Multi-agency partnerships and the transformation of domestic abuse support

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Domestic abuse has been rising up the political agenda in the past few years. 2019 saw the appointment of the UK’s first Domestic Abuse Commissioner, and last month, the updated Domestic Abuse Bill was introduced to the UK Parliament (expecting to see Royal Assent in April 2021). But domestic abuse is still a widespread and endemic problem across the UK, with figures suggesting incidents across all areas of the country and across multiple demographic groups.

Often people who experience domestic abuse are difficult to identify and can struggle to engage directly with domestic violence support services. However, there is a growing recognition that knowledge sharing, and partnership working between statutory services, like housing or health teams, is vital to identifying and supporting victims and survivors in a timely and effective way.

Increasingly, the criminal justice system, health sector, social housing providers, charities, and local government have been attempting to work together to ensure that they are all able to respond effectively and provide the necessary support to domestic abuse victims and survivors.

The impact of lockdown

The most recent Crime Survey for England and Wales released by the Office for National Statistics (ONS) showed that an estimated 2.3 million adults aged 16 to 74 years experienced domestic abuse in the last year (1.6 million women and 757,000 men). Research published by the London School of Economics (LSE) after the first lockdown found that in London domestic abuse calls to the police increased by 11.4% on average, compared with the same weeks in 2019. The increase was, in a large part, due to an increase in calls from third parties not directly witnessing the incident, including neighbours or family members.

Similarly a report from Women’s Aid found that those delivering services needed to grapple not only with increased demand for support, but also with the challenge of delivering effective support in a different way as many services were only able to be accessed virtually.

Coordinated community responses transforming support for survivors

Organisations are becoming increasingly aware of the roles they can play in supporting people who experience domestic abuse and in the early identification of people at risk. Research also suggests that if someone is experiencing abuse, there is a high likelihood that they will also be experiencing other “needs”, which may cause them to come into contact with multiple services at once. Co-ordinating the response between services encourages organisations to share information to ensure consistency of care and experience; it can also help identify any gaps in support and allow for appropriate signposting and places the onus on the organisations, rather than on the person experiencing abuse.

Coordinated community response (CCR) approaches encompass the broadest possible response to domestic abuse; CCR addresses prevention, early intervention, dealing with crisis, risk fluctuation, and long-term recovery and safety, working with a wide range of services, pathways, agencies, and systems.

The fundamental premise of the CCR is that no single agency or individual can see the complete picture of the life of a family or individual within that family, but all may have insights and can provide interventions that are crucial to their safety and wellbeing. The CCR enables a whole system response to the whole person. It shifts responsibility for safety away from individual survivors to the community and services existing to support them.

The CCR is made up of 12 components: survivor voice; intersectionality; shared objective; structure and governance; strategy and leadership; specialist services; representation; resources; co-ordination; training; data; policies and processes. Taking a CCR approach provides communities with method for coordinating a response to domestic abuse. It places survivors at the heart of decision making and is an approach many frontline services can and do take when designing and implementing support services for people who have experienced domestic abuse.

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A pilot roll out for wrap around housing support

The Whole Housing Approach (WHA) to domestic abuse was first conceptualised in 2018 by the Domestic Abuse Housing Alliance (DAHA) in collaboration with the National Housing and Domestic Abuse Policy and Practice Group This approach aims: “to improve the housing options and outcomes for people experiencing domestic abuse so that they can achieve stable housing, live safely and overcome their experiences of abuse.”

The approach enhances how people who have experienced domestic abuse have control over their own lives, considers what they want to achieve and change, and offers interventions based on this. The key principles of the WHA are outlined as: safety; inclusivity; empowerment; accountability; and prevention, with 12 additional key components which make up the practical application of WHA programmes.

The initial WHA pilot project was delivered in three areas from October 2018 to the end of March 2020. Six specialist domestic abuse organisations, as well as a civil society organisation, have been working with 10 local authority areas, including in London, Stockton and Cambridgeshire to establish comprehensive and consistent housing practices and deliver a WHA.

A whole housing approach toolkit has been published which contains more information on the pilots, evaluations and analysis of the programme. The toolkit includes a dedicated section for each of the twelve components of the WHA. Each section can be read as a standalone toolkit that outlines key initiatives to help survivors achieve safety and stable housing. It offers practical guidance and resources to local areas to deliver a consistent WHA to domestic abuse.

Image Via DAHA

Final thoughts

While the landscape of domestic violence support is varied and is delivered in different ways by different agencies, there is a growing understanding of the practical steps which should be taken to ensure that partnership working and effective coordinated responses between services are offered to survivors of domestic abuse. It is clear that there is an appetite among those who work within frontline services to improve the availability of support. The ultimate aim of a coordinated response and a wraparound service to survivors of domestic abuse is achievable if current best practice and effective pilot schemes can be built upon, with additional funding and wider roll outs.


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Devolving health and social care in England: an opportunity to transform how we approach health and care?

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In recent years, the Department of Health and Social Care (DHSC) has increasingly encouraged the transfer of powers over health and social care in England away from central government and towards city regions. These bodies, DHSC argues, are uniquely placed to understand the challenges faced by their local populations, the capacities and expertise of their local NHS and to develop plans for the future. This should enable them to approach health at a local level, promoting increased delivery of care in the community, and a greater integration between health and care services.

