Key NHS priorities

Community cohesion can contribute to the achievement of several other key NHS priorities:

World class and practice based commissioning

Commissioning is all about understanding the needs of your community and securing the best ways of meeting those needs. The commissioning process consists of five main stages and an understanding of the principles of community cohesion will help at each stage of the process:

• Stage 1 - Assessing the needs of your local population. To do this effectively you need to engage with all the different communities in your area, understand their concerns and how they interact with others. Understanding the needs of people who do not usually engage with public bodies can be difficult but is vital if commissioning is to produce equitable services and community cohesion is to be strengthened.
• Stage 2 - Identifying priorities. Decisions about priorities can benefit some groups more than others and this can lead to resentment if the process is seen as unfair. You need to be clear how you will address health inequalities as part of this stage. It is really important to ensure that the process is open and transparent and that all interests are taken into account.
• Stage 3 - Identify and stimulate potential providers. If your local community is changing it is important to find providers who are innovative and able to respond to diverse and changing needs.
• Stage 4 - Procure services and secure contracts. At this stage you need to ensure that the process is fair with a level playing field for all potential providers and then to establish a clear agreement with your chosen providers on what outcomes are expected and how they will respond to different communities.
• Stage 5 - Monitor, evaluate and review performance. Patient and public involvement should be included at each stage but it is particularly important at this stage where you should consider the impact of services on different communities (including non-users as well as users of services), whether there has been any impact on health inequalities and other shared targets, whether performance data is adequate and how to use the results of evaluation to inform the next commissioning cycle.

'The Commissioning Framework for Health and Wellbeing', published by the Department of Health in April 2007, summarises the characteristics of effective commissioning as:

• Putting people at the centre of commissioning
• Understanding the needs of populations and individuals
• Sharing and using information more effectively
• Assuring high quality providers for all services
• Recognising the interdependence of work, health and wellbeing
• Developing incentives for commissioning for health and wellbeing
• Making it happen: local accountability
• Making it happen: capability and leadership

With the introduction of Joint Strategic Needs Assessment, the commissioning process will be undertaken as a partnership between Health and Local Government as a key element of the broad strategy for an area. The next section considers how this will work.

Place shaping through Joint Strategic Needs Assessment and Local Area Agreements

'The Local Government and Public Involvement in Health Act' (2007) places a duty on Local Authorities and Primary Care Trusts to identify the issues for priority action through Local Area Agreements in the form of a Joint Strategic Needs Assessment. The JSNA will be the key document in identifying health and wellbeing needs and translating these into priorities for commissioning services, but the guidance document published by the Department of Health in 2007 makes it clear that the JSNA should not simply be seen as a tool for health and social care but should inform the Sustainable Community Strategy and the LAA targets. JSNA will be both a process for identifying the current and future health and wellbeing needs to inform planning and commissioning and a tool for identifying the 'big picture' for health, wellbeing and inequalities in an area. It will have the following characteristics:

• It should aid understanding of current and future needs over the short term (3 to 5 years) to inform LAAs and over the longer term (5 to 10 years) to inform strategic planning.
• It will be the joint responsibility of Directors of Public Health (many of whom are now joint appointments), Directors of Adult Services and Directors of Children's Services.
• It will include the active involvement of communities, service users, the third sector and other providers to develop a comprehensive picture of needs, particularly of vulnerable groups.
• It will sit on a clear evidence base of interventions that will most effectively meet local needs.
• It will include a core data set covering five domains: demography, social and economic context, lifestyle and risk factors, burden of ill-health and disability and services.
• The process of JSNA will include: identifying existing mechanisms for engagement, drawing and aligning evidence from existing assessments and plans, collecting, collating and analysing information from a range of agencies including LSP partners, service providers and community groups to identify gaps in service and unmet needs, using community involvement to provide information not available from other sources and aligning with three-yearly LAA cycles and with Children and Young People's Plan.

The Department of Health guidance emphasises the importance of community and user engagement at all stages of the JSNA, in particular supplementing the core data set with information from consultations, existing networks and forums. It states that: "Clear and relevant community engagement can facilitate and empower people by giving them the chance to voice their needs, whilst local ownership of the process will increase the relevance of services, improving their uptake and sustainability."  The guidance acknowledges that engaging with vulnerable and seldom heard groups will be particularly challenging but since they often have the most acute health needs and the poorest health, it is particularly important that such groups are involved.

Improving wellbeing

The concept of wellbeing was introduced through the Local Government Act of 2000. The Act included a new power of wellbeing for Local Authorities to take whatever action they consider necessary to promote or improve the economic, social or environmental wellbeing of their area. This was followed by the development of a series of Quality of Life indicators that are now used by Local Authorities and their partners to track changes in wellbeing and the quality of living conditions at the local level. Such indicators are now included in the new Local Government performance assessment framework, Comprehensive Area Assessment (CAA), reflecting a drive to improve wellbeing and quality of life.

It is clear from this definition that community cohesion is a key contributor to wellbeing. A report by Nicola Steuer and Nic Marks, 'Local wellbeing: can we measure it?' (2008) proposes the use of a number of indicators that are directly related to cohesion. These include the national community cohesion indicators from PSA 21 (see section on "How can we measure community cohesion"), measures on support and engagement (e.g. civic participation in local area, participation in local volunteering, percentage of people who feel they have other people to turn to or discuss problems with and the percentage of people who are satisfied with the support they receive from others). The report also proposes a number of indicators under the heading of health and mental wellbeing including mortality rates, adult participation in sports, self reported measure of overall health and wellbeing and self reported limiting long term illness.

