organisations that hosted visits for civil servants, Gareth and colleagues at Third .... For the health service provider
Making Scotland Better A CHEX and partners event 23 April 2013, Edinburgh
Building Blocks for developing dialogue in ‘Achieving Radical Change’ Welcome & Introduction – Kathy O’Neil, CHP Manager, Forth Valley - The Day Ahead…
‘Achieving Radical Change’ via community-led health’ – Janet Muir CHEX Manager
Develop dialogue between community-led health organisations and public sector agencies to build ideas and exchange practice for addressing health inequalities.
Learning Exchanges between community and voluntary health organisations & Scottish Government Lesley Benzie, Lifelink and Gareth Allen, Scottish Government Third Sector Unit
Benefits of partnership working - Maruska Greenwood, Director of LGBT Health & Wellbeing New relationships & new ways of working, David White, Assistant Manager Edinburgh CHP
Opportunity to exchange practice on specific themes – workshops Building the evidence – Healthy Valleys Shifting the culture – Institute for Research and Innovation in Social Services The ‘Health Issues in Community’ (HIIC) experience – participants/students from North Glasgow
Developing Dialogue at Tables Learning Exchanges – What do we think? What will we do? Maruska’s and David’s Presentations - What do we think? What will we do?
Taking responsibility to act & influence Runima Kakati facilitated an interactive session on what participants would do to ‘Achieve Radical Change’ via community-led health • • •
Individually With others at a local level With others at a national level
1
Welcome and Introduction
Kathy O’Neil’s warm welcome focussed on the opportunity for participants from different sectors to talk with each other on tackling health inequalities with community-led health approaches. She emphasised that CHEX had worked with their national partners NHS Health Scotland and Scottish Healthy Living Centre Alliance in planning the event.
Kathy talked about the direct relevance and indeed requirement for community-led health in Public Service Reform. The Christie recommendations highlight the significance and need for community members and community groups to act together and with others on health outcomes. Kathy mentioned previous and current practice that should inform future direction. In particular ‘Healthy Communities: Meeting the Shared Challenge’ the national programme that produced case studies from different parts of the country and raised awareness across different sectors of both the benefits and challenges of community-led health.
Kathy emphasised the obvious and more subtle range of experiences and expertise that different community and third sector organisations and statutory sector services bring to tackling health inequalities. Now more than ever there is a need for these to complement each other in achieving positive health outcomes. She went on to describe the intended outcomes for the day, emphasising the developmental aspect of the programme, whereby each component would build towards the final plenary session and bring together an expected rich bank of ideas and suggestions for each participant to take forward in community-led health approaches in tackling health inequalities.
2
‘Warm Up’ Session – But Why?
The ‘Warm Up’ Session probed ostensibly laudable statements about community organisations working with statutory agencies on health outcomes. Participants, in pairs, interrogated 2 statements each with each person asking the other ‘But Why’ (up to 5 times). The statements were: • • • • • •
We need real partnership working for health improvement Working together brings added value Shared understanding between our sectors is the way forward Our different sectors need each other if we are to make a difference Community-health is vital to my sector for health improvement Community-led health can bring added value to tackling health inequalities
The final response from each person was displayed on cards and taken forward into the final plenary. The Session caused hilarity and confusion in equal measures! Some participants found it helpful in taking a step back and drilling deeper down into what they really thought about the statements. While others found it frustrating and too much to think about in a ‘Warm Up’ Session!