Putting local places at the centre of “Build back better”

In August 2020 the Health Devolution Commission launched its final report, Building back health and prosperity. Among other themes, like taking a “health in all policies approach”, the report found that devolving accountability and power to a more local level creates the potential to understand communities and places better, and to meet their needs.

The NHS Long Term Plan has also outlined a new direction for the NHS based on the principle of collaboration rather than competition, and the introduction of new structures such as Integrated Care Systems, Integrated Care Providers and Primary Care Networks. These partnerships bring health and social care commissioners together to plan and deliver integrated and person-centred care.

In the context of “building back better”, awareness of how our external experiences and contexts impact our health and wellbeing (for example the impact of poverty, deprivation, housing, and unemployment) is increasingly important.

Beyond the immediate recovery from the pandemic, health devolution could be one way of opening up the possibility of integrating not just disparate services within the NHS – or even NHS and social care services in a locality – but bringing together in a combined strategy and structure all of the services, systems and partners in a community that have an impact upon the health of a local population, and the care services to better meet their health needs.

“It doesn’t have to be a battle”- partnerships and balance are the key to effective devolution

The move away from centralised processes and organisations towards more local ones can sometimes be portrayed as a rejection or an attempt to “break free” from central government. However, practitioners have been increasingly stressing that devolution does not mean complete independence, and that while improved local decision making will improve outcomes for local people, that does not mean that the need for some centralised decision making is completely removed.

On the contrary, some decisions should and will be taken at a national level, but the ability to distribute power, decision making and accountability to a local level will have significant positive impacts for improving “citizen voice”, transparency and co-production in decision making.

This is where the Health Devolution Commission argues that balance, communication, and partnership between the local and national infrastructure needs to be aligned so that devolution can be successful and sustainable. Integrated planning and management of long-term health care strategies is important, as is the ability to bring citizens and local decision makers into discussions about national health policy.

The Voluntary, Community and Social Enterprise (VCSE) sector, including patient voice and carers organisations, also plays an important role in linking together services and communities. As well as partnering to deliver services, these organisations also often offer vital bridges between statutory systems and those communities which can often be excluded from engagement with services or who can find it harder to access them. The commission also emphasised the importance of bringing these bodies into the conversation on devolution going forwards as they will be invaluable partners in the process.

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DevoManc providing the blueprint?

In 2016, as part of a pilot, control of the health and social care budget for Greater Manchester was transferred to a partnership team in the area comprising local authorities, clinical commissioning groups, NHS foundation trusts and NHS England.

The combined authority identified that the health of its population was one of the key obstacles to its economic growth. By relating the concept of regional economic prosperity with health, they began to see health in a completely different way – as part of a wider plan and an investment for growth, not a burden.

“It’s better to have decisions made locally, because local people understand what local problems are and what Greater Manchester needs. We need to work together.”

Lord Peter Smith, Chair of Greater Manchester Health and Care Board

The Greater Manchester Health and Social Care Partnership are working in partnership with other sectors including education and housing to support everything from good eating habits and exercise to education and everyone’s ability to earn a decent living. The partnership is taking action to give children the start they need, support independence in old age, tackle illness earlier on and even prevent it altogether by improving the lifestyles of local people.

Other areas of England are also currently undertaking their own health devolution journeys, including London, West Yorkshire and Harrogate, as well as some other combined authority areas. However, one of the big challenges is that currently, while we can learn from the experiences of those already on their devolution journey, there is no common, consistent or comprehensive understanding of what good heath devolution looks like, full evaluations of the benefits it brings or overarching strategies on how it should be developed.

This is something that will need to be addressed if health devolution is to be successfully rolled out across England.

Final thoughts

Devolution of health to a more local level provides an opportunity to tackle the big public health challenges of our time at source, and to create a better, more joined up community health ecosystem. It also provides the chance to share and collaborate, learning from best practice and delivering improved health and social care services at a regional and national level.

It has been suggested that the coronavirus pandemic, while traumatic in more ways than one for the NHS and its staff, may provide the re-setting point needed to implement some of the changes proposed in relation to greater health devolution. Proponents of this view argue that improved funding to support effective and high quality care, improved integration between health and social care, and greater positioning of health and assessment of the impact of decisions on health across all policy areas, should be among the top priorities as the country looks to recover from the pandemic.

As the Health Devolution Commission underlines:

The pandemic has shown we cannot go back to the way things were. We need a ‘new normal’ and we believe that comprehensive health devolution is the only viable solution to the challenges the country now faces.”


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Exploring Barnahus: a Nordic approach to supporting child abuse victims

Barnahus (which literally means Children´s house) is a child-friendly, interdisciplinary and multiagency centre where different professionals work under one roof in investigating suspected child sexual abuse cases and provide appropriate support for child victims.

Learning from the Nordic countries

Barnahus has assumed a key role in the child protection and child justice systems of many Nordic countries, including Sweden and Iceland. While there are some small differences in definition of the model across these nations, the general principle remains the same: to create a one-stop-shop for services that children can access under one roof. Services range from country to country, but usually include a combination of police, criminal justice services, child and adolescent mental health practitioners, paediatric doctors and social services.

The Barnahus model involves a high level of interdisciplinary working between different teams and allows for a complete package of care and support for a child to be created to reflect their needs. Within the Barnahus centres there are normally facilities including medical rooms, interview rooms, courtrooms, and residential facilities for those young people deemed at risk and who need to be taken immediately into temporary residential care.

