The asset based approach to health and wellbeing in communitiesMonday 5th November 2012Birmingham

www.assetbasedconsulting.net

Trevor HopkinsFreelance ConsultantAsset Based Consulting

Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.

Margaret Mead – US Anthropologist 1901 - 1978

Introductions and outline• What are the ‘Deficit’ and ‘Asset’ approaches?• “A glass half-full”

• Principles, Values & Key themes

• “What makes us healthy?”• Evidence, Action, Evaluation

• How could this help us strategically?• How to develop the JSNA to include asset mapping• Using Appreciative Inquiry to develop the H&WB

Strategy• Co-production for health• Outcomes based commissioning

• How could this help us locally?• Appreciative Scrutiny• Asset Based Community Development• Community Health Champions• Resilient Places

The dilemma . . .

Clients and consumers

have deficiencies & needs

Citizens have capacities and gifts

A deficit approach

• Much of the evidence currently available to describe

health and address health inequalities is based on a

deficit model

• This is a ‘pathogenic’ approach to health and well-

being

• The deficit approach focuses on the risks, problems,

needs and deficiencies in individuals, families and

communities

• Professionals then design services to ‘fix’ the

problems

• As a result the community and individuals can feel

disempowered or can become dependent

• People become passive recipients of expensive

services

Features of a deficit approach

• Policymakers see professional systems or institutions

as the principal tool for the work of society

• In Public Health practice this approach has focused on

‘risky behaviours’ and ‘lifestyle factors’

• “The collective term for these behaviours is the

subject of much debate, with professionals from

different fields preferring different terminology, each

having a view about what is pejorative and what is

not.” (Clustering of unhealthy behaviours over time – King’s Fund , August 2012)

• Services are targeted at specific needs & problems,

communities and individuals become ‘segmented’

An assets approach• Values the capacity, skills, knowledge, connections

and potential in individuals, families and communities

• It is a ‘salutogenic’ approach which highlights the factors that create and support resilience and well-being

• It requires a change in attitudes and values

• Professional staff have to be willing to share power

• Organisational silos and boundaries get in the way of people-centred outcomes and community building

• Never do for a community what it can do for itself

Features of an assets approach

• Changing from servicing people’s needs to facilitating their aspirations

• Redressing the balance between needs and assets or strengths

• A shift in emphasis from the causes to ‘the causes of the causes of the causes’

• A move from targeted to universal approaches

• Solutions that are developed by people and communities not by specialists and professionals

Key messages 1. • Asset principles help us to understand what

gives us health and wellbeing in a new way.• The theoretical and research evidence for the

positive impact of community and individual assets is well known and at least comparable to that of more familiar behaviour and life-style determinants of health

• Asset thinking challenges the predominant framing of health as the prevention of illness and injury rather than the promotion of wellness.

• Asset working can promote mental well-being which is both a cause and a consequence of

inequality and physical ill health.

Key messages 2.• Work to improve health enhancing assets has

not only to focus on the psychosocial assets such as resilience and confidence, but also on the social, economic and environmental factors that influence inequalities in health and well-being.

• Asset based approaches complement services and other activities that are intended to reduce inequalities in life chances and life circumstances and which meet needs in the community

• Assets are simultaneously an input, a measure and an outcome. This has implications for the design and evaluation of asset based working.

A glass half-full:

http://www.assetbasedconsulting.co.uk/Publications.aspx

How an asset approach can improve community

health and well-being

The Principles• Assets: any resource, skill or knowledge which

enhances the ability of individuals, families and neighbourhoods to sustain health and wellbeing.

• Instead of starting with the problems, we start with what is working, and what people care about.

• Networks, friendships, self esteem and feelings of personal and collective effectiveness are good for our wellbeing.

“Focusing on the positive is a public health intervention in its own right”

Professor Sarah Stewart-Brown, Professor of Public Health at Warwick Medical School speaking at a conference on ‘Measuring Well-being’

19 January 2011 at Kings College

Values for an Asset Approach

• Identify and make visible to health-enhancing assets in a community

• See citizens and communities as the co-producers of health and well-being rather than the recipients of services

• Promote community networks, relationships and friendships

• Value what works well• Identify what has the potential to improve health

and well-being• Empower communities to control their futures and

create tangible resources

Key themes

The defining themes of asset based ways of working are

that they are:

• Place-based

• Relationship-based

• Citizen-led

...and that they promote social justice and equality

“What makes us healthy?”The assets approach in practice:

http://www.assetbasedconsulting.co.uk/Publications.aspx

• Evidence

• Action

• Evaluation

Evidence 1. • There is growing evidence for the importance of

health assets, broadly defined as the factors that protect health, notably in the face of adversity, and for the impact of assets based approaches

• Individuals do not exist in isolation; social factors

influence individuals’ health though cognitive, affective, and behavioural pathways.

