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)

Scottish Parliament inquiry into preventative spending

The following is the transcript of the  Submission from Susan Deacon to the Finance Committee Inquiry into Preventative Spending.

Susan is a national champion for the early years in Scotland and an advisor to the Support from the Start Planning Board

I am grateful for the opportunity to submit evidence to the Finance Committee and welcome the Committee’s current inquiry into preventative spending.

Since the inception of the Scottish Parliament successive Ministers and Governments have recognised the importance of working to tackle the root causes of social problems and, in particular, the importance of taking action to give children the best possible start in life. While there have been  differences in emphasis and a variety of approaches to policy delivery and implementation along the way, there has been a consistent direction of travel which has commanded a high level of commitment and support across the political spectrum.

So too is there a vast body of research and evidence – much of which has been presented to the Committee during the course of this Inquiry  – which makes a compelling case for early intervention and preventative spend.

This begs the questions as to why we, and by that I mean Scotland, have not yet embedded in our public consciousness and culture, political debate, investment priorities, service design and professional practice a truly preventative approach and, in particular, have not been more successful in delivering a step change in how we support children and families to ensure that the lives of our youngest citizens are built on strong foundations.

Having spent more than 25 years involved in both the study and practice of politics, social policy, management and change, I have grappled with these questions from many angles. Since standing down as a member of the Scottish Parliament in 2007 and, most recently, taking on the role of Early Years’ champion with the Scottish Government, I have focussed much of my energy and efforts in examining the question of how we can get better at making such change happen.

In this submission I therefore offer a distillation of a few of my overriding observations and conclusions on some of the barriers to change and how we might overcome them. The focus of my submission is on children’s early years, but it will be clear that many of my comments have a wider resonance. The opinions offered are my own but are informed by formal study and, critically, by extensive dialogue with a very wide range of individuals and organisations. I am immensely grateful to those who have taken time to share their knowledge, opinions and insights with me. My work on early years is ongoing, and I will be reporting early in the new year, however I hope it is helpful for now to share these thoughts to aid the Committee’s deliberations.

 Raising awareness and public ‘buy in’ on the importance of Early Years

The problem is not lack of policy and research – in fact it is arguable that the proliferation of both has created a fog which needs to be cleared. Rather there is a need to build a shared popular understanding of why children’s early years’ experiences are so important and how big a part they plays both in individual life outcomes as well as the future social and economic success of Scotland.

This is important for two reasons. First, we need to create a climate and a context which is conducive to decision makers taking spending decisions which support early years investment – perhaps at the expense of more ‘acute’ or ‘crisis’ interventions. It is therefore important that the public does not see investment in, for example, parenting support, community groups or antenatal education as a ‘soft option’.

The second reason why public awareness and buy in is so important is because, as the current Early Years Framework acknowledges, there is a need for transformational change in how we parent our children and in what we do in the family and in the home. It is therefore not enough to simply limit the discussion to what professionals and public services can do, in fact it is arguable that we have to date got this balance quite wrong.

Such a public discussion needs to be plain speaking and accessible. Too much of our current debate in the policy and political worlds is locked up in ‘techno speak’ and jargon or is over laden with references to the latest policy document, research, tool or process. This needs to change. There can and must be a much more straightforward, ‘human’ discussion about what is going on in our families and our relationships, how that is affecting children and what we can do about it.

Some of the fundamental things which matter to children – love, cuddles, play, bedtime stories, routine etc – cost little but matter a great deal and we should not be afraid to say this.

 Developing a shared responsibility for supporting the Early Years

We can observe a pattern which goes something like this. We identify a problem (e.g. childhood obesity, youth disorder, poor literacy) and look to Government to fix it. Typically, Government accepts that challenge; puts in place a process; delivers a strategy; translates that into policy and an (often over-engineered) implementation process and, two or three years on, the problem (not surprisingly) isn’t ‘fixed’. This then becomes portrayed as a failure of the political leadership of the day so, we change Ministers or Government and start the same process all over again.

If ever there was a time to break this cycle, then surely it is now – and where better than in relation to children’s early years?

Government – and other public bodies – have a key role to lead, support and invest but they can only do so much. In allowing too much responsibility to transfer to professionals, and to government and its agencies we have, inadvertently, disempowered people themselves and this has militated against the very behaviours – in the home, the family and in our communities – which are widely understood to be a vital part of our social and economic well being.

I am under no illusions about the scale of the challenge to bring such a shift about and realise that it does not sit comfortably with our prevailing political culture, media debate or simply the way we think as a society. But I would argue that there is a big prize in working to foster this shared responsibility, to do so in a spirit of learning rather than blame and to get beyond the short-termism which bedevils us and stands in the way of sustained and sustainable change.

