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The asset based approach to health
and wellbeing in communities
Monday 5th November 2012
Birmingham
www.assetbasedconsulting.net
Trevor Hopkins
Freelance Consultant
Asset Based Consulting
Never doubt that a small group of thoughtful, committed
citizens can change the world. Indeed, it is the only thing
that ever has. Margaret Mead – US Anthropologist 1901 - 1978
Introductions and outline • What are the ‘Deficit’ and ‘Asset’ approaches?
• “A glass half-full” • Principles, Values & Key themes
• “What makes us healthy?” • Evidence, Action, Evaluation
• How could this help us strategically? • How to develop the JSNA to include asset mapping
• Using Appreciative Inquiry to develop the H&WB Strategy
• Co-production for health
• Outcomes based commissioning
• How could this help us locally? • Appreciative Scrutiny
• Asset Based Community Development
• Community Health Champions
• Resilient Places
The dilemma . . .
Clients and consumers
have deficiencies & needs
Citizens have
capacities and gifts
A deficit approach
• Much of the evidence currently available to describe health
and address health inequalities is based on a deficit model
• This is a ‘pathogenic’ approach to health and well-being
• The deficit approach focuses on the risks, problems, needs
and deficiencies in individuals, families and communities
• Professionals then design services to ‘fix’ the problems
• As a result the community and individuals can feel
disempowered or can become dependent
• People become passive recipients of expensive services
Features of a deficit approach
• Policymakers see professional systems or institutions as the
principal tool for the work of society
• In Public Health practice this approach has focused on ‘risky
behaviours’ and ‘lifestyle factors’
• “The collective term for these behaviours is the subject of
much debate, with professionals from different fields preferring
different terminology, each having a view about what is
pejorative and what is not.” (Clustering of unhealthy behaviours over time – King’s Fund , August 2012)
• Services are targeted at specific needs & problems,
communities and individuals become ‘segmented’
An assets approach
• Values the capacity, skills, knowledge, connections and potential in individuals, families and communities
• It is a ‘salutogenic’ approach which highlights the factors that create and support resilience and well-being
• It requires a change in attitudes and values
• Professional staff have to be willing to share power
• Organisational silos and boundaries get in the way of people-centred outcomes and community building
• Never do for a community what it can do for itself
Features of an assets approach
• Changing from servicing people’s needs to facilitating
their aspirations
• Redressing the balance between needs and assets
or strengths
• A shift in emphasis from the causes to ‘the causes of
the causes of the causes’
• A move from targeted to universal approaches
• Solutions that are developed by people and
communities not by specialists and professionals
Key messages 1.
• Asset principles help us to understand what gives us
health and wellbeing in a new way.
• The theoretical and research evidence for the positive
impact of community and individual assets is well
known and at least comparable to that of more familiar
behaviour and life-style determinants of health
• Asset thinking challenges the predominant framing of
health as the prevention of illness and injury rather than
the promotion of wellness.
• Asset working can promote mental well-being which is
both a cause and a consequence of inequality and
physical ill health.
Key messages 2.
• Work to improve health enhancing assets has not only to focus on the psychosocial assets such as resilience and confidence, but also on the social, economic and environmental factors that influence inequalities in health and well-being.
• Asset based approaches complement services and other activities that are intended to reduce inequalities in life chances and life circumstances and which meet needs in the community
• Assets are simultaneously an input, a measure and an outcome. This has implications for the design and evaluation of asset based working.
A glass half-full:
http://www.assetbasedconsulting.co.uk/Publications.aspx
How an asset approach
can improve community
health and well-being
The Principles
• Assets: any resource, skill or knowledge which
enhances the ability of individuals, families and
neighbourhoods to sustain health and wellbeing.
• Instead of starting with the problems, we start with what
is working, and what people care about.
• Networks, friendships, self esteem and feelings of
personal and collective effectiveness are good for our
wellbeing.
“Focusing on the positive is a public health intervention in its own right” Professor Sarah Stewart-Brown, Professor of Public Health at Warwick Medical School speaking at a conference on ‘Measuring Well-being’
19 January 2011 at Kings College
Values for an Asset Approach
• Identify and make visible to health-enhancing assets in a community
• See citizens and communities as the co-producers of health and well-being rather than the recipients of services
• Promote community networks, relationships and friendships
• Value what works well
• Identify what has the potential to improve health and well-being
• Empower communities to control their futures and create tangible resources
Key themes
The defining themes of asset based ways of working are
that they are:
• Place-based
• Relationship-based
• Citizen-led
...and that they promote social justice and equality
“What makes us healthy?”
The assets approach in practice:
http://www.assetbasedconsulting.co.uk/Publications.aspx
• Evidence
• Action
• Evaluation
Evidence 1.
