Social capital, bridging capital & rural health policy

Jane FarmerCentre for Rural Health, Inverness, Scotland

What?

•Scotland…Scotland…•Healthy, resilient communities & social capitalHealthy, resilient communities & social capital•The theory of building social capitalThe theory of building social capital•The reality…The reality…•The reality in different countriesThe reality in different countries•Involving policy & other stakeholdersInvolving policy & other stakeholders•Questions for future policyQuestions for future policy

A word about CRH

• Since 2000• Collaboration UHI & UoA• 14 staff/ 8 PhD students

Ways to provide rural servicesWays to provide rural services Health, care & community rolesHealth, care & community roles Community involvementCommunity involvement Tools/methods for measuringTools/methods for measuring & modelling change impacts& modelling change impacts

Academic evidence base

RURAL REAL-LIFE

APPLY TO CHALLENGES

Centre for Rural HealthUHI Millennium Institute and The University of Aberdeen working in partnership

Inverness

The policy place in Scotland

• Delivering for Remote & Rural Health• “community resilience”

• Better Health Better Care – “mutuality”

• Neo-liberalism• Globalisation• Recession• Scotland – less marketised than England… ‘good’

& ‘bad’

• (OECD rural policy review)

Higher & rising % of older people– Chronic & complex illness

Migration patterns

(Fear of?) service erosion

Security Access to A&E/ (risk)

Appropriate economic development?» Market failure

Transport issues

Infrastructure issues

Available & affordable good housing

Inconsistent weather

[Insular-ism & conflict]

Health service-related concerns of remote areas

What is a healthy, resilient community?

• Government seeks…

• Secure (new CFRs & emergency models)

• Looking after each other/ civic society• Free personal care – means – no domestic care

etc…. [so participation!!!]

• Healthy – walking clubs/ active

• Self-care…

• Anticipatory care…

=????

Fantastic visionary new opportunity?Fantastic visionary new opportunity?

OROR

Roll-back of the welfare state…?Roll-back of the welfare state…?

A Project aboutA Project aboutolder people as aolder people as a

positive force, doingpositive force, doingthings for communities, things for communities,

doing things for doing things for themselvesthemselves

O4O:Older people for Older people

O4O is about

• Responding to population change• Sustaining remote communities• Changing the way people think• Making a start on seeing older

people as a positive force

What is O4O?• Mechanism to involve (older) people in basic

level service provision for older people• Different models of doing this in different

partners & communities– Volunteering– Social enterprise

• Work with communities• Involve ‘business’ development• Built on local needs & resources• Cross-generational

What sorts of services?• Good neighbour / social support• Domestic help• Meals, shopping• Lifts/ transport• Educational support• Support for self care• First response/triage• Support for community alarm

schemes• Snow clearing & wood-chopping

Partners

• Highland – growing ageing population• Dumfries & Galloway – employment

opportunities• Northern Ireland – post-conflict• North Karelia – heavy demand for older people’s

services• Lulea – develop volunteering• Kainuu – learn from the project• Sommersooq, Greenland

Greenland

• Survey of older people in dispersed remote communities– What they do– What they’d like

to do– Activity &

participation

The O4O modelThe O4O model

• Local citizens explore their needsLocal citizens explore their needs• What would help keep older people living What would help keep older people living

healthily in their own homes & communities?healthily in their own homes & communities?• What would most help?What would most help?

• Process…Process…• Develop a social organisation…Develop a social organisation…• Social enterpriseSocial enterprise• Voluntary organisationVoluntary organisation• Co-operativeCo-operative

• O4O doesn’t give them moneyO4O doesn’t give them money

Why social organisations?

• Policy says…

• Social organisations/ civic society makes…– Social capital– Psychological health & wellbeing– Physical health & wellbeing

• Low evidence base!

• O4O – the theoryO4O – the theory– SC in the communitySC in the community

• People help each other & build networksPeople help each other & build networks• Build organisations & build networksBuild organisations & build networks• Work with us/ partner organisations – bridgingWork with us/ partner organisations – bridging• Volunteering = good for healthVolunteering = good for health

• Once built this capital can be applied to Once built this capital can be applied to other things (capacity)other things (capacity)

• + they have new ‘services’+ they have new ‘services’

At first that required…At first that required…

• CoheringCohering

• SupportingSupporting

• MentoringMentoring

• Looking for fundingLooking for funding

• Supporting bidsSupporting bids

Now that’s involvingNow that’s involving

• Education for capacity buildingEducation for capacity building

• Business planning & developmentBusiness planning & development

• Developing local social entrepreneursDeveloping local social entrepreneurs

What are communities doing?Highland….•Transport scheme•Supported housing•Helping•Heritage-identity-meeting place-cafe

Dumfries & Galloway….•Extending Foodtrain and other…

N.Ireland….•Shaping social enterprise ideas

Lulea, Sweden….•Village co-operatives•Inter-generational IT•Cafe

Karelia, Finland….•Volunteering

Greenland….•Needs & activities of older people

Contextual issuesContextual issues

• Scotland – SE – heavily promotedScotland – SE – heavily promoted

• Sweden (North – welfarist/left)Sweden (North – welfarist/left)• Enterprise is a ‘dirty’ wordEnterprise is a ‘dirty’ word

