Regenerating minds

Regenerating
minds

Peter
Huxley and Sherrill Evans of the Institute of Psychiatry report on a study of
the impact on mental health of an urban regeneration scheme in a deprived part
of Manchester.

The
link between poverty, social and economic deprivation and mental health
problems is well established. However, much less is known about the
relationship between socio-economic policy interventions and their impact on
individuals’ mental health and their quality of life.

A
number of small studies suggest that the risks associated with common mental
health problems can be reduced by interventions targeted at those who have
experienced job loss and unemployment¹ or those who experience
teenage pregnancy in the context of poverty.² There is also some
indication that the mental health of the population can be enhanced by
improvements to housing and the local area,³ and rehousing on the
grounds of mental health has been shown to improve anxiety and depression.⁴
However, to date, the evidence for social interventions making an impact are
modest, and studies have not been undertaken of large-scale, multi-faceted
social policy interventions designed to regenerate the urban environment.

In
the UK, urban regeneration has been undertaken since the late 1960s. A drawback
to studying the collective impact of these programmes in the past has been that
policies have implemented by different sectors operating under a variety of
governance arrangements, which resulted in a lack of co-ordination in both
policy implementation and evaluation. The Conservative government introduced
the single regeneration budget challenge fund (SRB) in 1994 to rationalise this
fragmentation. It combines 20 formerly separate programmes from five government
departments.

The
launch in 1997 of a major urban regeneration programme in Wythenshawe, a
disadvantaged area in south Manchester, provided an opportunity for a
co-ordinated response. The Wythenshawe initiative aimed to enhance employment
prospects for local people to compete for jobs, encourage wealth creation,
improve the environment and housing, address crime (including implementing
targeted programmes for youth) and enhance quality of life and social cohesion
for the 29,000 residents in the area.

Although
very little SRB expenditure had been committed at the time of the baseline
survey (a total of £575,000 from the SRB and £7m from all sources), £2.7m was
invested by the SRB over the study period. Some of the major developments are
not part of the SRB spending but part of the overall package of interventions
on the estate, including private sector finance, which amounted to a total of
£45m during the study period.

Mental
health and quality of life data were collected by postal survey (the largest
longitudinal study of its kind ever undertaken with more than 2,500 respondents
– just under 5 per cent of the population) at the start of the SRB programme
and 22 months later (1,344 respondents), and by interviews with more than 200
residents. Data was collected from the Wythenshawe area and a local area, which
matched Wythenshawe on deprivation indices, was used as a comparison.⁵

The
study examined ways in which people perceive the area as positive or negative
(see below). We asked about social contacts, social networks, social capital
and "collective efficacy" (the actions and willingness of local
residents to participate in community activities). The influence of the SRBs on
feelings of security and control are important given that entrapment and humiliation
have been found to be central to the formation of mental health problems.

The
table shows the most often endorsed questions we asked about experience of the
community. It shows that leadership, solidarity, social capital and a sense of
belonging and community emerge as the positive features of living in
Wythenshawe. Our overall subjective well-being measure is significantly related
to six of the 11 community experience factors. Higher overall quality of life
ratings are associated with a greater sense of belonging, less isolation,
better leadership, more leisure opportunities, more neighbourliness/security,
and the absence of the perception that the area is in decline. There are fewer
relations with mental health. Higher symptom scores are associated with less
neighbourliness and security, fewer leisure opportunities and the feeling that
the area is in decline.

Preliminary
results suggest that the SRB had a modest impact on local employment. At the
time of the first survey fewer than 150 jobs had been created. In the follow-up
sample only a handful of people came off benefit and went into work. The impact
was somewhat greater on safety: residents’ reports of physical assaults
declined in Wythenshawe and increased in the area of comparison, suggesting
that crime initiatives may have had a limiting impact on escalating rates.
Where most objective change occurred – in housing improvements – the
Wythenshawe residents had significantly greater satisfaction with financial
well-being, physical health and living situation than the residents in area of
comparison, but there did not appear to be any impact on mental health.

