Why I’m not pessimistic about councils’ response to vaping in the workplace

This past week has seen a continuation of different aspects of the debate about e cigarettes.  Neal Roff’s helpful and thoughtful blog for people new to using e cigarettes http://stormchildsblog.blogspot.co.uk/ was published.  And the equally helpful UKCTAS report on a depressingly “bad science” World Health Organization position statement was published http://ukctas.net/news/commentary-on-WHO-report-on-ENDS&ENNDS.html

But I want to turn to the report published over the last few days by  freedom to vape¸ http://www.tfa.net/freedom-to-vape/  a campaign of the Freedom Association http://www.tfa.net/about-us/

This report details the results of responses from local authorities to Freedom of Information Requests about vaping and smoking policies, sent earlier this summer.

“Councils ignoring PHE advice”

The report headline on their twitter feed says “87% of councils ignore Public Health England advice” on vaping being treated differently  You can read their comment posts and the report here http://www.freedomtovape.net/new_report_from_freedom_to_vape_87_per_cent_of_uk_councils_are_ignoring_advice_from_public_health_england?recruiter_id=107

Separately, another blog called vapers in power has published a blog linking to the “write to them” website encouraging people to write to local councillors about their policies https://vapersinpower.wordpress.com/2016/11/06/changing-how-your-council-sees-vaping/

Meanwhile, Simon Clark of FOREST has also written about this campaign on his blog http://taking-liberties.squarespace.com/ giving a different take.

Finally,  a report claiming – implausibly in my view and that of several lawyers I have spoken to – that councils are using “illegal” vaping bans was featured in The Mirror on 5th November http://www.mirror.co.uk/news/uk-news/illegal-vaping-bans-mean-third-9204911

Helping or hindering?

Transparency is always good, and indeed it’s helpful for citizens to write to their elected representatives giving their views on issues like this. I also note that the transparency of councils in Freedom of Information requests is far greater than the transparency of some agencies commenting on this, and the story is being used by some to bash councils and public health. I think that will prove counter-productive and some councils at least will decide not to tread on what feels like an increasingly fractious and flammable path, even if they can see good at the end of it.

One DPH recently told me anything they say positive is met by some people on social media – who really don’t represent vapers but many folk wouldn’t know that – with tweets about them being evil and how public health and tobacco control want shooting.  And then we wonder why public health folk are keeping their heads down in this debate.

The FTV report, while useful, doesn’t tell the whole story

There are several reasons why I don’t think the latest freedom to vape report tells the whole story. Doubtless some will disagree but let me list my reasons why:

  1.  The PHE report which contains guidance for workplaces https://www.gov.uk/government/news/vaping-in-public-places-advice-for-employers-and-organisations was only produced in July 2016.  The Freedom to Vape policy report was issued this past week. That’s just over three months between PHE guidance and the FOI report. The idea that most or even some councils will have considered, read and changed their policies on workplace vaping in that period is optimistic in the extreme, to put it mildly, given everything else they have on.  The Freedom to Vape report can’t be taken as more than a snapshot of what the position was at the time of the FOI. For many councils this will be in a queue of issues to deal with, and breaking even will be top of the list.
  2. How can I say that?  Because I know personally of a number of local authorities who are currently in discussion, or drafting revisions of policy and using, among other sources, the new PHE guidance and work from CIEH and others as a support. We are currently working on ours. I’ve commented on a few, and indeed many have commented on our draft policy.
  3. FOIs are an industry. Most local authorities employ a team to answer them. And I suspect (indeed having had informal discussions I know) that some councils have had their FOI team look at existing policy on the intranet and answer the FOI from freedom to vape. This won’t have captured that nuance. And it wont have captured those authorities where discussions have taken place but nothing is being written yet. The freedom to vape report, in that sense, misses out some work going on.
  4. You may say the FTV report will only miss a few local authorities doing positive policy development.  But local authorities tend to be pack animals. They watch and learn what others do and follow those they think are best, especially in an uncertain area.  And I know from speaking to people across the country that this is exactly what’s going on here. The few will shape the response of the many, in time. And three months is not enough for that to happen.
  5. It will take time, because there is no statutory duty on local authorities to do this, no policy obligation to do it either and the PHE guidance isn’t binding. Local authorities have discretion here and the key for people who are pro e-cigarettes is to help councils and support them use evidence and guidance sensibly and wisely. Frankly, the state of this debate will make some councils wish to exit the debate because it begins to look like a thankless low priority task when they’re about to fall off a financial cliff.
  6. Given everything else on the corporate agenda of councils (finances, social care, moving to business rate retention, devolution and so on) we need to find ways of making it easy for councils to do this. No amount of opprobrium and campaigning will make councils prioritise this if they think all they’re going to get is noise and hostility – even if it’s only from a few and the intention behind this report was about doing some good for peoples’ health.
  7. Several multinational tobacco manufactures have developed new, potentially risk reduced tobacco products which heat the tobacco but do not burn it. The Committee on Toxicology has been commissioned to evaluate the available evidence and at least some councils will probably  want to await this report before making any definitive statement or revision of policy.  Independent evidence on this latest development is extremely scarce but a study by the Dept of Public Health at the “La Sapienza” University of Rome suggests that it may be more appropriate to treat these products like e-cigarettes than to treat them like smoked tobacco.  What is likely is that councils, given everything else on their agenda, will not want to revise their policies several times within a year.

