Tackling Social Exclusion: Is There a Third Way?*
Ken Judge+
* An inaugural lecture given at UKC on 21 May 1999 + Professor of Social Policy, PSSRU, University of Kent at Canterbury: email –
[email protected] : Tel : 01227 827552
Discussion Paper 1542 May 1999
INTRODUCTION
Britain continues to be a deeply divided society. For more than twenty years income inequality, child poverty and social differences in death, disease and illness have increased dramatically. Social exclusion is endemic.
The Blair government through its much-vaunted "third way" is committed to reversing these trends. But is that a realistic goal? There are real signs that progress is being made. On the other hand, there are also some danger-signals that important lessons that need to be learnt will be overlooked.
The purpose of this lecture is to consider whether or not there is any substance to the third way as an approach to tackling social exclusion. But this presents an immediate problem. Hardly any contemporary domestic policy debate can be conducted without reference to either “social exclusion” or the “third way” and often both. Yet rarely if ever can political debate have been conducted so frequently with terms of such imprecision. Some ground clearing is a necessary first step.
The specific aims of the lecture are: •
to outline my understanding of some of the most significant contemporary characteristics of social exclusion;
•
to explore what the "third way" means in practice and to highlight the importance attached to developing new approaches to joined up government; and,
•
To make a critical assessment of progress to date at the local level in relation to health inequalities and to use the recently established health action zones as a case study for assessing whether the 3rd way has any substance.
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SOCIAL EXCLUSION AND THE THIRD WAY
To begin with it is important to say something about the way in which I want to interpret the terms “social exclusion” and “third way”.
Social exclusion Let me start with social exclusion.
Mark Kleinman, a colleague at the LSE, has written that it: … used to be an obscure term associated mainly with French academic sociologists and worthy if impenetrable European Commission documents on Doing Good. But the concept of social exclusion has moved to centre stage in British policy-making with remarkable speed. In doing so, its lack of precise meaning has been an asset rather than a liability … But in trying to understand the causes of problems, and to devise effective policy, this lack of precision is more than a liability – it is catastrophic.
So, is it possible to be more precise. One obvious starting point - given that with great fanfare New Labour have established a Social Exclusion Unit in the Cabinet Office is to look to the government for guidance. Unfortunately this is not very helpful. The “official” definition is that:
Social exclusion is a shorthand label for what can happen when individuals or areas suffer from a combination of linked problems such as unemployment, poor skills, low incomes, poor housing, high crime environments, bad health and family breakdown.
The most interesting feature of this definition is that it goes beyond the common usage of the term poverty and it extends to areas as well as individuals. In fact some people argue that “social exclusion may be thought of as a property of groups rather than individuals”.
Anyway, so much for the government. What about academic commentators? The ESRC has recently established a Research Centre for the Analysis of Social Exclusion at the LSE. Julian Le Grand, one of its Directors, has suggested that: 2
… an individual is socially excluded if (a) he or she is geographically resident in a society but (b) for reasons beyond his or her control he or she cannot participate in the normal activities of citizens in that society and (c) he or she would like to so participate.
To my mind this definition of social exclusion seems very similar to the broad notion of deprivation long advocated by Peter Townsend.
People can be said to be deprived if they lack the material standards of diet, clothing, housing, household facilities, working, environmental and locational conditions and facilities which are ordinarily available in their society, and do not participate in or have access to the forms of employment, occupation, education, recreation and family and social activities and relationships which are commonly experienced or accepted.
Personally, I remain to be convinced that any contemporary definition of social exclusion is superior to Townsend’s notion of deprivation. I particularly admire his work because he put real effort into measuring deprivation empirically as well discussing it conceptually.
