Community-led Health and Wellbeing Improvement: rhetoric overload – I feel the need for a Babel fish! John Cassidy February 2015

Iceland and Greece The IMF fiscal multiplier had a value of about 0.5 for all countries, meaning that government spending would shrink the economy. Hence cutting budgets would boost growth. The IMF admitted in 2012 that it had underestimated the harms that austerity could cause especially to public health. Greece economy grew at a steady 1.5% per annum over the 80s and 90s Greece 2001 heading for an economic boom EU Structural fund poured 24 billion euros in matched by government borrowing. In 2006 growth was 7.6%. Corporate tax cut from 40% to 25% to attract new businesses. Government overspending particularly on infrastructure projects. Greece’s economic data found to be fabricated – far weaker than claimed ! – panic. May 2008/9 Athens stock exchange fell by 60%. ECB gave 210billion euro to help pay of creditors (ie French and German banks who had fuelled construction bubble) – Robin Hood underground network of doctors. Health budget cut by 40% Mid 1990s Iceland reinvented itself as a tax haven - became the 5th richest country in the world in 2007 but banks invested in dangerous investments overseas to pay out high interest to investors. IMF - 50% of Iceland’s gross income to be paid to private investors over a seven year period – 30% cut in public health system to encourage privatisation - inspire private investors - Health minister resigned. Prime Minister forced out – referendum - 93% rejected paying off of Icesave’s private debts – A New Deal type strategy implemented 2009. McDonald’s pulled out of the country in 2012. Iceland’s economy grew 3% pa and unemployment went below 5%.

Rhetoric? ABCD Put empowerment of individuals and communities and reducing social isolation at the heart of action on health inequalities Pay attention to the importance of stress and mental health in shaping physical health and life chances Pay attention to the importance of personal and community resilience, people’s ability to control their lives and levels of social support Concentrate on the ‘causes of causes’ – that is invest more in the material, social and psychosocial determinants of health Need for public bodies to be built around people and communities, and work together to achieve better outcomes for those that use services There is substantial evidence that despite the intent of policy, practice frequently has lagged behind participatory rhetoric Inequalities and unfairness and social justice. Improving health and tackling health inequalities require different approaches. Tackling Inequalities requires all the health improvement strategies plus action on factors including discrimination and lack of access to resources and policies which reduce economic and social inequalities Talk is cheap, if we want a healthier society the Government must take steps now to reduce the UKs “dangerous and corrosively high’ levels of economic inequality – Richest 10% now own 40% of the UKs wealth. If income distribution was the same as in 1977 the bottom fifth would get £2000 more and the top fifth would get £8000 less Poor and unequal living conditions are the consequences of poor social policies and programmes, unfair economic arrangements and bad politics” (WHO/ NHS CEO Health Scotland)

Language used is critical Care services should map around the individual and community assets Informal, community capacity building and asset based approaches An outcomes based joint performance framework Mutually supportive four sector engagement Proportionate universalism Integration – history, cultures. Language, conditions of service From guidance on strategic planning for Health and Social care integration

Policies and Decision making Government task forces on health inequalities (2008, 2013, 2015) reviews and annual reports Better partnership working is needed to reduce health inequalities. To date there is limited evidence that strategies and interventions aimed at reducing health inequalities have made a significant impact”. Audit Scotland, 2012 The most disadvantaged people with the most complex problems and the fewest resources, also face significant barriers in accessing services. Health and Sport Committee, 2015 Reducing health inequalities should be at the heart of the Scottish Government’s drive for social justice ….and….. “Comfortable myths” about poverty A recent Office of National Statistics report in response to budget cuts has proposed that statistics on health inequalities no longer be collected! In the UK antidepressant use rose 22% between 2007 and 2009. In 2010 doctors gave out 3.1 million more antidepressant prescriptions than they had in the previous 2 years The priorities from the last Task Force on Health Inequalities - CPPs, 15-44, place standards, social capital Inequality in Britain is the fourth highest in the developed world and Britain has the fourth lowest life expectancy out of the 23 most developed countries (above Portugal Singapore and USA) Aneurin Bevin 1948 ”Put welfare of the sick ahead of everything else” Deficit running around 300% of GDP in 1948 *The real issue is not what needs to be done but how to galvanise a largely sceptical or misled public into supporting such policies Why not support these polices? Comfortable myths about poverty Glasgow Work assessment Centre became known as “Lourdes” –go in sick come out deemed for work Fraudulant claims – 0.9% of the welfare budget approx £1.9billion - less than the amount underpaid to claimants because of errors *Interventions reliant on individual choice are unlikely to reduce health inequalities Quantitative Easing- increased the wealth of the richest 5th of families, bank bailouts could pay for the cost of benefit fraud for a millenium Public sector organisations tend to adopt a hierarchical type of culture and are reactive to political agendas, often to the detriment of outcomes and is one where change initiatives can be restricted by short–term budgets. Advice to policy makers: More progressive distribution of income/wealth and greater investments in some of the public services supporting deprived and vulnerable communities

Complacency?: The epidemics Mental health Obesity Loneliness/lack of company Substance misuse Hidden! Complacency Carol Morgan CEO of Includem Hidden: Self harming and prescription drug addiction Mental health problems anxiety depression (8 million people) One of the highest rates of self-harming in Europe 45.000 a year sectioned under the Mental Health Act Inequality in Britain is the fourth highest in the developed world and Britain has the fourth lowest life expectancy out of the 23 most developed countries (above Portugal Singapore and USA) 10% of children have mental health problems at any one time More than 17,000 mental health unit beds have been closed since 2011 and budgets for mental health treatment have been reduced Mental health problems cost the economy £100billion every year

