Wellbeing: the impact
of inequalities
Dundee City Chambers
EVENT REPORT
In order to develop
services that promote mental wellbeing and help address health inequalities,
a wide range of local partners need to have, at the very least, a working
knowledge of the impact of their services on mental wellbeing and inequalities,
and at best, a sophisticated understanding of the relationships between
local partnership working, national priorities and the social determinants
of health.
Event proposal, June 2008
Introduction
This report summarises the process, aims
and outcomes of the above event, which took place in November 2008 and
was attended by 90 delegates from across Tayside and Scotland. The event
was the culmination of a range of formal and informal discussions within
services and partnerships on the importance of addressing health inequalities
and poor mental wellbeing, and demonstrated the ongoing commitment to
tackling these issues across Dundee and the rest of Tayside. The event
was sponsored by Dundee Healthy Living Initiative, Dundee Partnership,
Tayside Public Health Network, Dundee Association of Mental Health,
the Corner, Leisure and Communities Department (Dundee City Council),
Community Family Support Project, and NHS Tayside. Three international
experts in the research fields of inequalities, wellbeing and mental
health improvement- Professor Richard Wilkinson, Diego Zavaleta and
Dr. Lynne Friedli - were invited to Dundee to share and explore the
evidence base for mental health improvement and tackling health inequalities
with a wide range of stakeholders, including representatives from sponsoring
organisations and others such as Tayside Police, the Voluntary and Community
Sectors, academic institutions, Health Scotland, elected members and
local representatives. A brief bibliography of each speaker is presented
in Appendix 1.
The aims of the event were to:
Raise awareness of how social
and economic structures affect health inequalities, and how this links
to wellbeing;
Increase knowledge of how
poverty affects feelings of stigma and shame, and how this affects
service use; and
Raise awareness of the benefits
of positive mental health and the evidence base for various interventions.
The event was chaired by Mr. Sandy Watson
OBE, DL (Chairman of NHS Tayside) and a combination of formal presentations,
structured work in pairs, audience question and discussion time and
workshops were used to stimulate debate and develop potential agreement
for action (Appendix 2). Information gathered through the above methods,
including delegate feedback about the event is presented in Appendices
3 to 5.
National and local context
The event was immersed in the context
of the existing Scottish Government policy framework, in recognition
that improving mental wellbeing and reducing health inequalities are
national strategic priorities for health improvement. It is well documented
that health inequalities and poor mental health affect people living
in disadvantaged communities more than those in affluent areas and contribute
to, for example, levels of ill health, unhealthy lifestyles, educational
attainment, and employability. Therefore, the event also fitted with
local health-related programmes such as Keep Well, Dundee Healthy Living
Initiative and Pathways to Work. Through connecting the event to local
regeneration and community planning, the aspirations of the event planners
were that participants would be in a position to better support, develop
and integrate action aimed at improving health for disadvantaged people.
Since planning for the event began, Dundee
was identified by the Scottish Government as a test site for improving
mental wellbeing within a defined community, as part of the national
health inequalities strategy, Equally Well. Blairgowrie in Perthshire
was also identified as a test site, with a focus on addressing the multiple
and complex needs of service users. In addition to the previously identified
connections with existing structures and programmes, the event provided
an opportunity for participants involved in the test sites to discuss
how the evidence put forward from the speakers linked with their plans
for test site development.
Interactive sessions
The following information highlights
the main discussion points raised from the interactive sessions at the
event.
1. Activity to identify insights and
key stakeholder issues
Following presentations by Professor
Richard Wilkinson (Dysfunctional Societies- why inequality matters?)
and Diego Zavaleta (The ability to go about without shame: shame
and humiliation as missing dimensions of poverty analysis), participants
were asked to pair up with the person sitting next to them and use the
following questions as prompts:
What were your key insights/
learning points from the presentations you’ve just heard?
What are the implications
for your work?
Are there any contributions
you would like to make to the debate in relation to what you have heard
so far?
Significant insights were written on
Post-it notes and handed to facilitators at the end of the session.
All Post-it note comments are given in full in Appendix 3.
A number of key themes emerged from the
Post-it note comments and included:
The strong need for partnerships
and services to focus on tackling inequalities;
The importance of redistribution
of wealth and the resulting benefits for everyone;
The importance of respecting
and valuing people;
The need for new ways of working
and thinking;
The recognition that poverty
generates stigma and shame;
The importance of learning
from good work in other countries and sharing that learning; and
The need to publicise the
evidence more widely.
2. Work groups
In the afternoon and following the 3rd
presentation from Dr. Lynne Friedli (Mental health, resilience and
inequalities: developing social solutions for social problems),
participants were divided into four work groups as follows:
Angus and Perth & Kinross
(Group 1);
Dundee ‘Test Site’ (Group
2);
Dundee ‘General’ (Group
3); and
Dundee ‘General’ (Group
4).
Leading on from the morning activity
of ‘working in pairs’, the work groups were asked to consider the
following proposed questions:
What
does the evidence we’ve heard mean for local work (in terms of tackling
health inequalities and improving mental wellbeing)?
What kinds of partnerships
are needed to integrate mental wellbeing and inequalities and how do
we build them?
Identify three priority
action points for each locality.
Notes from work groups are given in full
in Appendix 4. Delegates acknowledged that the evidence base reinforced
the rationale and purpose of local work and supported the need to change
ways of working. There was agreement that the information presented
at the event needed to be shared more widely across Tayside and while
an evidence base existed, it needed to be incorporated and tested in
local situations and projects. Further work was required to look
at innovative ways of measuring indicators such as resilience within
and involving communities. There was support to tackle stigma
and shame within the workplace to promote a culture where people felt
valued.
