Local Healthwatch have been around for just over two years – and have an increasingly positive story to tell. At Leeds Beckett University we have been working directly with local Healthwatch in Leeds and Wakefield and more recently with Healthwatch England developing Draft Quality Statements – which we are now helping trial.
Earlier this year the Kings Fund produced a good report (Progress and Promise) based on a survey of local Healthwatch. In general terms this confirms our experience.
Focus and Impact
Local Healthwatch are unique – they are the only organisation that has a helicopter view of an entire local Health and Wellbeing system. In the world of localism and integrated health and care this is key.
The challenge that local Healthwatch face is matching this strategic leadership position with the resources they have at their disposal – which are very limited. This is compounded by the broad range of responsibilities that were placed upon them by the Health and Social Care Act.
Some of these responsibilities are more important than others in helping local Healthwatch fulfil their responsibility to use public experience to drive service improvement.
In the table below I give my opinion on the relative importance of four areas of local Healthwatch Activity and include the findings from the Kings Fund survey in the last column.
So, I think that while Enter and View and Advice and Signposting have some utility – the main opportunities for system impact rest with investigations and reviews and contributing to making the local system architecture work better.
Investigations and Reviews
While Investigations and reports are flagged up as areas that are progressing well the Kings Fund report notes:
“we were struck by how many local Healthwatch cited producing a report as evidence of impact, without any evidence for commitment to actions or actions taken as a result …. this is understandable, but reports ultimately only have real value if listened to and acted upon”.
We share this analysis we have worked with local Healthwatch supporting them develop capability on investigations and report writing. Our learning based on the experience of local Healthwatch is captured in the report ‘Local Healthwatch Investigations Briefing’ which provides a simple how to guide to conducting investigations that lead to change.
Local System Architecture
We are supporting Healthwatch Leeds as they use their mandate to strengthen the focus of the local health and wellbeing system on the experience of the public. Healthwatch Leeds already chair a ‘Peoples Voice Group’ that pulls together officers responsible for engagement across the health and and wellbeing system in the city.
This grouping includes engagement leads from the:
- 3 Clinical Commissioning Groups
- local authority adult social care
- voluntary sector networks
- NHS provider organisations – hospitals and community care
This group meet approximately every 2 months – sharing good practice, agreeing joint approaches to producing engagement publicity and developing ways to co-ordinate a shared approach to building relationships with citizens in Leeds.
Healthwatch Leeds have taken this further in another part of the local health system architecture. Rather than just commenting on individual Quality Accounts from all providers they arranged for all Quality Account leads to come together to share their draft findings. Again, some of the thinking is captured in a joint report we produced with Healthwatch Leeds – Local Healthwatch and Quality Accounts
“Sharing quality accounts across providers is a great thing to do – we have never done it before.”
Hospital Quality Account lead
Supporting continued development
The Kings Fund report suggests that in the majority of cases
“re-commissioning of local Healthwatch should focus on further refining the process and outcome performance expectation of existing providers and supporting them to improve.”
I would support this – but go a bit further.
Joint Commissioning – I think that Clinical Commissioning Groups need to be sitting down with local authorities to co-produce a forward commissioning plan – which they both resource. The logic here is clear – the direction of travel is towards integration and the two leading local commissioners need to take a shared approach – this is about engaging with the public in a coherent way across the health system.
Independent Challenge – It seems increasingly clear that an effective local Healthwatch is best placed to bring an independent, evidence based challenge to key public health concerns on health inequalities, service access and effectiveness. If public health teams wish to make a substantial contribution to keeping these important items on the agenda they should be funding local Healthwatch to provide this analytical expertise.
What do you think?
My last blog (Asset based working – its not just the community bit around the edges) looked at some of the challenges and possible actions required to mainstream asset based working. I was pleased to get a friendly critique from Simon Rippon, Trevor Hopkins and Jayne Hopkins who are doing interesting work in this area. Just to be clear – I don’t agree with everything they say (especially the point about people in my local not understanding participatory budgeting!) but its worth reading and helps develop our thinking. So I have republished their comment as a blog piece below – over to them…….