3
‘Achieving Radical Change’ via community-led health Janet Muir, CHEX Manager Janet challenged participants to think about what radical change would be brought
about through community-led health. What would it look like? What difference would there be in service delivery? How would community members be involved and influence local health outcomes? She talked about the barriers that can hinder change. In particular, political direction, organisational and cultural resistance, lack of the right type and style of leadership, lack of conviction and belief that working with communities will bring about new solutions and third and statutory sectors having to manage more and different demands in an effective and efficient way. Community-led health organisations have a history of roller coaster experiences in Scotland - both in policy and practice. Janet summarised some of the key developments. From the establishment of Community Health Projects in the 1990’s and introduction of Healthy Living Centres in 2000’s to the national programme Healthy Communities: Meeting the Shared Challenge which developed models to help collaborative working between public sector services and community-led organisations. The roller coaster however, has been driven by external influences that have forced organisations to struggle with: • • • •
the challenges of being recognised as key partners securing on-going resources for proven work programmes building on and scaling up successful methods being given the opportunity to input at a strategic level as well as an operational level.
Janet stressed actions that both community-led organisations and statutory sector agencies could take to address these challenges, illustrated by the ‘Achieving Better Community Development’ model, which shows the component building blocks in developing a ‘Healthy Community’.
4
Janet went on to introduce the following two speakers who described a model of Learning Exchanges that CHEX along with their national partners – Community Food Health Scotland, Voluntary Health Scotland and Scottish Government Third Sector Unit have explored and documented over the last year.
Learning Exchanges between community and voluntary health organisations & Scottish Government Officers Lesley Benzie, Lifelink and Gareth Allen, Scottish Government Third Sector Unit The Learning Exchanges were designed to help community and voluntary health organisations and civil servants understand one another’s roles and explore the potential for collaborative arrangements on the planning and delivery of policies on health outcomes. The partners were keen to build on opportunities to assist coproduction of services and create an environment for dialogue that would lead to mutual advantage for each partner. Lesley and Gareth outlined their experience of the Learning Exchanges. Lifelink is one of four community and voluntary health organisations that hosted visits for civil servants, Gareth and colleagues at Third Sector Unit co-ordinated 2 roundtable discussions at Scottish Government. Lifelink, a Glasgow-based charity provides early intervention solutions to stress and mental distress, self-harm and suicide for both young people and adults. The organisation hosted a visit for civil servants from different SG Directorates who heard about the organisation’s contributions to the delivery of national policies at a local level. Lesley noted at the outset that she was concerned that the Learning Exchanges would “just be another experience of inaction”. However, she particularly welcomed the opportunity to talk with SG officers with no pressure to focus on targets or funding proposals. Instead, all parties could concentrate on finding out about what each other did and how that affected one another. Gareth felt that understanding and awareness had been raised of the unique contributions that individual community and voluntary health organisations bring to health improvement. He anticipated that the learning could be built on and shared across a greater number of civil servants and community and voluntary health organisations over the next 2 years.
5
Benefits of Partnership Working Maruska Greenwood, Director of LGBT Health & Wellbeing
Maruska talked about the benefits of partnership working with statutory services and described the ways in which community and voluntary sector organisations both highlight and support communities that exist below the radar of public services. The work of the Health & Wellbeing Centre addresses lesbian, gay, bisexual and transgender (LGBT) health inequalities – social isolation, prejudice, and discrimination, prejudice and hate crime. The LGBT community suffer poorer health and mental health that the general population with poor self-esteem, high levels of addiction, high rates of depression, anxiety, self-harm, and suicide. Maruska emphasised the particular difficulties that face LGBT people over-fifty, a hidden group that health services know little about and seldom engage with. The organisation has supported and promoted the talents and experience of LGBT community members to campaign for greater awareness in statutory services, including a publicity drive through informational talks, blogging, and media coverage. LGBT community members participated in the City of Edinburgh Council’s ‘A City for All Ages’ Advisory Group, chairing and presenting at public meetings and responding to consultations. Throughout this process, trust and understanding were developed between public sector services and LGBT community members acting as a ‘critical friend’ to service staff, helping them to remain focussed and affect intended outcomes. A key outcome so far from this partnership working has been improved access for older people within the LGBT community.
6
New Relationships and New Ways of Working David White, Assistant Director of Edinburgh Community Health Partnership David reflected on strategies to narrow the gap in health inequalities over the last 30 years - statutory services have increased capacity in relation to population health, development of projects and initiatives with many individual successes. However, the evidence shows that this has had limited impact on the wider community.
