This think piece is a reflection from a member of staff at Aberdeenshire Voluntary Action on the issues that arise when developing community linking approaches to build capacity in the community to support health and social care integration

By Alison Grant, Community Health in Partnership Co-ordinator, Aberdeenshire Voluntary Action

Note: The appendices and annexes referred to in this document are part of the Community Links Worker Report. This discussion paper is Appendix 4 in that report.

There are many models of community linking including the examples considered by the Inquiry Teams in their Desk Research (see Appendix 6 in the Community Links Worker report). The key to all models is making the link between traditional health and social care services (statutory) and the third sector in its widest sense. In this discussion paper, I look at a range of issues arising from my own practice over the last two years, firstly as third sector organisational development facilitator (ODF) in health and social care integration (HSCI) and latterly as co-ordinator of the community health in partnership team with Aberdeenshire Voluntary Action, the third sector interface (TSI) for Aberdeenshire.

Third/community sector and working closely with a general practice team

At the 2016 Scotland Policy Conference Integrating Health and Social Care in Scotland [1] Dr John Montgomery (GP & lead clinician, Govan Social and Health Integration Partnership project) spoke of the importance of communication between all parties involved in the care of a patient with the multi-disciplinary team (MDT) being the crucial element to this. This practice has community links practitioners (CLPs) (Scottish Government/Health and Social Care Alliance Scotland funded programme)[2] as part of the general practice team with the aim of supporting people to live well in their local community by building links between the practice and local community resources.

The Govan CLPs “practically link into the voluntary and third sectors”. There is ongoing debate in Aberdeenshire regarding the appositeness of third sector presence at MDT meetings where patient details are discussed. Some HSC professionals recognise the benefits of a wider contribution to the discussion. Others consider it inappropriate due to client confidentiality and data protection. It is unclear if the CLPs are present at MDT meetings in the Govan practice, whilst HSC staff may suggest meeting the CLP or patients can self-refer. The literature advertising this service suggests a fairly formal approach with patients supported to identify individual goals and assistance offered to access local resources that will help patients to reach their goals.

An organic, informal approach to community linking in Insch

The Insch Community Links project had no formal referral pathway. Some health staff would recommend the service to patients with the onus on the patient/service user to contact the community links worker. Many leaflets about the service were given out to patients but most people engaging in the community links worker activities made the connection through local knowledge or knowing someone participating in the groups. This was an effective model that took time to become established and had a ‘light-touch’ approach to engaging participants.

Activities were user-identified with the community links worker exploring the practicalities and facilitating the establishment of particular groups. Lunch clubs, tea dances, games afternoons and walking groups are all successful examples. There was a focus on encouraging volunteers from within the groups to tke more ownership of activities e.g. training as walk leaders; identifying and risk assessing walks. The flexibility and variety of roles allows people to move seamlessly from participant to volunteer to group organiser.

All activities were strengthened by encouraging individuals to share their strengths and skills for the benefit of participants (see Appendix 3, and Appendix 4: Annex 2).

Loneliness, social isolation and improving mental health

A local government information unit report (March 2016) [3] indicates that:

Loneliness:

• can increase the risk of premature death by 30 per cent.
• can be as harmful for our health as smoking 15 cigarettes a day.

Lonely individuals are more likely to:

• visit their GP
• have higher use of medication
• higher incidence of falls and
• increased risk factors for long term care.

Participants in the Insch community links worker activities reported improvements to physical health conditions such as arthritis, Type 2 diabetes and high blood pressure also improved diet and weight loss. However, equally significant are the social benefits recognised by them – “social interaction”, “good company”, “part of a great community”, “meet new people”, “made many friends” – are some of the quotes from interviewees (see Appendices 2 and 3, and Appendix 4: Annex 2). Benefits for patients (and HSC staff) were recognised. Patients have something they can go on to and are less likely to ask for call-backs from community nursing team.

Billy Watson, Chief Executive, Scottish Association for Mental Health (SAMH), spoke at the 2016 Conference [4] of the correlation between social deprivation and poor mental health. His view is that mental health is currently still addressed by services “through a diagnosis driven medical model”.

He also suggested sport and physical activity might be “one of the most important things to invest in for the mental wellbeing of our nation.” SAMH believes the key to future success will be investing in local mental health models e.g. peer support, social prescribing, community development assets and greater self-management.

Working at a wider, macro level to support community linking – the need to build trust between public services and the third/community sector

Whereas the Insch Community Links and other link worker models looked at by the research team could be considered to operate at a micro level, the Community Health in Partnership (CHiP) Project in Aberdeenshire is concerned with linking on a macro level.

The CHiP team is working to:

• Support the third sector to recognise where they currently and potentially could contribute to health and wellbeing particularly around prevention and early intervention.
• Support the establishment of strong and sustainable links between health and social care services and the third/voluntary/community sector.
• Create a ‘vehicle’ to facilitate the direct exchange of views and information between sectors.
• Help the third sector to achieve parity of esteem and ensure the potential of voluntary and community group assets is fully realised in collaborative and co-production activities.

