Inequality in Islington
Decision-makers regularly approach local minority-led organisations about the experiences of their residents. However, those organisations are often too busy getting on with supporting their clients' immediate needs to respond. This means their work to reduce health inequalities impacts their ability to participate in discussions about inequalities.
Islington is a diverse borough with huge and widening socioeconomic and health inequalities. But historically, the views of these people have been overlooked, or they haven't known they could share their experiences. Similarly, the groups supporting them could not advocate more widely than on an individual basis.
To help tackle these issues, we set out to put people impacted by inequality at the heart of decision-making.
Why work with partners to engage more widely?
Like all Healthwatch, we're a small organisation with a big task. Islington has a diverse and transient population. Most residents were not born in the local area, 30% of residents are from ethnic minority backgrounds, and 20% are from white other backgrounds. There are many languages spoken, and wealth and health inequality are high. In particular, refugee and migrant communities and disabled residents are more likely to be experiencing poverty (including in-work poverty) and poor health.
We know that residents open up to professionals with whom they have a long-standing relationship and who they trust. For example, Voluntary Sector partners providing benefits advice work with people we know we need to reach.
What we did
Our first step (2013-14)
Local community partners told about a lack of access to interpreting services. As a result, we developed a mystery shopping project together. Partners' Community Language Support Services (CLSS)helped call practices and advocate for an imagined client needing interpreting. This allowed us to make a case for better interpreting service promotion to staff and patients.
Taking an opportunity for funded partnership work (2014-15)
Together with CLSS and several other partners, we put together a bid to deliver community research for our Clinical Commissioning Group (CCG). The CCG was aware that they were not hearing from residents from ethnic minority backgrounds and had made small funding pots available to do this. We decided to put in a partnership bid for all eight pots of money and deliver the work together, producing one overarching report to give 10 specific communities a voice.
We developed our partnership agreement as we went. This project worked because we trusted each other and fairly shared risks, responsibilities, and resources.
Where are we now (2015-22)
We've developed digital support for our residents, fundraising with partners to reach around 1,000 people. Our partnership has been invited to bid for several pieces of work and is considered one of the 'go-to' organisations for ensuring that a range of voices feeds into commissioning. Our Integrated Care System (ICS) will be providing us with £93,000 of specific funding to hear the views of our ethnically diverse communities and disabled people during 2022/23.
What we have achieved
Influencing services together
- Together, we've reported residents' views on various issues, including mental health, social prescribing, and the pandemic's impact. We've also influenced how our local partner's commission engagement, focusing on giving residents information to help them access support and asking for their views.
- Partners in the voluntary and community sector now commission us to evaluate their work, increasing our knowledge of what people in the borough need. A local Trust funder also recommends us for independent evaluations.
- The partnership flourished through the pandemic. We helped each other reach people and access information. We also worked with new partners, including Disability Action Islington, University College London and City and Islington College.
- We secured £64,000 of statutory funding for mental health support for communities from ethnic minority backgrounds, delivered through trusted local partners who can support residents to recognise the need for help.
- Raised awareness of inconsistencies around interpreting (for non-English speakers and British Sign Language users), though this work is ongoing. At one point, our CCG agreed to ensure all service specifications explicitly stated a need for interpreting, but this will need re-asserting within the ICS.
- GPs encouraged (by commissioners) not to rely on mental health self-referral for specific under-represented communities.
- Statutory Equality Impact Assessment will no longer be done by one person.
- Helped to keep residents updated on COVID-19 guidance and inform the borough's COVID-19 vaccine roll-out by sharing findings on what Islington's diverse communities are telling our partners and us.
Main issues people face
We have spoken to a broad group of residents who experience life in the borough very differently from each other. Although the issues have been numerous and diverse, some themes come through.
- Lack of awareness of what services are available and what they are entitled to use.
- There is a wide variation in understanding of public health messaging, such as COVID-19 or healthy lifestyle messaging.