• The quality and quantity of individuals social relationships has been linked not only to mental health but also to both morbidity and mortality. It is comparable with well established risk factors for mortality

Evidence 2.

• Stress buffering – relationships provide support and resources (information, emotional or tangible) that promote adaptive behavioural or neuoroendocrinal responses to acute or chronic stressors e.g. illness, life events.

• Social relationships may encourage or model healthy behaviours, thus being part of a social network is typically associated with conformity to social norms relevant to health and social care. In addition being part of a social network gives individuals meaningful roles that provide self esteem and purpose to life.

Action 1.

• Assets require both whole system and whole community working.

• Instead of services that target the most disadvantaged and reduce exposure to risk, there is a shift to facilitating and supporting the wellbeing of individuals, families and neighbourhoods.

• It requires all agencies and communities to collaborate and invest in actions that foster health giving assets, prevent illness and benefit the whole community by reducing the steepness of the social gradient in health.

Action 2.• Asset mapping• Toronto framework for mapping community

capacity • Joint Strategic Assets Assessment • Timebanking• Social prescribing • Peer support• Co-Production • Supporting healthy behaviours • Community development to tackle health

inequalities • Network building • Resilient Places• Appreciative Inquiry• Asset based service re-design• Assets – embedding it in the organisation • Workforce and organisational development

Evaluation• To evaluate health asset based activities requires

a new approach. Instead of studying patterns of illness, we need ways of understanding patterns of health and the impact of assets and protective factors.

• Methods that seek to understand the effects of context, the mechanisms which link assets to change and the complexities of neighbourhoods and networks are consistent with the asset approaches.

• The participation of those whose assets and capacities are being supported will be a vital part of local reflective practice.

How could this help us strategically?

• How to develop the JSNA to include asset mapping

• Using Appreciative Inquiry to develop the H&WB Strategy

• Co-production for health

• Outcomes based commissioning

Community asset mapping

The actual and potential assets of: • Individuals – heart, head & hand• Associations• Organisations

In a community this can also include:• The physical assets• The economic assets• The cultural assets

Primary Assets

Secondary Assets

PotentialAssets

Analysis of community assets

http://www.idea.gov.uk/idk/core/page.do?pageId=18364393

Community asset mapping/JSAA

http://www.assetbasedconsulting.co.uk/Publications.aspx

“Good organisations know how to preserve the core of what they do best.

Preserving the right thing is key.Letting go of other things is the next step”

David Cooperrider

Appreciative Inquiry

Principles

Reflection – remembering times when our culture, values and identity made us proud.

Affirmation - inquiring into those strengths and how we can use them to create the future

Action – practical planning towards the future

Characteristics

• Appreciative - AI looks for the ‘positive core’ of the organisation and seeks to use it as a foundation for future growth

• Applicable - AI is grounded in stories of what has actually taken place in the past and is therefore essentially practical.

• Provocative - AI invites people to take some risks in the way they imagine the future and redesign their organisation to bring it about.

• Collaborative - AI is a form of collaborative inquiry. It always involves the whole system or a representative cross-section of the whole system.

The appreciative cycle

Define

Discover

Dream

Design

Deliver

...building the path as we walk it

STOKE-ON-TRENT IS A VIBRANT, HEALTHY AND CARING CITY,

WHICH SUPPORTS ALL PEOPLE TO LIVE FULFILLING, INDEPENDENT AND HEALTHY LIVES

Healthy City: All children enjoy the best start in life and

everyone will live longer and healthier lives.

Vibrant City: Everyone will live, work and play in an

environment which supports them to live healthy and fulfilling

lives.

Caring city: Everyone is supported to live independent lives with fair access to high quality integrated health and social

care services when needed.

CITY OF STOKE-ON-TRENT MANDATE FOR HEALTH AND WELLBEING 2020

Starting Well: Children flourish and feel loved, valued and safe

Developing well: Everyone is able to achieve their potential and enjoy maximum independence and positive mental wellbeing

Working Well: Business thrives in the city and everyone has opportunity to be involved in meaningful activity (work, volunteering, caring)

Living Well: Everyone lives in a good quality home, in an area which they like and in an environment in which they feel safe across all generations

Staying well: Everyone has access to preventative health and wellbeing services and are supported to live healthy lives

Ageing Well: Everyone has a positive experience of ageing in the City and people are supported to live independent, inclusive and fulfilling lives throughout the life course

