Start small and build big – how a health creation approach can help tackle inequalities

Nailsworth Crescent is a housing estate in Merstham, Surrey, home to many families and communities, many living complex lives’.

It’s also a hot spot for health inequity: highlighted in linked data from across Surrey Heartlands Integrated Care System.

In practice, it’s not unusual to see patients in their 50s frailer than 90-year-olds living in more affluent areas of Surrey.

As a general practitioner, I have found the opportunity to work alongside people and communities to improve local health and wellbeing, to be transformational, and our work has been highlighted as a best practice example in the recent Next steps for integrating primary care: Fuller Stocktake.

Over the past two years, four GP colleagues and I have had a small amount of protected time each month to connect with people and places creating health outside of the health system across primary care networks (PCNs), and supported by our GP federations.

The Health Creation Alliance defines health creation as ‘a process through which individuals or communities gain a sense of purpose, hope, mastery and control over their own lives and immediate environment.’

Former NHS chief executive Lord Nigel Crisp defines it as ‘creating the conditions for people to be healthy and helping them to be so.’ We embrace both definitions and are committed to health creation alongside the wider prevention agenda.

In the lead up to the pandemic, local primary care colleagues and I became disheartened seeing an inexorable rise of people suffering from preventable conditions. We heard from patients about local conditions we felt powerless to change which were making them sick in the first place.

We started with conversations: going out of our consulting rooms and listening to communities, individuals and partners such as schools, charities and local authorities.

By combining the insights gained with population health management approaches and local linked data we worked to co-create improved local conditions for health and wellbeing.

As recovery in hospitals and GP practices continues, some people might argue this time would be better spent at the front door. But if we don’t focus and invest in the upstream causes of health and wellbeing in our communities, alongside delivering high quality clinical care, at some point the NHS will become unsustainable.

Underpinning all our work has been the use of data-driven decision making to ensure we’re taking a proportionate universalist approach. Working to improve health for our entire population and investing proportionately more for those affected most by health inequalities.

In Nailsworth Crescent, we anticipated local residents would know far better than us what the solutions might be to entrenched health inequalities.

When local GP Dr Tabassum Siddiqui and community development colleagues met with people from the estate, they said a mother and baby group, help with their housing and the opportunity to start a gardening scheme on the estate would make the biggest difference to their health and wellbeing – hospitals and medicines weren’t mentioned.

Working with partners, community members are now being enabled to lead on these solutions.

These are issues many teams working in primary care have little time to think about in between packed consultation sessions.

But in Surrey, we’re starting to see that through a commitment to thinking differently and collaborating with non-NHS partners, even a small amount of investment can go a long way.

We’re now in a stronger position to recommend local assets to our patients: from  community centres, and libraries to local leisure centres offering activities and discounted access.

Of course, local people can’t possibly lay new cycle paths or reduce the number of takeaways near the schools.

But through advocating for what our local communities tell us they need to be healthy, and working with our Public Health and local authority colleagues, together we can address these points too.

My colleagues and I have found our community work an immense privilege and joy and a refreshing change.

Connecting our healthcare system with our local communities has also revitalised some of our other practice colleagues and system partners, too.

There are many initiatives underway that can be described – communities and volunteers are arguably the heroes of this work and energise and inspire us continually.

We also hugely value the support of our analysts, local authority, school, voluntary sector and other system partners who have so many of the key connections and capability to effect change.

In NHS Surrey Heartlands, we’re now working to support other areas of the county to embrace and embed health creation, following on from a learning programme with the Health Creation Alliance and C2. There is great excitement in thinking about the opportunities for this work spreading more widely, and this work has of course already begun, including with the Core20Plus5 approach.

But for anyone in an integrated care system exploring what it means to create health, we would advise get behind your community leaders, start small, and build big. Soon you’ll see those green shoots of potential.

Dr Orrow graduated from Guy’s, King’s and St Thomas’ school of medicine in 2006. She was an NIHR academic clinical fellow in general practice at the University of Cambridge’s Institute of Public Health from 2008-2012, undertaking research and gaining an MPhil with distinction in the area of prevention. She subsequently acted as advisor to NICE Public Health Advisory Committees alongside her clinical work as a GP in Surrey. She is the founding director of Growing Health Together, a place-based approach to prevention and health creation commissioned by NHS Surrey Heartlands and embedded across East Surrey Place.