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Lancashire Fairness Commission: Synthesis of evidence
Introduction
Lancashire has some of the wealthiest and some of the poorest communities in the country which can mask poverty. There is good evidence that links health inequalities to social inequalities, thus fairness is about more than distribution of assets but instead how long and how well people can expect to live.
“...the distribution of health and well-being needs to be understood in relation to a range of factors that interact in complex ways. These factors include whether you live in a decent house .”1
Lack of fairness is compounded because individual services cannot address all problems in people’s lives. Currently the plethora of services aimed at particular need is hard to reach by many because they either do not know about them or do not qualify for support. Joined up approaches that make the most of overlap in provision can more fairly provide the social support that is needed to challenge the serious effects of austerity.
This synthesis has been compiled following thematic analysis of all the evidence provided to the Fairness Commission which includes responses to the online survey, presentations to the Commission by members of the public and expert opinion. These provide a rich data set that adds the human perspective to the more traditional data already available about social and health inequalities in Lancashire. In doing so it provides rigour and thus more valid approaches to tackling complex problems.
The overarching themes presented in this synthesis are complementary to the Marmot Review’s ‘Fair Society, Healthy Lives’ recommendations (2010), commissioned by Labour and implemented with cross party approval by the Coalition. The objectives were to: Give every child the best start in life; Enable all children, young people and adults to maximise their capabilities and have control over their lives; Create fair employment and good work for all; Ensure healthy standard of living for all; Create and develop healthy and sustainable places and communities; Strengthen the role and impact of ill health prevention. Key themes within this policy included the need to move beyond economic growth to well-being and to recognise the cost of inaction on inequality to the economy. Evidence from past economic downturns also suggests that inequalities will widen and the evidence presented appears to support this.
It is also clear that some issues and how they may be addressed span the life journey and attention to planning for this journey rather than a set of separate circumstances could be a positive way forward. As such the first section on Starting Well is important because it sets the values through which people’s needs will be addressed and the legacy that will affect living well and ageing well in the future.
Key issues include:
• Negative effects of labelling (qualifying criteria) used to judge whether people are eligible for services and estimate levels of provision required • Disconnect between services and splintered approach • Lack of universal services to address low income 2
Key messages for fairness include:
• The importance of social support and building capacities for participation • Co-operative approach to jobs and the economy • Asset building • Inclusion • Proportionate universalism • Education about the life-course • Fair access to knowledge, advice and support across the life-course
Starting Well
1. Impact of Austerity In 2012, 25 wards (9.7%) in Lancashire were in the top 10% nationally for child poverty rate, and in Burnley 80% of wards are worse than the Lancashire and England average. Digmoor ward, in West Lancashire, had the highest percentage of children living in poverty (42.5%). Austerity has hit low income families with children hard. Efforts to reduce the numbers of children living in poverty had reversed by 2011 and the ‘Due North’2 report suggests that there may be 3.5 million children living in absolute poverty by 2020. Work has ceased to become a sufficient solution to poverty for families with children. Two thirds of poor children live in working households. Overall across tax and service expenditure, the poorest families face cuts of around 8-9% of income, more than double the 3-4% cuts for the wealthiest families. As these families also need to spend more of their income on essentials (over half for the poorest couple families compared to 20% in the more affluent couple families) the impact of austerity is much harder. 30% of low and modest income families said they had nothing left to cut back on. Over a third of parents on low and modest incomes fear their money worries are having an impact on their children.3
The effects of austerity on nutrition are marked by the rise in people accessing food banks and a fall in people’s actual spending on food. Children from poor families are less likely to eat fresh fruit and vegetables.