But there is a wider issue here, surely?  Why focus on just councils?  What about NHS, civil service, other public sector and commercial and NGO/third sector employers?  From what I can see and the discussions I’ve had with local employers, many of them don’t seem to have moved very far since July either. That’s because this shift will take time. The HR world is still in many places working out what it means in terms of employment law and local workplace policies and contractual entitlements.

Don’t just dismiss the FTV report

There will be some who dismiss the FTV report as a hostile publicity stunt, done in haste and poorly thought through. That would be a shame. And that’s a line I am neither going to believe nor support. The report was done by people passionate about the benefits of e cigarettes, I believe done for good intentions, and it does give us a snapshot of where councils are at and where the opportunity lies. The task now is supporting the HR community with getting on with this.

Time to re-orient how we debate with one another

I worry that there is a danger that some councils will see the report through the lens of some quite frankly hostile social media coverage (some from people who don’t like local government anyway) and decide they will wait and see what others do rather than trying to change things and get even more opprobrium.  To that extent, there is a real possibility that some of the social media coverage around this may backfire.

There is a whole discussion about people saying public health and tobacco control are fit for nothing, well I’ll address that another time.

Some factual corrections to the recent debate

There’s also some factual things to correct here:

  • Media reports that PHE advocates vaping rooms are not correct.
  • PHE has avoided prescriptive guidance and has proposed 5 criteria to help form local policies. The fact they have avoided prescriptive guidance means employers have to rely on their own interpretation of the law and their local contracts. The idea that most or even many employers will manage this between July and end of October is a triumph of hope over reality.
  • A conversation with a knowledgeable employment lawyer this morning told me that they and their legal colleagues have met with derision the media claim that local authorities are acting unlawfully on this. As someone who has worked in HR, I personally cannot see the legal claim for this. Employers remain able or not to consider whether or not to allow vaping.
  •  Establishing a right to vape in law will be very difficult, and would undoubtedly need legal precedent

Where next?

The adoption of the PHE principles will take time. We’ve been working locally on our policy for several months. That wasn’t reflected in our FOI response to this. This is not cause for anger or depression.  Nor is it cause for trading insults. We need to take the heat out of this debate.

There are lots of challenges lying ahead in developing and taking an evidence-based approach to welcoming e-cigarettes and similar devices. Setting to each others’ throats or “bigging up” an issue as a legal one when it isn’t – at least not in the way some folk report it – is not a recipe for elucidation.

 

 

Advertisements

Seeing the wood for the trees: Participatory Planning in Public Health

Sometimes you need a method for trying to make sense of an issue when everybody has a different perspective and you need to deliver some clarity and direction.  And sometimes you need to get people to see beyond the trees of different evidence articles and try to produce a synthesis of what the issues are, informed by evidence.  I don’t know about you but I find this can be extraordinarily difficult.