In summary, there was agreement among
all of the work groups that strong partnership working was central to
driving this work forward. It was recognised that existing systems/structures
were not always established in a way that supported effective integrated
working. Barriers to good partnership working included:
Lack of agreement on priorities
and shared goals;
‘Competition’ between
services; and
The focus on measuring success
within individual agencies rather than partnerships.
Delegates proposed many
ideas to overcome such barriers, including:
Ensuring that the Community
Plan (CP) is explicit in recognising that mental health and wellbeing
are cross-cutting themes. It was felt that dividing the CP into
sections compartmentalised issues;
Exploring the potential to
share and pool resources- ‘Let’s create a pot of money, that’s
real partnership working’;
Sharing local examples of
good sharing/joined up work;
Ensuring clarity of roles
and frequent review of roles; and
Concentrating on good communication
e.g. face to face, valuing contributions, and recognising that people
are part of the solution.
While all work groups felt that genuine
engagement with communities was lacking, it was also recognised that
there was danger in putting communities at the centre without strong
partnership working with service providers and policy makers.
Priority actions
Work groups identified the following
priority action points:
Group 1
Ask/involve/look for the people
who don’t get involved or use services. Better access to data and
information sharing could help, including recognising the value of qualitative
data;
Consider the use of person-held
records, at least as an option. This has worked well with gypsy
traveller communities; and
Services for service users.
Recognise that services have a role to play in societal shift and fostering
resilience. Work with service users and not to
service users. Encourage and support informed decision-making
by service users and learn from direct involvement with communities.
Group 2
Establish a reference group
ensuring sign up from NHS, Council, Community and Voluntary sector partners.
This could provide a mechanism for disseminating lessons and practice;
Take great care with the use
of ‘language’ and approaches used to engage with communities;
Establish agreed rules of
decision-making and operation; and
Approach the private sector.
Group 3
Support and foster ‘co-production’/working
together and a collective ‘we’;
Look at less strategic organisations
and more voluntary sector and community member involvement. Strategic
thinking and behaviours should be more influenced by listening to communities;
Partnerships need to be local
or where people/groups form communities;
Use local intelligence and
resources effectively;
Communicate face to face and
value contributions;
Challenge attitudes and behaviours.
Group 4
Effective sharing of the evidence
base;
Write up of event
Accessible discussion and
debate with communities
Delegates should be responsible
for sharing today’s learning and knowledge with colleagues
Local Community Planning Partnerships
(LCCPs) could have a role in driving this work forward;
The recognition that wellbeing
and health inequalities are cross-cutting should be more explicit in
the Community Plan. Today’s learning and plan of ‘direction
of travel’ should be taken to the Community Planning Partnership;
Monitoring and evaluation
are critical to demonstrating change in communities. Although
this agenda is working towards long term change, we need to consider
short and medium term outcomes and appropriate evaluation methods.
3. Delegate feedback
Delegates were invited to complete evaluation
forms at the end of the event to give feedback on the usefulness of
the evidence presented and identify needs relating to training and further
support. Thirty-four (38%) forms were completed and responses
can be seen in detail in Appendix 5.
Delegates were asked to score their responses
on a five point scale (where 1 was ‘not at all’ and 5 was very useful/very
much). The majority of delegates gave positive feedback on the event
and the summary tables below show the majority responses, where points
4 and 5 on a five point scale have been combined.
How useful did you find the content
of the presentations?
Useful/Very useful
Response count
% response
Speaker 1
31
34
91%
Speaker 2
23
33
70%
Speaker 3
23
33
70%
Delegates commented on Professor Wilkinson’s
observation that increasing material wealth did not lead to an associated
decrease in inequalities and felt it was important to look at what could
be learnt from other countries where wealth distribution was more evenly
distributed e.g. Scandinavian countries.
How much did each presentation extend
your existing knowledge?
Much/Very much
Response count
% response
Speaker 1
20
33
61%
Speaker 2
23
32
66%
Speaker 3
16
32
50%
Diego Zavaleta’s work on shame and
humiliation provided new information for many of the delegates who completed
feedback forms. More respondents were familiar with the work of
Professor Wilkinson and Dr Friedli.
How valuable do you think this information
will be to you in practice?
Valuable/very valuable
Response count
% response
Speaker 1
24
33
73%
Speaker 2
20
32
63%
Speaker 3
21
32
66%
Again, the majority of respondents felt
that the work presented would be useful in practice, but recognised
the challenges of translating the evidence base into everyday practice.
Of 31 completed responses, 74% of delegates
(n=23) found the work group sessions useful or very useful. Twenty
respondents out of 30 (67%) indicated that they had identified training
and development needs as a result of attending the event. Support
requested to meet training and development needs centred on maintaining
and using networks and the opportunity to access events like this one.
There were several suggestions to organise a future event with communities
to look at community engagement and community views on the evidence
base.
Next Steps
The event organisers will ensure that
evaluation information is fed into related programmes such as Equally
Well and the Tayside Test Sites, Meeting the Shared Challenge, and Towards
a Mentally Flourishing Scotland action plans, as well as to event participants
and key service providers and policy makers. Tayside Public Health Network,
other relevant networks, and workforce development sections will be
encouraged to act on the learning and training needs identified. Local
links have been created with the guest speakers, which will be maintained
to ensure access to emerging evidence and expertise.
