Y Pwyllgor Cydraddoldeb, Llywodraeth Leol a Chymunedau

Equality, Local Government and Communities Committee

ELGC(5)-20-17 Papur 2/ Paper 2

 

1                  Introduction

 

The Equality, Local Government and Communities Committee have agreed to undertake three inquiries which look at poverty in Wales. One of these inquiries is looking into asset-based approaches to poverty reduction. The terms of reference for the inquiry are as follows:

·         how an assets-based approach to poverty reduction could work in Wales;

·         the evidence available on the effectiveness of this approach, and examples of international good practice; and

·         practical ideas for application.

This briefing summarises evidence available for these three points.

Defining Health Assets

“Health assets are factors or resources which enhance the ability of individuals, communities and populations to maintain their health and wellbeing. These act as protective or supporting factors to buffer against life’s stresses. They include the capacity, skills, knowledge, connections and potential in a community. This approach contrasts with a health deficits approach which focuses on problems or deficiencies in a community. These include, for example, deprivation, illness and health damaging behaviours.”

(Welsh Assembly Government, 2011)

2                  How an assets-based approach to poverty reduction could work in Wales

2.1           Public Health Wales work

A report on Proposed Indicators for Asset Based Approaches in Wales was published by Public Health Wales in 2015. This proposed a framework and identified a selection of potential indicators that could be used for measurement and reporting of asset based approaches in Wales. The framework proposed involved three broad dimensions:

1. People’s/Individual assets e.g. resilience, commitment to learning, sense of purpose, skills, talents, networks, knowledge, self efficacy.

2. Community assets e.g. family and friendships, networks, social capital, community cohesion, religious tolerance, intergenerational solidarity.

3. Structure (Organisational or institutional assets) e.g. environmental resources for promoting physical health, land, buildings, transport, employment, security, opportunities for volunteering, safe housing, political democracy and participation.

Cymru Well Wales has a commitment to empower our communities in all that we do. Cymru Well Wales is a movement of motivated organisations that are committed to working together today to secure better health for the people of Wales tomorrow.

Recognising good health and wellbeing requires a whole-of-society approach; partners in Cymru Well Wales are committed to thinking and working differently to create a Wales that we all want to live in, now and in the future. Partners in Cymru Well Wales share a commitment to:

1.   Acting today to prevent poor health tomorrow

2.   Improving wellbeing by harnessing activity and resources to amplify our collective impact

3.   Thinking and working differently to tackle health inequalities

4.   Empowering our communities in all that we do

5.   Learning from others to design innovative action for the future

2.2           Examples from Director of Public Health  (Richardson G) ABUHB Annual Report 2016; ‘Living Well Living Longer in Gwent’

                      

·         Chapter 5: The Living Well Living Longer Programme

·         Chapter 6: Wellbeing Champions

2.3           ‘Developing Asset Based Approaches to Primary Care: Best Practice Guide 2016’ Greater Manchester Public Health Network (2016)

This guide provides case studies of the application of asset-based approaches, analysing the impact of each approach, the model used, what makes it work at scale and commentary on the development and implementation. Pages 28-29 provide a ‘best practice’ guide for starting an assets-based development, which may be a useful reference for this aspect of the inquiry.

2.4           ‘Putting asset based approaches into practice: identification, mobilisation and measurement of assets’ Glasgow Centre for Population Health (2012)

This briefing paper includes a summary of key features of asset-based activities, methods for identifying assets – such as asset mapping, participatory appraisal and appreciative inquiry – as well as mobilising assets. Much of this paper is equally relevant to the third aspect of the inquiry’s terms of reference (see section 4.3 for details in this context).

2.5           ‘Summary findings from a scoping exercise into a national infrastructure for community-centred approaches to health and wellbeing’ Public Health England (2017)

This short report presents the main findings from a scoping exercise that was undertaken in June- September 2016 to explore what sort of national infrastructure, if any, is needed to enable and grow community–centred approaches for health and wellbeing.

Its findings acknowledge that a ‘whole-system, asset-based, collaborative infrastructure is needed’, calling for the approach to be owned and shaped locally to have impact. Feedback suggested that a national collaborating centre was a good idea to reduce competition, support good practice and co-ordinate organisational approaches. Stakeholders also highlighted the need for evidence and knowledge translation and implementation support to enable constructive development of initiatives.

