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Delivering better health services through community collaboration. Jane Farmer, La Trobe University Amy Nimegeer , Stirling University (La Trobe University Visiting Fellow). Outline. What’s /Who’s your community? Why do community/consumer participation? Example Remote Service Futures

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delivering better health services through community collaboration

Delivering better health services through community collaboration

Jane Farmer, La Trobe University

Amy Nimegeer, Stirling University (La Trobe University Visiting Fellow)

  • What’s /Who’s your community?
  • Why do community/consumer participation?
  • Example Remote Service Futures
    • Prioritising health services
    • Designing a workforce model
  • What happens in CP
  • Group interaction
  • Other examples
  • Q&A
  • Future
who is the community in health different knowledges different languages
Who is the community in health?Different knowledges & different languages

Their job

Their community

Clinical pradigm







Dealing in stereotypes

Knowledge driven by media & TV






Keeping out of the media

Want to get (re)elected

Getting good media


cp a conversation between different knowledges
CP = A conversation between different knowledges






A Broker?


national standards
National Standards
  • Standard 2: Partnering with Consumers
    • Partnership in service planning
    • Partnership in designing care
    • Partnership in service measurement & evaluation
      • Governance structures
      • Mechanisms
      • Actively involved in decisions making
      • Training for managers on how to create and sustain partnerships….
hwa leadership competencies
HWA Leadership Competencies
  • Leads self, engages others, achieves outcomes, drives innovation
    • Engages and enables consumers and communities

(involves consumers and communities in decision-making, health policy, education and training and healthcare redesign)

    • Builds coalitions across silos, organisations and sectors
arnstein s ladder of participation
Arnstein’s ladder of Participation

Arnstein (1969) Journal of the American Planning Association

possible outcomes we think
Possible Outcomes – we think
  • More acceptable decisions
    • Community shaped them
  • More realistic plans & designs/ innovation
    • Based on context & evidence
  • Health literacy/ health systems literacy
  • More likely implementation
    • Community will fight for it
  • Greater democratic involvement/civic literacy
  • Frugality?
evidence base for cp
Evidence base for CP?
  • Perceived benefits for physical, psychosocial health & wellbeing
  • Social outcomes for disadvantaged groups
  • Others experienced negative consequences
    • Depends on the individual & nature of the intervention
  • Tokenism/limiting to consultation only/not acting on information ->negative consequences
  • Failure of practice to match promise -> negative

Attree et al (2011) Health & Social Care in the Community

evidence base for cp1
Evidence base for CP?
  • Mixed evidence re social capital building
  • Partnership working
  • Extends reach of included views
  • Empowerment re further civic engagement

Milton et al (2012) Community Development Journal

  • Awareness of Health Services
  • Learning new skills – community members
  • New & strengthened relationships

Kenny et al (2013) BMC Health Services Research


Remote Service Futures:

Involving citizens in service design

goals were
Goals were:
  • Design an effective, cheap, do-able methodof community participation
  • The method is designed to develop new workforce / service delivery models
  • Designs are ‘hypothetical’
remote service futures project
Remote Service Futures Project

2 year project: 4 remote communities: 2 islands, 2 peninsulas (partnership with NHS Highland & Regional Development Agency)

Ways of providing services

Priorities &




People &




Aspirations, Assets

& Wants



Remote, rural


Nursing models

First responders



communities had similar health wants priorities
Communities had similar health & wants/priorities
  • Key Local Health Issues
    • Conditions associated with smoking
    • Associated with obesity
    • High blood pressure
    • Mental health
  • Key wants
    • Locally resident practitioners
    • How to deal with types of emergencies
    • Older people – anticipatory care
    • Improve local health (through volunteering/leadership)
rsf game
RSF Game
  • Form community/manager groups
  • Establish Community priorities of need (incl. assessed)
  • Use Skill Strips to decide which skills would address needs
  • Using anonymous practitioner cards, consider who has the needed skills
  • Using approximated budget, create service plans
  • Groups then report back to whole and justify plans
design outcomes
Design Outcomes





1 GP

2 pt nurses

1 GP

1 pt nurse

pt carers

-GP in next village (50mins)

-Peripatetic nursing team

GP in next village (50mins)

-2 local ft nurses


1 GP

pt nurse

3 pt carers

-1 nurse practitioner

-healthcare assistant

-pt Intensive home carer

-community volunteers

-volunteer first responders

New local practitioner with these skills:

