 
6. Enable an NHS workforce with the time, capacity and skills to be a real and valued partner to community-strengthening. 
7. Provide dedicated funding to strengthen the evidence-base for Health Creation. 
8. Health in All Policies: require an assessment of the impact of every new government policy on people’s health, before adopting it. 
9. Close the health inequality gap, while improving the quality of added years of life for everyone. Enable community development workers/Community Health Creators to be funded through the PCN Health Inequalities DES.
10. All social care and health providers need to demonstrate that they are socially and ethically responsible with personal accountability, and that they help to improve the material conditions of the communities they serve.

Over to You Sheffield!

I hope you have found these suggestions helpful. They could be implemented in your fair city.

Yours

Brian Fisher

Notes:

1. Public Health England (2017) Psychosocial pathways and health outcomes: Informing action on health inequalities. London: UCL Institute of Health Equity.

2. Public Health England (2018) Local action on health inequalities: Understanding and reducing ethnic inequalities in health. London: UCL Institute of Health Equity.

References

Every statement has an evidence-base behind it. The evidence can be found here:

https://www.ippr.org/files/2018-08/1535639099_prosperity-and-justice-ippr-2018.pdf

https://www.equalitytrust.org.uk/inner-level

http://www.healthempowerment.co.uk/wp-content/uploads/2016/03/CD-AND-HEALTH-LITERATURE-REVIEW-Brian-Fisher-Revised-edn-2016.pdf

https://www.theguardian.com/books/2017/sep/14/out-of-the-wreckage-george-monbiot-review

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/768979/A_guide_to_community-centred_approaches_for_health_and_wellbeing__full_report_.pdf

https://thehealthcreationalliance.org/wp-content/uploads/2018/11/A-Manifesto-For-Health-Creation.pdf

With inspiration from Harry Burns, ex-Director of Public Health, Scotland.

The publisher is the Centre for Welfare Reform.

Improve Health by Growing Community © Brian Fisher 2021.

All Rights Reserved. No part of this paper may be reproduced in any form without permission from the publisher except for the quotation of brief passages in reviews.