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Culture and Communities Select Committee

Review Panel for Hard to Reach Groups

Introductory Briefing Paper

Introduction

Following the Committee's decision to review the issues for the County Council regarding `hard to reach' groups, this briefing paper has been prepared to support Members in scoping this piece of work.

Preliminary discussions with officers have assisted in identifying areas of possible interest to the Review Panel and for which recommendations might eventually be made.

What is meant by `hard to reach' groups?

The term `hard to reach' needs clarification. In theory, every household in Hampshire is reached by Hampshire Now, but merely reaching households with a publication does not necessarily mean that the people of Hampshire have been reached in the sense implied by `hard to reach' if the expression includes a sense of `lack of connection' between an authority and its constituents. Neither is it particularly helpful to apply the term to the many `minority groups' or other classifications of people, as if to say that all members of such groups do not know of, or do not use services available to them.

It is proposed that people defined as `hard to reach' for the purposes of this review might include those who:

    a. are unaware of services provided by HCC or its partners, or

    b. are unable to take advantage of services provided by HCC or its partners, or

    c. are reluctant to take advantage of services provided by HCC or its partners.

The Panel has been asked to consider, in particular, how Hampshire County Council ensures that people in rural areas and members of `minority' groups are `reached', and whether there is scope for recommendations to be made that would enable the County to fulfil its ambition to maximise their wellbeing and enhance their quality of place.

Characteristics of `hard to reach' people in rural areas

The Rural Profile (get full reference) suggests that whilst it is generally true that rural areas are characterised by prosperity, nevertheless there are "individual households or persons in rural areas who may be suffering deprivation"... "This and other studies show hidden deprivation, not large numbers but scattered throughout rural areas" (Rural Profile p.4)

The key word here is `hidden'. For whatever reasons these residents are not flagged by socio-demographic research, nor by the `system' and are therefore hidden or invisible as far as the relevant and appropriate services are concerned. These hidden people may defined as `hard to reach' according to one or more of the criteria cited above. Discovering and attempting to ensure the relevant people are `reached' would appear to require innovative partnership-based solutions to keep costs within reason.

Characteristics of `hard to reach' people classified as `minority groups'

Many different characteristics have been used to describe a person as belonging to a `minority group'. Whilst the characteristic used may describe one thing that one individual has in common with others, it does not necessarily mean that all those who share those characteristics are `hard to reach'. Typical lists of minority groups include, for example, the:

    · Young

    · Elderly

    · Disabled

    · Minority ethnic groups

    · Homeless

    · Migrant workers

    · ...and many others

Many, or perhaps most members of these groups may know of the services available to them, and they may use those services. There may be some services, however, that certain minority groups tend not to use for specific reasons. Therefore, in certain circumstances, some minority residents could be defined as `hard to reach' on the basis of the criteria above.

If people share a specific characteristic that is relevant to their being `hard to reach' it suggests that it may be possible to target resources to ensure they have equitable access to services. For example, a hearing loop might be provided in locations where people with hearing loss need to hear information. In another case it might be possible to provide support funding to a community organisation to provide personal social care for elderly members of a minority cultural/religious group.

Many minority hard to reach groups are represented by associations or organisations in the `third sector'. The raison d'etre for the organisations' existence is usually the characteristic that defines the group. In many cases such minorities are `reached' by the organisations and will often have specialists who are knowledgeable about services provided by statutory and independent agencies and how they can be accessed. The County Council and other statutory bodies are often able to work through such organisations.

Not all members of minority groups belong to, or will be known by organisations relevant to the minority group, and may be unknown to relevant service provider organisations. Many minority individuals or households will be spread throughout rural or urban populations and some of these may be defined as `hard to reach' on the basis of the criteria suggested above. Again, these people are `invisible'

Aggregations of `hard to reach' people on the basis of locality

In areas of multiple deprivation and in some urban communities there are concentrations of deprivation. Socio-demographic profiles of these areas appear to show that these areas are composed of possibly more than a dozen social types (as defined by Mosaic). Each of these could be regarded as a minority group or type, and many members of these groups could be described as `hard to reach' if they do not access services which would contribute to their wellbeing(?). (there is a question as to whether local measures of wellbeing match those that might be assumed by others not part of that community)

The people in these groups are not `hidden', but the distinctions between groups may be difficult to recognise. One advantage, from the perspective of targeting measures to `reach' and include these people is that in most cases their locations are known. In addition, because there tend to be aggregations or concentrations of groups in locations, attempts to reach them may be more cost effective.