So I want to share with you two methods which work for me. The first is search conferencing for participatory planning when you are ready to build your strategy and want to work out from a range of stakeholders where you are headed.

The second is what I call the “Principles and Direction Sift” where you’re not sure you’re even ready to get a plan together, or where you might be but everyone seems to be pulling in different directions based on what they’ve read.

The Search Conference

For some time I have been using the Search Conference method for participatory planning. In the US it is widely used for community action.  The problem with this method is it can be a little cumbersome in the planning and running, when you’re not even at that stage yet.  But if you want some of my favourite reading on this try

Emery and Purser, The Search Conference.  The Publisher’s blurb about this book is actually quite accurate

Short guide to using Search conferences here

An article describing its use in food security

An article describing its (somewhat over-complicated) use in Northern Ireland

“Reviews and Commentary From The Publisher: The Search Conference is not just  another management tool, but a participative approach to planned change that engages the collective learning and creativity of large groups, inspiring people  to find common ground around new strategies, future directions, and joint actions. The process combines the best practices associated with strategic planning, systems thinking, and effective group communications – enabling participants to take part fully, rise above self-interest, and make decisions for the common good. Written by Search Conference pioneer Merrelyn Emery and Ronald Purser, this book uses a wealth of illustrative examples from a wide variety of nonprofit, business, and public organizations that attest to the  versatility of this important organization development intervention.”

And also there are times in public health when you can’t use a method quite at this level.

So here is the other method I use, the “Principles and Direction Sift”. Snappy title, I know, but it does have its uses.

The Public Health Principles and Direction Sift

This can be done in one meeting but often you get better results doing it over several sessions. It also seeks to be faithful to the scientific basis of public health and deal with the problem where evidence is lacking or silent. I’m not claiming this is perfect, but where I have used it it does work.

MEETING ONE

Step 1: Problem Statement

What, from a public health perspective, is the problem. E.G. epidemiology suggests there is no consistency of what follow up and support patients get after an NHS Health Check. Get everyone to state the problem, get them to agree the elements if need be and get a shared statement of the problem, challenge or issue. This could take 10 minutes or an hour. But get it out. It’s often good do to this as one meeting before you do the rest, and then everyone looks to find evidence and shares the evidence a week before the next meeting

If you are doing it in two meetings then at the start of the second meeting everyone needs to see and the group needs to revisit the problem statement.

MEETING TWO

Step 2: Evidence Assessment

Everyone reads and discusses the evidence and from the evidence identifies i) potential candidate interventions and solutions which have evidence behind them; ii) areas where evidence is not clear and iii) areas with no evidence. This could take between 15 minutes and an hour. But it should not dominate the session, the next stages are just as important.

Step 3: Evidence-current state fit

You group the interventions you currently have under which of the i), ii), iii) categories of evidence basis you agreed above, and if you need it a iv) category called “don’t know/uncertain/park”  What you should now have is a list of what you do with an idea of how they fit against the evidence. You will probably have at least some gaps where things you do have little evidence and where things with evidence are not being done well or at all.

Step 4: Principles and Priorities

Now you look back to the Step 1 problem statement and you compare the output from this with the output from Step 3.

You now need to work through and agree together an assessment of:

i) how well what you do now meets or addresses the problem and

ii) what principles (things like user acceptability, co-production, access) and

iii) which priorities (which bits of a strategy need doing first)

You are going to work on.

You will almost certainly have some stuff you are doing with evidence (and a pile of gaps) and some priorities you want to address with no evidence for what you can do about it.

For the former you need to ensure good implementation faithful to the evidence. Remember, implementation science suggests 30% of a programme’s value can be lost in poor implementation.

Step 4a: Navigating Uncertainty: Silence or Absence of Evidence

For the bits where there is no evidence, you cannot simply do nothing. You can either decide to do something pragmatic (which I would advise against unless that’s all there is you can do) or you can try to develop a logic model for some interventions where you can try to find evidence. A good way of doing this is to brainstorm from the principles those things which you think might be worth considering. Then you reality check them in the group.