Evaluations of areas that use this model of intervention have found significantly better outcomes for child victims and their families because of the multidisciplinary and multi-agency approach. Some discussions have also suggested that creating an adapted model for adult victims could also be a possibility in the future.

Reducing the trauma for victims of child sexual abuse

In England, it is estimated that only 1 in 8 victims of child sexual abuse are identified by the authorities. Children who disclose that they have been sexually abused face multiple interviews in multiple settings to a number of different people, often asking them the same questions. This can be confusing and frightening, as well as traumatic for many children who have to repeatedly recount the story of their abuse. Once the interview process is over, they can also then face long waiting times to access specialist therapeutic support.

The Barnahus model seeks to reduce some of the trauma experienced by victims of child sexual abuse by making the approach child-focused, emphasising the importance of a positive, safe and supportive environment in which to be seen by specialists, give evidence and receive support. For example, within the models used in Iceland children and young people are interviewed and examined within a week of the abuse allegation being made. These interviews are all conducted and recorded in a single location with specially trained officers and medical professionals, and they are then used in court as evidence, avoiding the victim having to revisit court in order to give evidence or testify.

Inside the centre, a specially trained interviewer asks questions, while other parties watch via a video link. Any questions they have are fed through an earpiece to the interviewer. Lawyers for the accused have to put all their questions at this point.

Another benefit to the model is that children who are interviewed are then able to access immediate assistance and counselling; in the current system in England, children may face cross-examination in court months after the alleged abuse, and would have to wait for victim support therapy.

Allocation of funding from government

In 2017, in response to the success reported in the Nordic models, the UK government earmarked Police Innovation Funding of £7.15m to help establish and roll out a similar scheme in London, which would see criminal justice specialists working alongside social services, child psychologists and other services and, it is hoped, pave the way to create a UK-wide Barnahus model in the future.

Building on the existing model in London, CYP Haven, which provides largely clinical, short term care, will provide a multi-agency, long-term support and advocacy service that is expected to support over 200 children and young people each year. Criminal justice aspects of aftercare will be embedded in the service, with evidence-gathering interviews led by child psychologists on behalf of the police and social workers, and court evidence provided through video links to aid swifter justice.


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Who’s caring for our young carers?

In less than two months time the UK will come together to recognise the 700,000 young people in the UK who provide care and support to families and friends, on Young Carers Awareness Day on 25 January.

Every day, children and young people provide physical and emotional care and support to their family members. Helping with household tasks, they care for young siblings, administer medication and deal with the emotional and physical stress of caring for a loved one with an illness. Estimates of the number of young carers living in the UK vary greatly. But Carers Trust suggests the number of young carers to be around 700,000 – that’s 1 in 12 secondary school-aged pupils. And those are only the ones we know about. Too many are falling through the net, going unnoticed and unidentified by services who can support them.

Attainment and employment

Earlier this year we joined in publicising the 2017 Young Carers Awareness Day, whose theme was “When I grow up”. The idea was to help people to understand how difficult it can be for young carers to realise their hopes and dreams for the future without the right support in place. A survey conducted by the Young Carers Trust found that over half (53%) of those surveyed were having problems in coping with schoolwork, with nearly 60% struggling to meet deadlines. Over 70% have had to take time out of school or learning specifically to care for a family member. A third admitted that they have to skip school most weeks.

With over 50% of young carers surveyed by The Children’s Society admitting that their caring responsibilities have caused them to miss days at school, and the burden of caring impacting on the ability of children to engage fully with school activities, it is unsurprising that young carers are twice as likely to be NEET as their peers. In addition, young carers in work find caring responsibilities have a disruptive effect on their workplace attendance, with understanding and flexible employers often being the difference between young adult carers remaining in work or becoming unemployed.

Mental health and wellbeing

Caring for a relative takes a massive toll on a young person. Recent reports published by Carers Trust and the Children & Young People’s Commissioner Scotland (CYPS) both show the significant mental health burden that caring places on a young person. Stress, isolation and anxiety that can come as a result of being a carer can have a significant impact on a child as they lose much of their contact with the outside world, become removed from social groups and miss out on opportunities to experience a “normal” childhood. Projects like Off the Record’s Young Carers Project in Croydon provide support and opportunities for respite for young carers. But it is clear that as child and adolescent mental health services  (CAMHS) are becoming increasingly stretched themselves, it is more important than ever to ensure that specialist services are also made available to young carers.

Partnerships working to provide support

Young carers often come into contact with multiple services. Education, social care, health and others all have an impact on young carers and their experiences and as a result can have a positive impact on their experiences too. Increasingly, services are being encouraged to cooperate in order to create a holistic support network for young carers, which encompasses every area of need they may have, and creates a seamless transition for young carers through all of their interactions with various services. Key coordinators and facilitators are vital in this role.

In the previously referenced report from CYPS, it was highlighted that many young carers felt positive about – and took pride in – their caring role, but that around two-thirds also said they felt “left out of things” at least some of the time. While they care for their loved ones, we need to make sure someone is caring for them.


Young Carers Awareness Day 2018 will take place on 25 January 2018.


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Going grey behind bars: meeting the care needs of older people in prisons

The population is ageing. People are living longer, and are in need of greater levels of care than ever before. But how is this increase in life expectancy and demand for care being met in prisons? Our prison population is also ageing, at a time when the sector is under increasing pressure, low staff numbers, higher levels of prison violence and disorder, and poor, crowded living conditions. In an environment which is largely designed to support young, able bodied men, how are prison staff and care teams liaising to help meet the needs of older prisoners?