- It is difficult to access information about some services because of how it's communicated and the channels and language used.
- Socioeconomic factors, including in-work poverty, caring responsibilities, and poor housing, impact people's health and their ability to self-care.
- Lack of understanding within some services of the needs of different communities and a perceived impatience for those who don't speak English well.
Working in Partnership - Step by step guide
Below is a step by step guide to the process we used to set up the partnership.
Criteria for selecting your partners
- Reach: Can the partner(s) reach people you don't, and can they demonstrate that they'll be able to reach people within the timeframes of your project.
- Due diligence: We work with small organisations, but we expect them to share our values. All partners need to have several key policies in place: Safeguarding, Health and Safety and Equality, Diversity and Inclusion. We can share policy templates if partners need advice.
- Turnover: Although we partner with organisations of all sizes when fundraising to deliver work, we prioritise smaller partners. Although we're approached by others wanting to join the partnership, we can't say yes to everyone. If partners with a higher turnover wish to work with us, we can do that, but we might request that they lead the bid-writing process.
- What resources you will need: Our Healthwatch budget is £156,000 a year, and this is taken up with staffing costs and overheads like having an office, volunteer expenses and the cost of events. If, like us, your core Healthwatch budget doesn't allow for contracting small organisations, think about which funders you can appeal to. For example, statutory bodies, public health, CCGs, NHS Trusts and GP federations. You can also apply to Trust funders. As these will be different for each area, you could ask your local infrastructure organisation for advice. You will also need to agree on how resources and risk will be fairly shared from the start. We pay partners in advance but hold back between 10 and 15% as a contingency in case any of the partners cannot fulfil their part.
- Decide who will do what: All the usual tasks are involved: project management, development of research questions and recording tools, briefing partners and responding to queries, undertaking surveys, analysing and reporting the findings, and presenting the results to commissioners. Agree from the start on who will do what.
- Collate and share findings: We use Excel as it's accessible to most organisations, easy to analyse, and can be added to existing databases such as the Healthwatch CRM. We try to agree on recommendations and next steps across the partnership and with relevant commissioners and providers.
- Promote your findings: Agree where will you take your findings and who (from the partnership) will take them. We have tended to lead this as we are often 'at the table'. But, we've also created co-chairing opportunities to take our evidence to decision-makers at events we don't attend.
- Showcasing: We discovered that partners talk about how good it is to work with us without even asking, so we're starting to formalise how we can all advocate for our research and the partnership. We've incorporated partner feedback into our Theory of Change. Partners say that working with us has increased their knowledge of what their clients are entitled to and enables them to access services more easily.
Challenges to collecting people's views
We've tended to find smaller, grass-roots organisations have the best reach and deliver more quickly. We've also worked with national organisations less successfully, as this needs more lead-in time.
Costs and resources needed
Small organisations are often extremely busy supporting residents with complex needs. Taking them away from this work to participate in health and care workshops and engagement needs resourcing. We've sought funding from a range of statutory providers, from housing associations, local Trust funders Cloudesley and Cripplegate and national funders; Charities Aid Foundation, the National Lottery (Awards for All) and Independent Age. We tend to be more successful with local funding bodies as we've built a strong reputation in the area.
Costs vary from project to project, depending on outputs, outcomes and deadlines.
Tips for success
- Work with people you know get results: Who are the people in your community working with residents experiencing health inequality? You'll know who they are; pick them as your partners.
- Share the risk: We originally planned to pay partners upon activity completion, but small organisations have small cash flow, so we usually pay in advance.
- Promote your partnership on your website: We spent a long time reeling off a long list of partners each time providers and commissioners asked us who was in the partnership. The partnership now has its own web page.
- Think about the name: We didn't know whether Diverse Communities Health Voice would be successful, so we didn't spend enough time agreeing on a name. We picked a long name, and no one remembers what the acronym stands for.