 Getting out of our boxes

For a small country, Scotland has developed a remarkable propensity to subdivide into a multiplicity of ‘boxes’. This is partly reflected in a cluttered public policy and public service landscape and in the propensity of Government, both national and local, to develop multiple parallel strands of policy, activity and investment – but the pattern runs deeper than that. Professional silos and demarcations and organisational and sectoral ‘agendas’ abound – and we can see this running right across sectors and activities.

All the evidence and experience tells us that the kind of support and services which really make a difference to children and families – especially the most vulnerable – need to be flexible, responsive and holistic. We need a really concerted effort to create the structures, systems and practices to bring that about.

There have been many years of ‘clunky’ and costly initiatives to foster better joint working, multi-disciplinary approaches, shared services, integrated plans etc etc, but I think we have to be willing to hold up a mirror and be honest that the impact of this effort and activity has not been on the scale that we might have hoped.

In the medium term – as is now widely acknowledged – there needs to be some rationalisation or consolidation of structures – if for no other reason than ongoing cost and efficiency. But structural change at agency level takes time and is costly and disruptive. In the short term therefore, I would suggest that there is a great deal more that can and must be done to foster the culture and behaviours which enable and support people to work together better across boundaries on the ground. This requires leadership at many levels both to drive such a change – but also to ‘let go’ and to release the potential and the creativity which exists both among our professional workforce and in communities themselves.

Alongside this there requires to be a much stronger and explicit recognition of the transformational impact which a preventative approach – often through small scale, locally developed projects  – can have.

 Focus on people not process

At the end of the day, it is people that make a difference. Across Scotland we have a wealth of knowledge, commitment and experience of people who at their own hand are leading change and delivering programmes, projects and activities which are having a real and positive impact. With just a little bit more support – or even simply ‘permission’ – they could do so much more.

I am encouraged that both at a national and local level there are a growing number of examples of where a more people-focussed, ‘lighter touch’ approach to change is being developed. e.g. bringing smaller groups of people around the table to drive practical action and change; supporting the development of creative partnerships across sectors and professionals; investing in and placing greater value in individuals who can broker and ‘oil the wheels’ of collaboration across professional and organisational boundaries and with families and communities. But we need to scale this up, and part of that is recognising that ‘no one size fits all’ and that people need to be allowed to get on with leading and driving change.

In short, we need to create a ‘bias for action’ and there is a real urgency to do this. The time, energy and money which is locked up in process is unsustainable and unhelpful. There is, for example, much more that could be done to consolidate and rationalise funding streams and simplify application processes – both nationally and locally – and so reduce the number of hoops and hurdles which professionals and voluntary organisations alike need to jump through – often to access very small amounts of money or support.

Our performance measurement culture also has become too much of an end in itself rather than an aid to performance improvement. There are still too many targets – often competing and conflicting within and across agencies – which get in the way. So too has our desire to develop approaches which are informed by evidence, led to an over dependence on research and analysis at the expense of action. How many research reports and conferences do we need to tell us that play is important to children’s development?

And while I would be the first to say that we should, where possible, measure and evaluate the impact of public investment, I say with feeling that I believe this is one area where we have ‘lost the plot’. Do we really need, and can we really afford – either in terms of direct cost or time delay – to construct a business case, do yet another pilot or carry out a formal evaluation on each and every project and activity before deciding whether to roll out the approach or to just get on with a project?

We know a great deal about what works and does not work, we just have to get on and apply that knowledge. Similarly we need to allow people to get on and do and test localised approaches in real time.

The fact is that it is difficult – in some cases nigh on impossible – to quantify the impact of preventative spend. It is hard to prove that if we had not acted or intervened there would have been a poorer outcome or to demonstrate short term improvements where change may be generational. But existing evidence, not to mention professional judgement, human intuition and experience  – and sheer common sense – can take us a very long way.

I acknowledge that there are tools, such as SROI (Social Return on Investment) which can help in this area, but I personally conclude that we should spend less time searching for measurement tools and more time getting on and doing what we know needs done.

I note also that when it comes to societal well being, many of the behaviours and relationships which matter and which do so much to contribute to our human and social capital – simply do not lend themselves to hard edged short term quantification. e.g. The grandad taking his grandchild for a walk in the park; the neighbour offering help and support to the young parents next door; the dads who take wee boys out to play football every week or the new mums who get together over a coffee to just meet and talk together with their babies. Maybe it is time to stop searching for proxies to count and measure all these things and accept that we know what matters to us as human beings.

 In conclusion, Einstein famously said that the definition of insanity is ‘doing the same thing over and over again and expecting different results’.

I genuinely believe that much of what we need to do to give children a better start in life is not rocket science but bringing about change will require us to think and work differently in the future.

 Susan Deacon is Honorary Professor with the School of Social and Political Science at Edinburgh University and was previously Professor of Social Change at Queen Margaret University. She was an MSP from 1999-2007 and is a former Scottish Health Minister. She is currently Early Years’ Champion for the Scottish Government.

