Guy’s and St Thomas’ Charity sought to test the hypothesis that a solution to the health challenges facing Lambeth and Southwark is to take a community-led approach grounded in the needs of individuals and the communities in which they live. The hypothesised solution was alternatively described as ‘increasing individual agency’ and the programme that may result from this hypothesis was called ‘Being Well’.

Pritpal S Tamber and Elizabeth Slade delivered this work on the basis that existing community-led programmes would yield experiential knowledge and observational knowledge. We recruited eight Formal Advisors with a blend of both.

We aggregated the Advisors’ experiential knowledge into 19 key themes and sought their recommendations for key articles and how to search PubMed.

The Formal Advisors recommended 25 articles. Our searches of PubMed yielded 1112 articles, of which we deemed 174 to be relevant. Given the time available, we read 103 articles; the 25 recommended plus the first 78 of the articles from PubMed ranked by their Source Normalised Impact per Paper (SNIP) score.

From the articles we learnt that what matters is whether people believe they have agency rather than whether they objectively do and that there are significant problems with the definition and measurement of ‘well being’. We also learnt that agency doesn’t so much create well being as be part of it.

Our responses to the rationale in the invitation to tender are:

• We agree that it’s important to ask people what is important to them, and not to see health as an end in itself, but advise not to use the term ‘well being’
• We agree that we can no longer treat individuals as passive recipients and that we must understand their priorities
• However it’s not whether they have agency that matters but whether they believe they have it (we also learnt that agency doesn’t so much create well being as be part of it)
• We agree that the solution is to take an approach truly grounded in the needs of individuals and communities, and advise that ‘community’ be defined as all those living in, working in, or providing services to a geographical area
• We advise that rather than seek a community-led approach, the Charity seek a community-defined one, the idea being that the community creates a shared agenda
• We agree that there do not appear to be examples that have improved outcomes in a sustainable way likely because few projects have operated at the four levels that we understand are needed – individuals/residents, community, the system, and policy
• We agree that there do not appear to be examples that have improved outcomes in a replicable way likely because people have tried to replicate an intervention rather than the process that led to the intervention
• We agree that arguments about how to improve well being and concerns about disinvestment are two likely reasons why few community-defined projects that have succeeded
• We agree that some communities will always require help; we also learnt that it’s important to work with the ‘ready’
• We agree there is often a dissonance between the priorities of residents and funders, and while this can be addressed through establishing a shared agenda the problems may not completely go away
• And while we agree that social networks likely cross geographical boundaries there is a need to be pragmatic and define community by the boundaries that resonate with those within them.

Building on our responses we propose the rationale be:

• As morbidity has shifted from infections and trauma to lifestyle-related chronic conditions, considering health only as the avoidance or treatment of illness (essentially a bio-medical construct) is increasingly limited
• Health care and public health’s dogged pursuit of health, while laudable, increasingly obfuscates the true value of health – a means to the ends that people seek
• Understanding these ends requires asking people what matters to them, and doing so with an open mind rather than trying to fit their answers into seemingly-established frameworks, such as well being
• None of this is to say that systems and policies exist to provide whatever matters to people. Residents and communities have the ability to provide for themselves but only if they believe they do; indeed, whether they believe or not is an important part of their health
• Now is the time for place-based capital able to make long term bets to lead in prototyping this new approach to ‘health’, including business model discovery and understanding how belief can lead to action

In light of our rationale we propose the objective of the programme that may result from this work to be:

• To increase residents’ and communities’ belief that they can affect their circumstances, and to learn how such belief leads to sustainable change

We suggest the working title be ‘We Can’ rather than ‘Being Well’ and propose eight design principles:

1. The programme should have a high-level aim that does not mention ‘health’ or ‘well being’
2. The Charity should communicate a long-term commitment but be clear that its funding should only be seen as seed capital
3. The programme should operate in geographic areas with boundaries that resonate with the community within them
4. The term ‘community’ should refer to all those present in the area, whether by living there, working there, or providing services to it
5. The Charity should invest heavily in a planning phase to truly understand the local context, communicate the high-level aim, and catalyse the redistribution of power
6. The community should agree ways of working, a shared agenda, and make key decisions, including the indices it wishes to track – it is important to accept there will always be tensions
7. The work should always operate at four levels – individual/residents, community, system, and
   policy; given the differences between these levels, there will always be tensions here too
8. There should be continuous learning and prototyping throughout the work, akin to how a start-up business hoping to be disruptive would operate: work with the willing (‘ready’ communities), learn continuously, iterate the approach, look to replicate, and look for ‘buying signals’ that suggest a possible business model

These design principles have informed our proposed approach. At the heart of the approach is the ‘hub’. It is an organisation, separate to the Charity, with staff to coordinate between the Charity, local projects, and all parts of a community. We propose that the Charity works with multiple communities at the same time, meaning that there will be multiple hubs.

In terms of next steps, we propose sharing the report internally, preparing for the road ahead, and sharing the report with external parties. Sharing the report internally includes with the Formal Advisors, all of whom are yet to comment on the final report. Preparing for the road ahead includes agreeing how to choose a community to work in, including its size, deciding how many communities to work in, and establishing a P&L and approach to funding aligned with prototyping. Sharing the report with external parties means engaging four UK-based organisations on a similar journey to the Charity.

As costing the next steps will depend on the Charity’s decisions with respect to speed and scale, we have not attempted this.