Reflecting on partnerships, identity and health inequalities

Presentation for NHS GrampianAugust 23rd 2011

Dr Rosie IlettDeputy Director

Glasgow Centre for Population Health

Aim of presentation:

•Who we are and does it matter?

•Strategic partnerships and what they do

•Health improvement and health inequalities – how do they interact?

•Decision-making – with whom?

•Working with the community

Community activists, service users, council staff, NHS staff?

Who are we and what do we bring ?

I’m genuinely passionate about health inequalities but that comes from my own experience I suppose. I’ve come from a working class background, I grew up in a family of six and there are only three of us left. So, I’m actually seeing the reality of health inequalities in a very, very powerful way. I get really, really cross when people start getting into that blame culture, ‘Well, it’s your own fault if you’re overweight’, ‘Well it’s your own fault if you drink too much’, ‘It’s your own fault if you’re driving an old car and have an accident’. (Allie)

I know it’s much, much more complex than that and I suppose that’s THE big thing that drives me and it’s at the heart of every single thing

that I do. (Allie)

This is about us too.

Who we are

What are our values and beliefs

How we understand people’s lives

How we think about inequalities

How we believe change can happen

What contribution we can make

In the NHS, most people know they don’t voice those kind of, wouldn’t voice a, racist comment in a public meeting or a private meeting, or even with work colleagues. Even if you felt that, you’d be more subtle. Most of the time. But I can think of a few examples, where it wasn’t that subtle. (Tom)

My father . . . gave me a perspective . . . that I've found surprisingly rare in the circles that I've worked in. I remember . . having a social conversation with a couple of colleagues, physically recoiling at the idea that my dad was a miner. ‘Oh my God, he's a miner's son’.

I'm quite proud of that. (Tom)

Have we created a professional elite who, on balance, have very, very little working knowledge of working class issues? (Tom)

Or LGBT, or disability, or asylum, or mental distress, or . . . . .

What is a partnership?

‘Means different things at different times to different people’

(Elston & Fulop, 2002, 207).

Two views on partnerships

Partnership ‘has almost become a panacea, a universal remedy for all ills and because of political realities it has to deliver results quickly’.(Kevin Woods, 2001).

‘It should not, of course, be assumed that in Scotland there is a trouble-free march towards a partnership nirvana’. (Bob Hudson, 2007).

Alternative definition

Or - is it the suspension of hostilities on a temporary basis in the mutually beneficial pursuit of joint funding?

Quote from Equally Well Test Site evaluation report 2011

The first 30 months of work in the Test Sites has reinforced the fact that there are significant challenges in making joined up multi-agency work effective; in transforming services from being reactive to focusing on early intervention; and in engaging service users in decisions about services.

Equally Well Test Site evaluation report 2011At relatively early stage in journey towards reducing health inequalities. Some underlying factors that will have impacted: •complexity of the area or theme •scale of inequality •strength of existing partnerships and networks – and whether open to change •success of previous attempts to tackle health inequalities •political priority accorded to area or theme •resources available.

Audit Scotland CHP report104. A key function of CHPs is to ‘tackle health inequalities, enhance anticipatory and preventative care, shift resources to community settings and provide a wider variety of services at local level’.However, CPPs have the lead role in tackling health inequalities and so CHPs need to work closely with them.

106. Since the Ministerial Taskforce’s baseline report in 2008, there has been indication of a slight reduction in health inequalities in some areas such as low birth-weight babies and first-ever hospital admission for heart attack . . . also evidence of the health inequalities gap widening in other areas, including deaths from CHD

Essential need Evidence

Solution focused Clear reason for partnership, how adds value and what success would be

Leadership Strong & committed leadership from partners & respective organisations

Vision Shared vision, and plan that operationalises it

Inequalities Clear recognition of need to address inequalities and integration throughout planning and partnership outcomes

Planning Explicit and structured planning, nurturing and maintenance

Resources and context

Time and resource investment, and understanding of operating context

Communication Open and honest dialogue including of potential difficulties and power

Contribution (roles)

Awareness of respective roles and responsibilities

Managing change Incremental, cooperative and be planned and understand impacts

Outputs Agreement about planned activities and outputs, and achieve results

Realism Aware of potential problems and ways of resolution

Evaluation Evaluation strategy that informs formation, development and maintenance

An ideal set of partnership components

Measuring process and outcomes

Process measures Outcome measures Shared purpose and need for activity Improved access for services users

Trust, reciprocity and respect Equitable distribution of services

Favourable environmental features Improved efficiency, effectiveness or

quality of services

Accountability arrangements - assess & monitor it

Improved staff experience

Leadership & management Improve service users’ life and health or reduce likely deteriorations

Engagement and commitment

Outcomes may be linked to other factors i.e. not partnership.