Achieved through: X% less children

live in poverty X%

Improvement in teachers identifying children as ready for school

X% children breastfed until at least 6 – 8 weeks of life

% reduction in low birth weight babies

Achieved through: Improved levels of

satisfaction with life

Reductions in number of NEETs

Reductions in pupil absence

Reduction in the number of 15 year olds who smoke

Reduction in number of hospital admissions as a result of self-harm, unintentional and deliberate injuries in under 18’s

Achieved through: % increase in

volunteering/community champions activity

Reduction in sickness absence rates

% increase in number of people with LTC in employment – including people with a mental illness or learning disability

Achieved through: % of greenspace in the

City is rated good quality and is accessible

All major plans for regeneration of the City are subject to an HIA

% reduction in fuel poverty

% reduction in statutory homelessness

social connectedness % self-reports of

feeling safe in the community

Achieved through:

Increase in literacy and numeracy in adult population

improved health related quality of life for older people

% reduction in hip fractures in older people

Reduction in number of falls and injuries in over 65’s

Achieved through: x % reduction in

smoking prevalence

x% reduction in obesity

x% reduction in hospital readmissions for LTCs

Reduction in number of excess winter deaths

Strategic Outcomes

Healthy City: Children will enjoy the best start in life and everyone will live longer and healthier lives Vibrant City: Everyone will live, work and play in an attractive environment which supports them to live healthy

and fulfilling lives Caring City: Everyone is supported to live independent lives with fair access to high quality integrated health

and social care services when needed

Co-production

“Co-production means delivering public services in an equal and reciprocal relationship between professionals, people using services, their families and their neighbours. Where activities are co-produced in this way, both services and neighbourhoods become far more effective agents of change.”

The Challenge of Co-production – David Boyle & Michael Harris, December 2009

“Services do not produce outcomes – people do.”

Co-production and social capital; the role that users and citizens play in improving local services – Jude Cummings and Clive Miller – October 2007

Further reading on co-production

http://www.neweconomics.org/publications/public-services-inside-out

http://www.nesta.org.uk/events/assets/features/the_challenge_of_co-production

The principles of co-production

• Recognises people as assets

• Build on peoples existing capabilities

• Promote mutuality and reciprocity

• Build peer support and social networks

• Break down barriers

• Facilitate rather than deliver

Co-production of health & well-being

Co-production for health

• Exploit the opportunities created by the integration of public health and local government.

• Use the new structures, approaches and democratic accountabilities to deliver public health outcomes and a reduction in inequalities.

• Maximise the new commissioning structures to improve health outcomes and reduce inequalities when money is tight.

http://www.sph.nhs.uk/sph-documents/local-government-colloquium-report

Key messages

• Use the transition to start to develop a new co-production model for health and wellbeing.

• Establish focused, agreed priorities which have meaningful outcomes for all partners.

• Use intelligence dynamically, creatively and succinctly and in relevant forms for different audiences.

• Promote an asset based approach to communities to understand and harness their assets and resource.

• Adopt a new approach to partnership and leadership whilst building on what has worked.

• The public health workforce has to change – a new business model needs adopting that is pragmatic, practical and delivers solutions to commissioners and providers.

Outcomes-based commissioning

• The transformative potential of co-production and assets approaches is not best served by traditional procurement models.

• The approach of co-production can be incorporated across the entire commissioning framework.

• Providers are usually contracted to deliver a service defined by its inputs and outputs with little reference to wider outcomes

• There is little or no requirement to identify and build on assets and capacity within the community

• Commissioning should be designed around outcomes

Combining commissioning &co-production

• The commissioning framework defines long-term outcomes

• Potential providers are incentivised to be innovative and flexible about achieving outcomes

• Co-production is specified as an approach that providers must develop

• New providers can emerge

• Commissioners can specify that providers develop preventative approaches to service delivery

• Wider social and environmental outcomes can be built into the assessment of value for money

Bringing it together

Kirklees Mental Health Partnership used an outcomes-based specification for the mental health advocacy service and mental health carers’ options service.

• The providers were required to base the service on the ‘principles of co-production’ and recognising ‘the assets of the individual’.

• The specification sets out a number of expectations of the service. It set out that: people will not be seen as passive recipients of the service; that they have ‘assets with value and expertise’; they will be enabled to ‘explore their potential to the fullest, push the boundaries, take risks and maintain or regain increasing control over their daily lives’.

• The six co-production principles underpin the specifications, and each one details the expected outcomes under those headings.

• The service is monitored through a consultative forum with 50 per cent representation of service users and 50 per cent from the different agencies, using quantitative data on client details, a framework of personal, community and economic outcomes

www.yhip.org.uk/silo/files/mental-health-carers-options-service--service-specification.doc

How could this help us locally?

