Improving health? Start local

Ideas about place based systems of care are currently fashionable in policy circles. I have previously written about initiativitis, (plus ca change, plus c’est la meme chose’ or ‘here we go again’) but I am resisting the cynical temptation to dismiss the rediscovery of the importance of place. Rather, I want to think through what some of the positives, and negatives of a place based system of care might be, and how they might relate to processes concerned with ‘responsibilising’ individual citizens and ‘activating’ individual patients. What scope is there in place based commissioning for effecting a degree of positive change within disadvantaged communities?

I was working in a disadvantaged neighbourhood, using an asset based approach to community development in an attempt to tackle health inequalities. I got to know some local families who told me they had previously enjoyed ‘healthy eating on a budget’ classes and asked whether I could help arrange similar classes for them. For me, this fitted neatly with the objective of empowering local people, so I liaised with other agencies and responded to this clearly articulated community request. Once a week about eight mums and their pre-school aged children met in a church hall. The children were cared for in a crèche while the parents were busy in the kitchen. A tutor from a local college took them through a series of recipes that they could cook and eat within a two hour session. Practical cookery sessions ended with a shared lunch for the group, including the children.

Towards the end of the eight week course, a colleague of mine, who worked in health promotion, with an interest in nutrition, asked if she could evaluate the ‘intervention’.  She duly turned up with a large diagram of food groups.  However, this evaluation did not inform future practice.  As is so often the case, evaluations are carried out because it seems like the right thing to do.  They become an end in their own right.  After the evaluation, she concluded that parents had learned new skills that they would be able to implement within their own homes. Her unit of analysis was individual families and her implicit theory of change was that these families lacked knowledge.  The implication of her evaluation was that education of families was the solution to their complex needs.

A theory of change with a different unit of analysis
My own assessment of the healthy eating on a budget intervention was that it may have been very difficult for the participants to use and apply the knowledge they had acquired, given the complexity of many of their daily lives. This deficit model of ignorant citizens in need of improved levels of health literacy or nutrition advice, advice to be given by an expert, risked stigmatising the participants. It demonstrated a lack of appreciation for the way daily lives are lived in local places and represented a failure to fully diagnose the causes of long standing social determinants of health. An emphasis on individual attitudes or behaviour may constitute one ‘theory of change’. A competing theory might be that individuals’ behaviour is determined in part by their social circumstances and if these can be changed by intervening at a community level then in the medium term that may have a broader impact. The asset based community health development ‘theory’ acknowledges that many determinants of ill health lie outside of individual control and are not easily susceptible to individual behaviour change.

Asset based community development
The cooking classes took place within a local church. Through multi-agency networking with a college, a social services department and community groups, the faith group built on the assets of the community rather than focusing on individual level deficits (contra to what the nutritionist had done). The Church that hosted the cooking classes developed a social enterprise and successfully applied for funding to sustain similar community initiatives, together with vocational training in basic food hygiene that allowed some local people to get jobs. Today there is a thriving community café and shop so that, irrespective of their individual circumstances, local people have a chance to socialise and eat a nutritious meal on a regular basis, now assisted by work done by people with learning disabilities.

In the BMA position statement on ‘behaviour change’ they pointed out the inadequacy of placing responsibility for health inequalities at the level of individuals – indeed similar critiques have appeared previously on this blog.  I tell my evaluation story in the hope those promoting place based commissioning might revisit asset based community development and avoid the flawed logic of ‘there is no such thing as society’. For sociologists these debates about agency and structure are very familiar themes.  ABCD is not a panacea and when public health budgets are under severe constraint this will be challenging but those with a commitment to building capacity in communities might take advantage of a policy shift towards place based commissioning. In this case the healthy eating community intervention contributed indirectly to the development of a sustainable community resource that many local people take pride in.

About the Author: Pam Carter is a Research Fellow with interests in governance, governmentality and the social relations of knowledge production. Pam is currently working with Professor Graham Martin on an NIHR CLAHRC East Midlands funded study of patient and public involvement in health and social care. She is on twitter @PamCarter25.