delivering better health services through community collaboration jane farmer, la trobe university...
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Delivering better health services through community collaboration
Jane Farmer, La Trobe UniversityAmy Nimegeer, Stirling University
(La Trobe University Visiting Fellow)
Outline• What’s /Who’s your community?• Why do community/consumer participation?• Example Remote Service Futures– Prioritising health services– Designing a workforce model
• What happens in CP• Group interaction• Other examples• Q&A• Future
Who is the community in health?Different knowledges & different languages
managers citizens
practitioners
politicians
StatisticsAreasLegislationRegulationRegistrationKeeping out of the media
Their jobTheir communityClinical pradigm
ContextualLocalPersonalDealing in stereotypesKnowledge driven by media & TV
Want to get (re)electedGetting good media
CP = A conversation between different knowledges
managers citizens
practitioners
politicians
EvidenceExamplesA Broker?
Why do community/consumer participation?
National Standards
• Standard 2: Partnering with Consumers– Partnership in service planning– Partnership in designing care– Partnership in service measurement & evaluation• Governance structures• Mechanisms• Actively involved in decisions making• Training for managers on how to create and sustain
partnerships….
HWA Leadership Competencies• Leads self, engages others, achieves outcomes,
drives innovation• SHAPES SYSTEMS – APPLIES SYSTEMS THINKING– Engages and enables consumers and communities (involves consumers and communities in decision-making, health policy, education and training and healthcare redesign)– Builds coalitions across silos, organisations and
sectors
Arnstein’s ladder of Participation
Arnstein (1969) Journal of the American Planning Association
Possible Outcomes – we think
• More acceptable decisions– Community shaped them
• More realistic plans & designs/ innovation– Based on context & evidence
• Health literacy/ health systems literacy• More likely implementation– Community will fight for it
• Greater democratic involvement/civic literacy• Frugality?
Evidence base for CP?• Perceived benefits for physical, psychosocial
health & wellbeing• Social outcomes for disadvantaged groups• Others experienced negative consequences– Depends on the individual & nature of the
intervention• Tokenism/limiting to consultation only/not
acting on information ->negative consequences• Failure of practice to match promise -> negativeAttree et al (2011) Health & Social Care in the Community
Evidence base for CP?• Mixed evidence re social capital building• Partnership working• Extends reach of included views• Empowerment re further civic engagementMilton et al (2012) Community Development Journal
• Awareness of Health Services• Learning new skills – community members• New & strengthened relationshipsKenny et al (2013) BMC Health Services Research
Remote Service Futures:Involving citizens in service design
Scottish Highlands & Islands
In a situation of protest & suspicion about changing service delivery models
Goals were:
• Design an effective, cheap, do-able method of community participation
• The method is designed to develop new workforce / service delivery models
• Designs are ‘hypothetical’
Remote Service Futures Project
Aspirations, Assets & Wants
Self-care/volunteering
Telehealth
Nursing models
First responders
Help-lines
Ways of providing services
etc
Budget
Priorities & Planning
Needs
Skills
People &Enablers
Budget
Remote, ruralcommunity
2 year project: 4 remote communities: 2 islands, 2 peninsulas (partnership with NHS Highland & Regional Development Agency)
Workshop Process
• Initial Meeting• Interviews• Community profiling
Stage One: Introduction and Context Mapping
• Community Workshop
• Interviews
Stage Two: Discovering Community Assets,
Challenges and Needs • Service Provider roadshow
• Community Conference
• Interviews
Stage Three: Meeting service providers, thinking
about future options
• Remote Service Futures Planning Game
• Interviews
Stage Four: Planning and Prioritizing
Communities had similar health & wants/priorities
• Key Local Health Issues– Conditions associated
with smoking– Associated with obesity– High blood pressure– Mental health
• Key wants– Locally resident
practitioners– How to deal with types
of emergencies– Older people –
anticipatory care– Improve local health
(through volunteering/leadership)
RSF Game1. Form community/manager groups2. Establish Community priorities of
need (incl. assessed)3. Use Skill Strips to decide which skills
would address needs4. Using anonymous practitioner cards,
consider who has the needed skills5. Using approximated budget, create
service plans 6. Groups then report back to whole
and justify plans
Design Outcomes
1 GP2 pt nurses
1 GP1 pt nursept carers
-GP in next village (50mins)-Peripatetic nursing team
GP in next village (50mins)-2 local ft nurses
Low attendance at final workshop
1 GPpt nurse3 pt carers
-1 nurse practitioner-healthcare assistant-pt Intensive home carer-community volunteers-volunteer first responders
New local practitioner with these skills:-health emergencies-social caring-leading community health-volunteering
A B C D
TelehealthVolunteeringInformation
Mobile phones
before
after
Reasons for differing engagement & innovation
• A = exerting power -> no absolute threat, island• B = split community, island -> security &
sustainability of community fears• C = fed up with current peripatetic model• D = young people, external and modern ideas,
health service connections
?