3                  The evidence available on the effectiveness of this approach, and examples of international good practice

3.1           Health Assets Reporting Tool – Public Health Wales Observatory (2015)

The Public Health Wales Observatory has produced an interactive tool showing indicators of health assets for small areas in Wales.

The tool presents health asset indicators on a spider chart and at the middle super output area level alongside comparative information for Wales. The indicators presented cover a range of topics across three domains:

3.2           Nuka Health Care System – Alaska

(Taken from King’s Fund website at: https://www.kingsfund.org.uk/publications/population-health-systems/nuka-system-care-alaskam)

Nuka was developed in the late 1990s after legislation allowed Alaska Native people to take greater control over their health services, transforming the community’s role from ‘recipients of services’ to ‘owners’ of their health system, and giving them a role in designing and implementing services. Nuka is therefore built on partnership between Southcentral Foundation and the Alaska Native community, with the mission of ‘working together to achieve wellness through health and related services’. Southcentral Foundation provides the majority of the population’s health services on a prepaid basis.

Service features

The Nuka System of Care incorporates key elements of the patient-centred medical home model, with multidisciplinary teams providing integrated health and care services in primary care centres and the community, co-ordinating with a range of other services. This is combined with a broader approach to improving family and community wellbeing that extends well beyond the co-ordination of care services – for example, through initiatives like Nuka’s Family Wellness Warriors programme, which aims to tackle domestic violence, abuse and neglect across the population through education, training and community engagement.

Traditional Alaska Native healing is offered alongside other health and care services, and all of Nuka’s services aim to build on the culture of the Alaska Native community.

Community participation and collaboration

Alaska Native people are actively involved in the management of the Nuka System of Care in a number of ways. These include community participation in locality based advisory groups, the active involvement of Alaska Native ‘customer owners’ in Southcentral Foundation’s management and governance structure, and the use of surveys, focus groups and telephone hotlines to ensure that people can give feedback that is heard and acted on.

As well as building strong relationships with the population it serves, the Nuka System of Care depends on collaboration between Southcentral Foundation and a range of local, regional and national partners. New collaborations are being established each year as gaps in services are identified and filled.

Outcomes

Since it was established, the Nuka model of population-based care has achieved a number of positive results, including:

·         significantly improved access to primary care services

·         performance at the 75th percentile or better in 75 per cent of HEDIS measures

·         customer satisfaction, with respect for cultures and traditions at 94 per cent.

There have also been reductions in hospital activity, including:

·         36 per cent reduction in hospital days

·         42 per cent reduction in urgent and emergency care services

·         58 per cent reduction in visits to specialist clinics.

3.3           Health 2020

The WHO Regional Office for Europe ‘Health 2020’ policy framework considers an assets-based approach to reducing health inequalities, defining health assets as ‘any factors (or resources) that enhance the ability to maintain and sustain health and well-being’ (p43). It states that ‘individuals, communities and countries may have capabilities and assets that can enhance and protect health, stemming from their cultural capacities, social networks and natural resources’ (p46). Pages 131-134 provide greater detail on the ‘social determinants of and assets for health’, looking at the social environment on the whole.

3.4           Torfaen Social Prescriber in Primary Care Setting

(Example taken from Welsh NHS Confederation briefing on social prescribing)

In North Torfaen, Aneurin Bevan UHB have appointed a social prescriber based in six GP surgeries. The social prescriber’s primary objective is to “to tackle the underlying causes of ill health and to promote self-help by connecting primary care with the range of services that exist across the community and public sector”. The initiative has been fully operational since January 2016.

151 referrals were made to the social prescriber between January and May 2016. Of these, 90 attended a face-to-face consultation and a further 30 were able to get the help they wanted over the telephone. 80% of GPs interviewed during this period said that they valued the service. They also commented that the impact had resulted in patients making fewer appointments with their GP and felt more in control of their own health and well-being.

Concerns about mental health, housing/financial issues and extended periods of loneliness and anxiety were overwhelmingly cited as the three top priority areas. Many of the patients being referred experience barriers to social engagement and suffer from a complex mental illness and so there is a need to ensure that there is a certain element of support in putting patients in touch with the appropriate service in a timely manner.