When you have a list, you need public health and topic experts to search for evidence. If there is evidence you can apply it to commissioning interventions and go straight to Step 5 in the same meeting or another meeting.  If there is no evidence then use Step 4b.

MEETING THREE

Step 4b: Navigating Uncertainty: What is worth trying?

Public Health and topic experts should come to this with a worked up statement of evidence where it exists, and where there is no evidence some form of assessment of the ideas put forward and a theory-based assessment of what might work and a model of how to commission and evaluate it. This will need robust frameworks to evaluate and monitor whether it works so you can try it and if it doesn’t work decommission it. You need the group to agree a consensus around this before you go any further.

Let’s be clear what I have just suggested in the paragraph above. I am suggesting, and I am by no means the first to do this, the application of scientific method to the policy and commissioning process where evidence is silent or lacking. In other words, we would expect public health science to be busy creating evidence for us. But we can try to do this in a policy environment, and authors have put forward a variety of ways of doing this. Matrix RCL (who were major figures behind the Campbell Collaboration, the social welfare and social justice Answer to Cochrane) put forward just such a model for commissioners and policymakers in a briefing which has been widely used. You can access this briefing at http://www.jimmcmanus.info/Public-Health-Resources.html under the heading “Will this policy work?”

So an example: Imagine the evidence is silent on how brief interventions translate to behaviour change in primary care. So going back to theory of behaviour change we design a brief intervention for behaviour change using the methods which the theory of behaviour change suggests is salient, work it into an intervention, work up a framework to judge its worth and commission a pilot to see if it works.

I could spend the length of a book digressing here on the philosophical underpinnings of evidence-based practice and science. I will refrain for now. But I will point you to Nancy Cartwright’s lecture on the philosophy of science applied to policy problems ranging from Tamil Nadu to social welfare, which you can find here.  A thought provoking take, whether you agree with her or find it total madness.

MEETING TWO OR MEETING THREE IF YOU HAVE A THIRD MEETING

Step 5: System Check

You now check where you have got to. You should have a statement of what you are going to do. You now need to check that there is congruence between the problem, the evidence assessment and the identified interventions.

You can now start the phase of working up how you will implement all this.

This is not a rigid method. It works for some things and not others, but what it seeks to do is use a disposition to be evidence-led wherever possible and integrate that into how you build and commission programmes and systems.  It also seeks to deal with the fact that for much of health and social care, the evidence is absent.

“The Scientific Method”

The key point here is what would a scientific method suggest? That’s actually logically quite simple: read, hypothesise, experiment, evaluate and adapt consistent with the theory and evidence to date.

If the theory and evidence to date is right, you should eventually find something which works, because that’s how scientists do science in an academic environment. (And let’s remember the history of hunch, hypothesis, gut instinct and theory in science is actually a crucible of invention, not a pure process.)

If you don’t find something which works, then either i) you’re not following the method and theory properly, ii) not implementing it well, or iii) the theory and state of the knowledge is wrong. Humility, perhaps, and real life experience of how fragmented our systems are would suggest much of the time the answer is i) or ii)!

Self management in chronic disease: yes, we can?

I was privileged on Thursday this week to be part of a (very large ) event run by Herts Valleys Clinical Commissioning Group, on their commissioning strategy, one of a series of events the CCG is running to get their strategy right. And I have to say, the passion and engagement in the room from several hundred people (we were in a big venue, and it was jam-packed solid) was palpable.

We got talking in the workstream on Older People and Complex Care, led by Dr Anne-Marie Essam, about self management and about the possible role of the behavioural sciences. A lot of work on self-management nationally and internationally has not delivered for a range of reasons. Yet Diabetes UK, Macmillan Cancer and even the early 1990s work on self-management for people with HIV by the US National Association of Social Workers demonstrates that it can be done and can work.

This tempts us to put self-management into the too difficult box, like the sigh and slump of shoulders when we read yet another study about an intervention not keeping people out of hospital.