Thanks go to the following people for
helping to make the event happen:
Sheila McMahonDundee
Healthy Living Initiative
Dr Liz MageeDirectorate
of Public Health, NHS Tayside
Sandy WatsonTayside NHS
Board
Stewart MurdochLeisure
and Communities, Dundee City Council
David LynchDundee Community
Health Partnership
Peter AllanDCC Corporate Planning/ Dundee
Partnership
Tom GarnettDundee Association of Mental
Health
Dr Drew WalkerDirectorate
of Public Health, NHS Tayside
Dr Karen AdamDirectorate
of Public Health, NHS Tayside
Catriona NessDirectorate
of Public Health, NHS Tayside
Deborah GrayDirectorate
of Public Health, NHS Tayside
John LetfordLord Provost,
Dundee
Ray MarraSenior Council
Officer, Dundee City Council
Gordon WilliamsonSenior
Council Officer, Dundee City Council
Prof. Richard WilkinsonThe
Equality Trust
Diego ZavaletaOPHI, CRISE
Dr. Lynne FriedliMental
Health Promotion Specialist
Pete GlenThe Corner
Audrie TaylorCommunity
Family Support Project
Useful resources
Powerpoint presentations from
the event can be accessed by selecting the ‘Conferences’ link on
the Directorate of Public Health Website at www.taysidepublichealth.com
Equally Well- report of
the ministerial taskforce on health inequalities can be viewed at
http://www.scotland.gov.uk/Resource/Doc/229649/0062206.pdf
Information on the Scottish
Government's national programme for improving mental health and wellbeing can
be accessed at http://www.wellscotland.info/index.html
Information on the evidence
base and further resources, including Professor Richard Wilkinson’s
latest publication can be viewed at http://www.equalitytrust.org.uk/
Dr Lynne Friedli has recently
written a report entitled Mental health, resilience and inequalities
for the WHO Regional Office for Europe, which can be viewed at http://www.euro.who.int/document/e92227.pdf
WHO and Commission on Social
Determinants of Health report, Closing the gap in a generation- health
equity through action on social determinants of health can be accessed
at http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf
APPENDIX 1
Speakers:
Professor Richard
Wilkinson
A leading researcher in health inequalities
and the social determinants of health, Professor Wilkinson has recently
retired as Professor of Epidemiology at the University of Nottingham
and Visiting Professor at the International Centre for Health and Society,
University of London. His letter to David Ennals (the Secretary
of State for Social Services) in 1976 played an important part in the
setting up of the Black Report, which highlighted for the first time
the effects of poverty on health. His work has identified how
income inequalities lead to poor health and how this manifests itself
in 3 key psychosocial risk factors in modern society - low social status,
weak social networks and stress in early life. He has evidenced the
harmful biological effects of chronic stress for people living in relative
poverty.
Wilkinson has written two major and
influential publications on the relationship between inequalities and
public health, ‘Unhealthy Societies: The Affliction of Inequality’,
and ‘The Impact of Inequality: How to Make Sick Societies Healthier’.
Diego Zavaleta Reyles
Based within the Centre for Research
on Inequality, Human Security and Ethnicity, University of Oxford, Dr
Zavaleta’s research interests include
poverty reduction, inequality, governance and participation. Recent
publications include developmental work on internationally comparable
indicators of shame and humiliation, recognising that these factors
are central to an understanding of poverty and how this affects psychological
wellbeing. In essence, Zavaleta's work can assist service providers
to consider how accessible their services are to people who live in
poverty, or whether, as Zavaleta's work has shown, people can feel humiliated
and ashamed of having to use services that are directed at "the
poor".
Dr Lynne Friedli
Dr Friedli is a
mental health promotion specialist, who works across the UK and Europe
to build alliances for public mental health. Her recent work
includes a report for the World Health Organisation (Europe) and the
Mental Health Foundation on Mental Health, Resilience and Inequalities,
a review of the evidence on ‘positive steps’ for mental health (with
Christine Oliver) for NHS Health Scotland, Mental Health Promotion:
Building an Economic Case (with Michael Parsonage) (Northern Ireland
Association of Mental Health, 2007), and Developing Social Prescribing
and Community Referrals (Scottish Development Centre for Mental Health,
2007). Lynne has a close association with Dundee and has been involved
with Dundee City Council, NHS Tayside and Community Sector colleagues
in developing her evidence base and assisting with the local direction
of travel in relation to mental wellbeing.
APPENDIX 2
APPENDIX 3
Outputs/ insights from work in pairs
The impact of inequalities
for society as a whole needs to be better known - ESPECIALLY by Scottish
and UK Governments who currently seem enthralled by big business, pursuit
of wealth etc. This should be published in Daily Mail and Sun!
In terms of taking this forward: already work closely with policy colleagues
in regeneration, community safety, health and going to continue this
and continue exchange of information, joint projects and approaches,
etc. Also need more research targeted towards parents/families/early
years which would hopefully result in long term improvements.
But organisations, partnerships can be very inflexible, bureaucratic,
slow, and complex which can inhibit effective response - Boo!
It's not just poverty and
material inequalities that matter - it's much more subtle. Social
and Cultural factors that damage our health and wellbeing, at the heart
of the individual/family, community and society. New forms of
thinking needed.
Relevance of shame/humiliation
discrimination. People won't claim benefits out of shame (embarrassed
they need the help). How poor people spend money on "show
objects/goods" rather than good food. Old people deprive
self of food/heating to give grandchildren "good" Christmas
presents. Society still discriminates against people perhaps on
how they look/dress etc. Not surprising but shocking that people
feel more discriminated by state/statutory services.
The Community Development
concept of empowering people and raising self esteem remains important.
Money does not buy happiness.
Money doesn't give a person
complete fulfilment.
The issue of high bullying
within the UK was a shock.
Community approach empowers
people therefore raising their own self esteem and confidence.
Issue that UK is highest for
levels of bullying.
It was great to hear speakers
who have views like mine.
UK showing such high levels
of bullying.
Implications of work.
Community Development approach which can empower people has a knock-on
effect of raising self-esteem and alleviating shame.
Confirmation that more subtle,
emotional, perceptual factors have to be taken into account.
Increasing pride - empowering
people. Limits to human potential. Flourish/set the people
free
Social, emotional and psychological
aspects of inequalities.