3.5           Voluntary Action Rotherham – Mental Health Social Prescribing Pilot

An evaluation has been carried out on a social prescribing pilot scheme in Rotherham, run by Voluntary Action Rotherham. The Rotherham Social Prescribing Mental Health Pilot was developed to help people with mental health conditions overcome the barriers which prevent discharge from secondary mental health care services. The service helps service users build and direct their own packages of support, tailored to their specific needs, by encouraging them to access personalised services in the community provided by established local voluntary and community organisations, and to develop their own peer-led activities.

Sheffield Hallam University’s analysis revealed:

·         20% reduction in the number of A&E attendees

·         21% reduction in the number of outpatients and a 21% reduction in the number of inpatients when follow-up meetings were conducted three to four months later

·         Wider benefits for participants, including gaining employment, undertaking training, volunteering and taking up physical activity

·         Social return on investment estimated at £2.19 for every £1 spent during the pilot.

 

The project was funded initially by a budget of £11 million. Sheffield Hallam University have estimated that the costs of delivering the service for a year would be recouped after 18-24 months. The potential cost savings were estimated to be anything between £1.41 for every £1 invested to £3.38 for every £1 invested.

4                  Practical ideas for application

4.1           Public Health Wales ‘Community Engagement for Empowerment’ Principles

The Public Health Wales Health & Wellbeing Directorate have recently developed principles for engaging with and empowering communities. These principles have been developed with colleagues who have direct experience of community development in Wales and academic partners from across the UK.  Fundamentally the Principles take an assets based approach, recognising the importance of building trusting relationships that are sustained over time, equally valuing all types of knowledge and expertise, importantly including that gained through the lived experience. Of particular relevance is the principle that we should be:

·         building upon what is in place, through acknowledging and valuing what the community brings to the table and releasing capacity within the community, before commencing work, to build assets;

·         focusing action on the whole system, not just the community

Evidence shows that done well, community empowerment is seen as health promoting in its own right.

Public Health Wales will shortly develop an action plan to embed the principles across the organisation, as well as develop guidelines to accompany the principles, seeking to act as an exemplar in our approach. Alongside this, Public Health Wales is engaging with colleagues in the third sector to co-produce a programme of work that will support them in their work with communities to improve health. In this way, Public Health Wales seeks to maximise the assets and services that communities access from the third sector.

4.2           Examples from ABUHB Annual Report 2016

·         Chapter 2: Community-oriented Primary Care

·         Chapter 4: Social Prescribing

·         Chapter 6: Wellbeing Champions

4.3           ‘Putting asset based approaches into practice: identification, mobilisation and measurement of assets’ Glasgow Centre for Population Health

 

The Glasgow Centre for Population Health Briefing (see Section 2.4) provides examples on how to mobilise assets through, for example, asset-based community development, social prescribing and time banking. In addition it provides guidance on how to measure and evaluate assets, as well as looking at the practical challenges of measuring assets.

4.4           ‘What makes us healthy? The asset approach in practice: evidence, action, evaluation’ Jane Foot (2012)

This publication provides guidance on how other organisations have approached asset mapping (pp 27-33) including reflection on the Toronto framework, timebanking (pp 34-35), social prescribing (p 36) and peer support (pp 36-27).

4.5           Asset-based Community Development – 5 Core Principles

A blogpost from Nuture Development provides a good overview of the 5 core principles, which are:

1.   Citizen-led

2.   Relationship oriented

3.   Asset-Based

4.   Placed-Based

5.   Inclusion focused.

4.6           Social Prescribing

Social prescribing is defined by the Centre Forum Mental Health Commission as ‘a mechanism for linking patients with non-medical sources of support within the community’. Social prescribing is about causes, not symptoms, and thus can be considered outside of a health remit, with more potential to focus on ‘societal ills’. It requires a collaborative approach between practitioners and the person they are trying to serve in exploring the range of options available to improve and maintain wellbeing.

The Welsh Government’s programme for government, Taking Wales Forward 2016-2021, includes reference to a social prescription pilot scheme for mental health.

 

5                  Bibliography

Barnett, K. (n.d.) Applying learning from Alaska’s ‘Nuka System of Care’. The Health Foundation. [Online]. Available from: http://www.health.org.uk/blog/applying-learning-alaskas-nuka-system-care [Accessed: 22 June 2017].

Dayson, C. & Bennett, D.E. (2016a) Evaluation of the Rotherham Mental Health Social Prescribing Project. [Online]. Available from: http://www4.shu.ac.uk/research/cresr/sites/shu.ac.uk/files/eval-rotherham-mental-health-social-prescribing.pdf [Accessed: 27 June 2017].