But having mentioned the word empirical, another obvious way of trying to get a handle on social exclusion is to ask how it has been measured. A recent Joseph Rowntree Foundation report - Monitoring Poverty and Social Exclusion: Labour’s inheritance - provides information about 46 statistical indicators which include: •
The numbers and characteristics of people on low incomes and those who selfreport that they experience difficulty managing financially
•
Data about low birthweight babies, children without educational qualifications and teenage pregnancy rates
•
Evidence about youth crime, drug addiction and suicides
•
Premature death, disease and disability among adults
•
Social isolation and chronic illness among pensioners
•
Levels of social capital and the quality of life in different communities
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What are we to make of all of this?
I am afraid that I cannot offer you a new and convincing definition. Social exclusion is clearly closely linked with poverty, deprivation, inequality and social justice. Many citizens in Britain are clearly denied adequate opportunities to participate fully in ordinary daily activities not only because of their own lack of education and skills but because of poor health, blighted neighbourhoods and the inadequacy of practical and social support when they need it most. These inequities are an offence to liberal theories of justice and any government committed to promoting a fairer society has no alternative other than to address them in some way. But is there a 3rd Way to do it?
The Third Way
When I first began to think about the Third Way there seemed to be three obvious ways of seeking clarification about its meaning. One involves examining the speeches and writings of Tony Blair and other leading New Labour politicians. A second is to review contemporary debate particularly among the social democratic intelligentsia who communicate their thoughts via Nexus, the New Statesman, the Internet, the Guardian and other such media. Finally, it seems essential to consult the writings of the academic who is purportedly Tony Blair’s favourite intellectual, namely Anthony Giddens.
Let me begin by taking just two examples from recent speeches by Tony Blair. •
The Third Way is about how to recreate the bonds of civic society and community in a way compatible with the far more individualistic nature of modern economic, social and cultural life
•
The 3rd way in welfare is clear: not to dismantle it; or to protect it unchanged; but to reform it radically – taking its core values and applying them to the modern world.
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This is hardly very informative. So much for politicians.
What about social democratically-minded commentators? Here there is much more to choose from. But my general impression is that the definitions and suggestions made by such people fall into one of two categories depending on whether they regard themselves as insiders or outsiders.
The insiders or potential insiders are not uncritical but they do tend to be more positive. Writing in the New Statesman, Julian Le Grand provides a broadly sympathetic account “of the Third Way that seems implicit in many of the government’s actions”. He identifies the new watchwords as being community, opportunity, responsibility and accountability. Julian acknowledges that:
… there are some tensions between these values ( especially between encouraging freedom of action by communities and the centralisation that may result from vigorously holding them to account)
and he expresses concerns about what he describes as “the potential for community tyranny” but on the whole he applauds the “robust pragmatism” of what he discerns as a distinctive Third Way.
In contrast, the outsiders, or those who see themselves in some significant respects as being excluded, are more critical. Such commentators see the Third Way as a middle of the road fudge or worse. For example, writing recently in the Guardian, Anna Coote represented the Third Way as a middle of the road obstacle to any radical feminist agenda in New Labour’s modern Britain.
All of this may be true. But if the Third Way if it is to be of any significance at all it must at least in part transcend the policies and practices of New Labour. So what can we learn from Anthony Giddens? His short book – The Third Way: the renewal of social democracy – does not claim to be the last word on the subject, but it does try to locate thinking about the Third Way in the mainstream of modern political ideas in a European and not just a British context.
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Let me give a flavour of what I have found valuable in Giddens’ treatment.
First, he is refreshingly honest about the bastardised history of the concept. … the term “third way” is of no particular significance in and of itself. It has been used many times before in the past history of social democracy, and also by writers and politicians of quite different political persuasions.
The phrase seems to have originated as early as the turn of the century, and was popular among right-wing groups in the 1920s. Mostly, however, it has been used by social democrats and socialists.
Secondly, he is clear that the Third Way must be located in the context of contemporary thought about social democracy.
From this starting point Giddens speculates about what the Third Way might mean in relation to: •
The relationship between the state and civil society and the promotion of democracy within the family
•
The development of the social investment state in place of the familiar welfare state
•
The role of the nation state and transnational institutions in a global age.