A care plan for ageing prisoners

A report published in 2017 by the Scottish Prison Service called for a specific care plan for ageing prisoners to react to and provide planning to reflect the change in demographic of the prison population. The report found that between 2010 and 2016, the number of men aged over 50 in Scotland’s prison population rose by more than 60%, from 603 to 988. According to a Ministry of Justice report on prison population, the number of inmates aged over 50 is projected to grow from 12,700 to 13,900 by the end of June 2020, a rise of 9.5%, while the number of over-60s behind bars will grow by 20% from 4,500 to 5,400 over the same period.

In July 2017 Prisons and Probation Ombudsman produced the Thematic Review: Older Prisoners, which stated that HM Prison and Probation Service needs a national strategy to address the needs of the increasing numbers of elderly prisoners. It highlighted six areas where lessons still needed to be learned: healthcare and diagnosis, restraints, end-of-life care, family involvement, early release and dementia, and complex needs.

The difficulties older prisoners face on prison estates are far reaching. Not only are there physical barriers to moving around and living within a prison environment, but the increased mental health and social care burden is significant, as well as the potential need to begin end-of-life care. Many prison inmates suffer from multiple, longstanding and complex conditions, including addiction, and these conditions are exacerbated by a phenomenon known as “accelerated ageing”, which suggests that prisoners age on average 10 years faster than people of the same age in the wider community.

While some prisons have effective care plans which allow older prisoners to live with dignity, often older prisoners rely on the goodwill of officers and fellow inmates to meet the gaps in their care needs. And while in England and Wales the Care Act means that, a statutory requirement to provide care lies with the local authority within which the prison is located, this is not a guarantee. Calls have been made for care planning in prisons to become more robust, with minimum standards of care and a clear pathway of delivery, with accountability and responsibility of specific bodies being made explicit.

 

Prison staff, care teams and the NHS in partnership

Any care planning for older people needs input from a number of different sources, and care planning for older people in prison is no different. It will require input from professionals across health, social care, and housing and the criminal justice system as well as wider coordination support and legislative and financial backing from central and local government.

Prisoners with physical disabilities or diseases such as dementia need specialist care at a level that standard prison officers cannot give. Research has suggested that prison staff are being expected to shoulder this extra burden, often having to perform beyond their duty to care for and look for signs of degeneration in prisoners, particularly those who show signs of Alzheimer’s and dementia.

A number of research studies have looked at the provision of training and the use of additional, multi-agency staff to try to bridge the gap in care for elderly prisoners. In 2013 a review was conducted of multiple prisons, including some in England, the USA and Japan, which examined the training available on each estate for prisoners with dementia and similar conditions.

A number of schemes have been trialled, including extra training for staff, the allocation of specific wings or cells adapted to cater to the specific needs of older and vulnerable prisoners, and the use of peer to peer buddying or befriending services to help with care and support. Some prisons have also trialled the introduction of “dementia champions” to identify and support those with early signs of dementia or Alzheimer’s.

Extra challenges on release

As well as social care needs inside prison, specific rehabilitative needs of older prisoners being released from prison is also something that prison charities and reform bodies are keen to raise onto the agenda. A report from the Prison Reform Trust in 2016 highlighted the challenges of rehabilitative and parole needs of older prisoners, commenting that older people released from prison are being “set up to fail” by a lack of adequate provision to meet their health and social care needs on release. It highlights the limited and inconsistent housing, employment, debt and substance abuse advice available specifically for older offenders and suggest that their particularly vulnerable position puts them at risk of serious harm or reoffending.

Final thoughts

The population of older prisoners in our prisons is growing, and it is clear that a comprehensive strategy is needed to ensure that the specific, and at times unique care needs of these prisoners are met. This will mean greater cooperation from social care, health and criminal justice agencies, but will also mean reassessing how we think about social care, how it should be delivered and funded. The needs of older prisoners go beyond physical adaptations, to mental health, dealing with social isolation, the onset of chronic illnesses and at times the provision and planning of end of life care.

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Buurtzorg: reinventing district nursing in Scotland

Buurtzorg roughly translates from its native Dutch as “neighbourhood care”. The model, used extensively in the Netherlands, has attracted international attention as a novel way to deliver community based nursing programmes. Its positive reputation and recorded successes in areas of Holland are attributed to its innovative use of locally-based and locally-aware nursing teams to deliver high-quality person-centred, but low-cost, care.

Seeking to improve core health outcomes

In the Netherlands, Buurtzorg was designed to engage three key health priorities:

  • Health promotion
  • Effective management of conditions (in a community setting)
  • Disease prevention

It focused particularly on the elderly, those who move regularly between hospital and home, and those with long term, constant care illnesses. It has also been used with patients with progressive illnesses such as dementia, with some nurses within the teams being given training to become dementia specialists where appropriate.

The model includes the following key elements:

  1. Holistic and personalised care – where assessments of need are integrated into and form the foundation of agreed care plans
  2. Mapping networks of informal care, and assessing ways to involve these networks in treatment plans
  3. Identifying other formal carers and organisations who provide care services and coordinate their input
  4. Taking steps to support the client in his/her own environment
  5. Promoting self-care and independence on the part of patients.

A number of studies of pilot sites across the UK and beyond have identified the positives and some challenges of applying the Buurtzorg model in different contexts. Some of these are outlined in the table below.

