How to support community-led approaches
Community-led health approaches are a key part of early intervention, helping to provide the building blocks for good mental health and wellbeing in communities. But, as we have seen, they are also under-funded and being overly-relied upon to plug the gaps in wider mental health provision (and other services which impact on mental health and wellbeing). This all risks preventing community-led health from doing what it is best at – building sustainable, resilient communities where people are connected and feel they have a stake.
We suggest the following ways in which community-led approaches can be supported better. They should be viewed as part of early intervention approaches more generally, with a focus on collaboration between sectors and joined up working. As the quotes below testify to, most of our suggestions chime with what people said in the interviews we conducted to inform this briefing. In addition, we have drawn on our extensive engagement with, and support for, community-led health organisations and workers over the years.
Partnership and joined-up working
We often hear about better partnership between public sector organisations and the community sector. But what does this mean, and what specific models are there out there to learn from and build on? In terms of what it means, partnership with community organisations involves different considerations that partnership between different public bodies. There is a significant power disparity between the public sector and community organisations, so partnership needs to acknowledge this and work towards becoming more equal.
This can be done via models which involve more collaboration, trust and innovation. One such model, by way of an example, is Alliance Commissioning which involves all partners involved in commissioning services, from commissioners to providers, co-designing how commissioning works, with shared principles and agreed outcomes.
Separately, the Edinburgh Futures Institute have developed an approach, accompanied by a useful diagram, which highlights ways to collaborate effectively as well as challenges to doing this. There is also a link here with the call by Scottish Recovery Network and other partners for peer leadership to be put in place “at every level of the system” with “influence over service design, commissioning, policy and reform”. The common direction of travel is around early intervention, co-production and empowerment.
Making and measuring impact
One area which can be improved through better collaboration is measuring impact. The manager of one of the CHEX network organisations we spoke to described how important aligning outcomes is to working effectively.
“I sit on the Strategic Planning group for ______ for Mental Health and Wellbeing [...] When we were reviewing the last strategic plan the question was ‘so how did we do against that plan?’ My point is, how would you know? Because you don't measure, you don't ask, you don't align the outcome with somebody who's gonna deliver it. So if you had said ‘we want to achieve XY and Z and the organisations that can work towards that outcome are them, them and them’ then you could ask them how we're doing against that outcome, but you didn't ask anybody to do the work, so you might have achieved that but how would you know? That didn't go down well, but if they had said “our aim is XY and Z everybody. That's what we're working towards. Here's the monitoring form with XY and Z written on it. Report on how you're doing.” (Manager or community-led health organisation)
The importance of trust was emphasised as well, with the manager of another organisation linking this with the issues of power and respect for the voluntary and community sector.
“If we're if we're assuming that organisations are funded, have passed that you know, rigorous application process, or commissioned, [...] our level of professionalism within the third sector shouldn't be sort of almost, you know, under query all the time.” (Manager of community-led health organisation)
The same manager commented that their organisation’s “local place-based knowledge and foothold works really well in helping those that use the services have their say in the services.” One manager of a voluntary sector provider illustrated how collaboration is undermined by inequality in partnership.
“As a third sector [organisation], I think it's quite common across the board for us to want to work more collaborative with, with statutory services just to get a better kind of holistic approach for families. We don't want to duplicate work so that we get what they need. But I think because they're so busy on their end and the kind of pressures they're under, we don't always get the same level of communication and referrals, like we're not getting back what we put in from some of these relationships.” (Manager or community-led health organisation)
Innovative models such to commissioning may also offer a way forward to address some of the issues around referrals which people in our interviews reported, including people being referred who organisations aren’t set up to support and increased demand reducing the ability of organisations to focus on early intervention.
“They [the local authority] will invest money in issuing tenders for whole family support, but it's crisis intervention, it's social work cases that they're taking, referrals from social work. Whereas the preventative side, which is the community-based early identification of potential mental health issues further down the line and doing the preventative work, that's the bit that doesn't get the investment.” (Mananger of family support charity).
CHEX has previously identified social prescribing as having potential in terms of improving links between clinical and community provision in order to provide more holistic and preventative care, especially in the context of mental health and wellbeing. Scottish community-led health organisations were directly funded to provide social prescribing under the SPRING social prescribing programme. Additionally, one review of the sustainability of different models of social prescribing has highlighted equitable working together of a range of local partners as contributing to a more sustainable model of social prescribing.
‘Investment’ - rather than simply ‘funding’
A key issue, understandably, was investment, but this went beyond calls for three-year funding. Participants in our engagement called for fundamental change in how services are funded and delivered, with the community sector being a more equal partner.
“And if we want to actually have a proper early intervention prevention service, then it has to be funded because the, the other end of that scale, you'll have less demand and services.” (Mananger of family support charity)
Broadening this out, there was a recognition that any efforts to shift towards early intervention are currently being undermined by the fact that decision makers see cutting funding for such approaches as easier, and less politically damaging, than making cuts to front line services.
In our response to the consultation on third sector funding by the Scottish Parliament’s Social Justic and Social Security Committee, CHEX strongly agreed that longer-term, unrestricted, funding of three years or more was needed in order to ensure community organisations can fulfuil their potential in terms of early intervention.
We argued for an increase in the overall pot of funding for the third sector at a national level. This can be thought of as a long-term investment in a better society rather than simply funding, which risks framing the community sector as something that is being kept afloat when it is a vital component of early intervention. Ultimately, this comes back to how we think about public services and the kind of society we want to live in.
At the time of writing, the Scottish Government’s Communities Mental Health & Wellbeing Fund is the most prominent funding stream aimed at supporting community-based mental health and wellbeing projects. This £15m per year fund has a focus on socio-economic disadvantage and is the type of funding stream which should be built on in order to invest in early intervention approaches to mental health and wellbeing.
The final point about funding and investment is that, like in the alliance commissioning model highlighted above, communities and those with lived experience need to be supported and able to meaningfully shape funding decisions. Scottish Recovery Network has made a similar point in relation to peer support, arguing that “decision-making about funding must involve those with lived experience.”
Flexibility in measuring impact
As we set out above, one of the major strengths of community-led approaches is how nimble and innovative community organisations are in responding to changing circumstances and community priorities. To enable them to flourish and contribute effectively to early intervention, they need to be given as much flexibility as possible to measure their impact and contribution to longer-term high-level outcomes.
This clearly ties in with the two other ways to support community-led approaches and grow early intervention which we have mentioned already around partnership and funding. Collaborative commissioning and working towards outcomes with more equitable funding would work best if it was accompanied by a collaborative, outcome-focused approach to evaluation and monitoring. Scottish Recovery Network has also emphasised the need for the co-creation of indicators and outcomes to ensure meaningful evaluation.
In 2020, CHEX was involved in the development of Recognising our rich tapestry: measuring the contribution of third sector organisations to tackling health inequalities, along with a range of other third sector organisations led by Evaluation Support Scotland. This resource provides tools to help collect evidence to link short term impact to longer-term strategic outcomes.
The approach has been used effectively to evaluate work by community-led organisations such as Man On! Inverclyde, a collaboration between Man On! Inverclyde and the NHS GGC Directorate of Public Health. We would like to see such an approach being used more often as part of collaborative working between the sectors.