Thanks Mark, but what a position you put us in! How to champion asset-based thinking and working at a locality level while actually changing the way that health and care systems work.
In Chapter 4 of our new report, ‘Head, hands and heart: asset-based approaches in health care’ published by the Health Foundation in April, we set out and respond to the principal challenges and criticisms of asset-based approaches. This chapter covers many of the points you make in your blog.
Not wishing to re-cover this ground, as our perspectives are there for people to read, we would like to add to this discussion by responding to your call to consider some of the factors that drive current deficit culture and hence behaviour in the current system.
Your blog seems to be aimed at an audience mainly in the ‘public health’ system. Whilst these are important players they are not the sole agents for systematising asset-based approaches.
Positioned in local government, public health has a huge potential to develop asset-based approaches, and some are doing just this. But the majority are stuck in a risk-based delivery model still attempting, not very successfully, to persuade people to change their lifestyles or health risk behaviour. We would argue that PH is complicit in perpetuating this emphasis. Our colleague Lynne Friedli has argued this too in recent published articles and seminars.
Asset based working is not just another public health ‘intervention’ it involves a paradigm shift in thinking about the health and wellbeing of individuals, families and communities based on ‘salutogenic’ principles.
You rightly say that this challenge to community development is not new and requires a “shift in power between professionally led public sector bodies and citizens and communities.” The recent report from Public Health England by Professor Jane South (A guide to Community Centred Approaches to Health and Wellbeing) articulates this well. But this is only part of the problem: power also needs to shift within organisations if professionals and practitioners are to work in asset-based ways.
Research sponsored by The Royal College of Nursing Group found that distribution of power in health and care systems is often hierarchical, based on professional status and gender. Driven by patient safety the NHS especially has attempted to challenge these imbalances in acute services over recent years with very limited success.
It is no better in many voluntary and community organisations as there is often a split between the frontline who ‘get and do’ asset-based working instinctively and the culture and systems within these organisations, often driven by public-sector commissioning procedures and outcome frameworks that are about process inputs and unhealthy behaviours, a deficit based emphasis. In our field work for the Health Foundation report a Community Development Leader commented that his organisation had spent years investing in community and voluntary services to do community work which in turn had built a parallel system and infrastructure that had become dependent on commissioning to survive – with little evidence they had made any impact in community-led action.
Participatory budgeting is a classic system-led response. It is, as John McKnight one of the originators of Asset Based Community Development would contend, building communities from the ‘outside in’ while asset-based working seeks to build community from the ‘inside out’. Even the words are exclusive, ‘participatory budgeting’ – try bringing that topic up for conversation at your local pub on a Friday evening.
Another factor driving current deficit culture is leadership that relies on positional power, direct control and organisational outputs. To support asset-based approaches we require new models of community leadership based on credibility and earned authority rather than positional or professional power. These characteristics will allow the building of new sources of power and influence and “…concentrate on enabling systems, organisations and people to work simply and seamlessly together, maximising the synergy of the collective rather than the individual. They also draw the best from diverse groups to enable a source of collective or shared governance where felt responsibility for achievement is stronger than imposed systems of accountability.” (A real paradigm shift in NHS Leadership? By Robin Douglas and Jane Keep. HSJ – May 3, 2012)
While agreeing that we need ‘a more systemic approach’ – it just depends on what you mean by ‘the system’. In many places local people are active, volunteer, form clubs and associations, help each other out and support more vulnerable people – organising what is seen as asset-based working! This has been happening for centuries and has sprung from local action not service-based ‘system’ action. And may have occurred due to lack of confidence in communities for established ‘mainstream’ public service delivery.
One of the approaches we suggest in our new publication is the use of a ‘Theory of Change’ to understand how asset-based change occurs. Theory of Change is about the central processes or drivers by which change comes about for individuals, groups or communities. This can be based on a formal research methodology and is well suited to asset-based approaches given the iterative and collaborative nature of the process, which involves aspects of systems and complexity thinking.