Residents’
main concerns about their neighbourhood remained the same at the end of the
study as they were at the outset. Their focus was on the absence of safe
playing areas for children, a lack of leisure facilities and the area’s
reputation.

Possible
explanations for these early results are that the SRB did not target residents’
specific concerns, or that the jobs that were created did not go to local
residents. The fact that the health strategy had no strong mental health
promotion component may also have been significant. Residents complained about
the lack of leisure facilities, which was interesting because an increase in
the opportunity for exercise might well be one of the most potent mental health
enhancing programmes. A further possibility is that two years is too short a
time for the whole scheme, or any of its constituent parts to affect individual
mental health and quality of life.

Nevertheless,
the main implications of the preliminary findings of this study would seem to
be that urban initiatives intended to enhance quality of life or mental health
need, as a basic minimum, to be aimed at promoting security, increasing leisure
opportunities, fostering social capital, and where necessary, improving the
image of the locality.

–
The study was funded by the Economic and Social Research Council.

Peter
Huxley is professor of social work and Sherrill Evans a researcher at the
Institute of Psychiatry. Other members of the research team were Claire Gately
of the Institute of Psychiatry, and Anne Rogers, Richard Thomas and Brian
Robson of the University of Manchester.

Experience
of the community

Positive
features of the area

Community identity
If I move I would want to come back; I will recommend my children settle here;
sense of belonging

Leadership
Local councillors are good at their jobs; the city council does its best

Solidarity
People stick together in difficult times

Social
capital
Neighbours provide help to sick and isolated

Negative features of the area

Collective
efficacy
No one joins in with projects that start here

Economic
viability
Very pessimistic about future employment prospects

Leisure

Most interests are not covered by available resources

Social
contact
People seldom visit one another

Safety

It is unsafe to leave the door unlocked at night

Social
cohesion
If you want to start something new you have to do it yourself; gangs cause lots
of trouble

Area
decline
There is too much crime; the local economy is deteriorating

References

¹
R HPrice, van Rynm and A Vinokur, "Impact of a preventive job search
intervention on the likelihood of depression among the unemployed" Journal
of Health and Social Behaviour 33, 158-167, 1992

²
DLOlds, CRHenderson, R Tatelbaum and R Chamberlin "Improving the
life-course development of socially disadvantaged mothers: a randomised trial
of nurse home visitation", American Journal of Public Health 78,
1436- 1445, 1988

³
DHalpern, Mental Health and the Built Environment, Taylor and
Francis, 1995

⁴
PJElton and JMPacker, "A prospective randomised trial of the value of
re-housing on the grounds of mental ill-health", Journal of Chronic
Disease 39, 221-227, 1986

⁵
Mental health was measured with the General Health Questionnaire and Clinical
Interview Schedule (Revised), and quality of life with an enlarged version of
the Manchester Short Assessment of Quality of Life (Mansa) called QolComm which
is available from the authors at the Institute of Psychiatry, Health Services
Research Department, De Crespigny Park, Denmark Hill, SE5 8AF

————————————————————————————

Crossing
the cultural divide

Overcoming
the divide between health and social care is seen as the key to making joint
working a success. Alison O’Sullivan, who works for both Bradford health
authority and council, describes the differences in management style and
decision-making she has found in the two as she works to draw together services
for older and disabled people.

There
is a national and local commitment to bringing health and social care services
closer together and, indeed, in some areas to join them as one. The drive to
integrate services on the ground is signalled strongly in the National Service
Framework for Mental Health¹ and National Service Framework for
Older People^,2 and the learning difficulties white paper, Valuing
People.³

Although
there is still much to be decided about how care trusts will work in practice,
the name captures the idea of an organisation that is a merger of health and
social care and not a takeover.

In
Bradford, good joint working relationships have been built over several years.
Last year this partnership was taken a step further through the creation of two
joint health authority and local authority posts – one for mental health and
learning difficulties and another for older people and physical disability
services, the post held by this author. During the nine months I have been in the
job I have begun to explore the many differences between the worlds of health
service and local government. There are obvious differences in language and
behaviour, styles of management and the ways in which decisions are made, and
the power and the roles of professionals in the systems.

