Community Engagement for Health: challenges and opportunities

1
Community Engagement for Health challenges and
opportunities

• Steve Cropper
• Centre for Health Planning and Management
• Institute for Public Policy and Management

2
Community Engagement really on the agenda?

• Modernisation creating conditions for full
  engagement
• Private sector/market good practices
• Limits to technocracy
• Democratisation
• Community radicalism voice, rights needs esp.
  disadvantaged
• Social determinants - involvement brings health
  benefit

3
Why communities?

• As convenient clusters of more or less needy
  individuals and settings in which local health
  interventions can be rigorously implemented
• Justifiable in terms of absolute improvements in
  health and wellbeing of those in poorest
  circumstances little contribution to narrowing
  the gap
• As mechanisms in their own right place /or
  social explanations of health behaviour,
  inequality.
• a range of local factors in the causal chain of
  health inequalities (Judge et al)

4
Contexts

• Community stress and change
• Fragmented or fragmenting communities
• Economic social stress and exclusion, anxiety,
  fear, loss of freedom
• No/few communal resources, facilities and
  activity
• Weakly organised or connected - lack/loss of
  voice, identity confidence stigma, a sense of
  marginality and powerlessness us and them
• Range of area based policy communities in the
  lead
• Further stress fatigue burden and risk
• Uncertainty/mistrust about outcome

5
Welsh Assembly Governments SHARP
6
Why community engagement?

• To stimulate capacity for (mutual and collective)
  self help
• New knowledge, skills, confidence and
  determinations and activities
• Access to the resources of communities to
  ensure best use of service investments
• Intelligence Advice - know-what, -how, -where
  and when
• Relationships community organisation,
  connections and linkages obligations and
  commitments
• Energy, time, enthusiasm, and care
• Trust, guarantees and legitimacy

7
Trust, respect, partnership?

• Id hear something theyre discussing and
  think Wheres that come from, whos said that,
  Ive not heard that anywhere. Has somebody
  mentioned it or has somebody in my community
  organisation agreed to it? I dont want to be
  taken by surprise. Its not about that is it?
  Its about knowing that everybodys aware
• Its like were not involved with a lot of
  the decisions, because we dont even know about
  them in the beginning. We dont know the reason
  theyve been taken because we just dont know
  where theyve come from they think that they
  can do exactly what they want with us
  because thats the only way they know to deal
  with things.

Resident, active, in regeneration area
8

• How can citizens so disillusioned become
  engaged in debate about future guiding values?
  Is it possible to use institutional design
  processes to break out of Putnams vicious circle
  of distrust, disengagement and weak democracy?
• Vivien Lowndes and David Wilson
  (2000)

9
(After Woolcock, 2001)
10
Community involvement integral
to action/ implementation
Provision and promotion of new types of evidence
Community involvement in consultation eg data
collection analysis
Arrangements for continuing community engagement
in decision making
Collective deliberation
Agency-led or -commissioned consultation
11
Salfords Gold Standards

• Value the skills, knowledge and commitment of
  local people
• Develop working relationships with communities
  and community organisations
• Support staff and local people to work with and
  learn from each other as a whole community
• Plan for change with and take collective action
  with the community
• Work with people in the community to develop and
  use frameworks for evaluation

12
What are the challenges of community engagement
for health?

• Accept that starting points may need to be
  elsewhere than the rigorous implementation of
  big wins
• Health may not be the priority choice for the
  community
• Other work to do before Wanless engine can be
  started
• Look to build a system and series of mutually
  reinforcing interventions/investments (without a
  grand plan)
• Not withdrawing as services are not (immediately)
  taken up look back up the stream to confidence
  building, relationship building activities
• So challenges to leadership and partnership
  across the range of agencies

13
Building relationships

• Communities not cohesive wholes
• No one way in and out (in terms of
  representation)
• Variety - balance formal and informal mechanisms
• Legitimacy (but often dysfunction) of formal
  systems of representation, accountability and
  governance structures
• Focus also on informal (indicative) voice
• Value scrutiny and challenge, encourage it,
  help it to organise
• Invest in new sources of leadership, energy
  action
• Variety of ideas that fit
• John Bennington and propositional planning
• John Forester and deliberative practice
• Lowndes and Stone - social capital vs civic
  capacity

14
Strategies and mechanisms

• Invest in places for interaction
• Physical focus, meetings, activities
• Invest in connections and connectors
• Champions, Coordinators, Animators, Brokers
• Exchange contents
• Interpersonal exchanges
• Collective resources
• Humanise
• Make relations personal, informal and social
• Recognise personal risks are being taken

15
Local action coordinators

• linking people up to help them to get involved
  and so build trust and support networks and give
  people and groups more power
• getting people to think about what they want and
  get them to do something about it
• helping to run community events
• visiting schools and community groups and
• keeping an eye on all the bits of the project in
  your area.

From Salford SARP Local Action Coordinator job
description
16
Restoring Hope

• Investments to support resourceful, committed
  individuals within their communities works
• Individuals develop
• Collective resources emerge
• Opportunities for small initial steps and to keep
  going reshape peoples experience of their own
  potential and that of their communities
• Can lead to significant change at community level
  and in relations between community and agencies
  needs systematically capturing and recognising
• But it is hardchallenge lies with public service
  organisations to modify (deep-rooted,
  taken-for-granted) practice and to sustain
  investment.

17
(From Forrest and Kearns, 2001)