David described a situation in which one young man, who had died of a drugs overdose. In last 2 weeks of his life, he had 22 interventions from public and third sector organisations. This example underlines the urgent need for more joined up working across all services and between statutory services and third sector organisations. David emphasised that outcomes should be considered from a holistic perspective aimed at meeting health and wellbeing indicators across communities. Constructive dialogue is required across services and with communities in which services are delivered. The community and voluntary health sectors have a vital role in helping to develop this dialogue and working towards strengthened partnership working. Often public sector staff are unaware of the role that community and voluntary sector health organisations play, together with limited understanding of their overall value in contributing to health outcomes. These organisations contribute to a number of different outcomes and help to address what David called ‘life wreckers’ of individuals and families. A more co-ordinated approach would significantly impact on areas such as teenage pregnancy, child protection, social isolation and hospital admissions.
7
The Junction Pilton Community Health Project
Persevere Comm Health Flat
Pilmeny
Health All Round Broomhouse Health Strategy Group
Lothian CHI Forum
Edinburgh Community Food
The Ripple at Restalrig & Lochend Comm Centre
NKS The Cyrenians
B’house & Sighthill Comm Health Hub
Edinburgh Community Health Initiatives
Link Up
LGBT Centre
(2012-13)
Piershill Comm Health Flat
Safe Start Infant Feeding Advisor Deaf Action
Broomhouse Centre
Wester Hailes Health Agency
Oxgangs Com Dev Worker
Community Renewal
Bump Start
Craigour Comm Health Flat SEHLI
Two examples of community-led health organisations in Edinburgh – Health All Round and LGBT Health and Wellbeing – illustrated the contribution to different outcomes with support and services in health eating, parenting, counselling, volunteering, cognitive behavioural therapy, complementary therapies and physical activity. David concluded in recommending 3 key actions to strengthen partnership working between services and community and voluntary organisations •
•
•
Joined-up working between public sector services and community and voluntary organisations must be developed to address existing fragmentation of services and lack of coherent and co-ordinated approaches. While case management is important, there is a need to build capacity through linking up services, sectors and approaches such as: community development, community and voluntary organisations, housing associations, arts, physical activity, volunteering, faith communities, political communities, business communities and social networks Implementation of ‘Total Place’ – a ‘whole area’ approach to public services aimed at delivering services at less cost.
8
Workshops on Specific Themes ‘Health Issues in the Community’ Facilitated by Charlotte McIntosh, HIIC tutor, this workshop was led by Sandra Blair, Louise Docherty and Jonny Durham all of whom had taken part in a HIIC Course. An exercise from the HIIC course clearly demonstrated how and why inequalities fundamentally affect our lives. Sandra, Louise and Jonny built on the exercise to expand on their own personal circumstances and to express how their learning through HIIC had made a radical impact on their own lives. Sandra, Louise and Jonny spoke passionately about how the content of the course had challenged them to think about their own individual circumstances and also that of their communities. They spoke about how the course had developed their selfconfidence and self-esteem and how they had gone on to tackle issues in their community. Sandra and Louise have successfully worked with young people to reduce gang violence in their area. Jonny has developed his photography skills recording the “dark places” of addiction and has turned this into an exhibition, which is currently being exhibited in a number of public buildings such as libraries. A lively discussion followed, whereby workshop members asked a series of probing questions about the course and how the 3 presenters had used their learning. The workshop reminded us that ‘radical change’ is not solely about structural processes and decision-making between agencies and organisations at a strategic level. It is also about the empowerment and aspiration for change that community members can take forward from a positive learning experience into their own lives and that of the wider community.