Our proposition for as Theory of Change toward asset based practice has four key stages
• reframing towards assets
• recognising assets
• mobilising assets
• co-producing assets and outcomes
The stages are not linear, but may be ordered to suit the particular situation and context of the initiative.
In the context of your blog and in response to your challenge to move asset-based approaches, indeed all forms of community work, into mainstream action we suggest we are still in the early days of Stage 1. The reframing of thinking is an obvious but critical stage in the move toward asset-based working.
Understanding how the public health system contributes to such activity is vital – is it to be a joint participant in local place based action? A commissioner of system development? It’s the inside-out or outside-in perspective that is part of the real politic of this agenda.
Reframing can signal a shift in practice culture towards an asset-based model and is a significant step. In our case-study research reframing towards assets was mostly described as an explicit activity or event in teams, groups and organisations. Often the reframing is a systemic action. Against this backdrop, current practice and priorities can be reassessed and new outcomes defined.
Whatever the trigger for the rethink, or the scale of the change envisaged, the first challenge is to change the culture.
Reflecting the values and principles of asset-based working we are growing this approach from the inside out at project and locality level. We would contend that it is too soon for this to be mainstreamed.
“Changing to an asset-based approach offers and creates a new relational perspective. It is not a set of tools or techniques that can be applied without a change in organisational culture and individual practice. It must be a process, not a top-down plan.”
(‘Head, hands and heart’ p.23)
What do you think?
While there are a growing number of examples of asset based approaches most of these are at project and locality level. What concerns me is how to move to a more systemic approach that actually changes the way that systems work.
This is not new – community work and community development have always faced this problem – trying to translate activity with people on the margins into mainstream action. Of course the biggest problem is that – like much community work – asset based approaches require a shift in power between professionally lead public sector bodies and citizens and communities.
Unlike in the past the ambition and rhetoric of asset based rhetoric can now often be heard at the top of local systems – among elected members, chief executives and so on. The challenge is that systems have a huge inertia and cultural baggage that means that even when people are well intentioned their behaviours and management techniques do not equip them to set in train actions that will allow asset based approaches to flourish.
So, the risk is that these will stay in the project or local community work box.
I think that an effective approach to achieving system change has to do two things:
- Have an analysis of some of the deficits presented by the current paradigm – so we don’t fall into the same ways of behaving.
- Use change techniques that play to strengths of asset based working – rather than to those that reinforce current system behaviours.
So, we need to consider some of the factors that drive current deficit culture and hence behaviour in the current system. If we do not recognise this we risk either reinforcing it or becoming frustrated by what might feel like unhelpful and obstructive responses.
A strategy for failure
When we present arguments about the need to shift to a more asset based approach it is assumed that:
- decision makers have the best analysis of what needs exist and how to allocate resources to respond to these – yet we know that much community led activity is not recognised in commissioning
- we will make our case to commissioners because they are the key decision makers and custodians of service outcomes – yet most of the resources they are responsible for are already allocated to big providers who are the ones actually responsible for delivering the services
- we will be able to demonstrate how asset based approaches by themselves will help meet government targets and make savings to the current system – yet many government targets focus on simplistic measures that have little relationship to lived experience – for example trolley waits and A&E waiting times, and asset based approaches are only part of the solution. Asset based approaches can help existing services and pathways be better – but they are not the solution in themselves and should not be judged in isolation.
This is not territory where we will win. We need a different set of arguments – that will release asset based approaches – I think that some of these are:
Vision – We need to set out our own view – building from the grassroots of what makes a fair community for all. I think that Fairness Commissions organised by a number of local authorities provide an important, alternative and local view that stands outside the sound bite policies of national government.
Information – It is crucial that local voluntary and community organisations have access to the data that allows them to locate their contribution into the wider context. This is a bit like a JSNA – but starting from the perspective of grass roots organisations rather than commissioners.