It is the second of these themes that is of most interest to me in the context of British social policy. There are a number of aspects that seem particularly important. The first is the familiar refrain: no rights without responsibilities.
Third way politics looks for a new relationship between the individual and the community, a redefinition of rights and obligations … Government has a whole cluster of responsibilities of its citizens and others, including the protection of the vulnerable. Old-style social democracy, however, was inclined to treat rights as unconditional claims. With expanding individualism should come an extension of individual obligations.
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The second theme that I want to highlight is the need to modernise the delivery of the machinery of government. Here what Giddens has to say resonates with many of Tony Blair’s statements such as:
… we know that … government itself must change if it is to be part of the solution not the problem.
Lesson number one is that government must not fall into the trap of short-termism …There are no quick fixes.
Lesson number two is that government has to learn to work more coherently … In every poor housing estate you can encounter literally dozens of public agencies … all often doing good work, but all often working at cross-purposes or without adequate communication
There is also a third lesson that is just as important … We will evaluate our policies – and improve them if they need to be improved. Finally, Giddens emphasises the importance of community building. Conventional poverty programmes need to be replaced with community-focused approaches, which permit more democratic participation as well as being more effective.
Community building emphases support networks, self-help and the
cultivation of social capital as means to generate economic renewal in low-income neighbourhoods …(such) initiatives concentrate upon the multiple problems individuals and families face, including job quality, health and child care, education and transport. Overall, in terms of what the Third Way might mean for thinking about policies aimed at reducing social exclusion, I think that four aspects are especially important. •
No rights without obligations for citizens
•
A new mixed economy and modernisation for public agencies
•
A new deal for communities
•
A clearly-defined performance management framework to achieve accountability at the centre.
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I now want to turn my attention to a case study of how Third Way thinking is being applied in practice to a particular manifestation of social exclusion by examining the role of health action zones in tackling health inequalities.
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HEALTH INEQUALITIES AND HEALTH ACTION ZONES
Socio-economic differences in health status have been recorded in Britain for over a century. However, it was not until the publication of the Black Report in 1980, which concluded that: ‘class differences in mortality are a constant feature of the entire human life-span’, that this aspect of social inequality came under close scrutiny.
Throughout the 1980s and 1990s a considerable body of evidence accumulated that showed the poor health experience in terms of premature mortality and excess morbidity of people living in disadvantaged circumstances. The latest data on life expectancy at birth by social class are shown in the next slide. For both men and women there is a social class gradient in health with men from professional and managerial occupations living, on average, five years longer than men with semi and unskilled jobs. For women the gap is three years.
Life expectancy at birth by social class, LS, England and Wales, 1987-91 82
L ife exp ectan cy
m en
w o m en
78
74
70
66 I/II
IIIn -m IIIm so cial class
IV /V
Source: Hattersley, 1997
Such inequalities can be found for illness, disability and most conventional indicators of health status and by every measure of social status. For example, the next slide, which is based on data from the General Household Survey, shows the rate of reporting health as ‘not good’ by respondents’ family income. Those people in the 9
bottom 20 per cent of the income distribution are four times as likely to say that their health is ‘not good’ as those in the richest fifth.
Income and health, adults 16-64, GHS, Great Britain, 1992/93 - 1993/94 Ag e /s e x s ta n d a r d is e d r a te o f r e p o r tin g 'n o t g o o d ' h e a lth
180 150 120 90 60 30 0 1
2
3
4
5 Richest
Poorest
Equivalent fam ily incom e by quintiles
Source: Benzeval et al. (1996)
In many ways there is nothing especially remarkable about these social variations in health in Britain. They are found in most if not all countries. However, what is particularly worrying is that a number of studies have begun to show that the health divide has widened in Britain during the past decade or so.