(References - Appendices ?)

Hard to Reach groups and the County Council's Corporate Priorities

The County's Corporate Priorities of maximising wellbeing and enhancing quality of place are aspirations for all of the County's residents, however those who might be called `hard to reach' as defined above, are the least likely to benefit from the County Council's commitment to its people. The working definition of `hard to reach' suggested above, proposes that there may be three broad components that as well as indicating why some people are hard to reach, also indicate where or how resources could be targeted to improve the situation.

Definition: part a) People who are unaware of services provided by HCC or its partners

    Current County Council activity: Corporate Communications

    Corporate Communications distributes copies of Hampshire Now (HN) to all Hampshire households four times a year. Each copy contains an A to Z of contact numbers for County Council departments and services. It also contains numbers for district council offices. If this publication does not reach every person, it potentially reaches most, but questions could be asked to test how effective this means of reaching people is, such as:

      · Does HN reach all of the households it is intended for?

      · If it does not, who does it `reach' and which age bands or groups does it not?

      · How is successful distribution monitored?

      · Does every person in a household read HN?

      · What is the target audience in terms of age, sex and background?

      · How is readership monitored?

      · Assuming some age bands and backgrounds are not interested, what alternative approaches are used to `reach' these people?

      · Do the contact numbers provided actually meet the needs of Hampshire residents?

      · Is the contact number list comprehensive enough? and

      · Do readers know from the list who they actually need to speak to?

    Groups such as the homeless and some travellers and gypsies may not have addresses, and not receive copies of HN. In addition to these questions there may be barriers to the effectiveness of written publications, such as where people have visual impairment, learning disability, or poor literacy skills. (Do areas of deprivation have higher than average levels of illiteracy?)

    It should be questioned whether by taking the perspective of a local authority to providing residents with information, it is possible that the perspectives of residents are forgotten. It could be argued that residents should not have to know what layer or agency of government provides specific local services, and that it would be better for information about services to contain clear contact details for county, district and parish provided services, and probably all locally provided central government services too. In the spirit of partnership it should be possible to add NHS and all third sector service providers in order to complete the range of resources available to the people who might need them.

    Current County Council activity: Departmental initiatives

    Most departments employ one or more equalities leads who have a role in explaining (usually to ethnic minority groups) the role of Hampshire County Council and how its services may be accessed. They are also able to feed back to departments any issues that affect access to services.

    Developing networks of relationships can be time consuming, and local initiatives also take time to take forward. Potential questions that could be asked about this more personal approach to `reaching' people might include:

      · How many equalities leads does each department have?

      · What groups or communities tend to be targeted by leads?

      · What groups tend not to be targeted?

      · What priorities are set, given the wide distribution of groups across the county?

      · What are the limitations of departmental leads in terms of the proportion of members of different groups that can be reached in this way?

      · What strategies are used to communicate with groups who may not be as well served by HN as the general population, because of language or cultural barriers?

      · How is the work or success of departmental leads communicated to the `centre' in terms of who is being influenced and what is being achieved?

      · Who consolidates this work to present an overall picture of the whole?

    In many publications the term `minority groups' includes older people and young people. It could be disputed whether these are really minorities, but the CC and other agencies specifically target resources and services for these groups. The issue is which people are nevertheless still `hard to reach' according to the practical definition adopted in this briefing paper.

Definition: part b) People who are unable to take advantage of services provided by HCC or its partners

Geography plays a significant part in how well people are served by HCC or its partners. The major distinction is between rural and urban areas where the challenges differ considerably.