Each
organisation has its story to tell and its own identity, and health agencies
and local authority departments do share many values. Crucially, both are in
the business of helping people. But many more differences, often subtle, are
hidden in the ways of doing things and in the histories of each organisation.

So,
what are the differences and what do they mean for joint working, integrated
provision, service planning and commissioning?

The
most striking and immediate contrast lies in the initial outward presentation
of the organisations – their public face. Even new health organisations have
confidence and front found in few local authority departments. Local
authorities in general, and social services departments in particular, tend to
undersell their collective knowledge and experience. Perhaps this is a response
to the value that the public and media attach to the respective services.
Everyone loves the health services; everyone loves to knock social services. Most
people use the health service, a much smaller proportion of the population have
first-hand experience as users of social care services. This may go right back
to the origins of hospitals on the one hand and the workhouse on the other, the
deserving and undeserving.

This
public face is more than just a matter of image. It colours how the
organisations initially relate to each other and determines behaviour. The
confidence of health organisations leads their managers to demand and draw firm
lines in ways that can be perceived as aggressive and confrontational by local
authority managers. Conversely, the desire of most local authority managers to
explore issues in depth may be perceived as weak and woolly by health managers,
who are more used to reaching agreement through a series of skirmishes than as
the outcome of discussion.

These
perceived differences may prove to be largely superficial once people start
really working together. But if the will is not there to progress beyond first
impressions, the differences can become insurmountable.

Communication
is vital if we are to promote better understanding and closer working. Speaking
the same language would help, yet there are different styles and different
conventions. The health services’ use of military language (for example,
"setting up the winter bunker"), de-personalising reference to
patients and medical conditions, and an apparent fixation with three-letter
acronyms seems to local authority ears reflective of a command-and-control
approach to managing. In contrast, the softer reference to people and service
users, talk of inclusivity and greater use of politically correct terminology,
suggest – to health ears – a vague and woolly approach to running social
services.

Neither,
of course, is a reality, but first impressions set the tone and act as a strong
influence on how individuals and organisations perceive each other. If the
contacts are passing and infrequent, there is much scope for these superficial
differences to be misread and for all sorts of assumptions to grow.

Differences
in management style can also be confusing on the ground. A nurse manager may
wonder why a social work manager spends so much time seeking the views of the
team, and why the team questions the reasons for the introduction of a changed
way of working. A social work manager would be puzzled to watch a nurse manager
seeming to order or instruct her team in an apparently abrupt manner, and
wonder how she would keep their co-operation and support. The no-nonsense
("Have you had your bowels open today?") and onto-the-next-question
style of getting on with the job contrasts with the desire to achieve consensus
and support, which is the dominant style in social care.

Education
and training for social care staff is heavy on analysis and on the
understanding of unspoken messages, creating an analytical approach to
management and leadership. But in reality this is a matter of difference in
style rather than substance. The social work manager is, in fact, instructing
staff to do something when seeming to ask them to do it, and the nurse manager
is seeking the views of the team when explaining how something should be done.

Using
the right style in the right setting is important, however. In the early days
of this job I was advised that to succeed in health I should seek forgiveness
(if necessary) after acting, rather than seeking permission in advance.

There
are also interesting differences in decision-making in the health service and
local authorities. These are rooted partly in the configuration of the
organisations. The local authority is a single body with different departments,
of which social services is just one, and with one set of decision-making
arrangements. Relationships between the different health organisations are more
complex. Each has its own board and makes its own decisions; the NHS trusts
relate directly to regional offices; the primary care trusts for the time being
are accountable to health authorities; and health authorities themselves remain
accountable for the performance of all health agencies in their area. Hardly
surprising, then, that decision-making and governance arrangements for health
are complex.

Health
organisations believe that local authorities take a long time to make decisions
and fear that this will slow down the pace of joint progress. It’s not that
simple.

Decision-making
in the local authority is formal. Papers are produced, briefings given, service
users and staff consulted, and public meetings held. At the end of all of this,
decisions are made by local elected representatives. The process is supported
by writing things down – not just formal reports to committee, but also
briefing notes, reports to scrutiny committee, internal discussion documents
and options appraisals. Any senior manager in a local authority can produce a
written document within a day to fit any one of these purposes.