The causes of health inequalities are complex. There has been considerable, and often acrimonious, debate about the relative importance of various different explanations. However, most of the evidence strongly suggests that it is the cumulative effect of adverse material and social circumstances that is the most important determinant of health inequalities.
Despite the massive accumulation of evidence about the causes of health inequalities, until recently government action in Britain to tackle them has been noticeable mainly by its absence. The Black Report was famously shelved early in the life of the Thatcher governments during a time when it was fashionable to pour scorn on concepts such as community or society. Health policy was preoccupied with 10
managerial concerns about value for money in the NHS rather than the health of the population.
This began to change slowly in the early 1990s with a clearer emphasis on the health of the nation. Work that colleagues and I did at the King’s Fund – Tackling Inequalities in Health: an agenda for action - began to make an impact, and the Department of Health also sponsored an investigation of the “politically safe” variations in health. But it was not until May 1997, when the Labour Party came to power with a massive majority and an election manifesto that included an explicit commitment to tackle inequalities in health, that things began to change dramatically.
There is now widespread recognition across government that two sets of policies are required to achieve this: •
general social policies to tackle social exclusion and inequality, and
•
specific health policies aimed at reducing health inequalities.
For today I want to focus on the role of health policy without in any way wanting to suggest that broader economic and social policies are not absolutely vital.
The Government has published a number of strategies that reiterate its commitment to tackle health inequalities. These include the green paper on public health, Our Healthier Nation, the white paper on the New NHS and various forms of priority and planning guidance.
Overall, a range of mechanisms are either already in place or are in the process of being put in place to enable the NHS to make an effective local contribution to tackling health inequalities. These include: •
the new roles being developed for health authorities as primary care groups take the lead responsibility for commissioning;
•
the emphasis on building partnerships with other public agencies such as local authorities and local communities;
•
the monitoring of central guidance about performance management and health improvement programmes; and
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•
the creation of health action zones.
It is health action zones that I now want to focus my attention on. They are a critical plank in the government’s plans for the modernisation of health and social services. If we want to learn whether there is any practical substance to the Third Way as an approach to tackling social exclusion then an examination of what health action zones are doing might help to inform us.
Health action zones There is no doubt whatsoever that Ministers regard health action zones as trailblazers for their policies and that they are seen as having a particularly important role in relation to tackling health inequalities. Frank Dobson, the Secretary of State for Health made this absolutely clear when launching the first wave of zones in 1998.
Health action zones are a key part of the Government’s drive to target areas with particularly high levels of ill health … and so improve the health of the worst off at a faster rate than the general population. This is the first time a British Government has set itself such a task
There are 26 health action zones. The first wave of 11 was established in 1998 and the second and final wave of 15 started life last month. The zones vary considerably in size and organisational complexity. On the one hand, there are relatively small zones such as Luton, which is based on a small unitary local authority with a population of 180,000 covering only part of a health authority. On the other hand, there are very large zones such as Merseyside, which is concerned with a population of 1.5 million and is based on multiple health and local authorities working together. The special allocations of finance available to HAZs are relatively small. Less than £100 million per year plus special funds for such initiatives as smoking cessation and health living centres has been earmarked. But it is expected that this finance will be used to leverage change in the more substantial mainstream budgets of health and local authorities.
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The next slide provides a simple model of what is expected from health action zones.
Building local partnerships
Resources, Support, Freedoms
National Policy context
A model of Health Action Zones New ways of delivering health and social care
Community empowerment
Improved health and reduced health inequalities
Tackling the root causes of ill health
Local evaluations
They are expected to operate within and contribute to a set of national policies that will provide resources, developmental support, and new freedoms from regulations. In return health action zones have to put real effort into building effective local partnerships to deliver on New Labour’s commitment to substitute collaboration for competition. Health action zones, therefore, are quintessentially partnership entities charged with three main tasks: •
Stimulating innovative ways of delivering health and social care
•
Promoting community empowerment
•
Tackling the root causes of ill health.
