Community cohesion is an important contributor to health
Health and community cohesion are inextricably linked. Health tends to decline (with premature mortality and increased morbidity, particularly in stress related conditions) in communities where levels of interaction are low and where people feel insecure. In more cohesive communities the reverse is true and it is much easier for public services to develop a dialogue with local people and to be sure that services are meeting local needs. Where such a dialogue has developed it helps public service agencies to understand the effects of their decisions on different groups within a community. It can, for example, help them to assess whether actions they are considering to meet the needs of one group may generate negative perceptions in other groups and enable them to address the issues that might arise.
On the website reviewing his celebrated book 'Bowling alone: the collapse and rise of American community' (2000) Robert Putnam suggests that, 'Joining and participating in one group cuts in half your odds of dying next year'. Putnam charts a decline in social capital in USA associated with a range of factors including changing patterns of work, television, computers and the changing role of women. He shows that Americans have become increasingly disconnected from family, friends, neighbours and democratic structures but he makes suggestions about how they can reconnect. An important lesson from Putnam's work is that where people connect well in cohesive communities the stock of social capital increases and that includes the state of people's health.
Similar work in Britain has also found a strong relationship between high stocks of social capital and improved health outcomes (see Petrou and Kupek, 2007).
The CLG report of 2005, 'Predictors of community cohesion: multi-level modelling of the 2005 citizenship survey' (page 31), found that 'The strongest negative socio-demographic predictor of cohesion is whether an individual has a limiting long-term illness or disability. The undermining effect this has on their perception of cohesion is approximately twice as strong as the next negative predictor.'
Most people would acknowledge that community cohesion is an important objective in its own right but, for health service managers, its significance goes beyond that. In many communities it is one of the important determinants of health and health inequalities. Where conditions are favourable, community cohesion increases social capital and reduces health inequalities and this in turn improves community cohesion to complete a virtuous circle. However, where there are factors that increase community tensions or reduce social interaction, community cohesion is undermined, social capital is reduced and health inequalities are likely to increase. The challenge for public service planners is to engage with all communities, anticipate problems and work out the appropriate interventions. The Commission on Integration and Cohesion's report, 'Our shared future' (2007), provides an analysis of the factors influencing the state of integration and cohesion. Clearly they vary from place to place but there is clear evidence of a pattern showing that cohesion is improved where there is a strong partnership and common vision amongst key public agencies and a clear commitment to community engagement.
Sheila Adam (2008) traces the development of local partnerships that have been encouraged by the Government to deliver programmes that strengthen neighbourhoods and communities. She notes that NHS guidance since the late 1990s has consistently emphasised the importance of partnerships to manage earmarked programmes and to 'bend the mainstream'. Local Delivery Plans include the requirement to work through Local Strategic Partnerships and Local Area Agreements and earmarked resources have been provided to promote joint action including Sure Start, Teenage Pregnancy Strategy, Neighbourhood Renewal Programmes, Area Based Grants and the New Deal for Communities. All these initiatives require NHS engagement, with the potential to achieve both community cohesion and health gain. Adam recognises that NHS organisations that are faced with many conflicting pressures, including reconfiguration, serious financial shortfalls, ever increasing expectations and the need to promote patient choice, may be tempted to regard some of the partnership initiatives as optional. However Adam argues that the NHS must hold its nerve and support the partnership programmes. She believes that such programmes should be clearly prioritised (with incentives) in our performance management framework. She is hopeful that Local Area Agreements will help through their stretch targets, freedoms and flexibilities but she also calls for more research to develop a much stronger evidence base to help in evaluating programmes and to ensure we are investing in what works best.
The link between indicators of poor community cohesion and health inequalities has recently been explored in research by the Neighbourhood Renewal Unit for the Audit Commission, in a review of community cohesion in the Cheshire and Mersey Local Strategic Partnership area. The research suggests that there is a correlation between a lack of cohesion and inequality in life chances at the local level leading to poorer outcomes between and within communities or neighbourhoods. Common characteristics of areas lacking in community cohesion are economic inequality, high incidence of poor mental health, and variable access to appropriate and high quality services. Lack of cohesion is also associated with higher levels of crime, fear of crime and antisocial behaviour. Often this is targeted at people from marginalised or otherwise vulnerable groups, but there may also be higher levels of crime committed by people from within these communities. Inequalities associated with lack of community cohesion typically reflect the experience of more recent arrivals to an area, particularly people from minority groups. But they are also commonly experienced by people who have lived in a specific area for a long time, sometimes all their lives, but who are marginalised or otherwise vulnerable. This might include people with poor educational attainment (reflected in their literacy and numeracy skills), children who are looked after or otherwise vulnerable, gypsy and traveller communities, and people on low incomes.
In 2004 Common Ground North West, a regional level NGO recognised that community cohesion can contribute to improving health and reducing health inequalities. They have worked with the regional health sector, the voluntary sector and Local Authorities to promote community cohesion through the development of community assets and understanding of the effects of conflict, racism and prejudice on the well-being of communities across the region. They established an open regional network and an annual conference to share best practice. Working with GONW they helped to generate the ten challenging questions that are used later in this guide and a guide for practitioners addressing issues that are specific to the North West region (see North West group, 'Community cohesion: developing the NHS contribution' , to be published soon).