Support from the Start – Development Session

On the 8th October the East Lothian service and community champions met together with the planning board and steering group members to look at how Support from the Start was developing, what the successes and  challenges had been and what was going to carry the work forward in a difficult financial period.

The Scottish Governments Joint Improvement team facilitated the event which started with participants reconnecting with the vision of the test site and then identifying actions that would bring the vision closer, and address the challenges.

A report on the session is linked here East LothianSupport from the Start Development Event -Final Report (2)

and a summary of feedback from participants here East Lothian Support from Start Event 8 10 – Feedback Report

The planning board will discuss the report, and implementation of the actions arising from the session at its next meeting in early December.

Civic conversation

 

Start of the Conversation

Engaging parents, communities and services in the message of early intervention and reducing health inequality has always been seen as of key importance for the test site. We have called the engagement process a ‘civic conversation’.

The following report summarises the first eighteen months of the ‘civic conversation’ and the next steps to be taken in developing the conversation

civic-conversation summary no pics

This version of he report has had some of the photos strippped out to keep the file size down – if you would like a version with pic email me on swray@eastlothian.gov.uk or steven.wray@nhslothian.scot.nhs.uk

What can you achieve for less than £600?

 

Summer transitions

Sometimes large amounts of public money can be spent with minimal return – but sometimes very small sums can free the creativity of staff and parents to make a difference. The enclosed evaluation was sent to me earlier today. Its an evaluation report on a piece of work taken forward by staff in Prestonpans that made me think wow all that happened because of £600.

Service champions for Support from the Start have access to a small ‘simple rules’ development fund. The idea behind the fund is to provide a resource for champions to test out ideas that might lead to service redesign that will contribute to tackling health inequality in early years.

Helena Reid wanted to build on work that the integration team had been developing on supporting parents whose children are in transition from nursery to primary school.  Being ready for school and the school being ready for the children that they are to educate is, to my mind, a key area where services can support parents and children to help themselves. There is no doubt that the more a child can take advantage of educational opportunities the more likely it will escape poor health in later life.

The enclosed evaluation of a summer transition programme gives an exciting glimpse of how services can support that transition process for children that may have difficulties and engage parents who may need support in getting their children ready for school.

I was excited reading it and I hope you are.

Summer Programme Evaluation 2010 (2)

Civil society or big society – its still parents supporting parents

Most support for parents is provided directly by parents to parents both informally and as part of constituted groups. 

Over the last eighteen months I have talked to many parents involved in baby / toddler groups or groups for parents. The need for this type of support was summed up for me this week when I was at the Patchwork toddler group, which was having its first session back after a few weeks break. I had arrived before the group started and as parents arrived I overheard many of them saying something to the effect ‘This is a God send’ 

How well does society / community  support parents to support each other?  My impression is that funding in this area is a mosaic of overlapping grants which are applied for competitively and therefore time consuming to obtain and account for. Support for community groups can be patchy and it can be difficult to sustain. Yet these groups are clearly part of the fabric of communities – should we be supporting them more strategically?

Patchwork EH32 is one of the community champions for Support from the Start. They have also been a beneficiary of the service development fund with Lorraine Congalton community development officer in Prestonpans and a service champion for Support From sponsoring a bid to help develop the capacity of the parents group to reach more parents.

Here are some of the people involved in Patchwork talking about the group.

Patchwork parent

Patchwork parent2

http://equallywell.myvoxur.com/uploaded_files/13

‘It takes a village to raise a child’

 We all intuitively know that communities have a vital role to play in children’s development and learning.  Science is increasingly pointing to the importance of the pre-school years to the child’s capacity to learn, as well as their future health and well being. Yet we don’t measure or assess what  communities contribute to their children’s development and learning pre school.  If we don’t measure it, how can we  change it?

The Early Development Instrument (EDI) is a way of measuring children’s development and readiness to learn by the time they reach formal schooling – it was developed in British Columbia and has been adopted around the world. East Lothian is to pilot EDI in a Scottish context in partnership with the Scottish Collaboration for Public Health. The instrument is a community level tool, it does not measure individual performance, but rather how many children in a given community are developmentally vulnerable on one of five domains. In effect it measures how well a community is supporting its early years children. Where it has been used in other countries it has allowed for a community to become more actively involved in supporting early years issues.

A small group has been established to organise the testing of the tool on a small scale and training staff in its use before rolling out accross East Lothian. A wider stakeholder group(s) will be brought together to once this initial work is completed to look at the information that is developed from the instrument and how it might be used.

Dr Rosemary Geddes prepared this presentation on EDI for the Support from the Start planning board held in July

Early Child Development in Scotland_July7_97-2000

EDI_communityeffects_summarySCPHRP (2)

Visit by new Permanent Secretary and Chief Medical Officer

 

On the 19th July Scotland’s new permanent secretary Sir Peter Housden, accompanied by Dr Harry Burns, visited First Step in Musselburgh to speak to a range of people involved in using or providing early years services. 