The primary goals of the zones are to improve the health of their local populations and to reduce health inequalities. Some zones have committed themselves to quite explicit reductions in health inequalities within their own areas. So one zone is aiming to reduce the health gap by 25 per cent by 2005. Other zones are slightly more cautious and their aim is to try to ensure faster progress in the most disadvantaged areas
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relative to the most affluent. Others have chosen to focus on specific health problems such as coronary heart disease where inequalities are known to be most evident.
We are currently engaged in the process of analysing the detailed implementation plans for the health action zones. It is too early to paint a comprehensive picture of what they are intending to do but one brief indication of the focus of their activities will give a flavour of the approach that they are adopting. The next slide summarises what more than 1,000 activities in the 2nd wave zones are trying to change.
2nd Wave HAZs: What are they trying to change? internal processes 17%
root causes 18%
lifestyles 17%
community empow erment 21% h& sc 27%
•
About one quarter of the activities are about modernising the health and social care delivery system
•
One fifth are aimed at promoting community empowerment
•
A little less than one-fifth of all activities aim to address either the root causes of ill health or aspects of lifestyles and behaviours
•
Finally, 17 per cent are focused on changing the process of partnership working.
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I hope it is evident from this quick review that health action zones do have a number of 3rd way characteristics. These elements include: •
A strong focus on social exclusion
•
A central emphasis on partnership, collaboration and joined up government
•
A genuine commitment to community involvement
•
A mixture of rights and responsibilities in the form of extra finance and new freedoms in return for tough accountability and performance management mechanisms
•
A requirement for local and national evaluation to be put in place
How are health actions zones responding to these new challenges and opportunities? First, there can be no doubt whatsoever about their commitment to tackling health inequalities. They may be somewhat ambitious in thinking about what they might be able to achieve. But the enthusiasm and the vision is unequivocal. Secondly, the early evidence from interviews with key stakeholders suggests that there is genuine enthusiasm for partnership working especially among senior managers in health and local authorities. For example, one health authority chief executive told us that:
I feel that we have succeeded in getting partners on board in a way that we definitely would not have been able to do, had we not been a HAZ.
There is more scepticism among representatives of community and voluntary sector organisations about whether the rhetoric will be translated into new ways of working, but it is still very early in the life of these zones to be too critical. What is much more problematic at the moment is the whole question of target setting and performance management.
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Targets and plans
I want to spend a few minutes talking about targets because it is central to my thinking about whether the 3rd Way has a useful contribution to make.
New Labour is preoccupied – some might say obsessed – with measurement and performance management in a quite unprecedented way. As the Observer reported last Sunday (16 May 1999):
The Treasury has a target for every aspect of your life touched by a Whitehall department, from what you eat and what your children learn to the courtesy of your driving test examiner. And if that makes you think like ending it all, don’t even think about it. The Government also has a target to reduce suicides by 17 per cent by 2010.
As far as health action zones are concerned both of the key Ministers of State – John Denham and Tessa Jowell – have emphasised the critical importance of targets in recent speeches.
The Government is making targeted money available and introducing new freedoms in the Health Action Zones to help them to rise to the challenge … This is money for modernisation, reform and results … In return, HAZs will report back on the progress they are making to introduce new arrangements, harness the new freedoms and meet clear targets.
How have the zones responded?
My overall impression from reading the operational plans submitted by health action zones is that to varying degrees they are all quite strong on identifying problems, articulating long term objectives and specifying routinely available statistical indicators that might be used for monitoring progress. On the other hand, they are much less good at filling in the gap between problems and goals.
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Health Action Zones Interventions
Expected Consequences
Goals
Problems Interventions
Targets
Indicators
Many of the 1st wave health action zones, in particular, found it difficult to specify precisely how they will intervene to address problems, and what consequences they expect to flow from such interventions and how precisely these relate to their strategic goals. As a result, the targets that they include in their plans lack conviction for a number of reasons.
