1. Social capital, bridging capital & rural health policy Jane Farmer Centre for Rural Health, Inverness, Scotland

2. What? Scotland…Scotland… Healthy, resilient communities & social capitalHealthy, resilient communities & social capital The theory of building social capitalThe theory of building social capital The reality…The reality… The reality in different countriesThe reality in different countries Involving policy & other stakeholdersInvolving policy & other stakeholders Questions for future policyQuestions for future policy

3. A word about CRH Since 2000 Collaboration UHI & UoA 14 staff/ 8 PhD students Ways to provide rural services  Ways to provide rural services  Health, care & community roles  Community involvement  Tools/methods for measuring & modelling change impacts & modelling change impacts Academic evidence base RURAL REAL-LIFE APPLY TO CHALLENGES Centre for Rural Health UHI Millennium Institute and The University of Aberdeen working in partnership

4. Inverness

5. The policy place in Scotland Delivering for Remote & Rural Health “community resilience” Better Health Better Care – “mutuality” Neo-liberalism Globalisation Recession Scotland – less marketised than England… ‘good’ & ‘bad’ (OECD rural policy review)

6. Higher & rising % of older people –Chronic & complex illness Migration patterns (Fear of?) service erosion Security Access to A&E/ (risk) Appropriate economic development? »Market failure Transport issues Infrastructure issues Available & affordable good housing Inconsistent weather [Insular-ism & conflict] Health service-related concerns of remote areas

8. What is a healthy, resilient community? Government seeks… Secure (new CFRs & emergency models) Looking after each other/ civic society Free personal care – means – no domestic care etc…. [so participation!!!] Healthy – walking clubs/ active Self-care… Anticipatory care…

9. =???? Fantastic visionary new opportunity? OR Roll-back of the welfare state…?

10. A Project about older people as a positive force, doing things for communities, doing things for themselves

11. O4O:Older people for Older people

12. O4O is about Responding to population change Sustaining remote communities Changing the way people think Making a start on seeing older people as a positive force

13. What is O4O? Mechanism to involve (older) people in basic level service provision for older people Different models of doing this in different partners & communities –Volunteering –Social enterprise Work with communities Involve ‘business’ development Built on local needs & resources Cross-generational

14. What sorts of services? Good neighbour / social support Domestic help Meals, shopping Lifts/ transport Educational support Support for self care First response/triage Support for community alarm schemes Snow clearing & wood-chopping

15. Partners Highland – growing ageing population Dumfries & Galloway – employment opportunities Northern Ireland – post-conflict North Karelia – heavy demand for older people’s services Lulea – develop volunteering Kainuu – learn from the project Sommersooq, Greenland

16. Greenland Survey of older people in dispersed remote communities –What they do –What they’d like to do –Activity & participation

17. The O4O model Local citizens explore their needsLocal citizens explore their needs What would help keep older people living healthily in their own homes & communities?What would help keep older people living healthily in their own homes & communities? What would most help?What would most help? Process…Process… Develop a social organisation…Develop a social organisation… Social enterpriseSocial enterprise Voluntary organisationVoluntary organisation Co-operativeCo-operative O4O doesn’t give them moneyO4O doesn’t give them money

18. Why social organisations? Policy says… Social organisations/ civic society makes… –Social capital –Psychological health & wellbeing –Physical health & wellbeing Low evidence base!

19. O4O – the theoryO4O – the theory –SC in the community People help each other & build networksPeople help each other & build networks Build organisations & build networksBuild organisations & build networks Work with us/ partner organisations – bridgingWork with us/ partner organisations – bridging Volunteering = good for healthVolunteering = good for health Once built this capital can be applied to other things (capacity)Once built this capital can be applied to other things (capacity) + they have new ‘services’+ they have new ‘services’

20. At first that required… CoheringCohering SupportingSupporting MentoringMentoring Looking for fundingLooking for funding Supporting bidsSupporting bids

21. Now that’s involving Education for capacity buildingEducation for capacity building Business planning & developmentBusiness planning & development Developing local social entrepreneursDeveloping local social entrepreneurs

22. What are communities doing? Highland…. Transport scheme Supported housing Helping Heritage-identity-meeting place-cafe Dumfries & Galloway…. Extending Foodtrain and other… N.Ireland…. Shaping social enterprise ideas Lulea, Sweden…. Village co-operatives Inter-generational IT Cafe Karelia, Finland…. Volunteering Greenland…. Needs & activities of older people

23. Contextual issues Scotland – SE – heavily promotedScotland – SE – heavily promoted Sweden (North – welfarist/left)Sweden (North – welfarist/left) Enterprise is a ‘dirty’ wordEnterprise is a ‘dirty’ word Finland – SE restrictions & meaningFinland – SE restrictions & meaning Volunteering is okVolunteering is ok N. Ireland – post conflictN. Ireland – post conflict Greenland – hugely dispersedGreenland – hugely dispersed