    Rural areas

    Rural areas are, almost by definition, characterised by small numbers or clusters of households distributed across otherwise relatively sparsely populated areas. The Socio-Economic Profile of Rural Hampshire developed by the Spatial Strategy Group draws attention to some of the key characteristics that can contribute to some people in rural communities being `hard to reach', not just by the County Council but by any providers of services in those areas.

    The people who are unable to take advantage of services may be unable to do so because:

      · The services are not provided at all in the locality

      · The services are not accessible by public transport

      Or

      · The services are provided, but infrequently, or not to the same level as those provided in most urban areas

    Limitations to service delivery in rural areas are normally due to affordability. The Secta: partners for change report, `Review of Evidence on Additional Costs of Delivering Services to Rural Communities' (2004) concludes that there are "...three potential reasons why the cost of delivering services per capita of needs-weighted population may vary between urban and rural areas..." The report cites:

      · Mileage costs

      · Time-related costs, and

      · Economies of scale tend to be lower

    Reducing the additional mileage and time-related costs, and improving the economies of scale do, and will require innovative thinking, exploiting opportunities for creative and efficient partnership working, such as reducing the number separate visits from partner organisations or even individual services within single organisations. The Rural Delivery Strategy draft contemplates possible responses such as developing service centres and local hubs which may help reduce the degree of isolation from services for some rural residents.

    The Outline Framework for a Rural Delivery Strategy (2008) also recognises the above concerns when is notes that, "...The socio-economic profile and appendices to this report touch on what these differences might be (such as the dispersed nature of deprivation in rural areas, isolation, poor accessibility, higher costs in service delivery, older age structure, problems in recruiting staff and in the importance of voluntary networks)".

    None of these observations is new, but `business as usual' cannot be an option if the hard to reach in rural communities are to receive more equitable access to HCC and partner-provided services that are appropriate to their needs. One of the important issues is the invisibility of those who need the services that they are currently not accessing. As the Hampshire profile document suggests, "...The general perception of rural Hampshire is that of prosperity..." and it goes on to say that in general it may be true. However the Commission for Rural Communities identified that ... "Many older homeowners are asset rich but income poor". Such households can blend into the affluent landscape which may effectively mask their real needs. Further information/research is required to identify who the hidden `hard to reach' people are in rural communities, and where they are.

    Potential questions might include:

      · Is it possible to identify all `hidden' potential users of services in rural areas?

      · Is there potential to share relevant information between provider organisations if permitted by recipients?

      · Do all potential service recipients want to be identified?

      · What potential exists to establish volunteer (?) local residents to watch out for the vulnerable in the community?

      · What minimum activities ought to be carried out in order to best identify the level of need in rural areas?

      · What minimum activities ought to be carried out in order to best establish which people or households are most in need of which services?

    Additional questions must exist around what responsibility, if any, local authorities NHS or other service providers have to proactively seek out those who might need their services? To locate all potential services users in a large county creates a major challenge, however because people's circumstances and health can change very quickly, usually in one direction, innovative solutions will be needed to address what is going to be an always moving target.

    Urban areas

    People in urban areas who are unable to access services provided by the County Council or its partners, may not access services for various reasons, such as:

      · The service sought may not be available when needed

      · The resident may be housebound, have a disability, or have caring responsibilities that prevent access to a service

      · The resident may not be entitled to the service, or the resident may think he/she is not entitled to it

      · The resident may have religious or cultural reasons for not accessing the service

      · The resident may feel pressured by his/her community or significant others not to access the service

    Services not available when needed

    Residents may find it difficult to access some services if they are not accessible at times when the person can use them, or needs to use them. Examples of this could be library or GP surgery opening times, both of which have recently begun to extend their hours in some areas.

    Access to services in urban areas is less likely to be because the services are not available to the local population, although some out-of-hours health services, for example, are not consistently available in all areas.

    Natural conditions that prevent use of services

    The reasons for not being able to access services are assumed in this case to be things that prevent residents accessing them. People from a number of minority groups may have access to an association or organisation that could represent them, either finding a way to achieve the desired outcome, or a way to lobby for better access, for example, Age Concern, or the Royal National Institute for the Blind.