Applying the model in Scotland

In a Scottish context, the model has been applied in a number of areas, with the initial pilots making way for a wider roll out of adaptations of the model. In March 2017, as part of a wider research project, nurses and management staff from NHS boards across Scotland met in Perth to discuss learning and exchange best practice around how the model could be adapted and further rolled out in the future.

It highlighted the different stages that many Buurtzorg areas were at in their roll out, with some like Aberdeen and the Borders far more established than Argyll, who were at the time only in the earliest stages of their Buurtzorg journey. The research and learning event gave practitioners the opportunity to engage and further cement both formal and informal learning networks, which have been identified as key to the success of the Buurtzorg model both in the UK and elsewhere.

The importance of information sharing and informal learning

Rolling out the model in test sites highlighted the importance of planning and learning, and of creating a strong sense of trust between practitioners and NHS management, but also between the Buurtzorg nurses and their service users and other professionals. This change in mindset regarding ways of working, and a change in the chain of accountability was something, which, according to those practitioners who attended the Perth event, many sites have found to be a significant barrier to effective implementation.

However it was also highlighted that promoting and facilitating the creation of formal and informal learning networks and learning spaces can be an effective way to generate conversation about best practice as well as allaying some fears that may persist regarding working culture and approaches, including partnership working with other agencies and understanding risk in the working environment.

In Scotland, approaches have varied, from encouraging nursing teams to create videos and then post them to an online forum, employing more formal training plans to incorporate multiple agencies and ensure that everyone is “singing from the same hymn sheet”, or holding informal drop-in or open space events where staff are supported in their role and given advice to alleviate and find potential solutions to issues.

Practitioners also highlighted that it is important to provide a space where teams can examine what did not work well, and why. Learning from mistakes can often be as beneficial as learning from good practice, as these can provide insights into issue management and resolution as well as how to implement the programme effectively.

It is also clear from feedback, that while a strong core network of nurses and other community based practitioners is vital to the success of Buurtzorg care models, the back team support is also just as important. Creating efficient and streamlined processes leaves nursing teams free to care for patients and allows them more time to develop and deliver the person-centred care which is a key element of the Buurtzorg model.

Final thoughts

Learning from the experiences of the trial projects in Scotland has provided invaluable insights on how the model can be applied and some of the challenges that can be encountered because of the differing context. This knowledge can then be used to shelter and steer newer projects away from danger areas toward best practice and innovative collaborative working. Applying Buurtzorg in Scotland gives the potential to create and implement new models of holistic person-centred care, where practitioners with local and specialist knowledge interact at a local level with other care providers, join up approaches and create a better care experience for service users.

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Community planning in the devolved UK

Community planning is all about how public bodies and other partners work with local communities to design and deliver services that suitably reflect the needs and priorities or a local area. Effective community planning incorporates strong partnership working and a shared vision which has been created especially to fit a set of local circumstances.

Providing effective and efficient services, promoting community engagement and enterprise and engaging the third sector are all things that could now be considered part of “community planning”. It is founded on the idea that communities know best; they know what they need, they know how it can be delivered and how they will use services in the most effective way to get the most value from them. With an increase in political devolution we have seen different approaches to delivering community planning emerge in England, Scotland, Wales and Northern Ireland. Some nations embraced it from a very early stage, others less so. However, it has become an increasingly popular model over recent years, with all four administrations now using some form of community planning model.

England

In England, the focus has largely been on housing and land use and the relationship between community plans (which consider services and public engagement) and local development plans (which focus more on the physical aspects of planning in the community, such as land use). Neighbourhood plans give communities the opportunity to develop a shared vision for and shape the development and growth of their local area. Neighbourhood plans are not a legal requirement, but a right which communities can evoke if they wish to. They are designed to fit alongside local authority produced “local plans” and provide an opportunity for communities to set out a long term vision for their area in terms of development, and “may encourage them to consider ways to improve their neighbourhood other than through the development and use of land.”

Scotland

The introduction of the 2015 Community Empowerment (Scotland) Act is a clear indication of the stance of the Scottish Government with regards to community planning. As well as statutory rights being strengthened with regards to consultation and community consultation, the legislation also places statutory requirements on public bodies with regards to supporting local community based service delivery, and actively engaging local people in decision making processes. As a result of the legislation 32 Community Planning Partnerships (CPPs) now exist in Scotland and they are responsible for developing and delivering community plans. These can take two forms:

  • a larger plan, which takes account of the whole CPP area (Local Outcomes Improvement Plan)
  • a smaller plan, which focuses on a smaller geographic area which has been identified as being in need of improvement (locality plan)

There is no limit to the number of plans CPP’s can create in a year, but the views of local communities are particularly important in creating these as that is the way to best reflect local needs and priorities.

In Scotland a consultation is also currently underway to consider ways to align community and spatial planning more closely, as it was recognised that planning for services should also be mapped along with physical development.

Wales

In a Welsh context the use of community planning focuses on resource allocation and the direction of resource to where it is needed. Promoting community cohesion and well-being through community planning is also something which can be seen in both Wales and Scotland. Increasingly, plans have attempted to incorporate a “place-centred”, “service focused”, “partnership led” approach, with the emphasis on individual need. It is hoped that by bringing service providers and other partners back in touch with the people who use their services that their views can be taken on in future planning projects. As in all community planning projects, partnerships are key; however in Wales one of the biggest challenges has been forming these partnerships and getting buy-in from local businesses. A similar challenge has also been seen with national level bodies.

