Over the last three years, the Director of Public Health in East Sussex has looked at the broad social and economic circumstances that together influence health in the county in a series of annual reports: people needing a tribe to belong to; a job or occupation to do, and a place to call home.
This year’s focus is on loneliness, social connections and community.
Here, Ben Brown and David Bishop, explore the county’s collaborative, evidence-informed approach to tackling loneliness, which builds on the work of the Campaign to End Loneliness.
The East Sussex Community Survey found that, in 2019, a quarter of people said they feel lonely often or some of the time, with 5% saying they feel lonely often.
Compared to East Sussex overall, people living in:
Loneliness is likely to lead to higher costs in the public and private sector due to greater service usage, absences and productivity losses.
Tackling loneliness is a priority of Partnership Plus, the partnership of local authorities, the NHS, the Voluntary, Community and Social Enterprise (VSCE) sector and other partners in East Sussex. Loneliness is also a topic area of interest that had been identified for scoping and exploration by the county council’s People Scrutiny Committee.
While everyone’s individual experiences of loneliness differ, we know that creating conditions where social connections can thrive is crucial not only for people’s wellbeing – supporting them to lead healthy, happy and fulfilled lives – but also the wider prosperity of our society.
We recognise that there can be no single solution to tackling complex public health issues. This is why we wanted to explore a systems approach to loneliness, where different parts of the system are better connected to create the conditions for residents to thrive.
To do this, we worked in partnership with organisations and people in East Sussex to deliver a Connected People and Places project during 2021/22.
The ten-month project sought to:
To succeed, we realised that it was essential to gain wide involvement of relevant parts of the system – including residents and communities – and to consider approaches that focus on strengths, assets and opportunities.
We anticipated that the design process would need to include:
As such, we chose a design and innovation approach.
We used a positively framed ‘Connection Campaign’ to explore how communities across the county could become more connected and how we might work together better to make this happen. This used Appreciative Inquiry – an action research approach that uses conversational interviews to uncover stories of what works well, what is valued and what matters most to people. This approach was chosen as we could use a few simple questions to open up a conversation and enable people to reflect on their experiences and interests. We hoped that using common but broad questions across all modes of engagement would enable us to identify trends and differences, and to help build an overall picture and narrative.
We used our existing rich networks within the county – including a Community Wellbeing Partnership with statutory partners, East Sussex VCSE Alliance members and others – and worked to involve new community groups and residents on this topic.
Any organisation or group with an interest in tackling loneliness or improving connection was invited to take part. We also approached specific organisations in contact with groups known to be most affected by loneliness.
To provide a foundational understanding, we commissioned Collaborate CIC to produce a rapid evidence review on approaches to tackling loneliness. Collaborate CIC is a social change agency with experience in helping local government and system partners to explore complex social problems.
Informed by the review, and using our collaborative approach, we used three main tactics for resident and partner engagement:
Through our engagement work, we also invited groups to provide information about their activities to promote connection, using them as case studies and celebrating great examples of community-led activity.
Taking a collaborative approach provided important context for how we might improve social connections in our county. Among the themes revealed was the effect that geography and people’s sense of place have on their experiences and ability to connect with others and to flourish. Without taking this approach, it is unlikely we would have captured this insight.
This provided a helpful framing for our work with partners, and enabled us to gain a common understanding of what loneliness is, why it is important and what works to address the problem.
It also informed our co-design approach to develop community wellbeing in East Sussex, involving relevant parts of the system, including residents and communities.
A fundamental aspect of the project was to better understand the different experiences of loneliness of different groups.
Through targeted engagement in each district/borough we were able to have conversations with a diverse range of people, including marginalised groups that may be at higher risk experiencing loneliness or have lived experience of loneliness. This includes carers, those living alone or in sheltered accommodation, ethnic minorities, religious groups LGBTQ+ individuals/groups, migrants, people with a disability or long term health condition and others. This was particularly important because we know that certain groups who experience severe loneliness are more likely to have poorer health and wellbeing (and other) outcomes.
The broad engagement included 345 responses to our resident survey. We also attracted over 130 attendees to the five partner workshops focused on each district/borough of the county.
