Chapter 2: Setting out the case for change – the role of the NHS in a local place

There is increasing concern about inequalities in different parts of the UK where the conditions for living life in good health are poor and deteriorating. Across England, wages, living standards and productivity are stagnating and more than one in five people (22%) now live in poverty. Poverty represents a profound economic and social loss to the UK: the British economy spends an estimated £78bn pounds dealing with the effects of poverty. People living in poverty are more likely to have poor health, and this is reflected in persistent inequalities in health outcomes.

People born in the most deprived 10% of local areas in England are expected to die nearly a decade earlier and have 18 fewer years in good health. While these inequalities are primarily driven by broader factors that sit outside the health system, there are several reasons why the NHS should and can play a stronger role in supporting their reduction.

The protection of health care spending relative to other parts of the public sector since 2011 creates a moral case for maximising the value and reach of NHS funding to improve population health and wellbeing. Health care accounted for 30% of public service spending in 2016/17 compared to 26% in 2009/10 and 23% in 1999/2000, and budget reductions to local government have put both public health and social care services under severe pressure.

There is also an instrumental argument: even if the root causes of poor health and health inequalities are primarily driven by factors outside the control of the health sector, it is the NHS that deals with many of the consequences. It faces increased demand from preventable behavioural and socioeconomic causes, and it is therefore logical to extract the most value from the NHS in its wider role within local communities.

Thinking of the NHS in this wider role goes with the grain of policy both in England and across the UK. The 2014 NHS Five Year Forward View demanded a ‘radical upgrade in prevention’, with the 2019 NHS Long Term Plan expanding on this to set out a strategy to strengthen the NHS’s contribution to tackling health inequalities and improving population health. The government’s Green Paper on prevention set out proposals to make progress on their ambition to extend healthy life expectancy in the UK by five years by 2035, (though the proposals have been criticised for not going far enough to narrow the inequalities between the richest and poorest needed to achieve this aim). Wales and Scotland have already adopted cross-government approaches to improving health and wellbeing, placing duties on public bodies to take action to tackle the socioeconomic conditions that widen inequalities.,

Since 2016, health policy in England has also encouraged the NHS to plan and deliver services in collaboration with other bodies locally. Sustainability and transformation partnerships (STPs) and the emerging integrated care systems (ICSs) bring the NHS and local government together to design and deliver services to meet local population needs from a common pool of resources. Though still very much under development, the promise of these partnerships is that the NHS may have more scope to establish and work towards common goals with sectors like housing, education and employment. In Scotland and Wales, health and social care are further integrated and NHS bodies have greater flexibility to work together to develop new approaches to improve population health.

Supporting inclusive economies

There is a growing synergy between the place-based lens of the NHS and broader policy that emphasises localism in shaping the socioeconomic environments in which we live.

The idea of inclusive economies – enabling all communities to benefit and contribute to economic success – has garnered significant attention nationally and internationally over the past decade. This is partly due to a recognition that economic growth has often failed to ‘trickle down’ and alleviate poverty or increase living standards across all communities as expected. In England, growth has been concentrated in London and the South, with other parts of the country falling significantly behind.

Inequalities and deprivation threaten long-term economic stability as many people become trapped in low-productivity work or are excluded from the benefits of growth altogether., Local leaders have therefore increasingly turned to anchor institutions to create the conditions needed to support a healthy population, and help tackle inequalities while boosting economic growth. Devolution and the subsequent creation of local enterprise partnerships (LEPs) and local industrial strategies have been promoted as ways of giving more power to local communities. Though an emergent area of policy, these agendas are seen as an opportunity to bring economic players together across a place to drive productivity and distribute growth more fairly across the country – although whether these policies will lead to a narrowing of inequalities remains to be seen., There is an inherent risk that increased localism could even widen socioeconomic divides if already advantaged places are better positioned to leverage local resources and capacities for the benefit of residents. This makes it ever more important to consider the distinct role that health sector organisations play as anchors in local communities, given that the NHS exists everywhere and carries with it significant assets that can be channelled for public good.

The NHS is a key part of the social and economic fabric in all communities, and as an anchor is well placed to work with other sectors to support place-based approaches that promote prosperity and create the foundation for healthy communities. There is growing recognition that health systems have an important and positive impact on economies, and can improve health and wellbeing (directly and indirectly) through the size and nature of their role., However, the complexities of the NHS have often meant that health care organisations have acted as institutional siloes, often looking upwards to regulatory bodies more than outwards to their community for direction and to drive change. But given the economic challenges the UK is facing and the recent focus on localism, there is now a key opportunity for the NHS to work with other local leaders to develop a common agenda and support economic strategies that improve the socioeconomic conditions of local communities. This goal is important not only for building more inclusive economies, but for the NHS itself; by more consciously leveraging its resources and actions, the health sector can have even greater strategic influence across a place and be part of broader conversations that improve the context in which it works.

Learning from anchor practices

In the chapters that follow, we set out examples of anchor practices in a health care context to show how the NHS can leverage its assets to maximise its influence. These examples come from the grey literature and interviews, highlighting existing anchor practices in the NHS and what it might take to broaden their impact.

There are many ways of considering how the NHS functions as an anchor institution. We restrict our focus to examples related to five key areas: employment, procurement and commissioning, capital and estates, environmental sustainability and working in partnership across a place. Many of the examples involve provider trusts, because of their relatively large size. This should not be taken to imply that other parts of the NHS cannot function as anchor institutions, or have less scope or responsibility to intervene in the social determinants of health. Indeed, the formulation of primary care networks (PCNs) in England may create new opportunities to work at scale and implement anchor strategies in primary care. While most actions will take place at the level of the organisation, the report discusses how local system and regional/national NHS leaders can help create an environment in which NHS organisations more fully embrace their anchor mission and maximise their contribution to local economies. We focus primarily on England, given its different context and recent opportunities, and given that the other countries of the UK are making more progress in some areas.

Based on our findings, we conclude by suggesting actions at each level of the health and care system, including by national and regional policymakers, by local system leaders (that is, STPs and ICSs) and by local NHS providers or networks.

* Announced in 2010, LEPs are private-sector-led partnerships between local businesses and local public sector bodies. Their aim is to help set local economic priorities and undertake activities to drive local economic development and job creation. LEP boards are led by a chairperson from local businesses, with board members drawn from local industry, educational institutions and the public sector.

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