This challenge of engaging national bodies in community planning has also been seen in Scotland. National bodies are expected to engage with rural and urban CPP’s in ways which reflect individual community need, something they had not been used to doing previously. As a result, promoting flexibility and adaptability and encouraging participation from a range of stakeholders in order to support the creation and delivery of community plans has been high on the agenda across the UK.

Northern Ireland

The situation in Northern Ireland is, to a large extent, still evolving. Executives at Stormont, as well as planners and developers, see engaging local people as important but they are also trying to find a model which works best for a Northern Irish context. Potential options for integrating community based models have included adopting models from England or Scotland respectively; creating their own model which takes elements from a number of different models; or making attempts to align the Northern Irish model closer to that of the Republic of Ireland.

Currently the legislative basis for community planning in Northern Ireland is set out in the Local Government Act (Northern Ireland) 2014. The Act makes a statutory link between community plans and local land use development plans, and makes the link between community planning for a district and well-being more explicit.

category-picture-community-development

Engaging difficult to reach communities in community planning

The views of local communities are particularly important when creating community plans, as their fundamental principle is to reflect service and resource need more effectively in order to benefit communities. As a result community planners across the UK face the unilateral challenge of getting people to engage. Different groups within a community may have different capacity and ability to engage. ‘Hard to reach’ groups are particularly important to the consultation process as it is often they who make the most use of services or have the greatest need for specific service provision. People in this group may include young people, older people, ethnic minorities or other socially excluded groups, and small businesses. They are also sometimes referred to as ‘seldom heard’ groups.

Methods to improve communication and consultation with hard to reach groups vary, but some potential barriers and solutions to engagement include:

  • Jargon and technical language – Policy and planning documents can be very long, and very dense, with lots of planning specific technical jargon, create an easy access version so that everyone can be engaged in discussions and not feel intimidated by “high level” documents.
  • Digital illiteracy – Increasingly consultation documents, some forums and copies of the plans themselves are held online, and improving access to these would help to encourage more people to participate.
  • Awareness and accessibility – Promoting consultations or community planning events, and holding them at a variety of times and in a variety of settings to allow people from different groups to attend. In addition providing them in multiple languages, using language that is more accessible for young people, or in a larger type size may also help to encourage people to participate.
  • Showing impact – Create follow up documents so that people can see how their input has made a difference. Even if the plan won’t be implemented for a number of months, let people know how what they said influenced or changed the decisions that were made.

It is clear that England, Wales, Scotland and Northern Ireland are at different stages in their community planning journey. However, they have all, in one way or another recognised the importance of engaging communities to identify needs and attempt to allocate resources accordingly. In many instances, these community agendas have not just been linked to spatial, or even service planning, but also to wider issues around inequality and well-being and how resources and planning across all areas can best be directed to tackle this. It may be that we see this reflected further in future legislation.


This blog reflects on a recent paper by Deborah Peel and Simon Pemberton “Exploring New Models of Community based Planning in the Devolved UK” a study funded by the Planning Exchange Foundation.

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Mobilising healthy communities: Bromley by Bow Health Partnership

Ian Jackson of the Bromley by Bow Health Partnership was the guest speaker at the first Glasgow Centre for Population Health (GCPH) seminar series of the year.

The Bromley by Bow Health Partnership (BBBHP) is a collaboration between three health centres and other non-primary care partners in the Tower Hamlets area of London. The aim of the partnership and the new primary care delivery model which comes with it is to transform the relationship between the public and primary health care. This means considering the wider determinants of health when the partners plan and deliver care, rather than treating healthcare in a purely biomedical way.

Edited image by Rebecca Jackson. Map via Google Earth

Edited image by Rebecca Jackson map via Google Earth

Effect of social determinants on health

In the 1890s Charles Booth created a map of London which categorized areas of the city of London depending on their levels of deprivation. The most recent Indices of Multiple Deprivation Report showed that those same areas considered deprived in the1890s are still facing the highest levels of multiple social deprivation and health inequality today. It is no secret that disadvantage has a negative impact on people’s ability to make the best choices when it comes to health. And disadvantage at a social level can have a significant influence on poor physical and mental health across a range of conditions.

More recent research conducted by Michael Marmot looked more closely at what determines health outcomes in populations, and the extent to which other factors influence people’s health, or rather their ability to be well.

He produced what is known as the 30/70 model: 30% of what determines your health is your genetics and improvements in pharmacology, the other 70% is related to other “external factors” including poverty, environment, culture, employment and housing. BBBHP has used this as the foundation for their primary care model, arguing that primary care providers are not just dispensers of medical products, but have a responsibility to contribute to people living healthier lives in their community.homeless

Social prescribing

One issue highlighted by the BBBHP was the significant number of people presenting at GP surgeries with “non-medical” ailments, or medical ailments triggered by “non-medical stimulus”. People were arriving at the practices and booking appointments because they were lonely and it gave them somewhere to go. Others were presenting with symptoms of depression, which on further investigation were found to have stemmed from issues around debt or domestic violence. A social prescribing service was set up by the partnership to try to tackle some of these non-medical conditions and improve the health of the general population by non-pharmacological means.