Shifting the culture of partnership working - Strengthening relationships and developing conversations to assist partnership working Led by Lisa Pattoni and Rikke Iversholt from the Institute for Research and Innovation in Social Services (IRISS) The workshop participants were invited to explore some of the challenges around developing constructive conversations in a partnership process. The purpose was to facilitate a dialogue around participants’ experiences of how partnerships are formed, in particular between community organisations and statutory sector partners who are working towards health and wellbeing outcomes. Participants were presented with a scenario based on a real life situation: a community-led health organisation had been awarded funding from the Older People’s CHANGE Fund to take referrals of people with mental health problems and support them in relevant volunteering opportunities. In the scenario, the organisation was trying to establish a dialogue with the local GP practice around the referral
9
process. Participants were asked to think about how this type of dialogue, in their experience, would usually go. This stimulated an interesting discussion around the barriers facing both ‘sides’ of the conversation. For the community organisations, there were frustrations around low uptake due to limited referrals; and feelings that the statutory services were not fully appreciative of the added value of the community organisation’s service.
Participants spoke about examples where they felt they faced barriers in convincing statutory sector partners of the quality and impact of their role in achieving personal health outcomes for individuals. For the health service providers, issues included: confidence in the quality of the service; restricted time in appointments to discuss the wider influences on a person’s health and wellbeing; concerns around evaluation of impact and quality assessment; and lack of awareness and understanding of community-led responses to health and wellbeing. In the second part of the exercise, participants were invited to discuss how they would ideally like the same conversation to go, and the experiences of those in the room revealed some valuable learning from where successful partnerships had been established. Examples similar to the scenario included suggestions around, for example, one single leaflet with information for GPs about where to refer patients; designated individuals to support referrals outwith the normal appointment time; and the use of evaluation in ‘convincing’ statutory sector organisations of the benefit of referrals to community organisations. A key message from this exercise was that, very simply, the opportunity to have this conversation between the sectors the key starting point, and that once this dialogue is opened up, the opportunity for linking with wider community support and networks can lead to increased benefits of more responsive services. 10
The power of community-led health: Evidence of Impact Clare Bell & Julia Miller, Healthy Valleys and Andrew Paterson, CHEX In this workshop participants explored the existing and potential contribution evaluation findings can make towards highlighting the power and impact of community-led health in tackling Scotland’s health inequalities. Clare and Julia from Healthy Valleys in South Lanarkshire gave a presentation on their ‘Grassroots’ project and how this has been evaluated. ‘Grassroots’ is a volunteer-led early intervention programme in which development workers and trained volunteers support pregnant women and families with children under 5 years old who need extra help. The project is funded by the Big Lottery to run from 1st April 2012 until 31st March 2015. It focuses on attending appointments, raising awareness of available services, health information and promoting health and wellbeing. ‘Grassroots’ uses an in-house ‘Family Outcome Star’ evaluation template to measure a range of things including confidence, parenting skills, wellbeing and community engagement/participation. The project works with families to identify scores out of ten for these factors, and uses the findings to develop Family Support Plans and to prioritise types of support. This evaluation is complemented by session records, activity evaluations and case studies. The project has also been externally evaluated, which demonstrated its effectiveness and recommended that the programme should be extended across a wider geographical area. The Big Lottery subsequently funded extension of the programme. More recently, Healthy Valleys commissioned the Universities of Strathclyde and West of Scotland to conduct a longitudinal study of outcomes, which is still in progress. Andrew then introduced CHEX’s exploration of ‘scaling up’ the evidence gathered and used by community-led health organisations. Andrew gave a summary of the consultation work done so far with the CHEX network, and future developments including: • •
•
Selecting one pertinent theme in health and social care, e.g., coproduction, older people’s care or asset-based health improvement Collecting evidence from existing research and community interventions in a particular geographical area, which shows the impact of community-led health in this area (e.g. existing studies, community profiles, community interventions) Ensuring this aligns with the priorities of high level policy (e.g. the current Ministerial Task Force into Health Inequalities).
