In his keynote at the 2018 Innovate for Impact Symposium Professor Frank Oberklaid emphasized that while a response to the complex social and health challenges we now face is much needed, the solution can’t be the creation of more program and services.
The current programs and services landscape
Many of our current governance and service models are not serving those most at need, and in some cases, outcomes for families experiencing the most disadvantage are getting worse. This is despite large scale investment in programs and services intended to assist those families. Some of the reasons for this include:
Much of the current service system was designed and introduced decades ago to address problems of that time, and are not adequate to address the increasingly complex needs of families or the range of challenges now facing children and young people.
Many of the service responses are not culturally grounded and have been designed using Western, white or Pākehā[1] models of health or for the ‘nuclear family’. These models miss opportunities for different responses and reinforce inappropriate or irrelevant models of health.
Current service delivery models are often based on an expert model that can reduce rather than build the capability of families.
Traditionally services and policy responses have not been developed with enough understanding of the specific context, issues and opportunities in which they operate, and most often do not involve or leverage the know-how and motivation of local community in their development.
Those most in need of support are also experiencing high and prolonged cumulative stress as a result of inequity, sustained disadvantage and systemic racism. Interactions with current services and programs (often designed to ‘help’ families) can make it worse, increasing stress through punitive policies, lack of flexibility or overwhelming requirements. This can add to feelings of shame and judgement[2]
The accumulation of toxic stress has further negative effects on health and wellbeing outcomes for families and reduces their ability to take up or engage with future potential services.
Service system interventions are most often shaped as individual interventions focused on particular aspects of people’s life creating silo’s around an issue or around an individual rather than a family as whole.
The ongoing focus on individuals and individual interventions is often done at the expense of attention paid to systemic issues or conditions that create or reinforce the situation in the first place.
Shifting to new approaches
Shifting away from a programmatic approach is not easy. The notion of a program or service is well understood, tangible and relatively easy to fund. Programs and services are our default way of responding—almost inadvertently the path of least resistance when wanting to appear to be addressing or ‘fixing’ an issue. And many benefit from and are invested in this status quo.
In addition the program and service model conceptualises and ties up skills, resources and expertise in particular ways that can be hard to dismantle, reconfigure or redistribute.
Decommissioning or defunding services is unpopular. And while current funds and resources are allocated to existing services and practices there is very little, if any, resource, structural support or time left for experimenting with different, more collaborative or holistic approaches.
There is a need to be experimental and learn as we go about different ways government and community resources can be configured to better address the issues that matter to community.
Testing new approaches raises a number of questions and challenges about capacity, readiness (and willingness), capability, administration and oversight for innovation.
Currently, labs and innovation platforms are playing a key role in creating places for experimentation and for new models that are developed, tried and tested with communities. For example at The Southern Initiative in Tāmaki Makaurau Auckland, co-design approaches have been used to create a temporary structure where multiple people, views, stakeholders, voices and forms of expertise from across different parts of the system can come together and try new approaches [3].
Similarly the Tāmaki Wellbeing Lab is dedicated to co-designing solutions that are relevant to communities, a key part of which is working alongside and enabling community to take a lead role in cultivating and maintaining their and their families and whanau’s wellbeing [4].
Such approaches are most successful when families and stakeholders from across the system work together to understand and engage with how the complex interactions of health, housing, social and economic needs at local and systems level impacts on current experiences.
This can result in a more holistic and connected framing of the issue and in turn can create the space for more collaborative, innovative and systemic responses.
There is increasing interest internationally in responses that recognise and re-distribute knowledge, assets and expertise differently. This includes reconfiguring government and community assets and resources outside traditional service models. For example there are growing examples of peer to peer, family to family or youth-led models that are strengths-based and culturally grounded.
What do new approaches offer?
Such approaches offer the opportunity to enhance and build upon existing resources within the community, and empower community to be involved in and lead their own responses. Examples include Empowering Parents, Empowering Communities (CCCH, Australia), Family by Family (TACSI – Australia), Talking Matters (Tāmaki – Aotearoa New Zealand), Ko Huiamano (Papakura, Aotearoa New Zealand), Winnipeg Boldness Project (Canada).
These models differ to traditional service models in that there is a redistribution of power and resource to support families to build capacity rather than receive a service. They are shaped and informed more by a kaupapa (purpose) or campaign rather than a service delivery structure. Knowledge, expertise, resource and governance of such is shared with, embedded in, recognised and grown in families and communities rather than (or complementary to) that held and exercised by service delivery teams or professionals.
Scale is more likely to come through changes in practices, attitudes, narratives and sharing of learning and knowledge transfer between families, than from service replication.
Considerations for community-led responses
As these kind of peer to peer approaches emerge so do questions about how they are best supported. Some of the questions we are currently grappling with include:
What is the value of peer-led responses for families and communities?
What is needed to support ongoing sustainability of peer to peer models?
How might we go about identifying the most appropriate financial and models and funding flows to support community-led responses— for example how are families compensated? Where does it come from? What governance models might accompany this?
What systems changes are needed to enable and implement new models? For example how does this interact with the policies in place for those accessing benefit support? What changes, skills, policy and infrastructure might be needed across the service system?
What kinds of scaling are appropriate and how do we determine and track value and impact?
What are the primary goals and outcomes of the peer-led responses? For example a sustained and scaled peer to peer model or a capacity building process for that acts as a springboard for other outcomes including formal employment?
While the co-design process can support whānau-led development of models and responses, the learning process inherent in developmental evaluation can assist in answering questions such as those above, helping communities identify and look at what existing barriers are, and helping providers from snapping back into the business-as-usual (BAU) approach.
It is significant that such emerging models challenge and disrupt conventional positions of power and privilege. They flip the model of expertise, diagnosing and treating. They also significantly challenge mainstream practice, practitioners and organisations.
The challenge and the need for such shifts in how we work, think and feel will be further explored in our next upcoming post ‘On power, privilege and possibilities’.
This post was originally published on March 27th, 2019 by the Centre for Community Child Health at The Royal Children’s Hospital (Melbourne) and the Murdoch Children's Research Institute.