For example, many specific targets are not clearly linked with strategic goals or objectives set out elsewhere in the plans. Other targets are not located within a specific time scale. Most importantly, and most frequently, specific targets are highlighted without any accompanying explanation of the mechanisms intended to achieve them. This omission is key. It breaks the critical link between the problems that HAZs are there to address and the ambitious goals that they rightly wish to set for themselves. It also limits the extent to which the intended outcomes in each HAZ can be perceived as part of a process of broader change, the type of change that is required to make significant improvements in health over time.
In recent months there is evidence that the process of target setting is improving. Many of the 2nd wave plans have greatly improved the ways in which strategic goals are linked with clearly defined activities and intermediate milestones or expected 17
consequences. However, a number of health action zones still need to undertake further development work before their plans in general and their targets in particular satisfy the requirements of a modern community health improvement process.
In part, the relative under-development of a number of the plans is to be expected. The historical strength of partnership arrangements between public agencies, and the degree to which community engagement and participation are already taken seriously, can have a very significant impact on the ease with which plans can be specified in any degree of detail. Not all HAZs start with the same comparative advantages. However, three problems appear to crop up over and over again.
The first is that health action zones appear to be most comfortable with articulating what I call aspirational goals rather than thinking hard about what they might be able to achieve and how. This approach is not unique to Britain.
Experience from a wide range of programs (in the USA) shows that identifying and agreeing upon long-term outcomes is relatively easy, in part because long-term outcomes are generally so broad as to be uncontroversial: for example, improved high school graduation rates, greater “sense of community”, or increased income levels.
Likewise, identifying early activities is relatively straightforward.
Intermediate and early outcomes are more difficult to specify because scientific and experiential knowledge about links between early, interim, and long-term outcomes is not well developed in many of the key areas in which (community-based initiatives) operate. Defining interim activities and interim outcomes, and then linking those to longer-term outcomes, appears to be the hardest part of the … process.
Nevertheless, if real learning is to be generated from the activities of health action zones it remains essential that continued planning efforts go beyond the diagnosis of problems and the articulation of aspirational goals. Fulfilling the potential of health action zones to make a major contribution to the modernisation agenda demands that they continue to put substantial effort into developing the strongest possible rationales for the investments that they choose to make.
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It has to be acknowledged that there is considerable scope for semantic debate about the differences between targets, goals, objectives, outcomes and other similar terms. Nevertheless, it is my contention that if the term “target” is to be a meaningful one for the purposes of policy and practice learning it needs to be clearly linked to beliefs about the expected consequences of interventions purposefully selected to address particular problems. In fact it is essential to do this if the evaluation of health action zones is to be successful
Evaluation I now want to say a little about our approach to the national evaluation of health action zones that we started at the beginning of this year. Health action zones are examples of what are referred to in the literature as comprehensive community initiatives. Such initiatives tend to have certain common characteristics. These include the following: •
They aim to promote positive change in individuals, families, communities and/or institutions
•
They develop a wide variety of mechanisms to improve social, economic and physical circumstances, services and conditions in disadvantaged communities
•
They place a strong emphasis on community building and neighbourhood empowerment
However, such community-based experiments also have a number of distinctive features that make their evaluation highly problematic. •
They tend to have very broad and ambitious goals that depend on achieving synergistic change
•
They are highly complex learning enterprises with multiple strands of activity operating at many different levels
•
Many of the activities, processes and outcomes that they are concerned with are difficult to measure
•
The communities where they operate are complex, open systems where it is difficult to disentangle the many forces at work.