There is not enough affordable and suitable housing for those claiming benefits and on low incomes. There is a direct relationship between poor housing, health and educational achievement, reducing children’s life chances. Austerity has compounded these negative effects:
Test scores from the Millennium Cohort Survey showed that children aged five in the poorest 20% of the income distribution were already 16.3 months behind those children in the top 20% of the income distribution
Currently policy judges children by the situation of their parents and not by their inherent vulnerability as children. This is unfair as children have no control as to their own situation. A few comments received by the Commission suggest that children are being considered as the property of parents who should only have children if they can afford them. The UK ratified the United Nations Convention on the Rights of the Child (CRC)4 in 1991 and it came into force in 1992. The CRC recognises children and families as fundamental to society and in need of special safeguards that as a Nation we have promised to implement. This is significant because changes to benefits, particularly the reduction in tax credit, suggest a move away from state responsibility for children experiencing poverty and deprivation to parents. 3
The focus on getting parents into paid work may also have a similar negative effect on attitudes to children and families. Attempts to reduce the numbers of children experiencing poverty have focused on increasing parental wealth and this wealth is now reduced through austerity. This has placed stress on family life in modest income as well as low income families as they try to budget around the rising cost of living. Parents who responded to the Commission’s survey reported ‘struggling for money’ and a fall in living standards including buying less fresh food, clothing, luxury items, holidays, and less access to free time activities. Access to and cost of transport and access to free facilities is dependent on where people live. There is also stress on families as parents travel further and longer to work, and through the high cost of childcare.
Austerity measures however mean that low income families are less likely to send their children to a formal childcare setting other than for the nationally funded available hours. This could accelerate the inequality in children's outcomes where good educational childcare is available. But only good quality childcare increases educational outcomes. The Nutbrown Review5 recommended that those working in childcare should be qualified to at least level 3 and that at least 30% of staff should be qualified to level 6 (Degree level). The real problem is the focus of education itself. The CRC (Article 29:1a) states that education should be ‘directed to the development of the child’s personality, talents and mental and physical abilities to their fullest potential.’ 4 A report by the Centre Forum6 suggests that government should be clearer about the purpose of childcare and also more explicit about what it is trying to do and the outcomes achieved.
It is evident that inequalities lead to significant differences in children’s development. The effects on language development are pronounced (with estimates that children from low- income families are likely to have heard around 30 million fewer words, on average, than their peers from better-off families by age 3). Emphasis on out of home childcare undermines the importance of the home learning environment and the need for more support for parents to develop this.6 Care should be taken in responses to the measurements used for assessment of children and children’s services. There is very little measurement of the social value that childcare facilities, Early Years Education and Schools provide. Tremendous effort to improve children’s lives in areas of deprivation can be unfairly masked by failure to meet the educational outcomes required by Ofsted. The standard 5 GCSEs at grade C or above may show differences in attainment and may highlight differences due to living in poverty but they do not show how much a child has flourished or what barriers they have had to overcome. They also do not show how well prepared young people are to live as adults or participate in society. Clearly families need fairer access to information to make choices about work and childcare.
Children and young people are judged continually and they feel this. Submissions from young people suggest that negative images such as gang culture are unjust and unrepresentative and they would like the chance to be more involved in society as well as be better recognised by their elders. Evidence of children and young people’s views were limited and needs further research. Evidence from the ‘Our Life’ films may address this gap. Where relevant, examples of children and young people’s work are provided where they could be a useful addition to the Commissions evidence.
2. Support to Build a Better Future Fairness can only be addressed by improving social support and participation as well as physical needs. Participation means inclusion and opportunities to be part of society at all levels from individual, to family, to community and through civil democratic structures. This is not the same as consultation; participation encourages people to develop the qualities necessary for self-determination and to build a better future co-operatively and with respect for others. 4
This starts in childhood and is an important part of the CRC that can be overlooked when services seek to intervene in children’s lives by interventions done ‘to’ them rather than ‘with’ them. The Lancashire Children’s Plan has adopted the CRC and how it describes the three main strands is useful for determining services:
- use maximum available resources, support and respect parents and families, ensure children’s survival and development, provide best possible health care, education,• Provision welfare support and play.
