Accountable Care Determinants Inequality Social Value STP

Role of anchor institutions in sustainable economic growth.

Went to an excellent session a month or two back

Ted Howard  of the Democracy Collaboraborative was the headline act

With a few able support acts

I learned a lot in a short space of time

In the spirit of democratising knowledge, here is my note of the meeting

1. What is the Democracy Collaboraborative

35 staff. Action oriented think tank

Mission = How do you democratise the economy of USA – address exclusion and inequity

Large local institutions have important role to play in this

Focused on the strategic approach to this issue

The operational grass roots level to this is around community resilience and learning from other non health movements – e.g. Much to learn from restorative justice

Historical areas of work

Greening supply chain of health care

Sustainability of health care

Localising of economic activity of health system

2. Why is this issue important

We know inclusive growth is important. We know “the economy” is one of the fundamental determainrat of health (that one is turning into a monster of a blog that I need to finish)

We know that there’s a great deal that can be achieved though the economic power of anchor institution

To address health inequalities you need to address social and economic inequalities

20% is health care – access and quality

Here is an opportuinity to directly address the economic influences on health with your existing budget

Strategic question to the anchor is

Can we incentivise the 80% to optimise impact on health and well being.

What can NHS system DO about social and economic determinants

Frontline level, service level, policy level (anchor institution

Dear anchor – conduct your business in a way that reflects your anchor status and builds capacity to address social determinants. Not just as a side issue but 100% of your activity

This leads to better economy – and should be done for economic reasons in addition to intrinsic  health reasons.

This is an under the radar and doable strategy that can address some of the underlying economic determinants of health that may never happen nationally given the political deadlock nationally…..

This has been going on for 8 years in the states.

The hospital network described above been going on for 2yrs

3. Economic anchor institutions tend to be:

  • Non profit or public
  • Sticky capital, rooted in place. Tend to not move on account of economic factors, they don’t leave when the economic going gets tough,
  • Economic engines – large purchasers, employers and investors
  • Hospitals, uni sector, local govt
  • Often large purchasing power

Domains of the business to look for progress and opportunity

  • Employer
  • Annual spend
  • Annual procurement
  • Investment and portfolios and endowments
  • I.e. Not really the core mission of delivering great services.

All the assets of your institution should be “in” – eg

  • HR /
  • Technology
  • Treasury
  • Research
  • Community benefit
  • Govt relations
  • Comms
  • Environmental
  • Service delivery

Economic assets are probably key

  • Hiring and workforce
  • Procurement and purchasing
  • Place based investment
  • An early ask was of the Cleveland Clinic ($1.8bn) = how they incentivise themselves around local supply chain
  • 25% of supply chain has to conform to green and local metrics
  • Hard edged indicator that were set were met.

4. Toolkits have been published

Full of practical aspects  and ideas

Three main areas with some practical examples


Inclusive local hiring

Equip local residents for q high demand front line jobs that are connected to job pipelines

Connect frontline workers to pathways for career advancement within the institution

Partner with local intermediary to train

Use cohort training model focused on specific positions

Paid internship programme with pathways to hire

“John Hopkins local”

Build, buy, hire


Local purchasing 

Connect vendors with contract opportunities within your institution

Build capacity in supply chain to access larger contracts

Identify gaps in the market…..can local suppliers help institutions fill gaps

Systematically work through supply chain and make public commitments

Lowest cost for every unit vs full economic impact of every purchasing decision you make.

i.e. factor in the externalities

How do we use the cities money as we purchase to buy from our own institutions as opposed to the w midlands, or Mexico

Keep £ in the local system.

92% of recent massive infrastructure investment was kept local

Economic and skill benefit


How is the endowment invested

Hedge funds or local social capital

Credit unions – invest in credit unions.

Invest in local businesses and local economy

Healthy Neighbourhood collaborations

5. The Healthcare anchor network

To help each participant accelerate their own mission and spread the model more widely

And invest wisely to achieve the broader social aim, as well as the clinical aim

Overall network Meet twice a year

Define the org imperative

Build the evidence base

Collaborative with wide range of stakeholder

Working groups – for significant themes

Community investment in land trust – purchase land to secure sustainable and affordable housing

What can hospital do in the housing economy??

6) Michael Wood NHS local growth advisor from NHS Confed  then posed som excellent questions for us to ask local

How do local partners see the NHS

Is it a cost or an investment

Is the NHS involved in a discussion about raising £ or spending £

STP is the iteration and NHS version of this.

  • Is STP about service sustainability or transforming the model
  • The NHS matters to local economy
  • Estates
  • Social inclusion
  • Workforce
  • Estates (Naylor report)
  • Local spend (do we know and understand our local supply chain and impact)
  • Commercialisation of research
  • How does the NHS £ impact on local issues and problems.
  • There will be no central message telling us to deliver this, or measure it
  • Liverpool have good CCG local framework

He advised we look out for NHS Confed products

Local growth academy

Local growth and the NHS

Webinar series

He also advised we check the Local Growth white paper – we need to check in our aspirations against this

One size doesn’t fit all

Give local leaders power to make decision

Shift power local

LEP, combine authority, locally elected mayors, localisation of fiscal policy (brr context)

The NHS is not within this context

7) Emily Huff ended with the strategic question of What is the NHS for

Moving from care and repair system to asset based health system

8 some excellent Points raised in Q&A after

Cleveland model = leveraging econ power of anchor institutions, greenest, local employment – access to employment opportunities for those left behind, buy local, Land trust investment, Employee ownership as better way of organising

Preston – based around 15 anchor institutions

Building on Cleveland. Go further.