• Finland – SE restrictions & meaningFinland – SE restrictions & meaning• Volunteering is okVolunteering is ok

• N. Ireland – post conflictN. Ireland – post conflict

• Greenland – hugely dispersedGreenland – hugely dispersed

Researching the impact of O4Os

1. Individual impacts• Health• Helping

2. Community impacts

• Health• Participation • Volunteering

3. Service provider impacts

• Costs• Activity• Falls, care packages,

emergency admissions

Some survey findings• 60.8% response: 1500 people 55+ (r&r)• 34% aware of O4O• 88% had helped a neighbour (6 months)• 13% provided unpaid personal care• 31% thought they could influence local decisions• 50% willing to use skills to help others (+39% ‘it

depends’)• 28% on management committee• 33% had participated in community projects• 5% said health ‘poor’• 12% no access to a vehicle• 22% had been held back by ‘emotional problems’ in 4

weeks

A concernA concern• Replacing existing social capital (informal Replacing existing social capital (informal

helping & reciprocity….helping & reciprocity….• ……with formal …with formal …• Disrupting evolved schemesDisrupting evolved schemes• … … though are those exclusive…?though are those exclusive…?

And in Canada….!“…the central concern arising from these reforms in Canada, as elsewhere, is that

the NPM reforms place matters of efficiency above those of equity and entitlement and that the negative impacts of these reforms are felt most intensely among less well off individuals and communities…”

“…each of the 43 [institutions] is findings its own solution to the problem of meeting expanding demands with limited resources, and this is creating diversity in local capacity to respond to demands for assistance…”

“…limits to community capacity among older people to provide for themselves and each other…”

• Cloutier-Fisher, D., Joseph, A.E., 2000. Long-term care restructuring in rural Ontario: retrieving community service user and provider narratives. Social Science & Medicine 50, 1037-45.

• Hanlon, N.T., Rosenberg, M.W., 1998. Not-so-new public management and the denial of geography: Ontario health-care reform in the 1990s. Environment and Planning C: Government and Policy 16(5), 559 – 572.

• Hanlon, N.T., Halseth, G., Clasby, R., Pow, V., 2007. The place embeddedness of social care: restructuring work and welfare in Mackenzie, BC. Health & Place 13, 466-481.

• Skinner, M.W., Rosenberg, M.W., 2006. Managing competition in the countryside: non-profit and for-profit perceptions of long-term care in rural Ontario. Social Science & Medicine, 63, 2864-76.

The realities of O4O…(OMG!)For communities:For communities: - exogenous ‘social engineering’?

- enterprising?- extent of capacity- internal community conflict- when it comes to the crunch…- is it possible to get beyond the grant? (how

do you make social enterprise work in small communities)

- why us/ why now/ want paternalism

• For service providersFor service providers• At management level: want it, but not to support its birthAt management level: want it, but not to support its birth

– Models of sustainable (small) community enterpriseModels of sustainable (small) community enterprise• At operational level – threatening and riskyAt operational level – threatening and risky• Availability of data to show change + how to changeAvailability of data to show change + how to change

For support agenciesFor support agencies• Providing training & support that fits remote & rural Providing training & support that fits remote & rural

communitiescommunities• Beyond advising into doingBeyond advising into doing• Targets based on outcomes = social entrepreneursTargets based on outcomes = social entrepreneurs

• GovernmentGovernment• Only interested if it worksOnly interested if it works

In different countries

• Sweden • Business model & paradigm shift?

• Finland• Volunteering? Apathy…

• Greenland• Some villages more engaged than others• Alcohol, bingo, etc…..

• N Ireland

Partners & partnership workingPartners & partnership working

Policy people….are integral

• Change & innovation at government level• Local health authority

• Bemused? Distanced…

• Local council• Does it work, make it work, waste of time• Two years ahead of itself

• Ambulance service• Interested in how to engage with communities• Want to integrate with our transport scheme

• Regional development agency• Right now we are interested in telemedicine…

Future policy…Future policy…

• Impacts…Impacts…• Health, service provision, does anyone care – Health, service provision, does anyone care –

enough?enough?• Models of social enterprise provision for tiny Models of social enterprise provision for tiny

communities – which?communities – which?• Is there really the capacity?Is there really the capacity?• Is it the role of researchers…?Is it the role of researchers…?

My questions for you…My questions for you…• What are your experiences?What are your experiences?• Can (and should) the health service explicitly Can (and should) the health service explicitly

seek to grow community capacity? If so, seek to grow community capacity? If so, how?how?

• Is social enterprise, as promoted by Is social enterprise, as promoted by government, really to build capacity or just to government, really to build capacity or just to shift service provision?shift service provision?

• Does social enterprise have a role in health & Does social enterprise have a role in health & social care provision?social care provision?

• How can it be made to work in small How can it be made to work in small communities?communities?

• What is different about Aus rural health & What is different about Aus rural health & Scottish rural health (context) that would Scottish rural health (context) that would affect outcomes of a thing like O4O?affect outcomes of a thing like O4O?

Centre for Rural Centre for Rural HealthHealthjane.farmer@uhi.ac.jane.farmer@uhi.ac.ukukwww.abdn.ac.uk/crhwww.abdn.ac.uk/crh