Tapping into Human Resources
and letting them flourish.
Social Capital - increase
engagement with the public. Leadership and support to communities
rather than public services.
Equalities discrimination.
Expanding the ability of people
to flourish.
Explains why people are underachieving
'put down'.
The person has to be valued
as a human not treated as numbers and labels.
Challenge of changing attitudes
has to be tackled by service state providers in delivery.
Learn from other countries
that seem to work e.g. Scandinavian. Change in value of material
wealth. Has to impact from top down/down up
What are Dundee's plans for
redistribution?
Social capital has to be seen
as crucial to change.
Inequality not necessary to
do with income.
We should change the basis
on which Dundee Partnership is formed - What about equality?
The need to focus on social
change rather than just service provision. Poverty is an equalities
issue.
The strength of the case for
redistribution as the plans to reduce health inequalities.
The need to keep the wider
agenda of relative poverty at the heart of approaches to tackle health
inequalities.
"Small things matter"
like PKC Community Warden Scheme - Repaid Lothian Rattray.
Partnership working is important
like Angus Hospital Discharge scheme.
"The ability to make
a difference" like PKC Domestic Abuse Forum.
We can't leave income inequalities
to other service providers.
Impact on work
Encourage us to think critically about the inequality-related mechanisms
that determine health and wellbeing, and what can be done about them.
Insights Pervasiveness
of relationship between inequality and various dimensions of health
and well being at aggregate level. Raised questions about mechanisms
and solutions at an individual level or a community level.
Finding ways to more pro-actively
reach people, without attaching stigma.
Note for Diego - shame is
difficult to measure because people are ashamed to admit the experience
of shame! People don't tend to label themselves as unequal.
Closing the gap raises standards
for all, not just those at "bottom".
Need to have greater understanding
of perception and experiences of services, by both those who use them
and, just as crucially, by those who don't.
People need a purpose in life
a reason to get up in the morning.
Inequality matters, wealth
does not.
To carry into work - equate
deafness to shame! Then see the outcomes/ impact on people
It's not just poverty and
material inequalities that matter - it's much more subtle social and
cultural factors that damage our health and wellbeing, at the heart
of the individual/ family, community, and society. New form of
thinking needed.
How do we get passed the "awareness
raising" and really affect the behaviour of policy makers and service
providers to work with people consistently in a respectful way?
Learning - from Thatcher's
example of individuals rather than community - are we emulating this
is service delivery?
Work with carers to try to
improve self worth to encourage them to bring about change in the NHS
and service to improve the environment and community where we live.
Environment effect individual's
feelings of self-worth, value and shame - whether in poverty or discriminated.
It's about power - who has
it and who doesn't - power to make change.
Have to bring forward thinking
and action that brings a holistic approach to working with individuals
and communities that cognisance of all dimensions of equalities.
The importance of tackling
the main stressors. Low social status, weak social affiliations
and stress in early life.
The policy implications on
the fact that increasing overall wealth in well developed countries
has a marginal effect on health. We have to tackle equalities.
The absolute importance of
respect and equality, to reduce humiliation (and the fact that state
organisations are the biggest source of discrimination).
Implications for work.
Think again/yet again about how we address some of the health inequality
issues out with our silos - easy to retreat back into single topic focus.
Whilst audience in this room
are all "believers" regarding the importance of inequality,
need to remember that the general population - daily mail readers are
not there yet.
Challenge of the complexity
has to be addressed by in integrated partnership approach.
Reinforced of/understanding
of relative poverty.
We (pkc) now have recruitment
which is mainly web-based - inequality?
People get used to living
in situations of poverty - reduces motivation/ability to get out of
poverty.
I am not clear on how we can
decrease inequalities from these presentations - I would be interested
to hear about ideas for solutions, now that we have identified the problems.
There is an opportunity to
appeal to people's self interest in equality.
Inequalities make the whole
of society poorer.
Action regarding shame/humiliation
- Care to show respect to each person irrespective of background.
Recognise inequalities and
work to enable most disadvantaged to have some opportunities.
ALL society benefits when
poorer, disadvantaged sections are treated more fairly. i.e. Intrinsic
benefit to all in promoting justice/equity
What to do? Ensure latest
evidence is in Test Site work and set up a researcher reference group
for the work
Inspiring - Studies evidencing
central issue of partnership working on inequality as a valid issue
and redistribution, how to do it?
Inspiring - Core issue:
Government outcome is economic growth. Find new measure like Wellbeing,
freedom, happiness and respects. Fairer and wealthier are incompatible
What to do next? Revise
the basis of our partnership working. From Specific conditions
and illnesses. To empowerment of communities to become assets
not liabilities
Address self-esteem issues
of individuals, communities - being valued makes a difference
SHAME/HUMILIATION - noted
in high levels in Government Organisations. NHS/LA?? Surely not!
SOLIDARITY - sense of belonging
with communities of relative poverty
Power of positive parenting
e.g. in Nordic countries, can impact
Reinforcement of need for
integrated approach - hurrah!
In order to work towards to
make happy and healthy communities all partners needs to have joined
up agendas and resources, real willingness to work together by valuing
each other!!!
Some of the work we priorities
will not address inequalities and may widen the gap
Services are focused on Flu
fighting with no time to be proactive to work towards prevention
Work driven by performance
management creates a particular focus which may miss the real problems
Learning - Opportunity is
now related to gaining wealth as opposed to broader terms
Practice points - Language
needs attention
Learning - Humiliation is
being used as social control. e.g. many of us feel ashamed at
lack of consumer activity
Materialism and media hype
causing increased mental illness. Stop following US example (6
x more advertising in US)
Challenging media - not accepting
things have to be a certain way
Belief in yourself and belief
in others. Taught to children from earliest age (promote optimism)
We need to shift our value-base
more towards Nordic countries and away from US's materialism driven
approach
It's about valuing each other
as well as valuing the self, we cannot have one without the other!