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So what approaches to evaluation and learning can we employ? Drawing on British and North American evidence about the evaluation of complex and comprehensive community-based interventions, we believe that “there is nothing so practical as good theory” in informing the design and implementation of HAZ plans. Two methods in particular guide our approach. First, realistic evaluation methodology emphasises the need to explore the ways in which specific change mechanisms interact with the circumstances prevailing in particular local contexts to yield observed outcomes. Secondly, experience with using a theory of change approach highlights the importance of encouraging and motivating stakeholders to engage in quite difficult and time consuming processes that: •
(a)) yield more convincing strategies or rationales for the interventions they select, and
•
(b) enable them to specify the expected consequences of purposeful investments.
We believe that there are a number of reasons why adopting a theories of change approach is appropriate for the national evaluation of health action zones. I want to emphasise three of them.
1. A theory of change can sharpen the planning and implementation of an initiative. Used during the design phase, it increases the likelihood that stakeholders will have clearly specified the initiative’s intended outcomes, the activities that need to be implemented in order to achieve those outcomes, and the contextual factors that are likely to influence them. These are the building blocks of any good evaluation, but they are especially useful for mid-course feedback to managers and for developing a knowledge base about how and why (initiatives) work.
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2. With a theory of change in hand, the measurement and data collection elements of the evaluation process will be facilitated. For example, a theory of change asks that participants be as clear as possible about not only the ultimate outcomes and impacts they hope to achieve but also the avenues through which they expect to achieve them. An evaluation based on a theory of change, therefore, identifies what to measure - ultimate and interim outcomes, and the implementation of activities intended to achieve those outcomes – and helps to guide choices about when and how to measure those elements. By providing guidelines for deciding among the various tools in the evaluation toolbox, the approach helps avoid the risk that evaluations will be driven by the tools themselves.
3. Articulating a theory of change at the outset and gaining agreement on it by all the stakeholders helps to reduce problems associated with causal attribution of impact. A theory of change specifies, up front, how activities will lead to interim and longterm outcomes and identifies the contextual conditions that may affect them. This helps strengthen the scientific case for attributing subsequent change in these outcomes (from initial levels) to the activities included in the initiative. Although this strategy cannot eliminate all alternative explanations for a particular outcome, it aligns the major actors in the initiative with a standard of evidence that will be convincing to them … At the most general level, the theory of change approach contends that the more the events predicted by theory actually occur over the course of (an initiative), the more confidence evaluators and other should have that the initiative’s theory is right
We believe that a theory of change approach can be blended together with realistic evaluation to provide a theoretically-informed framework for the community health improvement process.
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Realistic evaluation and theories of change Targets
Strategy
‘Change’ Mechanism
Context
Community Resources and Challenges
Rationale for Intervention
Purposeful investment in activities, intervention and processes
Negotiation of Prospectively Specified Expected Consequences yield practical milestones
Outcomes
Strategic Goals
Community Health Improvement Process
The slide illustrates the approach we are adopting. The starting point is the context within which initiatives operate – the resources available in the communities and the challenges that they face. The first step is to specify a rationale for intervening in relation to priority issues. This strategy should be translatable into clearly defined change mechanisms – what we call purposeful investments in activities, interventions and processes. The challenge is to specify targets for each of these investments that satisfy two requirements. First, they should be articulated in advance as the expected consequences of actions. Second, these actions and their associated milestones or targets should form part of a logical pathway that leads in the direction of strategic goals or outcomes.
Summary Any serious attempt to learn from the investment in health action zones requires that knowledge be obtained about the ways in which different configurations of contexts, strategies, interventions and their associated consequences will contribute to the realisation of the ambitious goals that HAZs have set for themselves. In my view, this means that there has to be the widest possible recognition of the fact that the continuous refinement and adaptation of HAZ implementation plans is an absolute necessity not an option. Promoting and achieving change in pursuit of ambitious goals
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will be possible only if HAZs are encouraged to invest in the planning process, to take risks, to accept occasional failures and to adapt to changing circumstances.