The
culture in health is much more oral. The process of producing strategic
planning and policy documents has so far rested with health authorities.
Strategic plans are developed through the largely informal involvement of a
wide range of stakeholders, and captured in documents such as the Health
Improvement Programme (HImP). Development of services is also driven by the
trusts, which present business cases which are then thrashed out as part of the
service and financial framework process.

The
formal documents – the HImP for overall planning and the individual business
plans for the health organisations – tend to reflect the decisions that have
already been taken, rather than informing the process of decision-making
itself. The decision-making is fragmented across a larger number of
organisations and can appear less formal. The health authority has therefore
played a key role in not only brokering the deals, but also holding the ring in
terms of strategic priorities. It is a significant challenge for primary care
trusts to pick up this responsibility for strategic commissioning of health and
social care services while at the same time developing their existing role as providers
of primary health care services and commissioners of secondary health care.

Importantly,
decisions are also made within different contexts. For health, the agenda is
nationally determined and regionally driven. The talk of "must be
dones" and the periodic summons to regional office or to London to have
the "deliverables" personally reinforced emphasises the sense of
central control and the imperative national agenda for health. The close
interest and long-term emotional investment in local services for councils,
however, sets a framework that emphasises local interpretation of national
goals and firmly holds on to the ability to determine local priorities –
priorities that may not always feature on a national agenda. This pulls senior
local authority managers closer to local elected representatives in a way that
senior health managers do not often understand. These are great differences in
accountability, which have a bearing on the way decisions are made.

So,
what is the added value of a job that straddles the boundaries? Most
importantly, it is the ability to make the processes visible and to bring into
view not only the things that need to be done to complete the job but to be
able to show the way in which things are done across different organisations.

By
being the person who advises both sets of organisations, it becomes possible to
guide policy and strategy decisions through both sets of processes. In doing
so, new pathways are hacked through the jungle that can be more easily trodden
a second time.

In
creating ways of enabling key managers from the different organisations to
communicate using common language and to understand the pressures and the
agendas in that wider context, a job such as mine can help ensure people and
organisations develop shared values and priorities. By being immersed in the
issues for both sets of organisations, it becomes possible to show each what
lies on the other side of the fence.

And
although the job is also about acting as interpreter, it is clear that the
future depends upon developing a shared and meaningful language understood by
all.

If
joint working is to form the basis of truly integrated services, we need to
ensure that people at many levels spend enough time together, that they talk to
each other properly, recognise shared values and develop a shared use of
language based on the same understanding of what the words really mean.

Above
all, they need to get beyond first impressions and stereotyped expectations. First
impressions are often misleading, but for the most part they are all that
people working in different parts of the system have on which to base their
knowledge of other agencies’ ways of working and values.

Yet
it is not hard to get past first impressions. In a small way we created an
opportunity in Bradford through two half-day seminars for front-line staff
involved with the National Service Framework for Older People. Three hundred
staff from all parts of the health and social care system, including the
independent sector, came together to discuss their initial take on the
framework and capture ideas about implementing it.

One
of the most positive elements of the feedback was the value of meeting people
working in other settings with the same hopes and fears and, most importantly,
sharing the same ambitions and ideas about how to improve things. There was a
buzz of shared enthusiasm and a sense that more could be achieved together than
separately.

Both
organisations want to change people’s lives for the better. Those who use
health and social care services can’t understand why we don’t just join
everything together. We owe it to them to get on with it.

Alison O’Sullivan is assistant director joint
commissioning at Bradford Health Authority and Bradford Metropolitan District
Council.

References

¹
Department of Health, National Service Framework for Mental Health, DOH, 1999.
See www.doh.gov.uk/london/mentalhealth/slides/tsld010.htm  

²
Department of Health, National Service Framework for Older People, DOH, 2001.
See www.doh.gov.uk/nsf/olderpeople.htm 

³
Department of Health, Valuing People, 2001. See http://www.doh.gov.uk/learningdisabilities/regionalworkersbackground.pdf