The wheels of change?

“A health asset is any factor or resource which enhances the ability of individuals, communities and populations to maintain and sustain health and well-being”.  These assets can operate at the level of the individual, family or community as protective and promoting factors to buffer against life’s stresses.”  Anthony Morgan, 2009

At national conferences that I have been able to attend over the last six months there has been a consistent theme of working with an assets approach rather than a deficit approach. Often these two approaches or models can be talked about as polar opposites, with the asset approach being all good and the deficit approach being all bad. That clearly isn’t the case – another word for deficit is need; and services identifying and targeting specific need can be very important in making a difference to people.

However, it feels to me that the thinking around the asset approach has a lot to offer public service, which has arguably been overly focused on responding to need / deficit with the unintended consequence of dependency and dis-empowerment. I think the key thing that the proponents of an assets based approach are trying to establish is that the control over who, and how,  needs are defined is sometimes even more important than the actual interventions that services provide. (There is a lot in this that will be familiar to people who have argued for community development approaches to health inequality over the last decade)

In my experience the deficit model is part of the accepted culture in statutory services, it is the way things are done. Yet where problems are complex with multiple interacting causes the predominant deficit model is probably the wrong tool for the job.   Such thinking  is challenging.  In particular many service planners and managers have become very attached to ‘action plans’ and it can seem like heresy to suggest that developing tables of neatly ordered actions  may not always be the best place to start with a complex problem like health inequality.  (For avoidance of doubt, I think planning in this traditional sense is an essential skill. As a Prince2 practitioner I like nothing more than being able to get all the ducks in a row and make a project flow from conception to completion) Compared to the orderly world of service planning working with an assets approach might seem ‘unplanned’, even ‘chaotic’;  it needs individuals to take responsibility for a common or agreed vision, to make connections with others and ultimately to  ‘get on with it’. 

Jenny Campbell (of Lifetimes Work) gave me a useful way to think about different approaches to achieving change, based on the humble wheel. Firstly she described a model with a central hub in the wheel. The hub is  where planning is done and decisions are made. Spokes radiate from the hub and transmit the power of the centre to where services are delivered. This model is very efficient and supports measurement of change – good for directing resources for example in managing waiting lists or developing  new service provision.   

The second approach is a model in which the focus is very much on the rim of the wheel, where services are delivered and used. Its strength is generated by making connections across the interior of the wheel. In this model the centre plays a much less active, but probably no less significant role, and change is generated by practitioners and service users making connections with each other directly not necessarily mediated through the centre. 

To me in terms of an asset based approach to tackling health inequality the second model makes sense – the strengths or assets are there in a community, its a matter of connecting them up creatively rather than through bureaucratic planning forums. (How many of you are aware of or involved in such forums that tie themselves in knots trying to connect everything whilst at the same time maintaining direction and control from the centre.) Key to an assets approach is a common vision – that all the partners are signed up to. It seems to me that the job of the centre in an assets approach is to constantly explain that vision so that the people on the rim of the wheel can develop the connections that are needed to do the job. The centre need to be in constant communication with the assets that are creating positive change and find ways of supporting, celebrating and disseminating it.

Dr Harry Burns has been a key proponent of an assets based approach, and I believe his work on ‘salutogenenesis’ gives a theoretical undderpinning for why such an approach could be successful in creating good health. As Chief Medical Officer for Scotland he produces an annual report on key public health issues and challenges. The latest report is entitled: Time for Change and he outlines his thinking about the creation of good health in Scotland and how an ‘assets approach’ can help with this. He illustrates what is meant by an Assets approach with the story of a community in Cornwall. I have reproduced it here because it is such a startling story of success.

Extract taken from the Chief medical officers annual report

Health in Scotland 2009 – time for change.

Beacon and Old Hill

When one thinks of Cornwall, one usually has a mental image of beautiful countryside, thatched  cottages and afternoon teas. Yet, in the mid 1990s, Cornwall housed one of the most deprived council estates in Britain. Penwerris, the electoral ward comprising the Beacon and old Hill estates which had a population of 6000, had, according to a University of Bristol report, the largest percentage in Cornwall of children in households with no wage earners, the second highest number of children living with lone parents. Unemployment rates on the estates were 30% above the national average, child protection registrations were high, postnatal depression afflicted a significant number of mothers, domestic violence was common and violent crime, drug dealing and intimidation were commonplace. By 1985, quality of life in the area was plummeting. “It had the reputation of being a ‘no go area’ for the police, crime and vandalism were spiralling out of control, and the community had become more or less completely dissociated from the statutory agencies.” (Durie et al) Two local health visitors, Hazel Stuteley and Philip Trenoweth are credited with beginning the regeneration of the area after a particularly disturbing series of events.