The social prescribing service, where GPs refer people to other local services for help, can be used as a replacement for pharmaceutical interventions, or be supplementary to them. GPs, or other primary care staff, may refer any adults over the age of 18 to one of over 40 partnership organisations. These range from walking groups to formal sessions with advisors in debt or domestic violence agencies, as well as art classes, community gardens and companionship services to combat loneliness. The organisations can provide help and advice on issues such as employment and training, emotional well being and mental health.Ölfarbe

The challenges of quality and funding

Maintaining quality in the provision of social prescribing is a particular challenge for BBBHP. They work regularly with trusted partners, particularly the Bromley by Bow Centre. However, there is no consistent quality check for many of the services from the health partners themselves. Evaluative studies and feedback sessions are used to assess quality and impact, and consider the scale of demand. And while it is acknowledged that more formal frameworks for assessing quality and impact of social prescribing services are preferred in formal assessments, in reality, word of mouth, participant feedback and uptake rates are used as a standard for quality as much as official feedback in a localised community setting.

A second issue is funding. BBBHP identified that finding long term funding was their main issue in providing security for providers and service users, as well as for GPs referring to services. Funding is vital not only to ensure the survival of the community groups who provide some of the referred services, but also to allow them to develop longer term partnerships and build capacity within the social prescribing service. The BBBHP works closely with the Bromley by Bow Centre, a key provider of support services for the local community, but like many services which rely on funding, they increasingly have to plan for tighter budgets.

blue toned, focus point on metal part of stethoscope

A final challenge for the staff at BBBHP was changing people’s expectations of primary care, and what it means to live well. Some patients were suspicious and reluctant to be recipients of “social prescription”, as this did not fit with the traditional expectation of what GPs should do to make people well. This can be a big change in mindset for some people, according to Ian Jackson, when people come expecting to be prescribed antidepressants but are instead “prescribed” a walking club or a debt advice service. He noted that the reaction from patients can sometimes be confused or hostile, and some patients do not even turn up for referrals.

Improving patients’ understanding of the benefits of social prescription, ensuring people attend referral appointments, and that social prescriptions have a long term impact is something which BBBHP are hoping to research further. They feel that looking at the long term impact of non-pharmaceutical interventions and how these feed back into the wider agenda of tackling inequalities is important to allow the partnership to continue to build healthy communities and save on primary care costs in the long term.

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Creating positive social connections to improve community health

Social prescribing and other associated projects have sparked new social connections. Members of the community have come together to form their own support groups. The Children’s Eczema support group run by local GPs and the DIY health scheme, which sought to educate and support parents who were anxious about minor ailments in children, have helped parents in the area to set up WhatsApp groups, organise coffee mornings and go to one another for support. Such initiatives are regarded by BBBHP as important in tackling wider, systemic social inequality in the area.

Currently, primary health care in communities is focused on illness. This needs to change, according to BBBHP, with local community-based health delivery based as much around social health as biomedical issues. Through its social prescribing and other services BBBHP has aimed to focus on supporting people in a holistic way, tackling health inequalities as well as biomedical illness, to allow them to make good choices to improve their health.


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Single sector Business Improvement Districts: the future of BIDS in Scotland?

As a model to promote economic development, Business Improvement Districts (BIDs) have been a success in Scotland. Under the watchful eye and guidance of the umbrella body BIDS Scotland, the framework has grown and in many ways looks very different from the 5 initial ‘pathfinder BIDs in 2006 (the first being Bathgate BID). However, the underlying principles, values and aims remain constant.

Single sector BIDs

The traditional model sees businesses within a local area enter into a financial partnership, with each member paying a levy towards improving and promoting economic development within a community, in partnership with local authorities and other bodies. By working together businesses can reduce costs, share risks and create new platforms for growth, while for local authorities the benefits include the potential to drive growth and investment in the local area and to obtain help in raising additional funds to do this.

However, the flexibility of the model and the way it fits it with both local and national agendas has been a big part of its success, and groups are now trying to apply the framework to new contexts in alternative and innovative ways. One of these new style frameworks is the idea of single sector BIDs. Their role was part of the discussion at the BIDS Scotland 10 year anniversary conference held in Perth last month.

Image via Rebecca Jackson

Image via Rebecca Jackson

Single sector BIDs, as supporters have pointed out, come with their own unique sets of challenges and benefits compared to the traditional BID model, but they are no less effective. They allow groups of businesses with common interests and common agendas to come together, cooperate, organise and collectively promote their goods and services with a view to develop not only their own businesses but those of others in their area and the local community as a whole.

A BID for food and drink

Within East Lothian plans are currently under way, and awaiting ballot, to officially form what is thought to be the world’s first ‘food and drinks BID’. They have adapted the BID model to cover a wider geographic area than the original BIDs model intended, as it was initially focussed around town and city centres and encompassed a number of different types of business.

Instead the single sector BID model encompasses businesses which sit within the food and drink industry, with a view to promoting East Lothian food and drink, support local business and create a unified voice and brand to market themselves and East Lothian as a quality provider of exquisite produce. They have had strong support from their local authority as well as from national bodies like Scotland Food and Drink. Together, local producers and sellers have been working with these statutory bodies to form their BID partnership. In May 2015 the partnership was awarded a seedcorn grant to develop their Food and Drink BID in East Lothian.

Because the businesses within the proposed BID are varied in terms of size and scope, it was decided to create levy bands relating to the number of employees, rather than rateable value, as had previously been the traditional model. The BID group also introduced a voluntary levy scheme for businesses such as farmers, who wanted to be included in the BID group as producers but were not eligible to under the current BID legislation.