tection - non-discrimination, promotion of children’s best interests and well-being, separation from parents only where in child’s best interests. • Pro - right to birth registration, name and nationality, right to express a view and have it taken into account; freedom of expression.”7 • Participation Lancashire Cultural Services prioritises the social support that children and families need to develop literacy and life skills before accessing academic and technical qualifications in a way that is consistent with this and there is good evidence to support such work:
A child taken to the library on a monthly basis from ages three to five is two and a half months ahead an equivalent child at age five who do not visit the library regularly. (The Reading Agency)
There are already 85,368 library members who are aged 12 and under. Further work could be done to increase this number. The service is also a good example of an across the lifespan service who already have good links with secondary schools, which could be utilised to address young people’s ideas about intergenerational work. They also provide parent and child sessions that could be further enhanced through the kind of partnership working that is discussed later in this synthesis. There is also good evidence for the positive benefits of family literacy programmes including increased parental access to education and involvement in their children’s schools.8
Lack of educational achievement by children and young people is seriously affected by low income and deprivation but that it is also more complex than this in that it is also about adult response (or lack of it) to children and young people’s aspirations and lack of social support. Children in more affluent families are more likely to have the kind of social support and experience that enhance education and participation. In other words, better inclusion. Austerity is working to take such support away from more children and deepen exclusion:
Having less money makes it harder to provide your child with the things that make a difference to improving their life chances, such as paying for sports clubs and music lessons at school – although things like gyminies at Fulwood Leisure Centre are cheap and helpful, it can be challenging finding affordable things to do with your child, particularly in the holidays.
Whilst some areas provide free services and activities, this is dependent on where families live:
Cannot get as much with children as things are so expensive. Free things in our area are too far way and costs money to get there.
Just had less money to spend on free time activities. Blackburn has a good scheme of free or reduced tariff family activities.
Young people recognise that bridging the gap between generations may be the way forward with suggestions such as ‘showcasing talent’ made to the Commission as well as ‘motivational 5
classes’ which would all involve intergenerational work. Concerns expressed to the Commission by adults may suggest that young people need more local activities such as:
Not enough to do for teenagers, apart from hanging round on the street, as in our area we have More Music which runs on a Friday night only and term time only. Not much else to do.
However, evidence from Young People suggests instead that it may be adults who are less comfortable with teenagers ‘hanging around’ and that instead they are happy to entertain themselves. Young people want access to meaningful activities. An image of a bin holding paper represented wasted ideas that were never acted upon, in some artwork completed by young people in Leyland and Lostock Hall. Young people have ideas and aspirations but they are not provided with the support to develop these.
Volunteering, work experience and apprenticeships offer ways to develop young people’s assets but there must be enough opportunities available to enable young people to make the most of their talents and choose suitable paths that interest them. Further evidence is needed to examine where apprenticeships are being offered and who they are benefiting. Programmes such as ‘Work Start’ suggest that the adults who offer these opportunities must be prepared to make the considerable effort that may be needed to support young people. Young people may also need support with transport to access such opportunities. Programmes such as the National Citizen Service are available to all young people aged 16 and 17 but the cost of these may prevent access by those from families with low incomes. Further evidence is needed to address where unfairness is happening in young people’s lives. Clearly young people need both the means and the opportunity to raise aspirations. Most companies are only paying the minimum apprenticeship wage (£2.72) and it is not possible to live on this or the under age 20 minimum wage (£5.13). If young people are to value such work, the value of such work must be recognised by adults.
There are economic as well as social arguments for investing in young people and childhood.
The Family Nurse Partnership estimated savings five times greater than the cost of the programme in the form of reduced welfare and criminal justice expenditures; higher tax revenues and improved physical and mental health. (DCSF, 2007).
3. Physical Health The effects of austerity on access to good food and nutrition have been evidenced to the Commission through data about the increase in people accessing food banks and through comments received. Cuts in benefits, benefit sanctions and low income mean that families are struggling to budget for essentials such as housing, fuel and food and this extends upwards to families on moderate income. Families considered to be better off are asking for more help:
Cost of living means I can’t afford to buy a variety of foods
Lost child tax credit – [would like] free school meals in KS2
Due North2 suggests that children who are not well nourished, living in poverty are less likely to do well at school. This begins before birth with the nutrition of pregnant women. Whilst some supplements are being provided for pregnant women and children, there was little evidence to show the impact of austerity on nutrition in pregnancy and particularly whether pregnant women are accessing food banks and what is being done to counter this. Lancashire is still under average for numbers breast feeding for 4-6 weeks but training is ongoing and East and 6
Central Lancashire have now achieved Stage 1 of the Baby Friendly Initiative and are working toward Stage 2 with assessment due shortly.