 In the Health Visitors’ own words:

“The flashpoint came simultaneously for us both, literally in Rebecca’s case, when she witnessed the family car ignite following the planting of an incendiary device. She was 11 years old then and although physically unhurt, she was deeply traumatised by this. Already in mourning for her friends’ pet rabbit and tortoise, which had recently been butchered by thugs from the estate, this was the final straw. As family Health Visitor for the past 5 years, I was a regular visitor to her home. Her Mum was a frequent victim of domestic violence and severely post-natally depressed. My caseload had many similar families with multiple health and social problems. Seeing Rebecca and her family’s deep distress, I vowed then and there that change must happen if this community was to survive. I had been watching it spiral out of control for long enough.”

 Thereafter, the two health visitors embarked on a series of meetings in which they tried to engage statutory agencies with members of the community. Of note was the fact that many individuals they thought would want to be involved in turning the area around refused to become involved and many of the public meetings held to encourage dialogue were described as ‘stormy’. What is apparent from the descriptions of the process is that the people were listened to. The residents identified the problems they were most concerned about and statutory agencies engaged with the community in designing a response. Residents became co producers of solutions rather that passive recipients of actions others had determined would be good for them.

 This was a critical part of the process. People learned that expressing their concerns was not a waste of time. They learned their opinions had value and that they mattered to others. Social networks developed and problems became shared. Importantly, solutions emerged from these interactions between people who had previously been alienated from each other.

 “The most significant aspect of the regeneration process on the Beacon and Old Hill estate was that, from the outset, there was no initial funding, no hierarchy, no targets, no business plan, only a shared vision of what the community wanted to be, rather than an obsession with what it had to do. Thus, the regeneration process was not a result of a predetermined plan. Rather, the process emerged as a consequence of the interactions between the members of the community, and between the community and its environment, namely the statutory agencies, the police, the council, and so forth. As the community evolved, so also the agencies and professional bodies co-evolved with the community.” (Durie et al)

 The story of Beacon and Old Hill is one of a few individuals being motivated by the failure of conventional approaches to a problem to try something different. In listening rather than lecturing, they heard the members of the community outline solutions to their difficulties. Finally, they were confident enough to allow solutions to emerge organically rather than through a conventional project planning approach which relies on the outcome being predetermined. In effect, leadership in this case did not involve taking a community in a predetermined direction, but rather involved helping individuals discover their own direction by awakening within themselves the capacity to take control of their lives. They had used an asset model rather than focussing on the deficiencies in the lives of the community

End of extract

The following is a quotation from the report on Beacon and Old Hill cited in Dr Burns report which defines the level of impact that was achieved in the community:

 “By 2000, the overall crime rate had dropped by 50%. Affordable central heating and external cladding had been installed in over 60% of the properties which significantly impacted on childhood asthma rates and schooldays lost. Child Protection Registrations had dropped by 42%. Post-natal depression was down by 70%. Breast feeding rates increased by 30% The educational attainment of 10-11 year old boys – i.e., level 4, key stage 2 – was up by 100%. The number of unwanted teenage pregnancies had been significantly reduced to the extent that in 2002 there were no unwanted teenage pregnancies.  And the unemployment rate was down 71% amongst both males and females.” (Durie et al)

The full report can be accessed here and is well worth a read  Community_regeneration_and_complexity

 If Support from the Start has been successful at all in generating change – its because it has built on the strengths of the people who deliver support to children and families that need it – whether they are community members, unpaid volunteers, voluntary sector staff, NHS staff or local authority staff. The key assets for early years health are the parents of the 0-8 year olds and the  staff and volunteers who support them -all Support from the Start has done is identified champions amongst them and given them space to come up with ideas.  Credit has to be given to senior managers and politicians who have said okay here is the vision  – we want to more effectively address health in targeted communities by  focusing on the early years of life, here is the space and some resources to do it –  you have permission to get on with it,  just keep us informed about what you are doing. ( Sometimes less is more and my failure as lead officer to produce an ‘action plan’ for  Support from the Start  – may well be my greatest contribution)