Imagine if all the community dance groups (or running clubs, advice centres etc) in an an area could each see how they contributed to the total number of people taking part in dance (or whatever) in a local authority area. They could use this information to apply for funding and be better able to make the case for themselves, rather than relying on commissioners to do so for them.
Flourishing community sector – we need decision makers across commissioners and providers to answer this question “what can we do to help grass roots voluntary organisations flourish in our area?” I suspect that part of the answer is to make it easy for people to come together to set up and run their own community organisations – key to this is making small grants easily available, but other examples exist such as the participatory budget process developed by Durham County Council.
Service and Pathway redesign – we need a different dialogue with provider organisations like big hospital trusts or GPs. We need to get round the commissioner/provider divide and support these big providers shift to a wider world view – engaging with the ‘citizen’ rather than the ‘patient’. Part of this has to involve these big providers developing collaborations with their local voluntary and community sector to together design pathways of care and support.
What do you think?
Recently I was on a panel making decisions on grant applications by voluntary organisations to a one off fund commissioned by Sheffield Clinical Commissioning Group.
Of the total fund just over £400,000 was focused on CCG health priorities – the fund was four times over-subscribed. Applications had to meet one or more of the following criteria:
- Reducing Urgent Hospital Admissions
- Support People with long term conditions
- Move provision of care to a community setting
- Reducing Life Expectancy inequalities in people with serious mental illness or learning disabilities
- Help all children have the best possible start in life
The selection process was organised efficiently and professionally by South Yorkshire Community Foundation – who gathered together a diverse panel which contributed to the competence of the overall process.
Details of the fund are here; I was struck at the number of applications from:
- organisations who support small groups of people who have very substantial needs. For example people who are homeless, substance misusers, women who have experienced domestic violence and people with complex learning and physical disabilities.
- groups who support people who while their clinical health needs have been addressed by NHS services continue to experience the impact of their health condition once they have returned home – such as people who have had a stroke.
- neighbourhood organisations who provide a bridge between people in communities and local health services – in particular primary care.
I realise that this is not a scientific survey, but I was left with the following thoughts – and these are general ones – not specific to Sheffield.
Easily Ignored Groups
The perfectly understandable focus on providing services for the whole population too easily leads to insufficient attention being given to small vulnerable groups with complex needs. This is particularly the case for groups of people whose poor social and economic circumstances are have a negative effect on their health. I think this is driven in part by the tyranny of population level targets but also by a default emphasis on clinical services which means that the crucial role of services that help people connect, build confidence and engage with mainstream provision is insufficiently recognised.
One of the things that worries me is the way in which mainstream commissioning can still ignore the complete care pathway. I set this out in an earlier blog – when I told the story of Stroke Action in Enfield. Its just not good enough to address peoples physical health problems and then put them back into the community – less physically able and less confident – this is a recipe for social isolation, poorer mental health and early re-admission. There are growing number of positive examples – such as Stroke Action and the Voluntary Action Rotherham Social Prescribing work which we need to be building on systematically across all commissioning pathways.
We need to be much better at taking into account the role of community anchor organisations with regard to helping build local community infrastructure that allows people to access support services in their communities, use public services more effectively on their terms and most importantly contribute through volunteering in their neighbourhoods.
Despite government imposed austerity I do think that commissioning organisations and big public sector providers can do more to address the deficits above.
I think that some of this is recognised in the NHS England 5 year forward view, with models such such as the (rather long winded) Multi-Speciality Community Partnerships being proposed. These could provide a mechanism for designing service models that have the voluntary and community sector in at the beginning.
In order for this to happen local commissioners have to raise their game this could mean:
- Local Authorities and CCGs developing volunteering and voluntary sector funding strategies through the Health and Wellbeing Board.
- CCGs pushing NHS providers to develop service pathways that reach out into communities and to do this in partnership with the voluntary sector.