What about the ‘How?’ Project models and social capital models Social models and medical models Deficit approach and asset approach Social cohesion and social capital “Little evidence that £500m funds to tackle inequality worked” (Government Committee Jan 2015) “Equally Well” …learning from test sites has, so far achieved a limited amount” (Audit Scotland June 2013) Social cohesion : shared values of communities cohesive communities are built on trust, hope, mutual respect and reciprocity Social capital: the capacity and will of members of communities to contribute to one another’s wellbeing – active and reciprocal voluntary effort, a strong infrastructure of diverse community groups and organisations Equally Well : Genuine cross government linkage around Equally Well has been limited. Project model: short term limited influence not sustainable, creates dependency Social capital model: less dependency long-term change, collective action community leadership Deficit approach: deficiencies and needs in the community, respond to problems, provide services, see people as clients done to, fix people, implement programmes Asset approach: assets in the community, strengths and opportunities, invest in people as citizens, role of civic society, focus on communities, help people take control of their lives, see people as the answer Social model: Focus on context of individual health, the links between poverty: social and material environment, and health outcomes require a holistic view of health instead of just a diagnostic ot pathological one . Medical model :addresses illness or poor health as a result of physical conditions and risks, health interventions have an intrinsically individual focus, focus on treatment and behaviour change

Medical and Social Models of Health – the imbalance While the NHS functions broadly as a “fix-me” service for delivering one –off medical remedies for defined conditions, it has far more difficulty dealing with the more diffuse, often only partly medical ‘help-me’’ problems that the troublesome cases were either partially or exclusively presenting with….Meeting ‘help-me’ demand requires skills and aptitudes that don’t necessarily coincide with traditional professional boundaries. While technical and clinical competence remained important in meeting ‘fix-me’ demands, it was paying attention to the social needs that made the biggest impact on better outcomes for both the individuals and the system as a whole. That puts a premium on interpersonal, organisational and problem-solving skills as the key attributes needed for understanding and helping people to rebalance their lives. (‘Locality’ report 2014) Locality principle: Services are local by default, help people to help themselves, ensure a focus on purpose, not outcomes, manage value not cost Better outcomes area consequence of effective intervention and thus cannot be managed directly. Managing by purpose enables learning and improvement. Mange value not cost – understand demand from the customer’s point of view, designing the service to absorb its variety ie help people to solve their problems Local by default – what matters is not the size but knowledge of context and that can only be obtained on the ground – understand demand in human terms – needs can only be understood in a local context – locality based help-me service. Failure demand accounts for 80% of demand into health and social care services ie demand caused by failure to do something or do something right for the customer ie representing with the same problem is one type of failure demand “What is very clear is that the interactions between individuals and the people and events which surround them are absolutely crucial to their health and wellbeing” CMO 2011

Community-led Health Improvement Governance Implementing a community led approach to improving health and wellbeing involves enabling disadvantaged communities to become involved as key stakeholders in the process of changing their own situation and supporting external agencies to work with communities and respond to a community-led agenda Processes involved: Engaging communities Supporting the capacity of communities to respond to their own issues/priorities Supporting the capacity of agencies to collaborate with each other and communities in order to respond to community need Asset based approaches to for improving health are not new. References back to 1971 in psychiatry and psychology and public health literature Asset based approaches already operating in a number of areas across Scotland – community engagement, community development, enablement, self management, community empowerment are used to describe the approaches. Wellbeing is about feeling good and functioning well a positive experience of life. Having positive relationships a sense of purpose and having control over one’s life *WHO 2007 Community –led approaches are fundamentally different from the provision of community-based services as they are concerned with community as the focus of, and mechanism for , change rather than community as a setting for health practice Assets/Capital - Financial, Built, Social, Human. Natural, Cultural, Political The ‘Third Sector’ is an umbrella term which includes social enterprises, voluntary organisations, co-operatives, charities, NGOs, civil society and community organisations

Healthy n Happy Community Development Trust Community led An ‘anchor’ organisation- why it works! Flexible and responsive Finance and sustainability Social enterprise Research and development Criteria for a CDT Aiming for financial viable independent, sustainability and not-for-private-profit Generating an income through enterprise and delivery of services and trading Community based, owned and managed Actively involved in partnerships and alliances between the community, voluntary, private and public sectors Promoting sustainable development and building sustainable communities Anchor organisations Embedded, trusted, respected, for the long term

Community-led Approaches to Improving Health and Wellbeing “The challenge we face, in its simplest form is how we make developing and supporting community-led solutions a part of mainstream business rather than an occasional project, add-on or experimental programme. This will present challenges including for example shifting resources, challenging the pattern of service delivery and potentially reassessing professional roles and responsibilities.” (‘Building a Sustainable Future’, Scottish Government, 2011)

Worth a Read (A good investment of time) “Understanding a Community led Approach to Health Improvement” SCDC, 2008 “A glass half full: how an asset approach can improve community health and wellbeing” Improvement and Development Agency, 2010 “The lies we tell ourselves : ending comfortable myths about poverty” Report by 4 Churches, 2013 “Saving money by doing the right thing” Locality and Vanguard, 2014 “The Body Economic”, David Stuckler and Sanjay Basu, Penguin 2013