Surprising about how high
the UK came up on the graphs in the first presentation. Queried
why the UK continues to follow the USA irrespective of the obvious good
practice of Nordic countries
Found 2nd presentation so
relevant to the individuals I support. Was very surprised that
shame is new to the field of research taking into consideration that
shame undoubtedly impacts upon all vulnerable groups at some point
Very interested in theory
of link working hours of lower classes being much higher than upper
classes
A need to identify poverty
in the context of geography i.e. Sub-continent of India against mainstream
Europe. A father in Europe who cannot afford a dowry for his daughter
might feel ashamed
Trickle down doesn't work.
We need to support people and families to build the strength of the
most deprived
Need to move resources from
dealing with consequences to causes of poverty/inequalities
All services need to reinforce
measures to increase incomes and build on these
The need to focus on equality.
Richard Wilkinson's comment that the Partnership should focus on raising
the cleaners wage to improve health inequalities - inspiring
Wellbeing is not an optional
luxury! Let's celebrate our lives more
Becoming recovery approach
converts
(Re)learning the Arts and
Crafts of living
Anger is an Energy
Get a better (spirit) level
on competitiveness, acquisitiveness, and joy
Valuing the "seemingly
mundane" in our lives
Change to the Dundee Association
of and for Mental Health and Wellbeing
Share the journey and Explore
the opportunity options
Small steps  Big impact
Empower the people to choose,
accomplish and find a purpose
Ideas of shame and humiliation
reinforce the need for community development and asset-based approaches.
Capacity and Resilience
We know the relationship between
inequality and poor wellbeing - do we know how to affect the pathways?
Re: Prof Wilkinson - I was
struck (again) by the problems associated with addressing the culture
of violence and competition within which our young people are growing
up
Re: Prof Wilkinson - I could
relate the point about work/life balance to personal experience.
Downsizing has made me happier!
Shame and humiliation is helpful
to understand in terms of context
Community wellbeing needs
to start with strengths and positives, however small
What can we learn from more
equal societies like Sweden, Japan etc?
Social work - need services
not to add to stigma, humiliation or shame labelling
Planned difference and diversity
training needs to take shame/humiliation and stigma on board
Humiliation as an obstacle
to inclusion
Focus on wellbeing rather
than (absolute) wealth
Social determinants of health
- multifactor but closely linked need to be addressed as one topic not
independently
Breaking vicious circle -
tackling problems "upstream"
Improving lives - reduce gap
by improving self-esteem of lower social status. Targeting services
directly at less well off groups to increase uptake
Inequality gap = how to address
this?
Stressors:- Within training
(managers) include more with regard to self esteem, differing individuals
situations affecting how valued they feel - threats to self esteem!!
Importance of how we see ourselves
and need to feel respect from others
Recognition of how life experiences
impact on how individuals address problems/issues
Impressed by the importance
of the psycho-social elements of wellbeing and how obvious/simple they
seem (when pointed out!)
Impressed that research taking
place into impact of shame and see potential for people to feel stigmatised
by service delivery intended to support them
Inspired by strength of the
case for redistribution, however, is the journey from inequality to
more equal going to give the same results achieved by more equal countries?
Inspired by the strength of
the case for redistribution - will take it forward in a small way through
encompassing redistributive effects in research planned for the CT sector
National policy dictates fairness
and has to start from there
Build community capacity to
influence change and develop the community ethos as a way of overcoming
stigma
The impact of inequalities
within a society rather than a national poverty "line" in
terms of consequence of life - mortality rate etc.
More work to be done about
helping colleague see the person behind the policy/process
This is about Social Justice.
Personally feel that the "church" has a major part to play
in this area, but how to involve it?
Never fully realised the link
of stigma and shame and humiliation in relation to poverty as well as
HIV/AIDS and mental health
Importance of enhancing sense
of collective agency of poor people
Domestic violence - shame
isolates whole families. Drug addicts within families - create
shame and humiliation. Need local support
People suffering shame and
humiliation are isolated - not participating therefore - how do we reach
them?
Shame/humiliation needs to
be discussed in communities - written into education teachings
We need to measure things
very differently to find solutions/make changes or we will always rely
on increasing services only that doesn't attempt etc, people we want
to help
What we need is redistribution!
It's what's going on families
what are the issues?
How do we involve those of
us that are "left outside" in determining what is mainstream
and who should give
Social status and how people
are seen is very important
Central importance of respect
Focus: How do we put Humpty
back together again?
Perception of individuals
to be taken into account by service providers and policy makers if actions/
campaigns are to bring fundamental changes
Young people need to grow
up in a different kind of world - or they'll replicate our patterns
Acknowledging importance of
relative inequality - is bad for all
Enlightened self interest
might be a political tool. Current SG goals (wealthier, fairer, greener)
are incompatible
APPENDIX 4
Comments from work groups
Work group 1Perth and Kinross, and
Angus
Facilitator:
Deborah Gray
Complexity of issues needs to be addressed
using an integrated approach.
BUT
Existing systems not set up this way.
How?
Local examples of sharing/joining up
working.
“Competition” between services –
losing focus on individual and waster of resources.
“Trust” in new services/individuals
Culture change – threat to medical
model in terms of MH services.
Need to always remember whom the service
is for and other services exist.
Value of VOI. Sector-perception
of more positive help.
Planning for service delivery-take into
account what currently exists on the ground.
Positive example of partnership working
– Angus – Hospital Discharge scheme – OT/care and repair/Acute
– Clarity of role? no threats re: stepping on toes.
Sense of working together – lack of
“preciousness.” – Social cohesion
Murray royal – “Champion” with
street cred to “sell” the service.
