COVID-19 continues to send shockwaves through people, places and communities across the UK. While the most immediate and visible effects are morbidity, mortality and the pressure on health services, the pandemic is also adversely impacting the economic and social aspects of our lives. For example, in the UK, the number of people claiming unemployment benefits increased by 1.4 million between March and December 2020. 7.3 million people reported falling behind on household bills, and GDP in November 2020 was 9% lower than it was pre-pandemic. These and other burdens have not been distributed equally and COVID-19 has exposed and increased unjust and avoidable inequalities. This will have unprecedented longer term consequences for the nation’s health.

Even before COVID-19, the UK was one of the most geographically unequal countries in the developed world. And there is recognition that the government needs to be much bolder to ensure the rhetoric of ‘levelling up’ becomes a reality. Widening inequalities and growing pressures on health care services in recent years have also prompted questions about the role and responsibility of large public sector organisations to tackle the wider determinants of health and to act as ‘anchor institutions’.

Organisations including hospitals, local authorities and universities are anchor institutions as they are ‘anchored’ in their surrounding community – they are unlikely to relocate and are rooted in and connected to their local populations. This provides an opportunity to maximise their influence on the wider determinants of health by adapting the way they employ people, purchase goods and services, use buildings and spaces, reduce environmental impact, and work in partnership (Figure 1). 

Our 2019 anchors report Building healthier communities argued that the NHS could make a far greater contribution to improve health and wellbeing, and reduce inequalities, by acting as anchor institutions.

This long read summarises insights from some local leaders around the UK who are engaged in anchor action to respond to the impact of COVID-19. This action is often part of a wider aim to tackle local health inequalities and improve community health and wellbeing. By sharing insights, lessons, and examples we aim to guide and inspire existing and emerging local anchor leaders.

Reflections from our conversations have also informed the design of the new Health Anchors Learning Network (HALN). Through its activities, the HALN aims to support NHS anchors and local anchor partnerships to develop their capacity and capability, grow evidence of the role and impact of anchor institutions, and scale up anchor action across the UK.  

Figure 1: What makes the NHS an anchor institution? 

From our conversations, it was clear that COVID-19 has created an urgency for more purposeful anchor action and partnership.

‘COVID-19 hasn’t actually changed any of our priorities or focus... [but it has] accelerated and exacerbated the challenges that we already faced and brought into stark focus some of the issues that were already there.’ (Deputy CEO, NHS foundation trust)

The places we spoke to all felt that the impacts of COVID-19 on their communities had increased the need for more purposeful anchor action. The way in which this is pursued will vary by local context, driven in part by the nature and severity of the short-term COVID-19 impact, inequalities faced and needs of the community. Differences may also reflect levels of economic prosperity and resilience prior to the pandemic. We heard examples from across all five ‘pillars’ of anchor action (Figure 1), however, employment was a central focus for many.

Addressing workforce shortages has been a longstanding issue for the health and social care system. Purposeful anchor action on employment can address recruitment and retention challenges, while also enabling the NHS to play a significant role in local socioeconomic recovery. This is especially relevant in the current context, as NHS organisations provide a more stable source of employment compared with other sectors, including hospitality and retail, that have been more directly impacted by COVID-19. We heard a renewed focus on schemes aimed at helping young people into employment, approaches to target recruitment at more deprived areas, and the development of programmes to upskill and train newly unemployed adults.

Stronger partnership working and embedding social value into procurement were also discussed in all conversations. Organisations and systems more mature in their anchor work were increasingly finding ways to tackle multiple pillars simultaneously. Reducing environmental impact and using buildings and spaces to benefit the community were less consistently mentioned as a priority during the acute phase or for the recovery phase of COVID-19.

At the time of publication, the UK health system is still in the eye of the storm. Despite this, the leaders we spoke to felt we cannot afford to wait until after the pandemic to act on this agenda.

Nine key lessons for anchor institutions

Insights from our conversations led us to identify nine key lessons.