    Not qualifying for services

    Some people, including the homeless, may not meet criteria that would entitle them to a service. The lack of an address would be a typical example for homeless people, but many services are provided on the basis of eligibility criteria. Other services may be free, but still require an address or complex paperwork to be completed. The latter may put off some residents. In areas of deprivation higher levels of illiteracy may disadvantage people who might otherwise use needed services.

    Cultural/religious taboos

    Ethnic minorities, on cultural or religious grounds may find it all but impossible to use personal social care services and some health services unless alternatives can be found. In some places the 3rd sector is able to provide alternative solutions, sometimes with grant support.

    The role of community support workers and equalities leads in local authority and health organisations tend to work primarily in urban contexts where the higher numbers of non-service using residents justify the allocation of such resources to improve access possibilities for such groups, even though the above reasons can be relevant to urban or rural areas.

    3rd sector voluntary organisations representing those with specific difficulties of access are important partners in helping statutory authorities to achieve their commitments to their public.

    Disadvantaged or deprived people in rural locations, "...do not show up as living in a deprived area..." whilst, "The small concentrations of deprivation in Hampshire... occur entirely within urban areas." (Hampshire Profile) Because of the differences in the reasons for people not using services in rural and urban areas as well as the contextual differences between the rural sparsity and urban density of population, it suggests that appropriate solutions will be distinctively different. Both, however, will require more effective and intelligent holistic initiatives to be developed with partner agencies.

    Potential questions that could be asked include:

      · What services may not be available when people want to access them - what evidence exists, or would need to be provided to test this?

      · How many and what residents, where, may be prevented from using services by their own `natural conditions'?

      · How could evidence for the above be produced, if it is not already?

      · What evidence exists that would indicate how many people in Hampshire may not meet criteria that would entitle them to a service - and how many people would this affect?

      · What types of cultural/religious grounds may be a barrier to the use of services and which communities (and how many people) are affected?

      · How many people in areas of deprivation might be defined as `hard to reach' (as defined in this briefing note)?

    Transition from a culture of standard, one size fits all, to the delivery of services to one that puts `choice' and `customer service' as priorities, and at the same time recognises the practical necessity of targeting resources and targeting where need is greatest, is both key to achieving HCC's corporate priorities, but must also be subject to negotiating bars to access of services. Preventing potential users of services by inappropriate criteria may defeat the promise of the service to improve people's wellbeing or quality of place.

Definition: part c) People who are reluctant to take advantage of services provided by HCC or its partners

By suggesting that some `hard to reach' people are reluctant to take advantage of services, it implies that some residents may exercise a personal choice, possibly because accessing a service may:

      · In some way bring negative consequences (means assessment?)

      · Decrease a person's sense of self worth (education reinforce lack of ability)

      · Challenge community values/norms

    Negative consequences

    There is reason to think that some `hard to reach' people may resist services if they believe they may be worse off by accessing them. Various pieces of research indicate the negative reactions by older people to the consequences of `means testing' when considering residential care, "...The idea of being forced to sell their home to pay for care caused great distress amongst some people. This was partly because they had hoped to leave it to their children as their largest financial resource. For many it also represented an asset which they had worked hard to achieve..." (Meeting the cost of continuing care: public views and perceptions, Joseph Rowntree Foundation, 1996).

    Fear of their finances becoming known to the `system' may be a disincentive for people to access services for which they have to be means tested.

    Sense of self worth

    Some services provided by HCC or its partners that deliver community services, may be perceived as an opportunity for some residents to reveal lack of skills or abilities rather than an opportunity to develop skills. Reading programmes or other programmes to improve skills or qualifications may be viewed by some people with fear or concern that they might fail or drop out if their past educational experiences have not been positive. The gap between where they are and where they might like to be may seem too wide a chasm. Reinforcing negative experience and low self esteem (measured against wider society) may seem a real risk.

    For those in areas of multiple deprivation, and particularly where generations repeat the experience of past generations, the measures of success or good self worth within those communities may have become distinctively different from in the larger community.