• There is growing evidence for the importance of health
assets, broadly defined as the factors that protect
health, notably in the face of adversity, and for the
impact of assets based approaches
• Individuals do not exist in isolation; social factors
influence individuals’ health though cognitive, affective,
and behavioural pathways.
• The quality and quantity of individuals social
relationships has been linked not only to mental health
but also to both morbidity and mortality. It is comparable
with well established risk factors for mortality
Evidence 2.
• Stress buffering – relationships provide support and
resources (information, emotional or tangible) that
promote adaptive behavioural or neuoroendocrinal
responses to acute or chronic stressors e.g. illness, life
events.
• Social relationships may encourage or model healthy
behaviours, thus being part of a social network is
typically associated with conformity to social norms
relevant to health and social care. In addition being part
of a social network gives individuals meaningful roles
that provide self esteem and purpose to life.
Action 1.
• Assets require both whole system and whole
community working.
• Instead of services that target the most disadvantaged
and reduce exposure to risk, there is a shift to
facilitating and supporting the wellbeing of individuals,
families and neighbourhoods.
• It requires all agencies and communities to collaborate
and invest in actions that foster health giving assets,
prevent illness and benefit the whole community by
reducing the steepness of the social gradient in health.
Action 2. • Asset mapping
• Toronto framework for mapping community capacity
• Joint Strategic Assets Assessment
• Timebanking
• Social prescribing
• Peer support
• Co-Production
• Supporting healthy behaviours
• Community development to tackle health inequalities
• Network building
• Resilient Places
• Appreciative Inquiry
• Asset based service re-design
• Assets – embedding it in the organisation
• Workforce and organisational development
Evaluation
• To evaluate health asset based activities requires a
new approach. Instead of studying patterns of illness,
we need ways of understanding patterns of health and
the impact of assets and protective factors.
• Methods that seek to understand the effects of context,
the mechanisms which link assets to change and the
complexities of neighbourhoods and networks are
consistent with the asset approaches.
• The participation of those whose assets and capacities
are being supported will be a vital part of local reflective
practice.
How could this help us strategically?
• How to develop the JSNA to include asset
mapping
• Using Appreciative Inquiry to develop the
H&WB Strategy
• Co-production for health
• Outcomes based commissioning
Community asset mapping
The actual and potential assets of:
• Individuals – heart, head & hand
• Associations
• Organisations
In a community this can also include:
• The physical assets
• The economic assets
• The cultural assets
Primary Assets
Secondary Assets
Potential
Assets
Analysis of community assets
http://www.idea.gov.uk/idk/core/page.do?pageId=18364393
Community asset mapping/JSAA
http://www.assetbasedconsulting.co.uk/Publications.aspx
“Good organisations know how to preserve the
core of what they do best.
Preserving the right thing is key.
Letting go of other things is the next step”
David Cooperrider
Appreciative Inquiry
Principles
Reflection – remembering times when our culture, values
and identity made us proud.
Affirmation - inquiring into those strengths and how we
can use them to create the future
Action – practical planning towards the future
Characteristics
• Appreciative - AI looks for the ‘positive core’ of the
organisation and seeks to use it as a foundation for future
growth
• Applicable - AI is grounded in stories of what has
actually taken place in the past and is therefore
essentially practical.
• Provocative - AI invites people to take some risks in the
way they imagine the future and redesign their
organisation to bring it about.
• Collaborative - AI is a form of collaborative inquiry. It
always involves the whole system or a representative
cross-section of the whole system.
The appreciative cycle
Define
Discover
Dream
Design
Deliver
...building the path as we walk it
STOKE-ON-TRENT IS A VIBRANT, HEALTHY AND CARING CITY,
WHICH SUPPORTS ALL PEOPLE TO LIVE FULFILLING, INDEPENDENT AND HEALTHY LIVES
Healthy City: All children enjoy
the best start in life and
everyone will live longer and
healthier lives.
Vibrant City: Everyone will live,
work and play in an
environment which supports
them to live healthy and fulfilling
lives.
Caring city: Everyone is supported to
live independent lives with fair access to
high quality integrated health and social
care services when needed.