I think that this could not only help build better local services but through stitching these services into the fabric of local civil society it helps to build an alternative narrative to the one that says that marketisation is the most effective and efficient way of improving health and wellbeing.
What do you think?
You would believe the above heading if you were to rely on Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies for your evidence. Of course this is not the case at all.
I recently facilitated a workshop for Public Health England on “strengthening the voice of the voluntary sector in Joint Strategic Needs Assessments”. As I said at the workshop – I think thats the wrong question.
The key issue for me is how can the experience of the Voluntary and Community Sector be used to improve local commissioning to tackle health inequalities and improve wellbeing?
While I welcome the ambition in plans like the NHS England 5 year forward view and the Due North report on Heath Equity which aim for greater investment in the voluntary sector neither of these quite hits the nail on the head.
Its not sufficient for statutory agencies (local government and NHS commissioners) to try to make it easier for the VCS to bid for contracts. Treating the VCS purely as contractors will fail to allow the experiential wisdom of the voluntary sector to contribute to strategic change for the better.
In order for this to happen the system needs to be much more permeable to the voluntary sector perspective. Crucially, statutory services cannot treat the VCS as though it works to the same rules as big public sector bodies – because it does not.
- VCS organisations use a wide range of different data sets – which do not easily read across to local systems.
- VCS organisations are worried about sharing service data with potential competitors
- Many are not convinced that providing data into JSNA processes will justify the effort involved in providing it, a recent report (In Good Health) by the Royal Society of Public Health supports this view.
- Most importantly, much VCS insight is based on relational rather than quantitative data.
As I noted in an earlier blog statutory agencies and the voluntary sector need to be using approaches that allow the VCS to to share a perspective on its terms.
In an earlier blog I wrote about one methodology that I have developed with Involve Yorkshire and Humber (Rapid Reviews) which led to real change in commissioning priorities, but there are plenty of other examples. Here are some that I have found out about recently.
This is an amazing piece of work undertaken for peanuts by a consortium of Housing Associations with support from the University of York. The organisations involved use the relationships they have with tenants to capture and share a small scale but in depth perspective of the real life impact of welfare reform. Keeping track of 100 households over a period of two years with tracking reports produced every 6 months.
This is an important report from NESTA sharing examples of how voluntary sector data can be used to provide insights into real time and future challenges. One example is a collaboration between Citizens Advice and St Mungos – a homeless charity based in London. There are a number of things that are interesting:
Data Science expertise – through a collaboration with Datakind UK volunteers from the data science community did an initial scoping over a period of two days – this lead to a smaller team of volunteer ‘DataCorps’ working over a longer period of time to resolve tricky issues.
In this case the work led to St Mungos and Citizens Advice working together to share data on clients, and led to three principles:
- Embracing openness – especially ways of sharing data across organisations that did not sacrifice confidentiality
- Democratising access to data – supporting others to have the skills to analyse the data – this has similarities with the GP Patient Survey dashboard that I have mentioned before.
- Emphasis on questions and exploration – Placing analysis and data into the public domain and creating opportunities for others to consider what this data might mean for their area of interest.
More Rapid Reviews and Local Healthwatch
I have already mentioned the Rapid Review work that I have done in Wakefield and Sheffield – another example I came across recently was a project led by the Sheffield Parent Carer Forum which captured the views of parents of children and young people with disabilities.
I am currently completing a piece of work for Healthwatch England and have been impressed by the number of local Healthwatch who are increasingly using this sort of methodology in their investigations.
What will help?
Local Public Health teams should have an explicit longer term and funded strategy (which includes CCGs) to support the local voluntary and community sector build analytical capacity and competence. This could be built around addressing specific priority at the same time allowing it to build competence.
Public Health England and NHS England
These two agencies need to develop a robust long term programme to support sharing of good practice and raise the expectations of local decision makers – in particular CCGs and Directors of Public Health. It is frankly not acceptable for local leaders to assume that current systems and capability need to mirror existing statutory practice.
What do you think?
At the heart of “Due North” is an argument about the need to establish a pan-Northern collaboration which is built on closer relations with the people who live in the North of England.
