Taking a place-based approach

18 December 2020

COVID-19 has brought a whole new language to public attention – phrases such as social distancing, furloughing and shielded are now in common use, acting as a prompt to look at our world with fresh eyes and bring into the spotlight issues and people who are more often in the shadows – those classed as vulnerable.

However, vulnerability is not a new concept. It is a long-term and growing issue that existed long before COVID-19 and extends far beyond the scope of the pandemic.

The response under COVID-19 could be seen to be just the tip of the iceberg – two million people were deemed particularly at risk from the pandemic and were asked to isolate and given shielded status.

This status was generally ascribed to the elderly and those with certain long-term diagnoses, however Guy Boersma, Managing Director of KSS AHSN, said that the true extent of England’s vulnerable population goes far beyond that 2m figure.

“When we talk about vulnerable we are looking at a range of conditions beyond those who were advised to shield during COVID-19 – from people struggling with their mental health to the newly vulnerable as a result of bereavement, to isolated carers and those who have lost work or income,” he said.

“It’s clear that this is an ever shifting group, with people moving in and out of vulnerability due to a range of factors that, generally, are out of their control.”

The new language of COVID-19 aligns with the concept of this shifting group; people who become socially isolated as a result of shielding, who lose their jobs or live on reduced furlough income, become the newly vulnerable. The challenge for services is how to respond in this new environment. Needs have changed almost overnight; continuing to provide services in the traditional way is impossible; how can we begin to build a new approach?

A place-based approach

People who live with physical illness recognise a national health service with standards that apply across the land. However, those whose lives are precarious, who live with, and are vulnerable to, mental and social health and economic challenges will recognise that their support has to be delivered locally.

But just how do you support people with a range of needs within a system – whether that’s the NHS, council, social care, children’s services or any of the other organisations that operate at a local level?

John Hitchin is Chief Executive of Renaisi – an independent social enterprise based in London that works with people and organisations to turn a place into thriving communities. And it is that emphasis on ‘place’ which distinguishes Renaisi’s approach.

“I’m often asked why we put so much emphasis on place when the majority of our work is around supporting people,” John said.

“And of course our work is about people – we’re about social change and you’ve got to think about the impact you’re having on individuals and how you’re helping their lives get better.

“But we are also interested in what the lens of place can do to further that support for individuals and their needs.

“Place is one way in which you can break down some of the silos and bureaucracies and ways of working, and we’re interested in how you can break those silos down in a way that means you can maybe do more for people with certain needs.”

Existing outside the system

Organisations may provide support within a service pathway or structured referral approach, but in John’s experience those seeking support approach providers in a different way.

“They’ll move between organisations, and so they’ll come to us if they’re looking for work. And if they like our team they’ll stay with us and accept that support, and if they don’t like us they won’t come back to the next appointment.

“They don’t try to understand the system, because they don’t feel like they need to – they feel like they need to build trust with whoever they are working with that can help them.”

A person-centred perspective

John’s experience at Renaisi ties in with the person-centred approach supported by National Voices – a coalition of health and social care charities in England, advocating for person-centred care.

Charlotte Augst, the charity’s Chief Executive, said that while carrying out a database exercise can help define and find vulnerable groups, it’s vital that you put the person and their rights at the centre of any intervention.

“It’s not a case of identifying 1,000 people who need help because they are, say, destitute, and going in with very heavy boots and saying ‘we have found you and we want to do this to you’,” she explained.

“The first question that you should really be asking is ‘what matters to you?’. Even if you think you have identified someone who probably will need some help, ask those questions. You’d be surprised, I think, about how little people often say they need.

“We talked to a lot of people who had their treatment and care disrupted as a result of COVID-19 for our What We Need Now report. And we didn’t hear from anyone that it was, for example, a shocking injustice or scandal that their hip replacement wasn’t going to happen as planned.

“This is not how people think about their needs. But what they did say was that if their hip replacement can’t take place then they want an explanation, and to know who’s in charge, and when they will be contacted again, and what they can do in the meantime to look after themselves.”

An agile response

The South West AHSN has been supporting and delivering place-based solutions since 2015, when it worked as a partner on the Transforming Ageing programme which focused on how to support social enterprises to scale up to meet the needs of their communities and health system.

And in 2019 the South West AHSN launched the Institute for Social Prescribing to inform the innovation and spread of social prescribing across the South West region and beyond.

Dan Lyus, the South West AHSNs Director of Partnerships, said that the legacy of this work has enabled them to quickly respond to the challenges of COVID-19 in parternship with local and regional organisations.

“It became apparent very soon that we needed a hyper-local response to COVID-19 to complement the regional and national systems. The need for support was being felt at street-level, and you could only really understand who was vulnerable at that level if you understood that street,” he explained.

“It was vital to be engaged with the organisations on the ground. Those GP practices that had developed social prescribing services and had community builders out in those communities already knew the streets.


“We were seeing social prescribers with existing networks create hyper-local place-based approaches. They were able to organise rapidly, knocking on doors and making those connections that went so much further than just a centralised response.