CITY OF STOKE-ON-TRENT MANDATE FOR HEALTH AND WELLBEING 2020
Starting Well:
Children flourish
and feel loved,
valued and safe
Developing well: Everyone is able to achieve their potential and enjoy maximum independence and positive mental wellbeing
Working Well: Business thrives in the city and everyone has opportunity to be involved in meaningful activity (work, volunteering, caring)
Living Well: Everyone lives in a good quality home, in an area which they like and in an environment in which they feel safe across all generations
Staying well: Everyone has access to preventative health and wellbeing services and are supported to live healthy lives
Ageing Well: Everyone has a positive experience of ageing in the City and people are supported to live independent, inclusive and fulfilling lives throughout the life course
Achieved through:
X% less children live in poverty
X% Improvement in teachers identifying children as ready for school
X% children breastfed until at least 6 – 8 weeks of life
% reduction in low birth weight babies
Achieved through:
Improved levels of satisfaction with life
Reductions in number of NEETs
Reductions in pupil absence
Reduction in the number of 15 year olds who smoke
Reduction in number of hospital admissions as a result of self-harm, unintentional and deliberate injuries in under 18’s
Achieved through:
% increase in volunteering/community champions activity
Reduction in sickness absence rates
% increase in number of people with LTC in employment – including people with a mental illness or learning disability
Achieved through:
% of greenspace in the City is rated good quality and is accessible
All major plans for regeneration of the City are subject to an HIA
% reduction in fuel poverty
% reduction in statutory homelessness
social connectedness
% self-reports of feeling safe in the community
Achieved through:
Increase in literacy and numeracy in adult population
improved health related quality of life for older people
% reduction in hip fractures in older people
Reduction in number of falls and injuries in over 65’s
Achieved through:
x % reduction in smoking prevalence
x% reduction in obesity
x% reduction in hospital readmissions for LTCs
Reduction in number of excess winter deaths
Strategic Outcomes
Healthy City: Children will enjoy the best start in life and everyone will live longer and healthier lives
Vibrant City: Everyone will live, work and play in an attractive environment which supports them to live healthy and fulfilling lives
Caring City: Everyone is supported to live independent lives with fair access to high quality integrated health and social care services when needed
Co-production
“Co-production means delivering public services in an equal
and reciprocal relationship between professionals, people
using services, their families and their neighbours. Where
activities are co-produced in this way, both services and
neighbourhoods become far more effective agents of
change.”
The Challenge of Co-production – David Boyle & Michael Harris, December 2009
“Services do not produce outcomes – people do.”
Co-production and social capital; the role that users and citizens play in improving local
services – Jude Cummings and Clive Miller – October 2007
Further reading on co-production
http://www.neweconomics.org/publications/public-services-inside-out
http://www.nesta.org.uk/events/assets/features/the_challenge_of_co-production
The principles of co-production
• Recognises people as assets
• Build on peoples existing capabilities
• Promote mutuality and reciprocity
• Build peer support and social networks
• Break down barriers
• Facilitate rather than deliver
Co-production of health & well-being
Co-production for health
• Exploit the opportunities created by
the integration of public health and
local government.
• Use the new structures, approaches
and democratic accountabilities to
deliver public health outcomes and a
reduction in inequalities.
• Maximise the new commissioning
structures to improve health outcomes
and reduce inequalities when money
is tight.
http://www.sph.nhs.uk/sph-documents/local-government-colloquium-report
Key messages
• Use the transition to start to develop a new co-production model for
health and wellbeing.
• Establish focused, agreed priorities which have meaningful
outcomes for all partners.
• Use intelligence dynamically, creatively and succinctly and in
relevant forms for different audiences.
• Promote an asset based approach to communities to understand
and harness their assets and resource.
• Adopt a new approach to partnership and leadership whilst building
on what has worked.
• The public health workforce has to change – a new business model
needs adopting that is pragmatic, practical and delivers solutions to
commissioners and providers.
Outcomes-based commissioning
• The transformative potential of co-production and assets
approaches is not best served by traditional procurement
models.
• The approach of co-production can be incorporated
across the entire commissioning framework.
• Providers are usually contracted to deliver a service
defined by its inputs and outputs with little reference to
wider outcomes
• There is little or no requirement to identify and build on
assets and capacity within the community
• Commissioning should be designed around outcomes
Combining commissioning &
co-production • The commissioning framework defines long-term
outcomes
• Potential providers are incentivised to be innovative and
flexible about achieving outcomes
• Co-production is specified as an approach that providers
must develop
• New providers can emerge
• Commissioners can specify that providers develop
preventative approaches to service delivery
• Wider social and environmental outcomes can be built
into the assessment of value for money
Bringing it together
Kirklees Mental Health Partnership used an outcomes-based specification for the
mental health advocacy service and mental health carers’ options service.
• The providers were required to base the service on the ‘principles of co-
production’ and recognising ‘the assets of the individual’.
• The specification sets out a number of expectations of the service. It set out that:
people will not be seen as passive recipients of the service; that they have ‘assets
with value and expertise’; they will be enabled to ‘explore their potential to the
fullest, push the boundaries, take risks and maintain or regain increasing control
over their daily lives’.
• The six co-production principles underpin the specifications, and each one
details the expected outcomes under those headings.
• The service is monitored through a consultative forum with 50 per cent
representation of service users and 50 per cent from the different agencies, using
quantitative data on client details, a framework of personal, community and
economic outcomes
www.yhip.org.uk/silo/files/mental-health-carers-options-service--service-specification.doc
How could this help us locally?