Dayson, C. & Bennett, D.E. (2016b) Key Findings from the Evaluation of the Rotherham  Mental Health Social Prescribing Pilot. [Online]. Available from: http://www4.shu.ac.uk/research/cresr/sites/shu.ac.uk/files/eval-rotherham-mental-health-social-prescribing-key-findings.pdf [Accessed: 27 June 2017].

Foot, J. (2012) What makes us healthy? The asset approach in practice: evidence, action, evaluation. [Online]. Available from: http://janefoot.com/downloads/files/healthy%20FINAL%20FINAL.pdf [Accessed: 22 June 2017].

Friedli, L. (2013) ‘What we’ve tried, hasn’t worked’: the politics of assets based public health. Critical Public Health. [Online] 23 (2), 131–145. Available from: doi:10.1080/09581596.2012.748882 [Accessed: 22 June 2017].

Glasgow Centre for Population Health (2012) Putting asset based approaches into practice: identification, mobilisation and measurement of assets. [Online]. Available from: http://www.gcph.co.uk/assets/0000/3433/GCPHCS10forweb_1_.pdf [Accessed: 22 June 2017].

Gottlieb, K. (2013) The Nuka System of Care: improving health through ownership and relationships. International Journal of Circumpolar Health. [Online] 72 (1), 21118. Available from: doi:10.3402/ijch.v72i0.21118 [Accessed: 22 June 2017].

Great Manchester Public Health Network (2016) Developing Asset Based Approaches to Primary Care: Best Practice Guide 2016. [Online]. Available from: http://www.innovationunit.org/wp-content/uploads/2017/04/Greater-Manchester-Guide-160516.pdf [Accessed: 22 June 2017].

Nurture Development (2017) Asset-Based Community Development - 5 Core Principles. Nurture Development. [Online]. Available from: http://www.nurturedevelopment.org/blog/asset-based-community-development-5-core-principles/ [Accessed: 22 June 2017].

O’Mara-Eves, A., Brunton, G., McDaid, D., Oliver, S., et al. (2013) Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis. Public Health Research. [Online] 1 (4), 1–526. Available from: doi:10.3310/phr01040 [Accessed: 22 June 2017].

Public Health England (2017) Summary findings from a scoping exercise into a national infrastructure for community-centred approaches to health and wellbeing.

Public Health Wales (2016) Introducing Cymru Well Wales. [Online]. 3 November 2016. Public Health Wales. Available from: http://www.wales.nhs.uk/sitesplus/888/page/87835 [Accessed: 27 June 2017].

Richardson, G., Aitken, S., Beer, W. & Burrows, G. (2016) Living Well, Living Longer in Gwent.

Southcentral Foundation (2017) Nuka System of Care. [Online]. 2017. Southcentral Foundation. Available from: https://www.southcentralfoundation.com/nuka-system-of-care/ [Accessed: 22 June 2017].

Southcentral Foundation (2015) Southcentral Foundation FY2015 Progress Report. [Online]. Available from: https://www.southcentralfoundation.com/wp-content/uploads/2017/01/Progress-Report_2016.pdf [Accessed: 22 June 2017].

Welsh Assembly Government (2011) Fairer Health Outcomes for All. Reducing Inequities in Health Strategic Action Plan. [Online]. Available from: http://gov.wales/docs/phhs/publications/110329working2en.pdf [Accessed: 27 June 2017].

Welsh Government (2016) Taking Wales Forward 2016-2021. [Online]. Available from: http://gov.wales/docs/strategies/160920-taking-wales-forward-en.pdf [Accessed: 9 March 2017].

Whiting, L.S., Kendall, S. & Wills, W. (2013) Rethinking children’s public health: the development of an assets model. Critical Public Health. [Online] 23 (2), 146–159. Available from: doi:10.1080/09581596.2013.777694 [Accessed: 22 June 2017].

World Health Organization Regional Office for Europe (2013) Health 2020 a European policy framework and strategy for the 21st century. [Online]. Copenhagen, World Health Organization, Regional Office for Europe. Available from: http://www.euro.who.int/__data/assets/pdf_file/0011/199532/Health2020-Long.pdf?ua=1 [Accessed: 11 February 2017].