Personal relationship between professionals.
Organisational Culture – internal –
external
Planners and policy makers. Measuring
successful for individual agencies, does not allow for partnership working.
Baby bumps example: good partnership
working.
Shared Goal
Policy level
Communication with and involvement of
services users.
Service users as individuals.
3 Actions
Ask/involve/look for the people
who don’t get involved/use services
DATA! Sharing. Including qualitative data-value.
Person held records – why
not?
(at least as an option) Good example – Gypsy travellers
Services for service users
Serves role in societal shift?
Service role in fostering resilience?
Cultural badges
Challenge the cycle of poverty/violence
etc. “With” not “to”
Informed choice/decision made by
service user.
Learn from involvement with
communities.
Work group 2Dundee ‘Test Site’
Facilitator: Sheila McMahon
What does evidence mean for
local work in mental health and health inequalities?
How would your resilience
score?
Talk to communities about
what makes them resilient – What about the comparator?
Indicators – evidence informed.
Consensus about what protects
our communities – ref JRF.
Test site – building on
the ground work – work – 17 years in Dundee (possibly 20 years longer)
Landmark event – optimism.
Co-operation, good will.
We’ve got to get the engagement
process right.
Danger – only putting communities
at the centre – partnership required with
service providers and policy makers. Need to have the evidence
– base and then test the evidence base.
Sustainability – but in
conjunction with creativity and revisiting the power/organisation or
“collective action”
“New ways of working”
– “New rules” at strategic and operational levels.
Decision making – often
translates into distribution of resources. Instead of directly
addressing inequalities.
Address language – get rid
of test-site as a name. Get rid of terminology related to deprivation
and disadvantage.
Action – Have this
discussion with people who live and work in communities.
Find out about relevant practice
e.g. work on oil refinery in Falkirk.
Asset model – how to make
it work well, effective and sustainable.
Changing needs – changing
responses.
Stop calling people service
users. Start calling people citizens.
Plans for new ways of working
within existing – infrastructure
what about existing plans just newly produced.
Re-articulation of community
assets.
Offer to service providers
within the context of mental wellbeing.
Engage with service providers
through framework and reporting within “health improvement performance
framework”.
Refer to NHS Health Scotland’s
indicators on Mental Wellbeing.
Direct link to local situation/settings/test site.
Develop tools that will be
supportive and not prescriptive – central resources are useful!
Action points
Possible reference group –
sign up from NHS, Council, Community/Voluntary sectors.
Great care to be taken with
use of language.
Great care with community
engagement approaches.
Approach to the private sector.
Establishing agreed rules
of decision-making and operation.
Reference group –
Mechanism for disseminating lessons and practice.
Work group 3Dundee (General)
Facilitator:
Catriona Ness
Three priority action points for Dundee
‘Co-production’ working
together
Collective ‘we’
Less strategic organisations
More voluntary sector com
members
Culture – listening to communities,
influencing strategic thinking/behaviours e.g. social prescribing
Partnerships need to be local
or where people/groups are communities e.g. LGBT but avoiding increasing
inequalities gap
Using local intelligence and
resources
Face to face
Valuing contributions
Challenging attitudes/behaviours
What kinds of partnerships are needed
to integrate MH and WB and inequalities and how do we build them?
Strong partnership relationships
LA/NHS/3rd sector
Money doesn’t follow patients
into the community – be aware how different sectors work
Avoid breakdown in communication
– don’t just ‘fit into model’, people part of the solution
Need clarity of roles so that
everyone understands roles – review 6 monthly
How can it be transferred
across sectors and accounted for – E newsletter
Partnerships should offer
choice
Voluntary sector to be more
political re their needs/wants from NHS/LA. Amplify what communities
want.
Face to face so important
Strategic work together as
well as operational
Does index of multiple assets
(Lynn Freidli) exist?
Value and don’t ‘tamper’
with existing assets e.g. DHLI – needs appropriate/realistic referrals
e.g. from GPs
Important for projects (including
vol sector) should include evaluation to collect evidence
This will be for long term
gains – so can’t expect rapid improvement
Don’t always need RCTs can
collect evidence in other ways – stories, narratives, personal accounts
Need more local partnerships,
local intelligence/knowledge, working relationships
What does the evidence we have heard
mean for local work (to tackle health inequalities and improve mental
wellbeing)?
Evidence can be challenging
as ‘beyond our control’ is it more a political agenda as opposed
to ‘managerial’
DHLI example was evidence
(positive steps) builds on and develops e.g. walking groups excellent
for MHWB, costs nothing to join DHLI, builds self confidence, motivations,
communities taking ownership, social reciprocity, giving-sharing information/skills/social
activities
Facilitation by professionals
in communities, not short of volunteers (1800 groups in city), volunteering
strategy short of opportunities, launch next week to reconnect in communities,
Volunteering – 23,000 in
Dundee, 75% in vol sector, time banking – exchange time, need connections
between agencies/organisations, remove/diminish barriers to involvement
Develop expand with young
people/peer education
Move from fight/demands to
having rights to be involved in decision making, campaigns can still
be successful – disability example
Sense of control (at work)
participation
People feeling valued, changing
social ethos, NHS/LA/teachers, will this tackle stigma/shame, use where
people naturally come together – schools, hospitals
Specific invitations to involvement
targeting groups e.g. taxi drivers, community health, community conferences
for community members
Need public resources –
how do we use this, remove isolated approaches/budgets
Dilemma – ‘nanny state’
v community empowerment – professional advisers
Involve communities – ask/listen
Evidence (local) suggests
social prescribing working
Police – every policy requires
impact assessment
Public sector staff needs
change of mindset breakdown them and us – its all of us
Important how we are with
people ‘sense of being’ attitudinal work required
In schools focusing on celebrating
success. Attainments in/out of school. Corporate parenting
v statutory response (LA)
Sense of public sector harder
to engage with communities as ‘target bound’/’driven’ or is
this an opportunity to put MHWB firmly on target agenda
Walking in
Work group 4Dundee (General)
Facilitator:
Liz Magee
1.