• Appreciative Scrutiny
• Asset Based Community Development
• Community Health Champions
• Resilient Places
Appreciative Scrutiny
• By using a solution focused
perspective participants in the
inquiry could see how successful
tobacco campaigns have been
with non-smokers.
• Public sector tends to focus on
negative behaviour and looking
at ways to change this, rather
than looking at the positives.
• That Appreciative scrutiny can
energise officers, politicians and
residents when working together
on an issue.
http://www.cfps.org.uk/domains/cfps.org.uk/local/media/downloads/L12_658_CIFPS_Appreciative_Scrutiny_FINAL_Sept_2012_for_web.pdf
Asset Based Community Development
The C2 Connecting Communities Project
• Locating the energy for change: through
face-to-face conversations, door knocking,
meetings with local groups and
associations, finding the (small) group of
people who could initiate and lead the
community
• Listening events: co-hosted by the
community and the agencies, the
professionals listened to what was positive
on the estate, what the community thought
the priorities were and what needed to
change
• Creating places and spaces for residents
to connect, build relationships, have
conversations and share knowledge, and
encouraging local activities such as street
parties, outings, raffles and so on
• Co-learning: through conversations and
open discussions communities and staff
came to realise that they both have the
same aims and they need each other if they
are to realise those aims
• Learning from similar areas that have been
successful: residents and agency staff
visited other estates to see what could be
done and to be inspired by the possibilities
– they now host many visits from developing
communities
• Challenging the negative image of the
estate, held by both residents and staff, so
that they all believed they could make
changes
• Supporting the community to lead the
partnership and to determine what the
priorities were and what would work.
http://www.healthcomplexity.net/content.php?s=c2&c=c2_background.php
Community Health Champions
• Altogether Better has developed an
award-winning, evidence based
approach to engaging and supporting
individuals in communities to become
Community Health Champions.
• Their ambition to to work to create
social value by unlocking the assets
and resources of individuals and
communities to create healthier
communities and better quality health
services.
• Work together to activate the full
potential of Community Health
Champions to improve the health and
well being of their communities
http://www.altogetherbetter.org.uk/amazing-stories-collection
Resilient Places “At the beginning of autumn, the Jewish community
celebrates the festival of Succos, translated as
Tabernacles - with its many colourful laws and customs.
One of those customs involves using a type of pine, a
type of fern, called cypress.
This story begins as much as twenty years ago at the
end of Succos. As we had done for many years
previously, we discarded all the cypress we had used
for the festival and thought no more about it.
Unbeknown to us, a branch of cypress has escaped the
black bin bag, and seeded itself in the crack between
the paving stones in our garden. Without anyone
knowing a tree began to grow which is now over 30 feet
tall.
The years passed. Our family grew, our community
grew and the tree grew. Good times came and went
and times of trial and difficulty came and passed.
Throughout it all, I tried my hardest, somehow trying to
control a life that no-one can ever control.
The tree is a gift G-d sent me to teach me just that. It
grows and flourishes without me. I didn’t plant it, I didn’t
tend it, yet its beauty and power is there for everyone to
see. It’s G-d’s way of reassuring me that He can do so
much without me and that He takes control of that
control which will always elude us.”
Postscript – An ‘ill wind’
A day after the picture on the front of this report was taken, it was gone. The tree, which had inspired Mrs
Gardner, her friends and family for so many years had been felled. Unseasonably bad weather in early April
2012, including strong winds, had unsettled the roots and it was threatening to fall down in the direction of the
adjoining College buildings. The photograph shows it was already starting to lean.
A pessimist would doubtless say this was something of a ‘bad omen’, giving a lie to the appreciative message
inspired by the tree’s remarkable development from the seeding of a discarded branch. However it is
interesting to note the diametrically opposite view was taken.
Mrs Gardner and others involved in the consultation process, remarked on the poignancy of the tree’s demise
so soon after it was used as a powerful metaphor for the consultative process on improving health and well-
being in a cohesive, faith-based community. The growth of the tree was an allegory for those things in life that
individuals can’t control but which can be achieved against the odds by a combination of pulling together,
positive thinking, and the strength drawn from shared faith, values and beliefs.
After surviving many storms the final wind had blown, the axe had fallen and the tree was a thing of the past.
But its message survives and will linger in the memory of many. It is an enduring message of hope against
adversity and the inspiration that can be drawn from the world around us. This is a recurring cornerstone of
Jewish teaching and appreciative thinking, illustrated just a few hundred yards from where the story of the tree
had been told.
The message had been delivered – the tree had served its purpose.
Resilient Places
It takes everyone to build a
healthy, strong and safe
community.
“The asset approach is a set of values and principles and a way of thinking
about the world.”
www.assetbasedconsulting.net