Promoting equality and diversity

During the preparation of this guide a number of people suggested to us that the NHS does not need to do anything new on community cohesion because it is already addressing the issues through its work on equality and diversity. We would agree that the equality and diversity work is a strong foundation but community cohesion is concerned with the wider social context of how communities relate to each other. It includes the need to cater for diverse needs of different communities but it also involves consideration of how communities perceive and respond to each other, for example, how young and old people perceive each other or how people of Pakistani, Afro-Caribbean or Indian origin perceive each other. Certainly some NHS organisations are already working on this but others are not. To develop the Health contribution further we need all organisations to expand from a view of equality and diversity for individuals to a consideration of how you can promote equity and a perception of fairness in the way you manage resources and address the needs of diverse communities. You need to build on your success in meeting the needs of individual patients in the way you address community aspirations.

Reducing health inequalities

Whilst Health service work on equality and diversity goes a long way towards addressing community cohesion issues, the same can be said for the work that is done to reduce health inequalities. Dealing with social injustice helps to reduce health inequalities and improve quality of life measures. When this work is based on a clear understanding of the social context affecting different communities, it is making a powerful contribution to addressing community cohesion as well as reducing health inequalities. When it treats each group separately without reference to the wider context, it has far less impact. There are numerous examples of the former approach. Here are just a few of them:

Community engagement and empowerment

Community engagement is an essential part of any approach to community cohesion. It is how we take the pulse of local communities. Question four of the ten challenging questions in this guide provides some suggestions about how to assess your effectiveness in this crucial area and points out some examples of good practice. Your approach to community engagement needs to be underpinned by up to date data on the population you serve so that you know who is living in each community and understand the area's diversity. Question viii of the ten questions discusses how you can ensure you have the best information available.

Two very helpful documents have been published during 2008 on the subject:

The first one is aimed specifically at health practitioners. 'A dialogue of equals: the Pacesetters Programme community engagement guide' (2008) written by Stafford Scott, is a guide to help NHS staff with responsibilities for patient and public involvement to understand better how to identify and create opportunities for engaging with seldom-heard communities or marginalised groups. It explains what is meant by community engagement and why it is important to involve people (rather than just consult them). It gives advice on how to develop a community engagement strategy, defines what is meant by a community, how to understand the difference between patient needs and community aspirations and it contains practical tips on how to engage with different community groups, illustrated with plenty of examples of good practice.

The second document is aimed at a more general audience, including Local Authorities as well as people in the Health service. 'Community Engagement and Community Cohesion' (2008), written by a team for the Joseph Rowntree Foundation argues that Government policies for community engagement and community cohesion have been developed in parallel and need to be brought together. It explores how this can be done, particularly focusing on how new arrivals can be involved and how we can promote solidarity and cohesion rather than competition and conflict between newer and more established communities. Some of the key points are:

• Informal networks are valuable but be aware that traditional leaders do not necessarily represent the voices of women and young people.
• New communities are diverse but they all experience a number of common barriers such as lack of information, difficulties in the use of English, lack of time or barriers to recognition.
• These barriers are often exacerbated by the growing fluidity and fragmentation of government structures. A "shifting landscape of service provision and governance" is bewildering and makes engagement more difficult.
• The most appropriate way of engaging with new communities who are dispersed across Local Authority areas may not be at neighbourhood level. We need structures that enable engagement at other levels.
• The research identifies a range of examples of good practice in addressing these issues, particularly by providing community development and outreach support.

Implementing the Darzi report

The final report of the 'Next stage review of the NHS' by Lord Darzi, 'High quality care for all' (2008) sets out a vision for the NHS of an organisation:

"That gives patients and the public more information and choice, works in partnership and has quality of care at its heart - quality defined as clinically effective, personal and safe."

The report recognises that people want a degree of control and influence over their health and health care and acknowledges that special efforts need to be made to personalise services "for those who for a variety of reasons find it harder to seek out services or make themselves heard". It contains a series of proposals to improve quality by involving people and giving them more choice and by working in partnership. This is entirely consistent with the principle of community cohesion promoted in this guide. In part 6 under question (iv) we say more about how the Darzi proposals for improved partnership working fit with community cohesion.

Mental health issues

It is generally recognised that there is a relationship between common mental disorders such as anxiety, depression and alcohol dependency and low levels of social interaction, withdrawal and fear of contact with others. Research by Dr Jane Parkinson in Scotland in 2007 has developed a set of indicators of both positive mental health and mental health problems. Parkinson's report identifies 55 indicators including high level constructs such as life satisfaction, depression, anxiety, suicide and drug related deaths and three sets of contextual constructs including individual factors such as emotional intelligence, healthy living, spirituality; structural factors such as social inclusion, discrimination and equality and community factors such as participation, social networks, social support, trust and safety. The report recommends further longitudinal studies to help investigate whether identified associations between mental health and key personal, social and structural factors are causal (and the direction of causality) or merely coincidental. In the meantime there is sufficient empirical evidence to support the argument that mental health problems can be eased by addressing the contextual factors.

Community safety, drug and alcohol abuse and anti-social behaviour

Primary Care Trusts are required by law to contribute to Community Safety Partnerships and can play an important role in sharing information and developing strategies that address crime and anti-social behaviour. They play a leading role in Drug Action Teams which address the harm caused by drug addiction and drug related crime through programmes of treatment, education and action on supply. Increasingly they are involved in partnership programmes to address the harm caused by alcohol abuse, which is becoming a serious health problem for many young people and fuelling a high proportion of violent crimes and anti-social behaviour. In many town centres and even in small rural communities these problems have divided communities, undermining community cohesion and generating fear amongst many residents. Effective response to these issues requires a clear strategy developed by a partnership of agencies (including PCTs, Police, Local Government, licensees licensing authorities, A and E Departments, planners, etc). It also requires a well developed approach to community engagement involving a wide range of different interest groups to understand different needs and views and to generate solutions that are fair to all.