Anne-Marie asked me to give a psychology/behavioural science geek take on self-management and why we seem to get it wrong. So here goes.

Self Management – aspiration and theory

Self-Management in chronic disease is a policy aspiration partly driven by experience of some people with some conditions (self-management in Diabetes) and by theory. So we have a policy chasing evidence. There’s nothing wrong in this, providing that the theory and concepts of self-management were rigorously designed consistent with best theory and evidence.  But a lot of research studies have suggested that where we are trying self-management, it’s not doing brilliantly well in practice.

But it remains good theory that people should be able to manage themselves, with help and support and skills, to remain as well and independent as possible, for as long as possible. And an ethical principle is that we have a duty to ourselves and to others to exercise some form of stewardship over our own lives, as long as we are able to.

A concept which heavily influenced me early in my career was that of the productive living strategy for people with chronic disease. Don’t talk about self-management if you can’t find a strategy and goals for people where they feel their lives are productive and valuable.  Jerry Johnson and Michael Pizzi wrote a book in 1990 on Productive Living Strategies for People with HIV/AIDS which was the right book at the right time, but now seems sadly out of print. This insight and concept is woefully underused still.

What’s wrong with the evidence, then?

Well, there’s nothing wrong with the evidence that shows self-management isn’t working well, except perhaps that most of these studies rely too heavily on one set of methods (quantitative OR qualitative) and so we don’t get a rounded and nuanced view of some of the issues. Human behaviour is complex, and as such it often needs to be researched in a way which understands that complexity. Qualitative AND quantitative methods are both needed.  Many studies point out there is a problem with implementing interventions consistently and well, and this in itself can confound any good study of whether the theory of self management actually works. Indeed, one of the insights of  Implementation Science is that implementation is every bit as important as evidence. Self-management is complex because human life is; so the reasons it fails are often equally as complex.

But there are many examples of patients who self-manage well. So what’s the issue we need to solve?

Needless complexity

Well, it might be that we are making things needlessly complex in two ways:

  • First, we over-complicate the theory and the interventions
  • Second, our complex health and social care system complicates things

Complex (many variables in an issue like self-management) doesn’t need to be complicated. That’s at least one area where we fall down.

A very recent paper in BMC Health Services Research is the latest in a line of research which suggests a number of issues with self-management. I am going to summarise these and several other papers. At least some of the reasons self-management fails to deliver are:

  1. We complicate needlessly
  2. The aspiration for self-management is good but it’s badly designed from the start
  3. providers and clinicians may not have time or skills to do it
  4. We don’t have good enough frameworks to understand what makes a person able to self-manage and what can enhance this
  5. The interventions we design to help people self-manage are sometimes overly difficult to access or put too many demands on peoples’ lives. For example, self management courses DAFNE and DESMOND for Diabetes have good evidence, but in their early forms taking a week to attend a class if you’re working is impossible for some people. And for some patients this is demotivating.  So we use a sledgehammer for a big blow when taking it more slowly might work just as well. Contrast this with the highly successful newly diagnosed with HIV courses running in a variety of places including Saturday Mornings. You can’t tell me HIV is less complex than Diabetes. This leads to another problem
  6. We sometimes stick to the evidence like glue “Only DAFNE works and you must attend it all week” when the obstacles to implementing this and difficulties for patients in achieving it actually demotivates and disengages patients. As professionals we need a more mature approach to evidence based praxis
  7. We often don’t use insights from behavioural science or health psychology in designing and implementing interventions
  8. Our clinical pathways, IT systems and financial incentives aren’t designed to make self-management work
  9. Patient-professional communications, as health psychology has shown, can often derail any well-intentioned attempt at self-management
  10. Peer support is often lacking or minimal
  11. Don’t reinforce the desire for self-management across all contacts with a patient
  12. A lot of research on self-management  and protocols for doing self-management are still using paradigms which are more biomedical than behavioural
  13. We don’t get blended learning well. I’m taking HIV again as an example because there is so much richness to learn from this field. Adults learn in a variety of ways. Combining easy to access support with information and tips and seeing it in practice works well. Check out how MyHIV has done it. It looks like it was designed using adult blended learning and empowerment theories. It clearly works for some people very well.