Evidence base
In practice and as part of
participatory practice, we can sometimes inadvertently highlight feelings
of shame and humiliation (clients)
The evidence presented today
will impact directly on the Healthy Working Lives programme and changes
will be made as a result
Good to have evidence to reinforce
purpose of work and rationale, but ‘attitudes still need to change’
to reflect this and make it work
Attitudes and behaviours are
particularly relevant at middle and top levels of management- this is
where the decision-makers are!
Evidence highlights the direction
of travel to achieve social production and social solutions
Crucial to disseminate today’s
evidence and discussion as widely as possible, but must be accessible
to all
For a start, share the meeting
report with all- Chief Exec’s and communities- everyone!
Sharing this information with
our communities across Dundee in an accessible way
Some of the group commented
on their observations that ‘collective action’ has declined
and today’s event verified that
In sharing the evidence, we
should be aiming for dialogue and consultation
Collective action-
how do we address increasing this?
We work in cultures and systems
with common traits- dictated to by cost effectiveness and risk aversion
(although we need to recognise that staff may need protection in some
circumstances)- ultimately leads to decreased contact with individuals
and communities
Tensions exist between social
and medical models of working
Performance management culture,
ways of working present barriers- focus on short term, easy to measure
targets
Collective action is
happening throughout Dundee- we need to recognise and find out and look
at what can be transferred from one community to another
How do we apply the knowledge
we’ve gained today?
Measurement and evaluation
are critical to the success of this work- the ‘test sites’ will
give us a really good opportunity to explore this
We need to ‘sign up’ to
this agenda as a society
Diego commented on the importance
of respecting colleagues and gaining respect from colleagues
We should value people!
We will need to adopt a long
term focus and recognise that change will take time to evidence
The evidence presented today
reinforces and supports the benefits of long term investment
The HWL programme is conducting
a national evaluation of its mental health courses in the workplace-
this will add to our knowledge
Role of trade unions and the
rights’ movement is crucial in looking at how we can increase collective
action
We need to recognise that
our best intentions can harm and cause stigma, shame and humiliation
Maybe we should be encouraging
people’s rights and making this about people’s rights rather than
telling people not to do this or that
We need to be innovative about
tackling stigma
There is a tension, particularly
within the public sector, between preventative and reactive- the distribution
of resources and the current financial climate will add to this tension
and it’s likely that resources will be cut from the preventative work
What is the baseline for wellbeing
in Dundee? How can we access that information or how can we establish
that?
We’re not talking about
creating more services- inappropriate (links with Wilkinson’s work)
We need to figure out what
the practical aspects of this work are
Targeted services in poorer
communities- should we not be thinking in terms of the whole population?
(link to Wilkinson and ‘relativity’)
Let’s look at social prescribing
and the environment and green spaces
Universality is crucial and
provides the rationale for ‘redistribution’- targeting has been
detrimental
Let’s look at time-banking
and co-production to increase good outcomes
Collective action is a way
to address decreased ‘power’ in individuals and communities
Let’s recognise our differences
There is a tension between
local and central government relating to targeting and provision and
sustainability of resources
When we talked about universality,
we need to be clear about what we mean about the implications for services-
need to recognise that targeting can work where needed and appropriate
Again, the concept of universality
gives a rationale for redistribution
I’m really talking about
where targeting is in fact ‘means’ testing’, which promotes stigma
and the poverty trap
2. Partnership working
Need agreement on priorities-
can’t get this right until we all agree!
Local Community Planning Partnerships
are still in their infancy in Dundee, but could they provide us with
a useful vehicle/mechanism? Representation across agencies and communities.
Broughty Ferry LCPP is setting
up a taskforce to look at wellbeing and value input from today’s network
of people
The Community Plan itself
is divided into ‘sections’- this compartmentalises issues- it needs
to be explicit that mental health and wellbeing cut across everything
in the CP
If we’re really serious,
shouldn’t we be looking at sharing and pooling resources? Let’s
create a pot of money- that’s real partnership working!
How do we engage with academia?
We’re very well placed in Dundee to work together. There is
a financial mechanism in place (recent development) to encourage universities
to work more closely with local authorities- scope to work with DHLI/
‘test site’? Need to explore this further
Academia has a key role to
play in helping us to address the complexities of ‘measurement’
and how we develop models that can demonstrate success
Need to recognise the potential
of social capital and harnessing that
3. Key action points
Information sharing- writing
up the event
This has to be fed into communities
in an accessible way e.g. focus groups to share discuss and debate
Each of us has a responsibility
to share today’s knowledge and learning with our colleagues
LCPPs- could they be the mechanism
to drive all of this work forward?
Wellbeing and health inequalities
are cross cutting- this needs to be more explicit in the Community Plan
We should take this learning
and plan of ‘direction of travel’ to the Community Planning Partnership
Although, we recognise this
is about demonstrating change in the longer term, we need to think about
short and medium term outcomes (NHSHS)
Monitoring and evaluation
are critical to achieving success in demonstrating change in communities-
social modelling
APPENDIX 5
DELEGATE FEEDBACK
Question 1
How useful did you find the content of
the presentations?
Answer Options
1 (not
at all useful)
2
3
4
5 (very
useful)
Response
Count
Speaker 1
0
0
3
8
23
34
Speaker
2
0
2
8
10
13
33
Speaker
3
1
1
8
9
14
33
Comment
(please specify)
17
answered question
34
skipped question
0
Comments
Very good mix- emerging evidence and
inspiring
Excellent spread of evidence and info
etc. Blank spots were the role of culture, but that's not surprising
as it's a tricky area.