Figure 2: Nine key lessons for anchor institutions

Lesson 1: Purposefully tackle inequalities

In our conversations there was a clear consensus about the importance of focusing on the inequalities exacerbated by COVID-19. Inequalities in various forms were a major impetus for anchor action. The type of inequality varied, with discussions on inequalities in health outcomes, equitable local economic growth, digital exclusion, and race and ethnicity-related inequalities.

‘Struck by events in the United States, Black Lives Matter and the disproportionate impact of COVID-19 on [minority ethnic] groups, we are determined to ensure that as employers, we are actively tackling inequalities and institutional racism.’ (Director of Workforce Development, NHS trust)

However, while there was agreement on the importance of tackling inequalities, there was at times a sense of ‘magical thinking’ that taking anchor action will automatically reduce inequalities. There were relatively few examples of anchor programmes based on local population data, or specifically describing how anchor strategies would tackle inequalities.

It is essential that anchor institutions purposefully identify specific inequalities and understand how their actions can tackle these. Using quantitative and qualitative population data and working closely with communities will deepen this understanding. A nuanced consideration of inequalities and equity should be embedded into the design, delivery and evaluation of anchor action.   

‘When you’re talking about building wealth or community-based approaches or trying to target some groups... I think if we just keep doing the same things all the time, we’re just going to further increase the inequalities.’ (Health Improvement Manager)

There were exceptions – for example, Barts Health NHS Trust has included inequalities dimensions in its employment measures, including an optional question for new recruits on whether they previously received free school meals. This is part of an organisational focus on inequalities, which also includes changes to recruitment and selection policies, increasing apprenticeships and ringfencing entry-level jobs for local people. The trust is also seeking to recruit locally for its COVID-19 vaccination centre. 

Lesson 2: Co-produce with communities

A core defining feature of anchor institutions is that they are both tied to and aim to benefit their local community. It is therefore essential that community co-production is included across all stages of anchor action. Developing a powerful narrative for change based on community experiences, priorities and assets, combined with local quantitative data, can help ensure the positive impact of anchor action – benefitting both communities and anchor institutions.

The centrality of co-production was recognised in our conversations. Some felt that COVID-19 had increased anchor institutions’ appetite for co-production, and enhanced existing relationships or created new ones between institutions and communities.

‘[The] response to COVID-19 has seen remarkable progress in enabling and empowering communities to lead change. It's all about relationships, understanding and trust – blurring the barriers between us and operating collaboratively and openly.’ (Chief Executive, local council)

However, in many conversations, participants recognised that this aspect of anchor action was less well developed, especially within NHS organisations where engagement is typically limited to patients and service users, and rarely extends to local communities. Many participants felt that genuine co-production was often overlooked, not happening, or taking time. Other partners including local authorities demonstrated more experience and learning in engaging the wider population and communities.

‘Inclusion of communities is so important but sometimes leads to a degree of “letting go” that anchor organisations struggle with.’ (Consultant in Public Health, local government)

Learning from and engaging with VCS as a core partner can also support NHS anchors to deepen their connections with local communities and therefore the ability to co-produce effective initiatives.

Anchor institutions should also consider co-production with their own staff. The NHS employs 1.6 million people across the UK. In many cases, NHS staff are also members of the local community, who could benefit significantly from well-designed anchor action. Case study 1 describes the importance of understanding the local population, including staff, in developing effective anchor action on employment.

Lesson 3: Establish anchor leadership

Clear and visible local leadership is needed to drive and unite anchor action. Our anchors report highlighted the need for senior executive and board-level support within organisations to ensure anchor action is resourced and prioritised. As anchors are increasingly working with others, many in our conversations also noted a need for visible place-based anchor leadership across new anchor partnerships.

To mobilise anchor action, leadership needs to be both strategic and action orientated to facilitate effective partnerships and ensure accountability and oversight for anchor work.

‘[This is not about] only bringing your mentality, but your personnel, budget, resources, and your ability to deliver on the ground’ (Chair of Board of Management, higher education)

One way of demonstrating this, is by proactively agreeing ambitious commitments. The Glasgow City Deal was developed by eight participating member authorities and local partner organisations to maximise opportunities for inclusive growth. As part of this, the region jointly committed to use an ‘outcome selection menu’ for public sector procurement. The menu requires suppliers to identify additional community benefits, such as job creation, work experience and supply chain development. While there was pre-existing support for community benefits, approaches to identify and quantify outcomes varied. Committed leadership has led to significant improvements in performance across key performance indicators, including an increase in contracts awarded to local businesses, the value of community benefits in contracts and performance on key equality outcomes.