That’s enough to be going on with and if you’re like me you’re now being tempted to groan with despair.

So how do we understand the problem?

As a psychologist by training, one of my disciplines is when the evidence is not promising or silent, to go back to theory  and seek to test it by rigorous design of implementation frameworks and equally rigorous evaluation. In Health Psychology there is a tool called Implementation Mapping , developed by Bartholomew and Kok in the Netherlands, to help you do just this. Their book is still in print and extremely useful.

When an intervention isn’t working in the way the theory suggests it should, there are several possible solutions

  1. The theory of self-management is bad and should be ditched (I don’t think
  2. We’ve got the wrong concepts, frameworks and strategies (I think this is what the research is saying)
  3. We implement it really badly (I think this is also what the research is saying)

Let’s be honest, self-management is a complex intervention (by which I mean it has multiple components, not that it’s rocket science) which requires a framework, training, skill and expectations for everyone. Can we hand on heart say we have done this?  I doubt it.

So what, if anything, can we actually do?

Allow me to bang the drum for psychology here by saying NHS and Social Care Commissioners should have access to a well trained behavioural scientist who gets the real world and helps design interventions and their training which works and spends at least half their time on this. An investment of £70,000 a year in behavioural science could help.

But in a regime of austerity this might be a step too far if people feel behavioural science is unproven. So let me suggest  a process for getting self-management right

At Strategy and Commissioning Level

  1. Get a small action learning set of interested people together. Patients and Carers who self-manage well should be part of this and a behavioural scientist or psychologist
  2. Review the evidence and literature together using a workshop approach so everyone understands it
  3. Come up with a framework for self-management together
  4. Test it to destruction by throwing every possible problem and bad management event at it
  5. Make sure it becomes everybody’s business and that everyone has a role and has appropriate training to support self-management
  6. Redesign the system of going into and out of hospital so it supports self-management for those capable of doing it
  7. Design and run better, more real world, self-management courses for patients
  8. Integrate qualitative data from patient experience into design of systems. There are ways of testing and assessing qualitative data.

At Clinician Level

Let’s be honest here, only partnership with patients and carers will help us get self-management right. I learned valuable lessons about self-management from the way my mum and dad managed their disability and heart disease respectively which helped me understand the theory and evidence better. There’s nothing wrong with clinicians using and reflecting on patient experience to dialogue with the theory and evidence. We should encourage it. Reflective real world practice is often referred to in social sciences as praxis – (not the Marxist sense of the word) but practice informed by theory and evidence and reflection on that.

So supporting praxis which understands the insights from behavioural sciences about self-management is crucial. One of the best ways of doing that is build workshops where patients and behavioural scientists and clinicians can share and reflect.

At Patient Level

The first thing to do is not start building unnecessarily complicated interventions. If you have ever heard of the Di Clemente and Prochaska states of change model for health behaviour, now is the time to  park it somewhere nicely for the duration of this project. It won’t work in this situation and was arguably never intended to be a theory or model for behaviour change anyway. Yes, it works in some situations, but actually has major limitations.

Susan Michie has proposed a behaviour change model which is actually more simple, well grounded in theory and supported by evidence. And it is this:

  • For most health interventions, capability plus motivation plus opportunity leads to behaviour.
  • This needs skills, support and reinforcement

She talks of the Behaviour Change Wheel and you can find two free papers here:

If we follow Michie (and a host of others) then there are two big tasks for us :

  1. at patient level we need to assess, build and constantly reinforce the person’s capability, motivation and opportunity to self-manage. Capability includes the skills to do it and also the belief they can do it, as well as the readiness. In other words, interventions which support and train and reinforce and motivate are more likely to show effect if they are consistent across someone’s encounters with people and the person believes they can do it. Some folk will never manage it (they will always need it done for them), others can and do everyday.
  2. That brings me to the second, we need a behavioural science approach to understanding how we turn those who can’t into those who could.