The issue with legislation regarding urban and rural BIDs and the increased difficulty rural businesses have in joining BIDS, (both because of their geographic isolation and their size and categorisation within current legislation) is something which the BID group in East Lothian have stated they are trying to address and mitigate as best they can.

Rural_Urban Landscape_iStock_000004526499Medium

Many observers are watching keenly to see if the single sector BID model could be applied across a wider geographical area, or across additional sectors. Suggestions have already been put forward for a canals BID within Scotland, a universities BID, as well as potentially creating food and drink BIDS in other areas such as Ayrshire and Perthshire. These could potentially form a network of BIDS across the food and drink sector, enabling individual businesses to create a stronger lobbying voice.

The future of BIDs in Scotland?

It is now the case that BIDs in Scotland are not restricted to town and city centres and can be developed in areas such as the tourism and visitor sector, commercial or industrial districts areas, rural areas, agriculture or, as this blog has highlighted, single sector business groups. The flexibility of the model and the increased levels of partnership working act as ways to spread accountability, create legitimacy through collective action and generate additional funding for a local area.

Together these elements make BIDs an interesting proposition for many businesses in Scotland and it is this flexibility, legitimacy and promotion of partnership which has driven the BID model into new and innovative areas, transforming the nature of the relationship between local businesses and statutory bodies within communities and transforming the nature of economic development and community resilience agendas.


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Telecare in the UK: lessons from Barcelona

By Rebecca Jackson

Telecare is technology to help people live independently, usually in their own homes, for longer. Usually delivered as part of a package of care, telecare devices can include things like: bed sensors, to detect if someone is out of bed at an unusual time; fall sensors; medication reminders; and alerts on screens or over loudspeakers. Such devices have led telecare to be heralded as a new dawn in patient-centred, independent living.  However, despite initiatives  to drive its application forward, not everyone in the UK is convinced about the benefits of telecare.

Practitioners and carers are sceptical about the potential of replacing traditional care with digital models to save money and the impact that this could have on standards of care. In addition, many patients themselves are uncertain about the use of telecare and digital health solutions, with many who have telecare systems within their homes choosing to continue to interact with primary and home care services in the same way as before. Much of the academic and expert-led research and evaluation of telecare programmes in the UK by organisations such as the Nuffield Trust and the Kings Fund has found little to no improvement in service, reduction in cost or reduction in workload for care teams in areas where telecare has been deployed.

While telecare in the UK appears to have stalled, elsewhere digital health solutions are not only successfully integrated into traditional care models, but are having a positive impact on the people in receipt of care, and reducing the burden of work on care providers.

Lessons from Barcelona

In Spain, the law has guaranteed access to telecare since 2006. Economic austerity has led to individual local authorities in Spain being given control over their budgets and therefore their provision of telecare. The approach in Barcelona has been highlighted as an example of best practice in telecare.

The system there – a cooperative venture between an independent provider and the local authority – sees carers take a proactive approach to telecare. The system does not just monitor and provide assistance in times of distress, but proactively engages with service users at regular intervals to help carers provide reassurance and build relationships.

As well as the emergency measures, such as fall sensors (typically the primary use of telecare in the UK), calls are made to check up on service users, provide reassurance, deliver general public health information and to mark important occasions, like birthdays. This can help to reduce feelings of isolation and loneliness, which in turn can lead to better general health and wellbeing.

Calls can also be made to highlight important information, such  as weather warnings; safety alerts and local events which the service users may wish to attend. These calls are backed up by visits from the care team, who work for the telecare provider. These visits supplement visits from municipal care and social workers and the two teams communicate and share information via digital platforms.

Digital healthcare as an enabler

The case of Barcelona shows us how digital healthcare solutions, and more specifically telecare, can be used as an enabler – a tool to allow the local authority to pursue a joined up and preventative approach to healthcare which has positive benefits for recipients.

Such approaches could also have a significant impact on the UK’s 3.8 million unpaid carers. Telecare has the potential to reduce some of the burden and stress of caring for a relative, which in turn can have positive effects on the health of the person in receipt of care. It can also  form an effective part of reablement programmes – supporting people as they leave hospital or return to independent living.

However the approach to delivering telecare in Britain is as much about culture as it is about the technological infrastructure. Using telecare as part of a preventative, person-centred approach should produce better outcomes. In this sense, implementation of telecare in the UK still lags behind other countries. Key lessons could also be learnt from programmes in Norway and the Netherlands in relation to telecare in dementia settings.

Generally, the targeting of telecare services also differs – in the UK it tends to be aimed at elderly people with complex and diverse needs, while in Norway and the Netherlands the focus has shifted to those suffering from chronic illnesses.

Local solutions

In the UK, some local authorities have been experimenting with digital healthcare, although local authority budget cuts have meant that in many cases these have been cut back to focus delivery on the most vulnerable clients.

The lessons in digital healthcare that Britain can learn from places like Barcelona could be key to the successful roll out of digital healthcare solutions in the future. The Barcelona example highlights the enabling role that telecare can play in joining up health and social care and promoting a more preventative approach to healthcare.

Opportunities to develop telecare strategies and deliver them in partnership, as in the Barcelona model, show that it cannot be delivered in isolation, or be used as a replacement for existing carer-led services. Instead telecare has the potential to be a supporting tool to ensure effective care outcomes. It could also help care services in Britain to tackle the increasing demand of an ageing population.


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