• behaviour
• competencies
• health system
• management
• role model

Anchor institutions are traditionally defined as large public sector organisations which are rooted in place and connected to their communities.1 As the anchor movement generates more energy and reach, some have begun to define anchor organisations more broadly to include businesses and voluntary organisations, although these are not always able to commit to their long-term presence in an area in the same way that universities, local authorities and hospitals usually are. Anchor approaches refer to a place-based approach, where ‘anchors’ consciously use their assets and spending power to maximise social, economic and environmental impact, improving the social determinants of health and tackling inequalities.2 Over the last 2 years, the HALN,3 a free UK-wide network for people responsible for or interested in anchor approaches in health funded by The Health Foundation,4 has been gathering learning and insights on how to successfully lead and implement anchor work.

Many organisations and systems are shifting away from transactional to transformational approaches to change.5 In response, anchor institutions need leaders who can provide direction, set priorities and facilitate equitable partnerships.6 But according to a recent HALN survey,7 60% of respondents felt they had inadequate sponsorship for their anchor work, presenting a significant challenge for the future of this movement. For the past 2 years, HALN has engaged with anchor colleagues across the UK and we have heard a clear call out for leaders to provide encouragement, accountability, supportive challenge and protection of resource. Through this work, useful insights have surfaced for leaders across health and care.8 9

One key insight that emerged is that place-based leadership in times of crisis necessitates transitioning from organisational to systems leadership, looking beyond the boundaries of any single institution. Nevertheless, this process starts with an internal focus asking, ‘why are we here?’ and exploring the bigger picture of the ecosystem in which the organisation operates in order to sharpen the intentionality of any planned action. Effective systems leadership involves building equitable partnerships and, as Lord Victor Adebowale stated recently to a HALN audience, ‘leaving your egos at the door’. This applies to organisations big and small: ‘if you’re a provider of anchor services in a community, by definition you’re an anchor—you can lead from anywhere in the system’.10 Leading anchor work requires partnering with other local anchors around a common vision, and opening the doors for others to join and scale the impact, in much the same way as a movement.

Making an impact as an anchor is sometimes described by our leaders as balancing a social movement with business as usual. Focus on only one of these areas and we risk either not generating the vision and passion required to make a difference or not changing how the NHS behaves in practice. Both are explicitly needed.

In England, the inclusion of the new Integrated Care Systems’ (ICS) purpose of helping the NHS support broader social and economic development may prove to be a significant milestone in this agenda. Through Lord Adebowale’s role with the NHS Confederation, he highlights how they have been working with system leaders to understand what they can do in this space and published the first literature on this ICS purpose in December 2022.11 He believes that this core ICS purpose reflects the next phase of the anchor journey—moving from an institutional to a system-wide view of what can change. Dame Jackie Daniel has been a CEO in the NHS for over 20 years but she reflects that it is only relatively recently that CEOs have been expected to lead for economic, environmental and social impact. Adding these wider expectations in addition to the accountability for healthcare delivery requires the development and adoption of new leadership behaviours. In her current role in Newcastle, Dame Daniel invested significant leadership time to support the formation of ‘Collaborative Newcastle’—a city partnership of anchor institutions that has focused on joint economic and environmental improvement as well as health and care service integration. Intentional, purpose-driven leadership is necessary to successfully create the conditions for effective anchor work—this includes explicit CEO sponsorship and commitment to anchor goals, public advocacy and empowering bottom-up change within and between anchor organisations.

Governance structures, although perhaps not the most invigorating of topics, are a critical tool for creating sustainable anchor strategies. At its core, the anchor approach is about place-based multisector partnership so embedding collaboration with the voluntary and community sector is central—they have the expertise and knowledge to create effective partnerships with communities. Effective governance structures provide a framework for collaboration and ensure that the strategy is genuinely sustainable and accountable.

For example, Birmingham and Solihull’s Reducing Health Inequalities Strategy has been developed and agreed by system partners and explicitly acknowledges anchor work as an important building block. They have a ‘People Power and Health Inequalities Committee’ with a complementary Health Inequalities Stakeholder Board whose membership includes local authority Public Health Directors, Executive Leads from NHS providers, GPs and community representatives. This links to other boards in the system which themselves have explicit responsibilities to reduce health inequalities. Having these governance processes ensures the strategy is implemented and provides accountability for the commitments. Given the multitude of pressing short-term priorities, it would be easy for good intentions to become waylaid, hence matching process to intention is key. Clear governance structures and processes are not an end in themselves but a means for specific outcomes.

One example is the ‘I Can’ initiative, overseen by Birmingham and Solihull’s People Board, which has resulted in over 200 unemployed residents with little or no previous NHS experience being successfully recruited for NHS jobs. The original aim was ‘100 Jobs’ per year for 3 years but the redesign of NHS recruitment processes and targeting achieved by the partnership involving relevant NHS HR teams, local authority teams and the voluntary and community sector has resulted in a successful model ready to be scaled up further. ICS Health Inequalities Associate Director Salma Yaqoob reflects that key to their success has been working with neighbourhood-based partners who can reach into communities where people would otherwise not have been aware of NHS job opportunities and provide candidates with additional support and training to ensure they are ready for work.

Dr Dominique Allwood is chief medical officer of UCLPartners where she co-chairs the Anchor Strategy and Change Network. Dr Allwood recently chaired the HALN webinar on leadership and shares her reflections. ‘Anchor leadership’ requires intentionally tackling inequities, to both maximise the value that anchor institutions can deliver, but also the distribution of that value. Thinking about local impact is essential but insufficient on its own; an anchor leader needs to also consider acting equitably and proportionately within a local area.2 This may be new to many healthcare leaders, but an essential component of equity is justice, focusing on how to change systems and structures that create and perpetuate inequities such as racial equality.

People care deeply about the issues they work on as well as core pillars of anchor action such as the creation of inclusive spaces, climate health, racial equality or employment. One of the most critical aspects of effective anchor leadership is tapping into the latent potential and motivation of staff and communities. Actively platforming and celebrating these conversations and enabling staff and residents to work on these issues together, rather than in isolation, can create a positive and innovative work culture, driving transformational change.

Anchor leaders have a unique opportunity and responsibility to harness the potential of staff, communities and partners to create real impact, and current policy frameworks as well as a shift to greater integration in healthcare which should incentivise systems leadership and provide helpful levers for collaboration. Strategic, flexible and collaborative leadership is necessary to bring about cultural and behavioural changes, secure resources, and drive the transformational shift towards intentionally focusing on the social determinants of health—all of which is necessary to address the complex challenges and entrenched inequalities we face today.