Issue 7: Nov 2013

REDRESSING HEALTH DELIVERY IN SCOTLAND

By Janine Ewen, Health Improvement MSc student

Scotland currently faces significant demographic changes, large scale reductions in public sector spending and inequalities of living, including in terms of health and wellbeing, are rife.  The ‘asset based approach’ was introduced around four years ago, bringing a sharp focus on everyday workings in health improvement to reverse a system of dependency on public services, with the hope of establishing the presence of local voices at the heart of the decision making process.  The approach will be applied across Scotland in the hope that this new investment will allow people to be more proactive, healthier and happier and consequently enabling people to have a real, positive impact on themselves as well as their wider community. The Asset based Approach is a methodology that seeks to uncover and use the strengths within communities as a means of sustainable development.

Public Health is being taken more seriously

The UK National Health Service came into operation on the 4th of July 1948 and was made available on the basis of citizenship rather than the payment of fees or insurance premiums.  This came with best of intentions, aiming to promote equality in health for all. However it also came with a substantial and increasing cost; one which it seems amazing could not have been predicted long in advance of it putting strains upon the service.

The NHS has been beset with problems throughout its lifetime.  Despite the high value that has come to be associated with the system of healthcare, the issues of a growing dependency, little self-management and huge costs seem not to have been appreciated and as such the service has now had to take gigantic steps back to restore and rebrand itself as a service of support, rather than a service that can continue to place its future in jeopardy.

The good news is that the field of Public Health seems now to be taken more seriously as a profession and as an immediate matter of assistance to change healthcare practice.

The good news is that the field of Public Health seems now to be taken more seriously as a profession and as an immediate matter of assistance to change healthcare practice.  The discipline concerns itself with a focussed examination of societal problems that are deep-rooted and that need to be brought to the surface for creative and effective interventions to take place.  According to Charles-Edward Amory Winslow, Public Health is ‘the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals’.  The definition sums up every possible means of improving health and the inclusion of a wider variety of key stakeholders.  Globally, Public Health has for years come up against the medical profession, resulting in investment going towards treatment and scientific research instead of Public Health services.  It is easy to identify with medicine; hospitals, GP surgeries, health clinics and a vast range of health professionals; whereas public health doesn’t have such a visible, “immediate” impact and often it can be unclear whether lives have been saved or improved as a result of its initiatives.

Public health needs to be taken seriously to meet NHS and third sector delivery targets for a longer term impact, and for the issues to be properly and widely considered; not just by healthcare professionals, but by all citizens.  Generally today this has been acknowledged and now we are working in a period of transition from the acute NHS service setting, to a community development target, through using the asset based approach.

So where does the approach stand at this present time across Scotland?

Christopher Littlejohn, a Consultant in Public Health working for NHS Grampian was able to give a personal perspective of its current success, as well as examples to support the update. “My immediate reflection is that 'co-productive' community development work has long been going on across Grampian. We have been seeking opportunities to work collaboratively with communities and their local organisations.”

At the one-day conference in Aberdeen last year, entitled “Delivering Asset Based Approaches for Public Health: Responding to the Challenge”, developed by the North of Scotland Public Health Network, there was a general feeling of…“Are we not already working this way? Some of us have always used local participation in determining organisational objectives.”

It became clear early on in the day that perhaps some professionals had been working in the pathogenic reductionist approach, focussing on disease and ill-health, rather than looking at it from the other way around - by looking at people and what assets they have to bring to the table without focusing primarily on their problems.

Mr Littlejohn shed light on a rural development in Banff and Macduff for example, using NHS funding to build and strengthen assets for older adults and their carers (see points of reference for further details).  Another illustration of asset involvement by NHS Grampian, seeking ways to incorporate assets-based working into the day-to-day work of healthcare delivery, is with a current and on-going review on how it delivers healthcare for people who ask for help with new or suddenly worse health problems, such as daily visits at GP practices, A&E departments, and at evenings, nights and weekends (see points of reference for further details).  Both the carer’s strategy and emergency waiting times are priority and current strategic focuses of the Scottish Government.  The Carers Strategy for Scotland 2010 – 2015 is driven to support carers to manage their caring responsibilities with self-confidence, in good health, and to have a life of their own outside of caring.  Within the strategy, there is a real sense of keeping carers at the heart of progress…‘Carers, as equal partners in the delivery of care, enable people with illnesses or disabilities to remain at home and in their own communities safely, independently and with dignity. Carers can, prevent avoidable hospital admissions and contribute to people's overall health and well-being’.* (Carers and Young Carers Strategy for Scotland 2010 – 2015 Part 5)