The discussion focussed on ‘scaling up’ evidence and how best to harness robust evaluation in influencing policy. It was suggested that distribution of a shared template across the field so that data could be collected consistently and collated effectively. The building of economic evidence was viewed as important and the 11
Food Train was cited as a strong example of compiling and using this type of evidence. The workshop recommended that compiling and using evidence, 2 key questions should consistently be addressed: 1) 2)
How do we use evidence to convince statutory services to shift shrinking resources? How do we get shared understanding and increase positive ways of working together?
12
Taking responsibility to act & influence – Circles of Influence Runima Kakati, Independent facilitator
The final plenary session was an opportunity for participants to articulate how they would take forward community-led health approaches in their own situation, work with others at a local level and with others at a national level. The following are examples of what participants committed themselves to doing in their own job and also what influence they can exert in working with others at local and national level.
What I will do?
• • • • • •
• •
‘Spread the word’ within statutory organisation – power value and impact of community-led health work Review partnerships to identify new and missing partners Take the discussions from today to local planning groups Promote HIIC as a key tool for learning about health improvement and then do something. Clarify and understand the share definition of community-led initiatives – EFC Ltd, CHEX etc. Follow up with Health Scotland’s Head of Equalities. Read Healthy Weight Communities Evaluation. Find out about Food Bus. Understand role of Health Scotland Google the facilitator and make an approach to her with regard to RNIB’s work around eye health Get out more, meet others, and develop networks and relationships 13
What I will do with others locally
• • • • • • • •
Locally, I will propose we re-direct funds to community-led initiatives to community involvement in health Link with partners local to set up initial event for community-led health initiative in Fife Consider more structural approach to supporting our community partners, e.g. political activism, training and mentoring opportunities Feedback to learn about today’s conference. Discuss different evaluation methods used in departments Support more projects which build recognition of processes which create partnerships Share delivery plans, identify opportunities to work together to enhance delivery Develop ‘scaling up evidence’ work on local area and linking into local groups Ask Healthy Valleys to see evaluation templates
14
What I will do with others nationally?
• • • •
• • • • •
Participate in national consultations e.g. food labelling or on the new FSA body Share the learning/experience from the ‘Total Place’ we are supporting Identify appropriate people national level and contact to look for areas of possible future joint working Bring what I’ve learned to my local MSP, whom I know having worked for him, pass on what I’ve learned, ask him to bring it up in communities and in parliament Encourage local organisations to take part in consultations at a national level through the Inverclyde Third Sector Forum Support NHS Boards/CHCP/CHPs to commission developmental work – community development is not a dirty word! Hold the Government to their proposal for change. Ask/fight for transparency and inclusion in regard to making policies so they are community-led Find out themes emerging from the Task Force and link ‘scaling up evidence’ work to them Request a slot/session at next RNIB Senior Managers’ Forum to feedback a
15
Developing Dialogue & Generating Ideas Each presentation generated lively discussions and after each one, participants discussed in small groups their responses, expressing new insights, implications for policy and practice and the potential for change. Thoughts and actions were captured by facilitators and displayed on cards, which were grouped for use in the final plenary. Key themes emerged on: •
Promoting and supporting communities’ priorities
Health Boards and other public sector agencies need to promote and support work with community organisations. But this is difficult when many staff in Boards still view their job as only treating patients rather than viewing patients as community members with talents and skills. Can we identify good practice where these barriers have been overcome? •
Building activities, processes and strategies to prevent poor health
Preventative services need to be inclusive of all groups of people or we will pay the price of those excluded groups making heavy demands on services at a later stage. Greater priority and more resources need to be given to upstream processes and activities. We need to ensure that tobacco is included in the list of identified ‘wreckers’ of ill health. Can we identify good practice and evidence of inclusive practice that has led to prevention of people requiring health care? •
Sharing of learning across sectors and with community groups