My impression is that local HAZ leaders do not need to be persuaded of the need for retaining flexibility in the way in which their plans are developed. However, many of them still shy away from clearly articulating the reasons for choosing to intervene in particular kinds of ways and/or specifying the expected consequences of the investments they make. Failure to do so seriously inhibits the potential for HAZs to be a real learning community.
I have suggested to Ministers and senior officials that they should offer genuine assurance to HAZ leaders about the importance of risk taking and the legitimacy of adaptation to changing circumstances. But at the same time it remains important to continue to emphasise the need for HAZs to work harder at clarifying and strengthening the intrinsic logic of their implementation plans. All communities and stakeholders must be convinced that ambitious goals are backed up by plausible proposals.
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CONCLUSION Let me now conclude by returning to the question I posed at the beginning. Is there a third way to tackle social exclusion? Well, if the third way is defined to include the modernisation of government and the promotion of community building then health action zones can clearly be represented as Third Way examples of tackling one important manifestation of social exclusion. The zones are clearly based on the notion of collaboration and partnership rather than competition and quasi markets. They are committed to taking social exclusion seriously. They have harnessed enormous enthusiasm aimed at redressing inequalities.
The main problem I have identified is that the short term needs of performance management run the risk of crowding out the long term commitment to sustainable development that is an essential feature of community regeneration.
Reflecting on experience with urban regeneration in Britain over the past two decades, Mark Kleinman suggests that it is critical to think carefully about the social context within which community building takes place. He argues, for example, that:
… it is now becoming clear that …“social capital” is as important to economic development as economic capital.
This has two important implications for community-based regeneration efforts such as health action zones. •
At local level, real partnerships involving long-term commitment by a range of groups need to be made. Real partnerships involve negotiation, innovation and risk-taking. Risk and the occasional failure should be seen as indicators of good health, not as cause for concern.
•
At national level, there needs to be … a move away from the current obsession with quantitative performance indicators and the development of broader measures which emphasise long term development and sustainability …
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Initial findings from our interviews with key stakeholders in health action zones emphasise the validity of these points. One City Councillor told us that:
… delivering the programme is constantly going to be about balancing goals, which is going to take a bit of time to achieve and, therefore, is not going to be acceptable to the Department of Health … because they … want to see things in the short term. So what we have to do - to manage that as a process - is to make sure that we are delivering things in the short term … in order to … give ourselves the opportunity to work on those areas that really matter.
What this implies is that Ministers have to be persuaded to modify their approach somewhat, but local partnerships have to help deliver quick wins. What is needed is a new vocabulary to describe development in ways that demonstrate tangible progress in the short to medium term while keeping long term goals firmly in mind.
Ministers have every right, indeed they have a responsibility, to monitor progress. But they have to be persuaded that relatively small steps are all that it is reasonable to expect to begin with. In return local agencies and actors have to develop and articulate strategies for investments in activities, interventions and processes that trace a logical pathway between needs assessment, priority setting and long term goals. This is a challenging but essential requirement for all of those who advocate the need for freedom and diversity at the local level. But we have to acknowledge that they need help to do this.
In fact, a critical assumption held by the national evaluation team that I am leading is that we have a developmental role as well as a more conventional research one. We believe very strongly that evaluators have as much to contribute to sharpening and clarifying questions about design and implementation during the early stages of initiatives as they do to evaluating successes and failures at a later stage in the process.
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Let me finish with three propositions. •
First, that whatever definition of social exclusion is adopted, social determined inequalities in health are closely related to it.
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Secondly, that a key feature of the “third way” in relation to social exclusion is the need to modernise public services and the way in which the agencies that deliver them relate to citizens and communities.
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Thirdly, that some distinctive aspects of the “third way” do have a contribution to make to reducing social exclusion provided that a potentially serious conflict between competing principles is acknowledged and resolved. With a government obsessed by performance management to an extent undreamed of by its predecessors it is important to ensure that central requirements for accountability do not undermine the promotion of local innovation, community participation and social entrepreneurship that are critical aspects of the modernisation agenda.
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