Moved £12-15m of spend that used to leave the city into the city

Multiplier effect on local economy

Starting a public bank to address economic exclusion (Dakota state public bank – Dakota less impacted on by global turndown than elsewhere in state, the publicly owned bank kept lending to local businesses.

Preston exploring this – NHS and LA puts its £ into this to do banking…important leveraging effect

Anchor strategy population

Tends to work at min of 400k or more perhaps

Power imbalance between big institutions and communities

At it’s most strategic level – tricky to get right

Easy to see how this might work local level.

Local procurement of food, carbon miles etc

Different way in, but mission broadly the same

Getting providers who aren’t interested in long term investment but are interested in immediate cost base.

Rest of the public sector is talking about economic, local, growth, cost v investment

NHS is way behind here. Give tools to the NHS to catch up.

Where are the regulators have to say on this matter in NHS context. This might be a driving factor.

Key advice from Ted Howard

Keep creating and recreating a big picture vision of what is possible

Keep sharing examples of where things have worked despite local or national defaults

If you want to do this job – you need to be intentional and hold feet to fire

This path is NOT the path of least resistance

Make public commitments

Hold yourself to account to progress back to the community

how best to take on in NHS (or other econ anchor)

What is the potential for FT model to co invest in social outcomes that achieve health and well being ends.

NHS is large % of local economic power

Larger % further north as private economy weaker

Kaiser has monetised health not illness – Prevention reduces the income stream of many of our providers

Focus on BOTH rational side to journey (business case, metrics and governance) and emotional side – the right thing.

Appeal to all ideologies

What is the formal system of accountability where you combine financial accountability with social and wider economic accountability – Triple bottom line accounting 

Got to make it hard edged enough that the CFO say this is the right thing, and doesn’t unravel when times get tough.

This is an alternative model to free market economics. Arguably an approach that all ideologies can agree on and something in it for all sides of argument (liberal and conservative)… not another big federal investment, good for CSR, more efficient way of harnessing and utilising resources in local economy…..then the social reasons…..

Frame not as big “government programmes” but about getting more efficient use of £ already committed AND local multiplier effect AND social gains.

CSR – Tesco have made great strides, the NHS has barely started

24m ROI argument. – Financially / Health and well being of community /

Carbon ….. 24 case studies……….SDU website

Map of deprivation from the 80s is largely akin to now – aka regeneration has failed

Funding injections didn’t address the mainstream commitment of £ base – the institutions we want to continue to support

This is a route into permanent change of the way an economy works (at least the public economy)

In times of plenty, we didn’t make the mainstream better, we funded stuff at the margins to correct the deficiencies of the mainstream.

And thus we never corrected the problems in our view of allocative value in the mainstream (in everyday language we failed to shift upstream).

Depoliticise this.

Make it not a feature of left or right, or greens, or middle

Find arguments for all brands of ideology. Make it practical fiscal and economic and political sense from lots of different perspectives.

why local matters
Large national providers not invested in place

Can’t respond and flex locally

Not in tune with our local ethos

National v local policy differences.

Less anole to tie up with other org locally across nhs, local gov, or vcs

If there is to be national contracts, local role is to ensure standards, rules, ethos is fit for local circumstances

Issue Here in terms of what can / can’t be contracted for

Opportunities for NHS

In ACO model what we trade is health services

in a wider model the traded commodity is health and well being

Link it to a contemporary policy and service problem

Inclusive growth is huge opportunity and role / place of NHS debate

Skill escalators – short term apprenticeships

There are 3 organisations that will b here in 20y time – hospital, job centre, local govt. better structural links between the 3 critical”

Localism is a challenge to nationally centralised system

NHS is massively centralised

Challenge for NHS is how it responds to devolution and this agenda.

Natural path will be to centralise

In the Paris climate change talks, it was the case put by the USA Mayors that changed the game

National is to set the context, local is what matters.

The creativity is local.

Best way of protecting from market forces, Brexit, etc is local……

this cannot be done from a centrally managed system

This agenda is part of health creation.

Help needed from national bodies

Regulatory bodies need to acknowledge the concept of social value in their inspection regime or how they regulate the orgs

Triple bottom line accountability is well documented in the private sector… it not built into the mission of the NHS…. much to learn

NHSE and NHSI – not at top of shop but some levels below

Unleash the creative potential that already exists.

Indicators of inclusive growth more broadly

% of staff who are located in community and live locally

What % of local sum of resource ends up in local economy

housing well being indicators



Poor state of repair


Water / leccy shut off non pay of bills

Key websites

All up

Excellent afair

Lots of interesting and fresh learning packed into a short space

Thanks Health Foundation for the event, and the invite.

Some of (well most of) my twitter buddies were there so they may comment further

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