The Scottish Government Quality Strategy is the approach and shared focus for all work to realise the 2020 Vision, including reducing in and out patient waiting times. It states: 'The Quality Strategy aims to deliver the highest quality healthcare to the people of Scotland to ensure that the NHS, Local Authorities and the Third Sector work together, and with patients, carers and the public, towards a shared goal of world-leading healthcare'.

However this is just one area of Scotland, and I was eager to get a generalised perspective. A representative from NHS Health Scotland believes existing confusion on the appointed approach is hindering its intended impact.  An honest response was given when asked for their perspective…
“For me, asset-based approaches fundamentally misunderstand the causes of, and problems resulting from, inequality and poverty and leads to an unwarranted focus on the role of services and a loss of democratic accountability of those services as they are put out to a variety of providers.” and “I have not seen its impact yet.”

The focus on people to step up to the mark and makeshift their own services, despite the best of intentions, can be damaging for people themselves if no progress is made...

In truth, we can’t lose accountability; otherwise services themselves will become meaningless. The focus on people to step up to the mark and makeshift their own services, despite the best of intentions, can be damaging for people themselves if no progress is made, and potentially losing the value of becoming ‘assets’. The approach cannot guarantee funding for ideas and will always be driven by national policies.  What if suggestions can’t be followed with funding, what if there is no government policy to support it? Healthcare services themselves only have a certain amount of ability to change deep rooted societal problems. Will the shift in care, shift further from the government, to service responsibility, to the people, then where…? It could end up being a vicious circle.

Overall, there are asset based activities going on in Scotland, and an unquestionable number of public participatory consultations with the general public have surged. Unfortunately, there is a general feeling of a huge “rush” to implement and form partnerships without time or strategic planning, with a cause for concern on the following questions:

  • Are we all working in the same way?
  • Is practice transparent?
  • Are we hurrying the approach to form such a quick transition?
  • Has the approach been communicated in the most efficient way possible?
  • What if local assets do not want to participate in consultation and focus groups?

It is still too early in its implementation for it to be evaluated throughout Scotland, but the approach is already being considered in service delivery objectives as well as a policy focus by the Scottish Government.

Points of Reference
Asset based approaches to health improvement: http://www.healthscotland.com/documents/5535.aspx
Health improvement - asset-based approaches: http://www.gcph.co.uk/work_themes/theme_4_assets_and_resilience/health_improvement_asset_based_approaches
‘Assets in Action: Illustrating asset based approaches for health improvement’: http://www.gcph.co.uk/publications/374_assets_in_action_illustrating_asset_based_approaches_for_health_improvement (this profiles 19 projects across Scotland adopting this approach)
The ScotPHO (Scottish Public Health Observatory) website on assets http://www.scotpho.org.uk/life-circumstances/assets
19 projects are available online from the Glasgow  Centre of Population Health for viewing http://www.gcph.co.uk/publications/374_assets_in_action_illustrating_asset_based_approaches_for_health_improvement
(see  www.nhsgrampian.org/nhsgrampian/gra_display_simple_index.jsp?pContentID=8645&p_applic=CCC&p_service=Content.show&).
Charles-Edward Amory Winslow, 1920
www.ouraberdeenshire.org.uk/images/2013%2004%2025%20april%20lcpg%20min.doc and the attached proposal, which is what the minute refers to).
Caring Together: The Carers Strategy for Scotland 2010 – 2015 http://www.scotland.gov.uk/Publications/2010/07/23153304/0
http://www.scotland.gov.uk/Topics/Health/Policy/Quality-Strategy

By Janine Ewen, Health Improvement MSc student

Issue 7: Nov 2013

Issue 7: Nov 2013

HEALTH, WELL BEING AND AGEING: SCOTLAND 2020

Re-energising the move towards integrated care

Scotland's move to integrated care can learn from elsewhere by focussing on two key differentiators between successful partnerships and those paying lip service to integrated working: Shared outcomes and common language is one, the other is demonstrating mutual investments and mutual benefits.

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