24. Researching the impact of O4Os 1.Individual impacts Health Helping 2. Community impacts Health Participation Volunteering 3. Service provider impacts Costs Activity Falls, care packages, emergency admissions

25. Some survey findings 60.8% response: 1500 people 55+ (r&r) 34% aware of O4O 88% had helped a neighbour (6 months) 13% provided unpaid personal care 31% thought they could influence local decisions 50% willing to use skills to help others (+39% ‘it depends’) 28% on management committee 33% had participated in community projects 5% said health ‘poor’ 12% no access to a vehicle 22% had been held back by ‘emotional problems’ in 4 weeks

26. A concern Replacing existing social capital (informal helping & reciprocity….Replacing existing social capital (informal helping & reciprocity…. …with formal ……with formal … Disrupting evolved schemesDisrupting evolved schemes … though are those exclusive…?… though are those exclusive…?

27. And in Canada….! “… the central concern arising from these reforms in Canada, as elsewhere, is that the NPM reforms place matters of efficiency above those of equity and entitlement and that the negative impacts of these reforms are felt most intensely among less well off individuals and communities…” “…each of the 43 [institutions] is findings its own solution to the problem of meeting expanding demands with limited resources, and this is creating diversity in local capacity to respond to demands for assistance…” “…limits to community capacity among older people to provide for themselves and each other…” Cloutier-Fisher, D., Joseph, A.E., 2000. Long-term care restructuring in rural Ontario: retrieving community service user and provider narratives. Social Science & Medicine 50, 1037-45. Hanlon, N.T., Rosenberg, M.W., 1998. Not-so-new public management and the denial of geography: Ontario health-care reform in the 1990s. Environment and Planning C: Government and Policy 16(5), 559 – 572. Hanlon, N.T., Halseth, G., Clasby, R., Pow, V., 2007. The place embeddedness of social care: restructuring work and welfare in Mackenzie, BC. Health & Place 13, 466-481. Skinner, M.W., Rosenberg, M.W., 2006. Managing competition in the countryside: non-profit and for-profit perceptions of long-term care in rural Ontario. Social Science & Medicine, 63, 2864-76.

28. The realities of O4O…(OMG!) For communities: - exogenous ‘social engineering’? - enterprising? - extent of capacity - internal community conflict -when it comes to the crunch… -is it possible to get beyond the grant? (how do you make social enterprise work in small communities) -why us/ why now/ want paternalism

29. For service providersFor service providers At management level: want it, but not to support its birthAt management level: want it, but not to support its birth –Models of sustainable (small) community enterprise At operational level – threatening and riskyAt operational level – threatening and risky Availability of data to show change + how to changeAvailability of data to show change + how to change For support agencies Providing training & support that fits remote & rural communitiesProviding training & support that fits remote & rural communities Beyond advising into doingBeyond advising into doing Targets based on outcomes = social entrepreneursTargets based on outcomes = social entrepreneurs GovernmentGovernment Only interested if it worksOnly interested if it works

30. In different countries Sweden Business model & paradigm shift? Finland Volunteering? Apathy… Greenland Some villages more engaged than others Alcohol, bingo, etc….. N Ireland

31. Partners & partnership working

32. Policy people….are integral Change & innovation at government level Local health authority Bemused? Distanced… Local council Does it work, make it work, waste of time Two years ahead of itself Ambulance service Interested in how to engage with communities Want to integrate with our transport scheme Regional development agency Right now we are interested in telemedicine…

33. Future policy… Impacts…Impacts… Health, service provision, does anyone care – enough?Health, service provision, does anyone care – enough? Models of social enterprise provision for tiny communities – which?Models of social enterprise provision for tiny communities – which? Is there really the capacity?Is there really the capacity? Is it the role of researchers…?Is it the role of researchers…?

34. My questions for you… What are your experiences?What are your experiences? Can (and should) the health service explicitly seek to grow community capacity? If so, how?Can (and should) the health service explicitly seek to grow community capacity? If so, how? Is social enterprise, as promoted by government, really to build capacity or just to shift service provision?Is social enterprise, as promoted by government, really to build capacity or just to shift service provision? Does social enterprise have a role in health & social care provision?Does social enterprise have a role in health & social care provision? How can it be made to work in small communities?How can it be made to work in small communities? What is different about Aus rural health & Scottish rural health (context) that would affect outcomes of a thing like O4O?What is different about Aus rural health & Scottish rural health (context) that would affect outcomes of a thing like O4O?

35. Centre for Rural Health jane.farmer@uhi.ac.ukwww.abdn.ac.uk/crh