Process outcomes• Health system literacy– What there is, when to use it– Who to approach– What to expect– How much it costs– “…I had no idea, when I had my accident, it cost £9,000
for the helicopter to pick me up!”– “…it made me feel like I was managing the health
service…it made me realise how complex it is…”• Satisfaction and trust• Managers’ ‘contextual’ or ‘community literacy’
increased
Issues with the Scottish Study• Inclusion• Sustainability• Scalability over regions and/or larger communities• When/how is a community decision made?• The role of the mediator/broker – essential?• Changing structures– Democracy too far? Health services had trouble with
changing• Communities are not homogeneous unities –– Heterogeneous disunities!
Working with Scottish rural communities
• Challenges around unhelpful categorisations• People acting as gatekeepers• Being told to go away!• When do you disengage?• Remoteness also a challenge for engagement
(getting people around the table)• Biggest challenge was actually with the health
care staff! Have to be willing to implement.
Any actual change outcomes
• It was meant to be a hypothetical project but led to some community mobilisation
• What actually happened as a result– One community started a CFR scheme– One designed a new hybrid health care role which
will be taken forward but not in partnership with community
– Triage flowchart– Change in NHS Practice, incorporated into guidelines
Audience Participation
• Turn to your colleague & discuss:– What community participation have you done &
what for?– Identify a key project for which you’d like to use
community participation?– Why do you think community participation is
important for that project?• We’ll pick on people to report back
Other examples
Community co-production- older people as a
positive force, doingthings for communities,
doing things for themselves
Community Action
- Meet community
- Publicity
- Generate confidence/ enthusiasm
Community engage in O4O concept
- Discussion with community
- Building trust
Community identify needs
Initiatives selected to take forward
Support from Project:
- Building capacity
- Building confidence
- Accessing finance
- Accessing information
- Skills needed
- Community capacity
- Models of social organisation
Community action/ entrepreneurshipSocial
organisation model established
- Community takes on roles
-Business planning
- Resources
- TrainingO4O delivers services
Process of O4O social organisation creation
Highland….•Transport scheme•Community Care Assynt•Village hub (following heritage DVD)•Community DIY scheme (failed!)
N.Ireland….•Supporting existing voluntary groups to become more socially enterprising
Lulea, Sweden….•School + older people facility•Village helper•IT training scheme
Karelia, Finland….•Examined formal volunteering & tried to transfer to other communities
Greenland….•Working groups established with individual communities to do activities for/with older people
Services
Real&Tangible
LessTangible
Heathcote
Rochester
WarracknabealRural NorthWest
Larger communities require adaptations to
the process?
RSF in Rural Victoria
NHMRC funded – Population Health Planning Method for Rural Medicare Locals: oral/dental
health (2014-17)
• 6 rural communities – Vic & Qld• Rural has poorer oral/dental health• Method to involved community members in
designing local oral/dental health service• Priority-setting, budget• Partners: state dental health services, RFDS• & engage Aboriginal associations
Thinking beyond workforce planning…
Designing public health interventions that work for YOUR community of users:• NHS Forth Valley – cardiac rehab and staff services• Working with children to design public health
games (smoking awareness)• NHS Forth Valley and Stirling University working
with socially disadvantaged women and Carlton Bingo to design public health interventions that could take place at the Bingo Hall
Participation is the new paradigm
• Crowdsourcing– For funds– For research
subjects– For research
helpers/ community participative research
Overall thoughts, conclusions & lessons
• It is hard to do this well!• Put some parameters around what you are trying
to do– What is the project, what are the outputs, focus?
• Ongoing or project-based?• Community=stakeholders• Be adaptive • They can design pretty cool & innovative things ->
are you ready to implement them?
Overall Conclusions, continued.
• Community members know as much as you, it’s just a different kind of knowledge
• You need to work together to create a new kind of knowledge: one that combines evidence based decision making with narrative and experiential understanding
• Community participation should change and educate YOU as much as it should the community participants
• Solutions designed with service users can be more context-appropriate and embedded than those arrived at unilaterally