Excellent
Good speakers offering topic from various
angles. Good overview of subjects.
Didn't understand a lot of what 3rd speaker
said. I felt she was thinking in a code I didn't have! Also
2nd speaker was a bit too academic for me.
They all seem to talk my language
All very good
Largely academic- light on practical
solutions
Speaker 1's graphs were very USA focussed-
would have been good to hear Scottish perspective
Excellent speakers providing thought
provoking ideas
All speakers gave very informative presentations
which will assist me with my work
All were extremely interesting and thought
provoking
Good to see evidence of what we already
knew
Very informative
All excellent- wanted 2nd speaker to
connect his ideas on 'shame' to wellbeing and health
Very useful information
1st and 3rd very useful. 2nd less useful
and not so well presented. 1st and 3rd were inspiring and affirming
and gave me confidence in my work.
Question 2
How much did each presentation extend
your existing knowledge?
Answer Options
1 (not
at all)
2
3
4
5 (very
much)
Response
Count
Speaker 1
0
3
10
11
9
33
Speaker
2
0
4
7
13
8
32
Speaker
3
1
4
11
8
8
32
Comments
(please specify)
9
answered question
33
skipped question
1
Comments
Very helpful
I knew bits of it, perhaps most, but
not all.
Definition of what the social solutions
proposed mean would have been useful
Very much turning preconceived ideas
on their head
Speaker 2 was very interesting and thought-provoking
and good use of Adam Smith work
I have a good working knowledge of the
topics
Knew 1st speaker's work before
Only because I've read and debated a
lot about these topics recently- still well worth doing
They confirmed it- have read Speaker
1's work and find it inspiring- similarly with Speaker 3
Question 3
How valuable do you think this information
will be to you in practice?
Answer Options
1 (not
at all valuable)
2
3
4
5 (extremely
valuable)
Response
Count
Speaker 1
0
1
8
13
11
33
Speaker
2
0
2
10
12
8
32
Speaker
3
0
3
8
11
10
32
Comments
(please specify)
10
answered question
33
skipped question
1
Comments
Directly useful for wellbeing agenda
in Tayside and Test Site
Particularly Speaker 3 on mental health
as a social phenomenon requiring social solutions.
Will give me food for thought and inspiration
for learning
Restraints of policy makers and attitudes
not changing quick enough
Will need some thought- always hard to
take the theoretical into reality/practice.
Very valuable as consolidates the purpose
of existing practice and allows more quality in pathway practice
It is always valuable to know that others
have the same views as me
Will use this information in future events
3rd speaker's work very thought provoking
Again, 1st and 3rd were VERY valuable
and inspirational
Question 4
How useful did you find the workshop
session?
Answer Options
Response
Frequency
Response
Count
1 (not at all useful)
0.0%
0
2
6.5%
2
3
19.4%
6
4
45.2%
14
5
(very useful)
29.0%
9
Comments
(please specify)
27
answered question
31
skipped question
3
Comments
Useful to get ideas for taking forward,
but query if group was too big
Great range of people/interests sitting
round the table.
Very helpful set of issues
Yes, community development is essential,
however need opportunity to explore how this might be difficult for
organisations e.g. culture, targets etc.
There was a good discussion about universal
re: targeting service provision
Good open discussion- some good ideas
shared and also discussed limitations due to budget cut etc
Gave the impression that providers at
a loss and panic now they have Test Site status.
Good participation on a huge input
Valuable discussion
Very good. Ideal forum to explore and
expand the issues raised- well organised, everyone was able to contribute.
Very difficult to hear, but useful to
hear others' comments
Just hope talk becomes action
Very well conducted, encouraged everyone
to speak; lots of suggestions/comments recorded, very relevant.
I very much enjoyed the workshop discussion
and action points raised
Need a clear action focus
Could not hear as was at the back- difficult
to follow
Great to have people sharing ideas and
own experiences around one table- from both voluntary and statutory
sectors
Good opportunity to meet and talk with
a variety of organisations
Useful to hear about new test site in
Dundee for mental health and wellbeing
Excellent discussion and good input from
all of the group
Noisy background so difficult to hear
speakers and facilitator
Excellent
Great to hear experience, views etc of
colleagues working on the ground
Good all participants from same area
Sorry had to leave, but I'd like to know
how it went
Too large
Question 5
Has this event highlighted any training
and development needs for you?
Answer Options
Response
Frequency
Response
Count
Yes
66.7%
20
No
33.3%
10
Comments
(please specify)
15
answered question
30
skipped question
4
Comments
Need to keep the best of current research
involved in this work
Along with organisation (public body),
to see communities as source of asset, not just need.
Need to find out what a lot of it means!
Good to have further days like this to
see impact of such events
Big time for all government departments
and charity organisations
Clear understanding of social factors
influencing inequalities
And my organisation
Follow up on 'shame'
Discuss the issue with fellow workers
Mental health and wellbeing and what
is currently available
Training for my team
Ongoing development
Further developments at local level required
Accommodated through Equally Well Core
group
More input from speakers 1 and 3
Question 6What support would help
you to meet these needs?
Maintain and use useful networks
Organisational culture shift-
ability to listen plus ability to tolerate mess.
Will learn as I go along by
working with others
Less talk more action please
Self research
Summary of day
Lots
Better listening
Time and space
DHLI or CHP to talk to LCPPs
Links to national developments
A copy of Speaker 1's slides
please!
Networking. More excellent
conferences like this one.
Question 7How could the structure
of today's event have been improved?
Very good venue- super hospitality.
Good signal of the priority for the council. A bit hot?
Not sure- it was well structured
and well organised
Congratulations on organising
this very helpful event.
Structure was fine
Well organised and structu