The collection of case studies we collated show that there is already a wealth of activities, services and initiatives across East Sussex making a huge contribution in preventing, alleviating and tackling loneliness, which is something to be celebrated.
We have used these to showcase the rich examples of spirit and dedication that people and organisations in the county show in fostering social networks, tackling stigma and discrimination, and creating the infrastructure that supports connected communities.
We used the Campaign to End Loneliness’s Promising Approaches framework (2015), updated as Promising Approaches Revisited (2020), to inform how we described the work we wanted to achieve with partners. The framework sets out a way of understanding different approaches to addressing loneliness, and how they work together in a community to create an effective response to individuals’ experience of loneliness.
We used this, and Collaborate’s Connected Communities Model, as the basis to develop our own model.
The model is a starting point to help us understand the system as a whole. It illustrates the different layers and roles within the system. As with any model, it’s a simplification. In reality not everything fits neatly into layers and the boundaries between layers are more blurred.
Figure: Layers of a connected system (including explanatory examples)
During the project, we identified different layers in the system and advised that dedicated learning spaces would need to be created within and across each layer to create the infrastructure that will embed learning as the default way of operating.
In the course of delivering the project it became clear that the understanding and experience of systems thinking and working is highly variable within and between the different partner organisations.
The stakeholder workshops and discussions provided some opportunities to gain a common understanding of loneliness in the context of how the local system operates, but we knew that further sustained work to ‘test and learn’ together would also be needed.
A key recommendation of the report is for the public, private and VCSE sectors to work together to make progress on preventing and tackling loneliness through a stewardship approach. In the workshop held to discuss the draft recommendations there was a recognition that this was of the highest importance, but there were some differences of opinion over how feasible it was believed to be. Some of this was driven by a lack of understanding of:
In practice, a systems steward can be a person, organisation or group that takes responsibility for helping to nurture a healthy system. This involves helping people achieve together what they can’t alone through making best use of collective relationships, insights and resources.
Once the project recommendations were agreed we spent further time with partners through a series of workshops to agree exactly what stewardship means in East Sussex, along with deciding how the approach could be best supported in our context and with interested stakeholders.
Tackling loneliness requires collective action. No single organisation, sector or segment of society has all the solutions to this complex societal and individual problem.
Reaching a common understanding of the key concepts of systemic change and the different mindsets, behaviours and structures required will be an enabler for any systems approach.
National government is making legislative changes in the form of Integrated Care Systems that will demand greater collaboration between the NHS, local government, and wider delivery partners including the VCSE, to deliver improved outcomes to health and wellbeing for local people. Place-based partnerships will find adoption of these changes smoother if there is a more widespread understanding of how to use the principles and practices of system thinking to work beyond organisational boundaries and formal authority in service of the whole.
The headline recommendations from the report are designed for East Sussex, but could also be adapted and transferred across context where appropriate:
Work is currently underway to establish a stewardship approach, with a two-year programme focusing on social connections and loneliness, funded by East Sussex County Council. This will help to build trusting relationships, promote learning and enable people and organisations to work together meaningfully towards common goals.
The council, working with the East Sussex VCSE Alliance, has appointed an organisation to support partners to actively participate in the stewardship approach. A programme facilitator is currently being recruited, after which the stewardship group will be formed, its vision agreed and the stepped implementation of its work programme taken forward. For example, this may helpfully build on existing local work to develop social infrastructure (e.g. through the Making It Happen programme) and shape future policies that can promote social engagement, interaction and cohesion (e.g. the memorandum of understanding between public health and planning authorities).
This is not a short-term endeavour; it will require combined and sustained efforts from all parts of the ‘system’ to make further progress on tackling and preventing such a complex social problem as loneliness.
Anyone with a shared passion and ambition for these issues is invited to get involved in what’s to come.
David Bishop has worked in a range of public health roles in Sussex over the last 18 years, focusing on health improvement approaches in communities and settings.
Ben Brown takes the lead for public mental health and suicide prevention in East Sussex. Before starting his career in public health nine years ago, Ben was a qualified mental health nurse working in children’s services and safeguarding.
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