After a tour of  First Steps facilities staff, volunteers and services users took part in a discussion facilitated by Susan Deacon about some of the challenges to, as well as the supports for, early years in East and Midlothian.

Many issues were brought up in the short period that was available for discussion – but what heartened me was the tremendous positive energy there was in the room ( no doubt contributed to by the wonderful home baking provided by First Step) This energy and enthusiasm for what a difference early intervention can make was there despite the awareness of the challenges faced by parents and children in some of our communities,  and of the funding issues faced by statutory and voluntary services. 

The other issue that chimed for me was the importance of services not stigmatising their users and the importance of the community seeing a service that is something anyone can access when the need is there. I was reminded of a  rather ugly phrase use by Sir Micheal Marmott – ‘proportionate universalism’ – services that are universal but provided in proportion to the need. The universalism of a service prevents it from being stigmatised, but it makes no sense to provide universal services equally, because need is not distributed equally. First Step is respected within its community because of the hard work and dedication of its staff – but also, I think, because it has that element of a universal service with additional support built in to address more complex or enhanced need.

Mapping support and interventions for attachment

 

Service mapping has been one of the goals of the test site in East and Midlothian – this has been focused on the ten medium term outcomes for the test site. These outcomes draw on existing service planning for health and social care services and were agreed as part of the  logic model for the test site by the planning board for Support from the Start. The objective of  the maps is to represent the path to achieving the agreed outcomes – what is that we are already doing that helps us achieve the outcome we are aiming for and what are the gaps.

Improve emotional well being  (draft)

Support from the Start Breastfeeding pathway summary (2)

Increase proportion of newborn children breastfed at 6-8 weeks (final)

Reduce Obesity Levels in p1 (draft)

Reduce pregnancies in under 16 year olds (draft)

Oral health draft)

Reduce Smoking Rates in Pregnancy (draft)

Increase opportunity for involving parents and children in services (draft)

Increase number of Health Impact Assessments on new developments (no pathwayidentified as yet)

Improved outcomes for looked after children (no pathwayidentified as yet)

Improve Readiness for learning (Draft)

Janice Macleod (School nurse manager and Leisa Randall (educational psychologist are now leading on the mapping of an attachment pathway for East Lothian. This work has been generated by discussions in the service champions action learning sets and Janice’s indefatigable enthusiasm for early intervention and the role of attachement 

A session has been organised to bring ‘stakeholders’ together to map out what is already happening to support the identification of attachment issues and how children and parents who are having difficulties with attachment are supported and access services. The output from this session will help to inform what interventions need and can be developed to shape this area of work in the future.

Mapping an attachment pathway V3

The outcome for pathway mapping session will be posted here

It’s more complicated than that…

Inequality in health outcomes has been described as a ‘wicked problem’. 

This is not said because of the social justice issues involved, but because of the fact that health inequality is created and maintained by a multiplicity of interacting factors. This complexity means that there are no simple levers at a national or local level that can be pulled or pushed to resolve ‘wicked problems’. 

For example, many people think of health inequality as created by poverty – true, but it is more complicated than that.

Some people think that its a matter of individual responsibility – if people did all the right things to look after themselves we would not have the level of inequality that we have – true, but is more complicated than that. 

Some people think its an issue about access to the right services, or levels of education – true, but is more complicated than that.

All of the above, and others,  are important and interacting factors in the creation and maintenance of poor health. All this means that work on one factor or aspect of health inequality alone, whilst potentially beneficial in its own right,  will not have the outcome of reducing inequality.  

Public services are organised for the delivery of services to individuals and communities and can struggle to formulate an adequate response to ‘wicked problems’ like health inequality.  It requires a long term focused effort from a range of different agencies and the active involvement of those whose health is targeted. Equally Well was conceived as non-traditional response to the ‘wicked’ problem of inequality – but there are others that we can also learn from.  One such is the ‘Total place’ programme in England which has attempted to approach some of the ‘wicked problems faced by public services with a different mindset.

For example

One of the central ideas of Total Place is that the long-standing machine metaphor of organisation and social systems is handicapping our ability to understand the environment we work in and how to change the behaviours of those systems.

I recently took part in a fascinating discussion as part of the Midlothian operational steering group for Equally Well , which centred on how the approach Equally Well was adopting to engendering change was different to more familiar approaches. I will write about this in another post but I revisited the Total Place document with that discussion in mind and the quote above resonated for me.

Although it is a fairly long document the following report is well worth reading for those interested in ‘doing things diffeently’ as it summarises and reviews the ‘Total Place’ experience and process.

Total-Place-a-practitioners-guide-to-doing-things-differently1