    Community values or norms

    Communities are in part defined by their common values or norms. If services provided by HCC or partners in community provision do not reflect local values, or seem to be at variance from them, pressure, direct or indirect, may be exerted by the community on those who otherwise might wish to take advantage of services. In deprived communities, for example, it is not uncommon for health to be poorer. Smoking cessation and healthy eating services provided in communities appear to be consistently resisted. There may be a number of reasons that contribute to the slow progress of public health campaigns, but it is feasible that core aspects of local culture or peer pressure may influence local choice and take up of available services.

Potential questions that could be asked:

    · If some households/residents are afraid of the negative consequences if they consider accessing HCC or other available services, should the CC, possibly with other services providers consider alternative options to address this issue?

    · How many people, and for which services might negative consequences be an issue?

    · What local research or engagement has been, or might be undertaken to test the extent, or not, of whether a sense of self worth is an issue in accessing services?

    · What alternative approaches to encouraging people to access services and health programmes are being trialled where local values or norms do not support such intervention?

    All assumptions about who are not accessing either HCC services or those provided by other service providers should be tested. It is also important to get to the bottom of why some households or individuals either do not, or feel unable to access them. It seems clear that achieving the priorities of individual organisations, is likely to be dependent upon good, effective, partnership approaches and not solely on each organisation working solo.

Summary

This briefing provides a simple, practical definition of what `hard to reach' might mean for the County Council and others providing services to the people of Hampshire. Hard to reach is defined as people who:

    a. are unaware of services provided by HCC or its partners, or

    b. are unable to take advantage of services provided by HCC or its partners, or

    c. are reluctant to take advantage of services provided by HCC or its partners.

The criteria are practical, but any assumptions would need to be tested against evidence, or by acquiring appropriate evidence.

Each section of the paper concludes with a set of possible questions that could be asked of departments, or partner stakeholders who deliver services to Hampshire residents.

The top level analysis that underlies this briefing suggests that the challenges to improve access to services in rural areas are fundamentally different to those in urban areas, requiring different strategies.

The rural issues appear to be predominantly about how to deliver a higher level of service amongst relatively small communities spread across the county - efficiently and effectively (ie. organisational efficiency). In addition little information is known about the `hidden' hard to reach people in those areas - either who they are, or where they are.

The hard to reach in urban areas, by contrast tend to be characterised primarily by concentrations of deprivation, or some minority groups. Whilst availability of services in urban areas is greater than in rural areas, there are still, nevertheless, many hidden people who do not access services that they might benefit from. Urban challenges appear to suggest cultural and longer term solutions are required that mean working with the communities to jointly find ways forward to which all stakeholders can commit themselves.

It is suggested that some, particularly older people, may resist accessing services if they fear the potential consequences of means testing. Others too, may have reasons for not wanting to access services provided by HCC or other organisations.

It is difficult to get a clear picture either of the extent of the challenges of `hard to reach' in rural or urban areas, or of where and what work is being done or planned across the county. No means appears to exist to consolidate this kind of information within HCC, but especially in this era of greater partnership working it would make far more sense to map all that is known of these issues for all statutory and 3rd sector partners across Hampshire.

The `hidden' residents in rural and urban areas, are just that, they are unknown to services providers. Furthermore there is an element of the problem being driven from a statistical assumption that these hidden people exist. They may exist and be in real need, but as the set of possible solutions increases, the possibility of tailoring or personalising services to meet individuals' needs may potentially include increased use of local and voluntary resources. Communities may need to be supported to help provide their own solutions?

*** what new information is required to assist HCC & partners to address this? ***

*** effective partnership working is going to be key to HCC realising its priorities in terms of `maximising wellbeing' and `enhancing our quality of place' ***

*** if services have very long waiting lists, residents may refrain from attempting access because they think it is a waste of time ***

*** in rural areas the keys are knowing who and where those in most need are, and the solution is mostly around finding organisational efficiencies IF access to services is to be improved - In urban areas the keys are recognising that not all `minorities' are excluded from using services, but those minority member who do need services, are recognised and that unnecessary barriers are overcome to improve access and resident experience ***

*** do not forget migrant workers and young families in rural areas ***