Study after study suggests to us that self-management is difficult. That doesn’t mean it’s impossible. If we make it work, the benefits to patients (better quality of life), to NHS and Social Care (less cost) and to everyone (people with chronic disease able to live well with dignity) are clear. The problems are we use the wrong models, implement them badly and assume it’s either too easy or too difficult.

Who’s up for trying?

Helping community agencies be effective in community safety and public health

 

To support agencies wanting to bid for the  fund for communities created by Hertfordshire’s Police and Crime Commissioner I found and shared a set of resources and tools which people might find useful.  I shared these on twitter and lots of people came back and asked for more resources.

So  here, in one place, are a range of tools and resources for you to use and share.

A good place to start is reading the Hertfordshire Police and Crime Plan.

 

Evidence for what might work in crime reduction and community safety

There is a lot of opinion about what works and what doesn’t in crime reduction. I am going to point you to the resources which I and colleagues have found to be most rigorous

  • The Campbell Collaboration has a host of systematic reviews on crime and social issues
  • A Knowledge hub of a range of things which work is here
  • Thinking of doing something on fear of crime, try here or here
  • Reducing youth crime and anti-social behaviour: a useful resource is here
  • If you want to train up community practitioners, you might find some training models here for crime reduction and here  and remember Neighbourhood Watch do a programme of training for community advocates
  • Publications by Jim McManus on crime reduction and community safety including hate crime and designing out crime are here

 

Networking and support for agencies working to reduce crime

  • CLINKS helps voluntary and community agencies who work in reducing crime and re-offending

 

Understanding Health Inequalities, guides for community agencies

  • The Royal College of Nursing has a really useful webpage and guide

 

How on earth do I evaluate and monitor whether this works?

Evaluating (i.e. finding what the impact of your intervention was and whether it’s worth it) is very important because we need to know whether projects work, do nothing, or do harm. Community agencies so often find evaluation a world where experts talk jargon at each other. Here are my top resources for communities wanting to evaluate:

  • A very simple, straightforward and easy menu of tools for evaluation and monitoring aimed at not for profit and community agencies is here.
  • If you need to get your head round what evaluation is and why you need to do it, Evaluation Support Scotland has some excellent resources
  • The Kellogg Foundation Handbook is free and one of the best whole system approaches to evaluation you can find. This provides a tried and tested model used in major and minor projects in developing countries. I have used it and it works.
  • If that’s too ambitious you can try Charities Evaluation Services who have a range of tools on evaluation
  • Prove and Improve is an online toolkit to help you demonstrate projects work and improve their quality and impact

 

What about attempting a cost-benefit analysis?

The Office of Public Management has a really useful tool, Valuing Public Services on how to measure the value of services and interventions

 

And finally…

Can you explain something in plain English rather than Jargon?  (Ok, yes I fail often at this.) Try this tool http://www.splasho.com/upgoer5/

 

If there is stuff you want but isn’t here, tweet me @jimmcmanusph or email publichealth @ herfordshire.gov.uk  with “Ask Jim” in the title

What can a Public Health mindset bring to making communities safer?

Hertfordshire’s Police and Crime Commissioner has done something visionary.  He has set up a fund for communities to put together “innovative local schemes which aim to make our communities safer”. This fund is linked to the Police and Crime Plan for Hertfordshire, which takes an “everybody’s business” approach to reducing crime and making communities safer.

Less than an hour later I had tweets and emails asking me what evidence communities could use. Then people started asking me how they could develop and put evaluation frameworks around bids. Then partners asked – can we use the Herts Public Health Partnership Fund given to LSPs and Districts to match fund where there are clear links and overlaps? (The overwhelming view of the Public Health Board was yes.)

This set me thinking, what does Public Health have to bring to the table?  More years ago than I care to remember, I produced briefings on crime and community safety among other work I did in community safety and crime reduction. My public health training helped me find the evidence and organise it into tools which went to statutory crime and disorder reduction partnerships.