Difficult to attribute outcomes : unlike process measures are

rarely exclusive to partnerships

Scottish targets and measuring• English targets for reducing social class differences in infant mortality and

geographical differences in life expectancy never matched in Scotland as method for addressing health inequalities

• Scotland’s later introduction of health inequality targets more health improvement than tackling health gap. Embody health inequalities as about health disadvantage – deficit.

• Scotland now prioritising individual responsibility, lifestyle, self-management / personalisation, and NHS as vehicle for tackling health inequalities (Issue for local authority role and partnerships, may limit likely outcomes).

• Decisions about health promotion and tackling health inequities often based on deficit model - may disproportionately lead to policies and practices which disempower not benefit.

• An assets approach to health embraces `salutogenic' notion of health creation and participation of local communities in health development.

More likely to reduce inequalities

• Structural changes in environment• Legislative and regulatory controls • Fiscal policies• Income support• Reducing price barriers • Improving accessibility of services • Prioritising disadvantaged groups • Offering intensive support • Starting young

Less likely to reduce inequalities

• Written materials and information based campaigns

• Campaigns reliant on people opting in• Campaigns and messages for whole

population• Whole school health education approaches • Approaches which involve significant price or

other barriers• Housing or regeneration programmes that

raise housing costs

So - why do we keep doing them?

Possibly competing goals

Because the better off tend to gain more from social and public health policies, two public health goals:

• improving population health

• reducing health inequalities

may sometimes conflict.

Partnership with the community:challenges for decision-making

• Who represents local area/community of interest reps need to negotiate legitimacy / authority

• Elected members and ‘lay reps’ power moving away from democratic structures

• Decisions concerning competing groups, areas, services default to less contentious areas (government priorities) to avoid difficult choices

• Partnership working as threat and de-stabiliserthreaten purpose of agencies and staff identities

Partnership with the community:challenges for staff

The identity of professionals within each service is often closely bound up with their professional perspective on client groups and how their problems and issues are understood and addressed. Collaborative work requires professionals to acknowledge the perspective of others as equally valid, and in some cases this can be experienced as a threat to identity and expertise’ (Goss, 2007, 42-43).

So why don’t we do that?

• Fear of discrimination

• Might be judged

• Not objective enough

• Not really professional

• Keep work and home separate

• Nothing to do with work

Do you ever talk about your background at work?

Oh God. No. I don’t actually – that’s strange, I suppose. I don’t know - it’s just that separation of work and the more personal stuff. But I don’t. Actually there’s probably something in there about, well, people will start to apply those judgements that they make, they’ll start applying them to me. I think there is something about that in there. If people know too much about you then they make too many judgements about you – the wrong ones. (Allie)

Changing the culture and power?

Do you create the culture as a manager, who says to your staff, not, ‘You will do the following equality things’ but, ‘Do you understand some of these determinant issues’? Its not about saying that people don’t have personal responsibility for what they do in their lives, but do you understand some of the things that led them to where they’ve got?

Why identities are important to health improvementCreating a safe environment is brought about by marginalized individuals taking the risk to express their identity (Lips-Wiersma and Mills, 2002,185).

If public policy makers and managers responsible for implementing equalities legislation are not representative of the diverse society and cultures they are there to serve, they will not find it easy to service their diverse communities, or indeed to work in partnership with voluntary sector organisations rooted in these communities (Page et al, 2008, 370).

It really does matter

Engaging with diversity and equality is no longer an option for public service managers as they need to do more than eliminate discrimination instead ‘to promote equality’.

(Page et al, 2008, 379).

NHS Grampian HI workforce…

• Who are ‘we’?

• How do we work in an integrated way?

• How to evaluate process and outcomes?

• What is community engagement?

• How can we reduce inequalities?

• Why do things that we know don’t work?