Lessons learned from tackling health inequalities

In our recent history, cities have been the great engines of global health and prosperity. Yet, this has always masked deep health inequalities. Urban centres are responsible for both the best and worst health outcomes in ways that are systemic and entrenched but also amenable to change.

The cities we live in shape our health in ways that are both local and specific, as well as global and generalisable. Here, I’ll share how this informs both how we think about place and how we use it to shape our approach in practice. It has led us to describe our work as both place-based and place focused.

Guy’s & St Thomas’ Foundation is one of the UK’s largest foundations. We are a funder, investor and researcher. We have been working in the London boroughs of Lambeth and Southwark for over 500 years. So, in many ways, our approach to improving health has always been firmly rooted in local assets and community.

Our place is like many other inner­-city areas – vibrant and changing all the time. Around 600,000 people live in the boroughs, roughly the same as a city like Glasgow or Boston. It’s densely populated (twice the average in the capital), and like many other cities, there are high levels of income inequality, where affluence and poverty live side by side.

The area is a fascinating testbed for work on health inequalities. The range of health outcomes in our boroughs is as wide as the range of health outcomes across London as a whole. It is also one of the most ethnically diverse places in the UK, making it a mirror to the world’s future population.

Through Impact on Urban Health, we focus on a few complex health issues, all of which are intrinsically linked to concentrated urban poverty. These include challenges like reducing childhood obesity, slowing progression to multiple long-term health conditions, and addressing the unequal health effects of air pollution. Success for us is addressing local health inequalities in such a way that we also have a national and international effect.

We work where people are, and with how they live. To do this, we combine data analysis, international evidence of what works (and doesn’t) and listening to the experiences of local people to better understand the connections between people’s health and where they spend their time.

We then design and carry out applied research on different approaches based on what we’ve learnt. Our work is highly experimental and designed to replicate.

For us, place-based working means first looking to understand the lived realities of an issue and then unlocking capacity for change by engaging with a wide range of local actors.

Take childhood obesity for example. To help us target our work, we use different types of statutory data – from local authorities, schools, and the NHS – but then combine that with commercial data (for example, where people are shopping and what they are buying) alongside transport data (how and where people are moving to and from).

When we first started exploring the issue three years ago, data in Lambeth and Southwark demonstrated that rates of childhood obesity tracked extremely strongly with an area’s average income.

Spending time with local children and families helped us understand what was happening beneath this data. Ethnographic accounts and purchasing diaries showed families are up against a flood of unhealthy food options, and reduced financial resources only limit healthy options even more. This helps us to specifically target local interventions ranging from helping low-income families access vouchers for fresh fruit and vegetables at East Street Market, to piloting a healthy takeaway service in Herne Hill.

We also work to make sure that the people and organisations with the potential to create change have the opportunity to do so. To help us, we look to the experts: residents, community leaders, local businesses and social sector organisations.

As part of our multiple long-term conditions programme, for example, residents are teaching us about the relationship between their finances and their health. We partner with “anchor organisations” – whose purpose and mission are intrinsically bound up in an area – to get a nuanced understanding of the challenges communities face. For instance, we have helped the Southwark-based settlement Pembroke House to create the “Walworth Living Room”. This is a blended model of clinical and non-clinical approaches to long­-term health conditions, located in a neighbourhood setting, and based on community organising principles.

Most recently, we have been working to address the structural inequalities of the pandemic. It is clear Covid-19 has not been experienced equally – especially so for communities of colour. Our place has one of the highest proportions of Black residents in the UK.

Two current examples of this include our work with Black Thrive, a Lambeth-based collective, on understanding the evolving employment needs of local Black communities. Another is a digital project with The Social Innovation Partnership to understand people’s lived experience of Covid-19 through stories, insights and ideas from residents. We don’t yet know what these projects will lead to, but we anticipate dedicated funding, collaborations with community members around how funding is spent, and other co-produced solutions where communities design the parameters of their own research and initiatives.

Working in a specific place also brings another, often overlooked, benefit. The issues we work on are complex and best understood as the outcomes of wider systems – for example, transport, education, employment, housing and the policies that influence them. However, complex systems working is easier to describe in theory than deliver on in practice.

The lens that a specific geography brings, especially in a global city like ours, is a useful way to make sense of this complexity. We describe this as being “place focused”. Our defined geography allows us to see the actors and interests around issues, spot pressure points where we can reshape systems and, importantly, measure and observe effect.

For example, childhood obesity is an issue too complex for one sector to tackle alone. Within an inner-city context, that means working with schools, urban planners, supermarkets, fast food outlets, policymakers and anyone else who plays a part in what ends up on young people’s plates.

Creating more affordable, convenient and healthy food options has required us to engage at a national and even international scale. For example, we’re working to influence food retailers through a national partnership with the Consumer Goods Forum. This involves testing healthy nudges in over 200 local stores with every major supermarket. Insights from this work were crucial in influencing the government’s recent obesity strategy.

At the same time, we’re working with the investors that can influence food retailers and manufacturers. Our Healthy Markets campaign has attracted over $1 tn of assets from pension funds and other investors dedicated to reducing childhood obesity.

Working in this way also attracts different partners. For example, the Clean Air Fund, a global coalition of some of the world’s largest philanthropies, has invested in our air pollution programme. They see it as a practical way of learning specific, local insights that can inform their work in many other urban centres.

First, we are learning that the more specific the insight, the more generalisable it is. A common concern about place working is that it can be a bit like looking at someone else’s holiday photos. We’re not finding that to be the case.

For instance, families in our place who are on lower incomes are both more likely to live in areas with high numbers of corner stores and more likely to rely on convenience shopping than wealthier neighbours. Through a Good Food Retail project in Southwark, we found that convenience store owners have a lot of control over what’s in their shops and are important personalities in a community. Yet, almost nobody focuses on convenience stores owners as influencing our health, begging the question: do we understand well enough who the creators and gatekeepers of unlocking impact are?

Second, we are finding that in work like ours the national/local distinction can be a misleading one. They’re both sides of the same coin. Of course, some things are best done at the national level and some locally. It is the connection between the two that is vital.

For example, with Big Society Capital, we have set up a fund investing in healthy and affordable snack food brands. These brands need routes to national retailers if they are to be sustainable. But the snacks also need to be attractive to the right audiences, which they can improve through deep access to the opinions and feedback of our local communities. Our fund connects retailers, entrepreneurs and residents – and only works if they all link effectively.

And third, we are learning where we add the most value as an organisation. Fascinatingly this is often in different places than we expected.

We’re seeing that our funding is only part of the picture. As important seems to be our issue expertise, connections to local decision-makers, and ability to convene networks, people and ideas. Likewise, a substantial element of our endowment is in property.

We’re finding that we can develop this in ways that support local employment and healthier environments at greater scale than we ever could as a grant maker.

In conclusion

At its best, working in and through a place focuses efforts and energy. While not without its complications, it offers outsized opportunities for positive change. Crucially, it allows for fresh approaches. Given the urgency of the issues we are working on, this feels an approach that can be of great use to many.

This article was originally published by Charity Finance on 1 September 2020. You can read it here.