I often say one of the ways I describe Public Health  about four Ps:

  • A Perspective (or Mindset) which focuses on
  • Populations and sub-populations; which is
  • Prospective (it looks to what can be improved, prevented or avoided) and goes retrospective to understand where we are today
  • Protective – seeking to protect communities and individuals from risk to health and life

The mindset of Community Safety is very similar. Both Public Health and Community Safety work in similar ways: through communities, through skilling people up, commissioning and using interventions which have evidence of effectiveness and sometimes, when the evidence is silent, going back to good theory to build an intervention and evaluate whether it works.

The Evidence

Crime impacts on Health in a range of ways, and there is a great deal of literature on this. Things like acquisitive crime to feed drug habits, and the devastation of domestic violence and hate crime are perhaps the ones that spring readily to mind. But there are other issues too:

  1. Evidence suggests that ongoing stress from high levels of crime and high fear of crime contributes to a stress pathway that can lead to mental ill-health, poor resilience and even heart disease and stroke.
  2. Victims of crime are more prone to physical and psychological ill-health on an ongoing basis.
  3. Disabled people are typically more victimised for property crime than the general population
  4. Hate Crimes have enduring mental health consequences
  5. Victims of violence often develop adverse coping mechanisms which develop health problems
  6. Ongoing phantom pain and unexplained symptoms among people who are victims are not uncommon

By contrast, communities which have strong self-efficacy (i.e. they believe they can do what they need to) are more resilient (i.e. they can handle challenges and problems more easily and return to a good state of functioning more readily), healthier and more able to address issues of relevance to their communities like crime and disorder. They also have lower fear of crime.

Building resilient communities

So how do we build resilient communities? In essence where people share the same place and public realm we need to support communities find strengths, self-confidence, skills and solutions at individual and interpersonal level, have strong links with each other and develop a sense of affinity for those they live next to and nearby.   Where people share the same identity (sexuality, faith, nationality) finding common ground and sharing common interests are salient. This is neither new nor rocket science.

But often we lack the insight of the behavioural sciences. And it can be quite simple to harness these. We talk about community development in the UK. In the US they talk about Community Advocacy. Community Advocacy has at its hear building capacity in communities to help themselves, to do, to believe in themselves. The approach works in Community Safety as well as Health.  It is particularly effective for marginalised communities and those experiencing hate crimes and has a strong track record in the US. The role of a range of diversity groups  such as Faith Communities in Health Advocacy in the US is particularly striking, working as they do for very marginalised communities. We have much to learn from them.

Building resilient communities is something which public health and community safety could do together, because everyone benefits. Addressing specific types of crime (hate crime, domestic violence) also brings ongoing benefits to both agendas.

The Public Health Contribution

Taking just the range of issues above, Public Health has a lot to bring to the table. The prestigious John Jay College of Criminal Justice actually has a whole programme of courses on health and crime.  I am going to list just some of the things public health can bring to the table:

  1. Sharing epidemiological skills so we can understand better the distribution of crime in time and place
  2. Working together on public resilience and mental health agendas
  3. Finding and appraising evidence for effective interventions (see my next blog post)
  4. Helping NHS commissioners and providers respond early and effectively to victims of crime
  5. Training Police and others in preventing victims of hate crime becoming more traumatised
  6. Providing drug and alcohol services and pathways which cut crime and disorder and help people with problems
  7. Providing training to communities who want to implement and evaluate programmes
  8. Sharing evaluation, evidence appraisal and policy appraisal skills with people in crime reduction
  9. Ensuring services for those likely to become victims of hate crime encourage and support people to report
  10. Ensure the cycle of crime in troubled families is broken by finding effective interventions for people to thrive
  11. Find interventions which help children thrive emotionally and value themselves and others
  12. Using the public health role in licensing to the best good of communities

The new landscape of the NHS means NHS Clinical Commissioning Groups are responsible authorities for Community Safety Partnerships. This could be seen as yet another burden on new CCGs. The challenge is to find ways of integrating the CCG agendas with the community safety agenda, and picking some concrete issues and projects to start with.

My next blog post will do two things: signpost agencies to sources of good evidence in crime reduction, and signpost them to resources to help them evaluate interve