“Through the South West AHSN, these local teams continue to collaborate; sharing and spreading what they have learnt across the region. From innovative local systems to digital applications for local services – often what works in one place, is learning for the next.”

The role of research

Issues of vulnerability, diversity and inclusion have long been of interest to researchers at population and individual levels. COVID-19 has in many ways magnified inequalities and increased the precariousness of many people who were already vulnerable.

The new NIHR Applied Research Collaboration Kent Surrey and Sussex (ARC KSS) has supported some of this work and also funded new research on volunteer support for isolated people, looking at how to improve communication and information for people in minority communities and improve remote support for young people with mental health problems and for people with dementia.

Professor Stephen Peckham from the University of Kent and Director of ARC KSS, stressed how research is important in understanding people’s experiences and in developing solutions.

“There is a real concern about the impact of COVID-19 on people from ethnic and minority backgrounds as well as how to support people who have been more isolated due to the pandemic, particularly older people and people with mental health problems,” he explained.

“Understanding how services and society more widely can reduce vulnerability and address new forms of exclusion is important, and not just in terms of people’s health and social wellbeing. The research community in Kent, Surrey and Sussex has worked closely with local health, social care and other public and voluntary organisations and groups to develop research that addresses these issues. Working in partnership is important to ensure that research is both relevant and impactful.”

The importance of trust and collaboration

One of the key benefits of working at a place-based level is that it becomes possible to build strong collaboration and trust between the different organisations that, together, can support the varied needs of an individual.

“It takes time to build trust, and in my view it tends to occur at a relationship scale – it’s never Organisation X trusts Organisation Y, it’s the people in Organisation X trusting the people in Organisation Y,” John explained.

“The phrase that my team have probably had enough of me saying is that collaboration is a muscle. You’ve got to use it and strengthen it and make sure that other people are strengthening it too.”

Scaling success

Within health and social care there is, understandably, a tendency to want to replicate successful initiatives across a county, region or even nationally.

However, with a place-based approach focusing so much on local relationships, facilities, services and needs, is it possible to export a specific place-based project to a different place?

Organisations often talk of ‘rolling out’ tried and tested innovations to new locations, but according to Charlotte Augst, that’s looking at it the wrong way.

“Don Redding, who used to work at National Voices, said we need to stop talking about rolling out innovation – it’s not a carpet that you can roll out, it’s parquet flooring.

“It needs to be laid in place, and it’s a bit bumpy and there’s a step here and there’s an awkward corner there, and therefore you need all the tools to lay your parquet so that it’s nice and smooth and shiny.

“And that’s probably the role of the centre or the AHSNs to say we need these tools, here is a map, here is what others have done to get around an awkward corner like yours, and to be that sort of enabler.”

Dan Lyus agrees that the AHSNs are well placed to support a place-based approach to projects. Since its inception seven years ago, the AHSN Network has developed a collaborative approach that can bring partners together to tackle urgent challenges through multi-sector partnerships.

“Where organisations have a way of looking at their local area which allows them to understand, at an early stage, where vulnerability lies and where the risks are, then the AHSNs are able to support them to respond to that,” he said.

“The AHSN Network is good at building the capability for improvement within a system. We understand the conditions that enable innovative practice to spread across the system, and have the skills to undertake an evaluation of a project’s impact and surface the learning while the project is occurring.”

Moving towards a Community of Practice

The AHSN Network is in the process of developing a Community of Practice (CoP) which uses a place-based approach to tackle vulnerability. Convened by the South West AHSN, it will provide a forum to share ideas, approaches and best practice, with the aim of developing a wider health equity in communities across England.

The CoP approach is welcomed by John Hitchin, who feels that more places are needed in which people can critically discuss place-based approaches.

“You need more forums for groups or individuals to come together to talk about it, to build shared language and some agreed frameworks and ways of thinking, and I’m really keen to advance that – the more we talk about place-based approaches in a critical way, the better,” he said.

Person-centred, place-based

Collaboration, trust, frameworks, forums and communities of practice are all key building blocks to develop person-centred, place-based support. However, Charlotte Augst said that there’s one more vital ingredient that’s needed.

“My feeling is that where we see success, it has a lot to do with the connection between the head and the heart. And that’s something that we ignore at our peril – it’s imperative that humanity lies at the heart of your actions,” she explained.

“Because it’s hard, you know, to make change. It’s hard, and within five minutes, if not five weeks, you will come across something that seems like an insurmountable obstacle. That’s just the way it is, because the system is designed to deliver the outcomes it delivers, so you will bump into all the system limitations.

“And that’s why you need someone who says ‘I won’t take no for an answer, I won’t let this happen, I won’t let this idea die, I won’t let my patients continue to get poor outcomes, and I won’t tolerate these inequalities’.

“When it works well it’s because there are leaders who have made that connection. And it’s difficult because it requires us to do very different change management, doesn’t it?”

More from this issue of Innovate

Pockets of success

The urgency of the vulnerability challenge