Ensure that project learning ‘best practice’ around third sector activities is captured to inform future delivery and design of health and social care services.

There are many examples of cross-sector collaborative practice working well. However, the question of ‘trust’ comes up repeatedly in discussions with HSC professionals: “How can the third sector be trusted to effectively deliver what they say?” Standards of voluntary sector providers and levels of training are also concerns. Unfortunately, it is examples where things have not gone well that tend to stick in people’s minds and create barriers to future collaboration.

Many voluntary and community-based activities succeed because of their more informal approach. The danger is that placing additional bureaucratic demands on organisations could be a disincentive, particularly to those largely dependent on volunteers.

Interestingly, during a series of workshops on the theme of integration, some voluntary organisation staff said that they felt undervalued by HSC professionals. One of the reasons for this was around perceptions of volunteers not being ‘qualified’.

It is absolutely right that the needs of vulnerable patients are taken seriously and that evidence of ability to support them provided. But can we ‘trust’ individuals who have the capacity to assess and take personal responsibility for decisions around engaging in community or voluntary led activities? This would then remove the responsibility from the GP or other HSC professionals.

During desk research the inquiry team found evidence to suggest that where GPs had direct contact with third sector providers they were more inclined to recommend or endorse those services or activities to patients (see Improving Links in Primary Care report – listed in Appendix 6: Annex 1).

Needing a national message and greater public awareness on community capacity-building

At the 2016 conference several speakers spoke of the need to work with the community and voluntary sector. The expectation that communities will be able to develop initiatives in response to unmet need is growing. However, many communities are unaware of this and instead are exposed to the largely negative media stories – ‘NHS crisis’, ‘GP shortage’, and ‘underfunding of NHS’ – creating a sense of helplessness.

There is no doubt that we face increasing health inequalities and changing demographics and that our ability to carry on providing services at current levels unsustainable. Health and social care integration is transformational change and for that to succeed all partners need to be fully aware and engaged. In order to stimulate community capacity-building then a national message (from government) would help individuals and communities to become more involved with the integration agenda and encourage ideas and discussion around prevention and self-management.

In conclusion

As far as the participants are concerned the informal approach of the Insch community links worker model worked for them. Hosting the project within an established local organisation – in this case The Friends of Insch Hospital – and having the support of a voluntary service support organisation (CVS Central & South Aberdeenshire which then became Aberdeenshire Voluntary Action) provided ‘back office’ assistance when needed.

Buy-in from HSC professionals in the early days was also a key element. The activities in this model centred around social and physical needs.

In other areas different approaches will be required. For instance, the Govan CLP project functions in an area of high deprivation with increased premature multi-morbidity and social difficulties. A more structured and holistic approach to community linking is required to tackle the many barriers to achieving and maintaining wellbeing.

Speaking at the 2016 Conference, Dr Andrew Fraser, director of Public Health Science, NHS Scotland, said:

“It is one thing to be free of disease but it is quite another to be free from worry about having your housing tenure in a good place, having enough money to heat your house, enough food including some fresh food in the fridge… That’s all part of what health and social care in a holistic sense is all about.”

There is much expectation of communities’ capacity to tackle health issues such as social isolation and poor mental health. Building trust and meaningful relationships between the public sector (including GPs) and third/community sector and indeed, within the third sector itself, and will take time but is essential to progress.

Community linking is a complex area of practice that is generating a range of issues and dilemmas that will need to be discussed and worked out over time by public services and third/community sector in Aberdeenshire. Part of the focus of the CHiP team’s practice is around the need for a culture change and the subtle emphasis of this ethos to all stakeholders. Establishing a sustainable and meaningful way to enable information and views to be exchanged and respected is a key piece of work going forward.

Note: All quotes above are from the reporting of the speakers at the 2016 Scotland Policy Conference: Integrating Health and Social Care in Scotland held in Edinburgh.

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[1] Conference organised by Scottish Policy Conferences in March 2016. Material referring to particular presenters here is drawn from participation at the conference and reporting notes provided by the organisers to conference attendees but shouldn’t be understood as a verbatim account of their views.

[2] View at: http://www.alliance-scotland.org.uk/what-we-do/our-work/primary-care/national-links-worker-programme/

[3] Report no longer available (free of charge) from LGIU. See Scottish Parliament report on social isolation from 2015: http://www.parliament.scot/S4_EqualOpportunitiesCommittee/Reports/FINAL_Report.pdf

[4] Conference organised by Scottish Policy Conferences in March 2016. Material referring to particular presenters here is drawn from participation at the conference and reporting notes provided by the organisers to conference attendees but shouldn’t be understood as a verbatim account of their views.

Training picture: CC BY-SA 3.0 Nick Youngson / Alpha Stock Images

First published in 2016 as Appendix 4 in the Community Links Worker Report.