Create opportunities to share learning whereby community-led health is shown to make a real difference to health outcomes. Cross different boundaries and don’t just use established points of communication. Inclusive practice should be built on good practice e.g. LGBT involvement showed how community-led health approaches helped find solutions and made a difference. Do we know of good practice that shares learning meaningfully and ensures that the inclusion of equality is automatic and systematic? •
Building and coordinating processes to influence policy and practice
Create opportunities to help widen and deepen the public sector’s understanding of community-led approaches to tackling health inequalities. The level of partnership working should extend across the Health Board to all groups in minority ethnic communities and dementia sufferers. Do we know of public sector agencies that are working with equality groups and other third sector organisations to influence both the shaping of policy and implementation of practice? •
Strengthening partnership working
Dialogue needs to happen at all levels; not just national and local. The Learning Exchange between community and voluntary health organisations and SG Officers 16
could be applied at a local level. Strong partnerships need understanding and commitment by all those potentially involved to have a positive, lasting impact. NHS needs to understand the depth and breadth of the voluntary sector in order to have a realistic view of the competency of the Sector. Address ‘empire building’ by certain agencies and officers. Focus on building bridges between sectors and aim to cross boundaries – cultural, organisational and geographical. Can we share effective partnership working between statutory sector organisations, third sector and community organisations that has contributed to health outcomes and addressed health inequalities? •
Resources
Hidden costs for community-led health organisations e.g. supporting participation of community members and hosting meetings. Major resourcing decisions need to be taken away from Community Planning Partnerships – communities are not involved! Funding is getting harder and harder and harder! Address perception that community-led organisations are short-term projects (some have been around for over 20yrs). There needs to be a long term approach to funding and there is a political dimension to this. Resourcing and funding the community and voluntary sector has been a major issue for time in memorial. Most long term sustainability is achieved through organisations morphing into social enterprises or having a mixture of funding that enables retention of independence, creativity and ability to address unmet need. How best to share practice on the long term sustainability of community-led health organisations?
Achieving Radical Change via community-led health – The Way Forward Community-led health organisations and approaches are achieving change, but we need much more of them! It is clear from this Event that when and where community-led health is integral to health improvement processes and activity, good health outcomes for the wider community are more achievable and sustainable. The presentations demonstrated the value and impact of community-led health in effective partnership working. The discussions generated ideas and suggestions to get round problems, scale-up approaches and invest in partnerships working. The ‘influence circles’ captured what individual participants are committed to doing in the delivery of their own work programme and in collaboration with others. However, it also clear that despite the history and impact, the on-going challenge to invest in community-led health organisations and this approach is imperative. We were reminded from colleagues in the public sector that there remains a vacuum of knowledge and understanding about what community-led health organisations can do and contribute. Advocates must find new routes into policy and practice to raise awareness and develop dialogue across different organisational, cultural and geographical boundaries. While building on tried and tested routes of sharing 17
lessons through case studies and other forms of evidence, much more is required to convince policy makers and local planners to shift resources towards community-led health, upskill the public sector workforce in methods and approaches and work with community-led health organisations as equal partners in strategic planning as well as operational delivery. We have the tools to help us e.g. Community-led Health for All: Learning Resource (http://www.chex.org.uk/media/resources/publications/Communityled%20for%20All%20final%20web.pdf.). We have new opportunities to exploit and develop this work with our third sector and public sector partners at strategic levels through Community Planning Partnerships and Integration of Health and Social Partnerships e.g. use of the ‘Engagement Matrix’ (http://www.chex.org.uk/media/resources/publications/briefings/Engagement_Matrix_ finished_WEB_version_VHS_110213.pdf. ). We have a national policy arena that aspires to community organisations coproducing services with health professionals http://www.scotland.gov.uk/Topics/Government/PublicServiceReform. But, if community-led health is to play its full part, the dialogue and partnership working must influence structural decision-making to: • • •
Address organisational and cultural resistance Build the necessary leadership that is committed to this way of working Realign the resources to fully invest in this way of working
18
