Synopsis, 'Creating Community Health'

Modern medicine has led to incredible advances in health, but progress is faltering. Life expectancy has stalled, and is now decreasing for some groups for the first time in a century. Inequality is rising sharply, driven by extractive economic systems, worsening the health of all of us. Those carrying the highest burden of risk are the marginalised, and Covid has shown us yet again how being of minority ethnicity is a risk factor for worse outcomes. Poverty, poor housing and employment and reduced access to services are all bad for our health. 

Poor health outcomes won't change until the causes are addressed, and the causes of those causes. Addressing the social determinants of health needs a societal approach, but the institutional nature of much current healthcare provision leaves services stuck in reactive mode, without the power to intervene upstream. Healthcare services produce healthcare rather than health, but only 20% of health outcomes are attributable to clinical care, leaving 80% subject to 'social' factors that determine our health. 

Many of these health determinants are modifiable, just like cholesterol or blood pressure. Interventions are available that reduce loneliness, increase activity and connections, and these happen within our communities. Participation and associational life is happening all around us in Men's Sheds, community gardens, groups and meeting centres. The activity and social capital that comes from these connections is good for us. Who we know helps us get by and get on in life, opening up support and opportunities which benefit our health. Joining a group halves your mortality, by increasing connections and sharing the fun of participating.

Social medicine is nothing new, dating back to Virchow who first recognised the effects of inequality on health, but the new PCN (Primary Care Network) structures allow a more local approach. The recognition that increasing social capital improves health has led to the development of social prescribing link workers based in GP surgeries, connecting people to non-medical sources of support. This works well at PCN scale, local enough to allow a deep knowledge of the community. 

Social prescribing relies on there being community activity; signposts need to point somewhere. Medicalising access to community support by requiring GP approval is actively unhelpful, though. A flourishing and accessible society will not need social prescribers. 

There is strong evidence for the benefits that healthy communities bring. Being in greenspace is good for us, encouraging exercise and time together in an environment that is inherently relaxing, especially for people with sensory issues such as dementia or ADHD. Volunteering, learning and staying active are all health-creating, our social capital increasing with each group we are a member of. 

Organisations across health and social care are recognising the value of community-based approaches & recommending their adoption. But how can statutory services build community? These approaches, by definition, develop from the bottom-up rather than top-down; by the community, for the community. Deep roots bring resilience. 

The design of our third places, the spaces where we meet, is one way to encourage association. How we get around, how we connect, and the environment around us all influence our health. Proper active transport infrastructure brings activity into daily lives while opening up more sustainable transport options. 

Social infrastructure is just as important as the physical, promoting the opportunities to connect that create the spark of associational life. Building social infrastructure offers a way to support community activity without being directive.

The local responses to Covid have shown how communities were best placed to respond quickly. Engaged and empowered communities are more resilient, better able to face the challenges ahead. The mortality and morbidity losses from exceeding planetary boundaries (as described in Doughnut Economics) will increase until we make changes. Healthcare has a large role to play, contributing about 11% of the UK's emissions. Changing to lower greenhouse-effect inhalers and anaesthetic gases will help, but the biggest potential reduction in environmental impact comes from reducing unnecessary healthcare. 

Our health is just as subject to the political determinants as social ones. Austerity policies are estimated to have caused a third of a million excess deaths so far. The safety net is on the ground for many, welfare cuts worsening health outcomes while increasing healthcare costs. 

Increasing connections rebuilds those safety nets. Developing social infrastructure that encourages civic participation promotes these connections, opening up health-creating behaviours such as companionship, activity and learning. We can build antifragile systems using open data and the power of local, circular economies. Empowered citizens take back control of our health by building connections and reclaiming our social capital.