• Appreciative Scrutiny

• Asset Based Community Development

• Community Health Champions

• Resilient Places

Appreciative Scrutiny

• By using a solution focused perspective participants in the inquiry could see how successful tobacco campaigns have been with non-smokers.

• Public sector tends to focus on negative behaviour and looking at ways to change this, rather than looking at the positives.

• That Appreciative scrutiny can energise officers, politicians and residents when working together on an issue.http://www.cfps.org.uk/domains/cfps.org.uk/local/media/downloads/L12_658_CIFPS_Appreciative_Scrutiny_FINAL_Sept_2012_for_web.pdf

Asset Based Community Development

The C2 Connecting Communities Project

• Locating the energy for change: through face-to-face conversations, door knocking, meetings with local groups and associations, finding the (small) group of people who could initiate and lead the community

• Listening events: co-hosted by the community and the agencies, the professionals listened to what was positive on the estate, what the community thought the priorities were and what needed to change

• Creating places and spaces for residents to connect, build relationships, have conversations and share knowledge, and encouraging local activities such as street parties, outings, raffles and so on

• Co-learning: through conversations and open discussions communities and staff came to realise that they both have the same aims and they need each other if they are to realise those aims

• Learning from similar areas that have been successful: residents and agency staff visited other estates to see what could be done and to be inspired by the possibilities – they now host many visits from developing communities

• Challenging the negative image of the estate, held by both residents and staff, so that they all believed they could make changes

• Supporting the community to lead the partnership and to determine what the priorities were and what would work.http://www.healthcomplexity.net/content.php?s=c2&c=c2_background.php

Community Health Champions• Altogether Better has developed an award-winning, evidence based approach to engaging and supporting individuals in communities to become Community Health Champions.

• Their ambition to to work to create social value by unlocking the assets and resources of individuals and communities to create healthier communities and better quality health services.

• Work together to activate the full potential of Community Health Champions to improve the health and well being of their communities

http://www.altogetherbetter.org.uk/amazing-stories-collection

Resilient Places“At the beginning of autumn, the Jewish community celebrates the festival of Succos, translated as Tabernacles - with its many colourful laws and customs. One of those customs involves using a type of pine, a type of fern, called cypress.

This story begins as much as twenty years ago at the end of Succos. As we had done for many years previously, we discarded all the cypress we had used for the festival and thought no more about it. Unbeknown to us, a branch of cypress has escaped the black bin bag, and seeded itself in the crack between the paving stones in our garden. Without anyone knowing a tree began to grow which is now over 30 feet tall.

The years passed. Our family grew, our community grew and the tree grew. Good times came and went and times of trial and difficulty came and passed. Throughout it all, I tried my hardest, somehow trying to control a life that no-one can ever control.

The tree is a gift G-d sent me to teach me just that. It grows and flourishes without me. I didn’t plant it, I didn’t tend it, yet its beauty and power is there for everyone to see. It’s G-d’s way of reassuring me that He can do so much without me and that He takes control of that control which will always elude us.”

Postscript – An ‘ill wind’

A day after the picture on the front of this report was taken, it was gone. The tree, which had inspired Mrs Gardner, her friends and family for so many years had been felled. Unseasonably bad weather in early April 2012, including strong winds, had unsettled the roots and it was threatening to fall down in the direction of the adjoining College buildings. The photograph shows it was already starting to lean.

A pessimist would doubtless say this was something of a ‘bad omen’, giving a lie to the appreciative message inspired by the tree’s remarkable development from the seeding of a discarded branch. However it is interesting to note the diametrically opposite view was taken.

Mrs Gardner and others involved in the consultation process, remarked on the poignancy of the tree’s demise so soon after it was used as a powerful metaphor for the consultative process on improving health and well-being in a cohesive, faith-based community. The growth of the tree was an allegory for those things in life that individuals can’t control but which can be achieved against the odds by a combination of pulling together, positive thinking, and the strength drawn from shared faith, values and beliefs.

After surviving many storms the final wind had blown, the axe had fallen and the tree was a thing of the past. But its message survives and will linger in the memory of many. It is an enduring message of hope against adversity and the inspiration that can be drawn from the world around us. This is a recurring cornerstone of Jewish teaching and appreciative thinking, illustrated just a few hundred yards from where the story of the tree had been told.

The message had been delivered – the tree had served its purpose.

Resilient Places

It takes everyone to build a healthy, strong and safe

community.

“The asset approach is a set of values and principles and a way of

thinking about the world.”

www.assetbasedconsulting.net