Lesson 4: Develop a shared vision

Developing a shared anchor vision and narrative can help make the case for coordinated place-based anchor action. It can help identify and unite disjointed anchor work across anchor institutions and partnerships, while providing flexibility for individual organisations to progress their anchor action at different rates.

‘We have buy-in from partners, but what does that mean and how do we make it “real”? How do we create a mutual sense of direction and accountability?’ (Director of Public Health)

Agreeing a shared language for anchor action is also important. While the concept of anchor institutions is increasingly recognised in the UK, it is not always used consistently and related concepts such as social value and community wealth building are more common in some areas and sectors. 

Many leaders also commented that anchor visions benefit from being situated within existing strategic priorities – a reflection that echoes our 2019 report.

NHS organisations can increase their influence as anchor institutions by working with businesses and local enterprise partnerships (LEPs) to build shared system-wide programmes of work. NHS organisations in ‘left behind’ areas may particularly benefit from linking their anchor action to wider local regeneration efforts in order to maximise their influence and impact.

Case study 2 describes uniting partners from the NHS and other sectors around a common vision for a large-scale redevelopment project in Humber, Coast and Vale.

Lesson 5: Nurture anchor partnerships

The importance of collaborating to maximise impact and reduce duplication was a consistent theme of our conversations, which is reflected across these nine lessons. There were, however, clear differences in the intention and scope of anchor partnerships depending on local contexts and structures.

Some places have a broad agenda through formal ‘integration’ – for example, via integrated care systems (ICSs) in England, health boards in Wales and community planning partnerships (CPPs) in Scotland. Others have built their partnerships with a specific focus on anchors. Partnerships provide good platforms to drive anchor action across organisations, although NHS organisations are at varying stages of maturity within these different partnerships.

Several places have formalised partnership working using anchor charters or shared commitments. These can help build collective focus and action. Lancashire and South Cumbria, for example, have developed an anchor charter to define and measure progress against anchor activities among local partners in the ICS. Some have established explicit anchor partnerships in their region, while others are driving anchor action within wider partnership structures. Case study 3 provides an example of an integrated partnership working to support COVID-19 response and recovery.

Lesson 8: Develop metrics and embed evaluation

Participants valued the recent speed of implementing anchor approaches, however, they recognised the importance of ensuring effective measurement to capture impact and improve.

Without proper measurement anchor strategies could fail to tackle inequalities or, at worst, unintentionally increase inequalities. For example, pre-employment programmes could inadvertently fail to reach those who had most barriers to joining the health and social care workforce.

There may also be a tension between prioritising ‘local’ impact versus impact on reducing inequalities. For example, prioritising local employment may positively impact on local communities overall but may fail to address inequalities. In some cases, anchor action will be both local and equitable, but this is not a given and careful measurement can help to both define and capture desired impacts.

Good anchor measurement includes defining the local population, understanding inequalities, establishing baselines, monitoring progress over time, building a local evidence base, and embedding co-production throughout.

‘It’s easy to say you’re an anchor institution, it’s easy to say you care, but how do you know and how do you know how you are doing?’ (Director of Public Health)

Setting ambitious targets can also contribute. For example, as part of its green strategy, Mid and South Essex NHS Foundation Trust has a target to decarbonise its building stock by 60% over the next 5 years. 

‘What gets measured gets done, and it helps create a mandate to take more purposeful action.’ (Chief Executive Officer, university hospital trust)

While realising the impact of some projects may not be possible for many years, interim metrics may demonstrate the potential impact of anchor action and maintain engagement. For example, Willmott Dixon, the main contractor for the construction of a new multi-storey car park for Dorset County Hospital, estimated that the building project will generate a social return on investment of over £4m in the form of local employment, training and apprenticeships and greater use of local supply chain partners.