So, I welcome the call to help communities to develop capacity to participate in local decision making through investing in the VCS and training and action to engage community members. But as I said in an earlier blog we need to do much more than this.
Reading Due North I asked myself the question:
Question – “Does Due North help me champion grass roots action in Sheffield?
Answer – “yes it does bit – but I need more”
Many of us know of good examples at a very local level – the problem is these are not being systemised and local voice is not heard consistently enough at the top of organisations.
The very local story
In Sheffield 4 General Practices now have over 100 practice champions who are working on a voluntary basis supporting GP’s connect with their communities. These are all practices serving very disadvantaged communities.
I am a trustee of one of the voluntary organisations – Darnall Wellbeing – who deliver this service and their Practice Champions are part of a wider volunteering network that connects with the Somali, Pakistani, white working class and Roma communities in that area. Local people in disadvantaged neighbourhoods are working on the ground sorting out community cohesion, advocacy and access to health services. They are capacity building for themselves.
Nonetheless the challenge remains – translating this local energy and expertise into powerful influence at place level. I think that one of the reasons this is difficult is because the city wide commissioning and provider bodies struggle to change their practice to make it easy for community activists to contribute at an organisation or system level.
At the recent Due North/Health Equity North one year on conference Tony Dylak from Royds Community Assocation in Bradford helpfully summed up these challenges calling for among other things – a greater recognition of the contribution that ‘patients’ can make and the need to see the voluntary sector as an equal partner.
Service and System
So, system level organisations and agencies need to consider what they can be doing to strengthen citizen voice. I think that this is where it gets really hard. A lot of the structures that operate at a system level are dominated (with the exception of local councillors) by professionals who speak on behalf of local citizens. By professionals I mean primarily managers from public sector bodies (mainly the NHS and Local Government) and the Voluntary and Community Sector.
Of course they are well intentioned people – but they are constrained by their own organisation and services (they don’t usually have whole system view) and by their responsibilities for meeting their targets and contracts. This too often leads to relationships that operate within a paradigm that ignores conflicts brought on by competition and mistakes activity for systemic action.
Again, in Sheffield the Sheffield First Partnership has been trying to get to grips with this. They set up what was in effect a select committee process to seek to understand what good might look like with regard to community cohesion and voice; taking evidence from a range of witnesses – including voluntary sector organisations, the police, fire service and private sector.
The outcome of this investigation is a “Fuzzy Framework” that seeks to provide a platform for a more self aware collaboration on this agenda across the city. It is very much a work in progress – but is a positive attempt to try to be more self conscious about this issue.
When Trade Unions are mentioned there is an awkward grin and shuffling of feet
Finally, at the recent Due North/Health Equity North conference in Chester someone in the audience raised the point that well established forms of collective solidarity such as the trade union movement are too easily ignored when it comes to seeking to strengthen public voice. Its interesting because public health and the NHS are often keen to develop relationships with the private sector – there is a hard edged glamour to this. Yet when the trade union movement is raised the response is usually an awkward grin and shuffling of feet.
The role of grass roots community organisations and Civil Society
So, I think we need to be much harder on ourselves if we are to make progress here. This agenda is moving on rapidly – in an excellent blog Catherine Foot from the Kings Fund calls for “not forgetting engaging patients and communities” in the implementation of the NHS England 5 year forward view.
At the moment it is striking that few local Health and Wellbeing Boards have clear strategies that set out how they will create an environment where grass roots community organisations or volunteering can flourish.
I think we need to be more self aware about how we connect with citizens – this means doing more than talking about apparently value free ‘interventions’ such as ‘building capacity’ or ‘funding the voluntary sector’.
I would also go a bit further than Catherine – if we are to rebalance our relationship with citizens we must see this work as sitting within the wider responsibilities that local government has for local democracy.
It means generating a debate with a purpose – what sort of civil society do we want and why?
Then taking action to strengthen it.
What do you think?