-health emergencies

-social caring

-leading community health


Low attendance at final workshop





Mobile phones

reasons for differing engagement innovation


Reasons for differing engagement & innovation
  • A = exerting power -> no absolute threat, island
  • B = split community, island -> security & sustainability of community fears
  • C = fed up with current peripatetic model
  • D = young people, external and modern ideas, health service connections
process outcomes
Process outcomes
  • Health system literacy
    • What there is, when to use it
    • Who to approach
    • What to expect
    • How much it costs
    • “…I had no idea, when I had my accident, it cost £9,000 for the helicopter to pick me up!”
    • “…it made me feel like I was managing the health service…it made me realise how complex it is…”
  • Satisfaction and trust
  • Managers’ ‘contextual’ or ‘community literacy’ increased
issues with the scottish study
Issues with the Scottish Study
  • Inclusion
  • Sustainability
  • Scalability over regions and/or larger communities
  • When/how is a community decision made?
  • The role of the mediator/broker – essential?
  • Changing structures
    • Democracy too far? Health services had trouble with changing
  • Communities are not homogeneous unities –
    • Heterogeneous disunities!
working with scottish rural communities
Working with Scottish rural communities
  • Challenges around unhelpful categorisations
  • People acting as gatekeepers
  • Being told to go away!
  • When do you disengage?
  • Remoteness also a challenge for engagement (getting people around the table)
  • Biggest challenge was actually with the health care staff! Have to be willing to implement.
any actual change outcomes
Any actual change outcomes
  • It was meant to be a hypothetical project but led to some community mobilisation
  • What actually happened as a result
    • One community started a CFR scheme
    • One designed a new hybrid health care role which will be taken forward but not in partnership with community
    • Triage flowchart
    • Change in NHS Practice, incorporated into guidelines
audience participation
Audience Participation
  • Turn to your colleague & discuss:
    • What community participation have you done & what for?
    • Identify a key project for which you’d like to use community participation?
    • Why do you think community participation is important for that project?
  • We’ll pick on people to report back

Community co-production

- older people as a

positive force, doing

things for communities,

doing things for



Process of O4O social organisation creation

  • Meet community
  • Publicity
  • Generate confidence/ enthusiasm

Community Action

Community identify needs

  • Support from Project:
  • Building capacity
  • Building confidence
  • Accessing finance
  • Accessing information

Community engage in O4O concept

  • Discussion with community
  • Building trust

Initiatives selected to take forward

Community action/ entrepreneurship

Social organisation model established

  • Skills needed
  • Community capacity
  • Models of social organisation
  • Business planning
  • Resources
  • Training

- Community takes on roles

O4O delivers services



  • Highland….
  • Transport scheme
  • Community Care Assynt
  • Village hub (following heritage DVD)
  • Community DIY scheme (failed!)




  • Lulea, Sweden….
  • School + older people facility
  • Village helper
  • IT training scheme
  • Greenland….
  • Working groups established with individual communities
  • to do activities for/with older people
  • Karelia, Finland….
  • Examined formal volunteering & tried to transfer to other
  • communities
  • N.Ireland….
  • Supporting existing voluntary groups to become more socially enterprising





Rural NorthWest

Larger communities require adaptations to the process?

RSF in Rural Victoria



nhmrc funded population health planning method for rural medicare locals oral dental health 2014 17
NHMRC funded – Population Health Planning Method for Rural Medicare Locals: oral/dental health (2014-17)
  • 6 rural communities – Vic & Qld
  • Rural has poorer oral/dental health
  • Method to involved community members in designing local oral/dental health service
  • Priority-setting, budget
  • Partners: state dental health services, RFDS
  • & engage Aboriginal associations
thinking beyond workforce planning
Thinking beyond workforceplanning…

Designing public health interventions that work for YOUR community of users:

  • NHS Forth Valley – cardiac rehab and staff services
  • Working with children to design public health games (smoking awareness)
  • NHS Forth Valley and Stirling University working with socially disadvantaged women and Carlton Bingo to design public health interventions that could take place at the Bingo Hall
participation is the new paradigm
Participation is the new paradigm
  • Crowdsourcing
    • For funds
    • For research subjects
    • For research helpers/ community participative research
overall thoughts conclusions lessons
Overall thoughts, conclusions & lessons
  • It is hard to do this well!
  • Put some parameters around what you are trying to do
    • What is the project, what are the outputs, focus?
  • Ongoing or project-based?
  • Community=stakeholders
  • Be adaptive
  • They can design pretty cool & innovative things -> are you ready to implement them?
overall conclusions continued
Overall Conclusions, continued.
  • Community members know as much as you, it’s just a different kind of knowledge
  • You need to work together to create a new kind of knowledge: one that combines evidence based decision making with narrative and experiential understanding
  • Community participation should change and educate YOU as much as it should the community participants
  • Solutions designed with service users can be more context-appropriate and embedded than those arrived at unilaterally
Jane Farmer

La Trobe Rural Health School