Some participants also expressed a clear ask for national guidance on anchor measurement, and a view that systems could take a role in developing shared metrics.

Universities also have a key role to play, both as anchor institutions themselves and potentially in supporting the NHS and other anchor institutions. This could include acting as a formal evaluation partner and sharing learning; or influencing through anchor partnerships and encouraging others to robustly measure activity and impact.

Lesson 9: Share insights to overcome challenges

Local leaders highlighted that the external policy environment plays a large role in the success of anchor institutions, and there can be some tension between national and local priorities. National procurement rules, in particular, were seen as a barrier to effective local anchor procurement strategies. These rules tend to prioritise reduced cost and increasing efficiency, making it harder to deliver social value through local suppliers. Many felt they needed more local control and funding available in order to make significant progress, and a greater recognition of long-term impact rather than a focus on short-term deliverables, particularly within the NHS.

‘The national drive, national incentive and mandate is to put everything through the national process. That has a lot of national financial savings attached but doesn’t support the work we need to do on anchor institutions and supporting local economies and local communities.’ (Chief Finance Officer, university hospital)

Despite this, we heard examples of successful anchor action within the current context, albeit that COVID may have temporarily enabled this. During the first wave of COVID-19, Mid and South Essex NHS Foundation Trust purchased products including personal protective equipment (PPE) from local clothes manufacturers to meet increasing demand. The trust is planning to sustain this relationship in future. In the short term, sharing opportunities and tangible examples of progress between areas may help to maximise anchor action and impact.

Local anchor leaders can contribute through sharing evidence, experience and expertise on what they have managed to achieve.

The NHS has committed to supporting anchor action in the NHS long term plan, and has recognised the important role anchor institutions will play in COVID-19 recovery. 

One way in which national policymakers can build on these commitments and support effective anchor action, is by considering the impact of national policies, and providing clarity on how anchor action fits within existing national frameworks. The Department of Health and Social Care’s legislative proposals to reform the current competitive procurement process, may provide NHS organisations with greater flexibility.

While the potential gains are great there are significant complexities, tensions and interdependencies in this work, and acting as an anchor institution is not always easy or straightforward. We have explored some of these tensions and highlighted positive practice through nine key lessons. The Health Foundation, in partnership with NHS England and NHS Improvement, will build on these lessons and continue to support health anchors through a new UK-wide Health Anchors Learning Network.

The local leaders we spoke to for our conversations about anchors and COVID-19 represent a small proportion of the many UK anchor institutions at varying stages of progress. However, across a range of places and people we heard energy, enthusiasm and commitment to anchor action. Leaders were clear that anchor institutions have both the opportunity and the responsibility to improve economic and social conditions for their local populations, improving population health and reducing inequalities.

The current context is exceptionally difficult, and the immediate priority must be to protect people from the direct impact of COVID-19 wherever possible. But we also heard that leaders felt they could not wait until the pandemic is ‘over’ to act – COVID-19 has increased the urgency, the need and their determination. We heard examples of accelerated anchor action, enhanced innovation, and powerful new partnerships harnessed in support the NHS response to COVID-19.

The inequalities thrown into sharp focus by COVID-19 are not new, and must be addressed urgently. Anchor institutions can, and should, be at the heart of this effort, helping to deliver a more equitable and sustainable COVID-19 recovery.

Supporting information

Conversations were held across a range of geographical locations with local health care organisations acting as a local convening partner. These include:

• Barts Health NHS Trust and East London Foundation Trust
• Mid and South Essex Foundation Trust
• Humber, Coast and Vale Integrated Care System
• NHS Greater Glasgow and Clyde
• NHS Forth Valley
• Dorset County Hospital NHS Foundation Trust
• Lancashire and South Cumbria
• Newcastle Collaborative.

Acknowledgements

The authors would like to gratefully acknowledge:

• our convening partners in the eight areas where the conversations were held 
• the organisations that provided case studies and examples of practical anchor action
• everyone who commented on earlier drafts of this work, including colleagues within the Health Foundation. and externally from NHS England and NHS Improvement, NHS Confederation, and the Innovation Unit
• all those who participated in these conversations and generously shared their insights.