Whilst schools continue to provide a piece of fruit for infant age children and school dinners must include a portion of fruit and vegetables, this does not mean that children access these meals. The introduction of free meals to all infant age children provides potential for further uptake but this could be supported further in schools by attention to the social aspects of mealtimes. Preston Schools Council produced a Charter outlining the social structures that they would like to change at lunchtimes following their own research in seven Primary schools during 2013/14.
Inequalities also exist in the weight of children (measured through the National Child Measurement Programme 2012/13) with some Lancashire districts above the National average for obesity. Good nutrition and exercise both play a part in tackling this. In England only 51% of children reach the daily guidelines for physical activity (All-Party Commission on Physical Activity, 2014).
This highlights the importance of looking across the life-course for possible solutions to problems. Lancashire has many open spaces and these can be put to good use by all ages. South Ribble has over 468 open spaces with 60 classed as parks. Continued investment and innovative intergenerational volunteer projects, increases use and maintenance of such spaces. Other areas in Lancashire should have the same access to green spaces. In Bristol the City Council have an ‘accessible green space standard’. All children are entitled to play spaces within 10 minutes walk from their homes.
East Lancashire has some of the highest rates of dental caries in the country but schemes in place to tackle this are reducing the numbers. Smile4Life is being operated across Lancashire.
Those experiencing housing difficulties and homelessness are adversely affected.
Homeless children are three times more likely to be absent from school than other children and have lower levels of academic achievement that cannot be explained by differences in their levels of ability. Homeless children are particularly disadvantaged because of disruption to their schooling caused by homelessness.
Whilst the evidence of ‘the housing affect’ is clear there is very little attention to this in policy.
The Marmot Review1 argues that tackling health inequalities involves tackling social inequalities. Suggestions to improve unfairness are around better sharing of information and partnership working, for example between Lancashire children’s services and housing services. However a splintered approach to provision that is reliant on targeting only areas classed as having the greatest need means that problems can be left to develop in better off areas. An example of this is teenage conception rates which are falling across Lancashire; pockets exist which are well above the England average and cannot be explained by poverty in our more affluent boroughs such as South Ribble.
The School Health Needs assessment and action planning process implemented by the Health Improvement Service and the Children and Family Health Services was set up to meet a gap in data assessing the health and well-being of school age children. It is being used to inform school health teams East and Central Lancashire and increase children’s participation and supports delivery of the governments Healthy School Programme for 5-19 year olds. More children and young people have been able to directly request support from school nurses highlighting the need for such support.
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4. Mental Health and Well-being Around 60% of looked-after children and young people have emotional and mental health problems and a high proportion experience poor educational, health and social outcomes after leaving care. One-third of children and young people in contact with the criminal justice system have been looked after.
Children in poor families are nearly three times more likely to suffer mental health problems than those in high-income families.
Submissions to the Commission also stress the need to build resilience in children and young people. Barnado’s suggest a dynamic view of resilience and that it arises from multiple interactions and influences on children’s lives at individual, family and community level as well as through broader physical and social environments. By taking an asset focused approach to practice such as through nutrition programmes, one to one tutoring and healthcare, resilience could be increased. Tackling poverty may help to improve children’s resilience. But resilience is also built by experience of processes that make:
“efforts to enhance children’s self efficacy and self-worth by providing opportunities for successful mastery of experiences, and programmes that teach children better self- regulation skills for controlling their attention, emotions and behaviour.” 9
An asset based approach rejects the idea of victims and labelling people as just vulnerable and instead recognises people’s survival of challenging situations and capacities to resist those who will harm. In this way resilience is about relationships and how these are negotiated on a daily basis. Provision of services for all children rather than just those who can be grouped into special groups by need or deficit, ensures that children are not unfairly missed when support is needed. This is especially important for mental health services and others that operate on qualification by age and severity of distress. Fifteen year olds who are not yet in crisis may be referred to adult mental health services because of delays in assessment and lack of available resources through CAMHS. This is compounded by lack of service knowledge about what alternative services are available in young people’s home or school areas when they have to travel a long way to be assessed. A situational approach to children and young people’s services could more fairly address both the lack of fair access to knowledge for children and young people and a better indication of where need lies.
An East Lancashire College is using this approach to good effect through the onsite school nursing team. The example shows how adverse experiences can remain undetected in children’s lives where they are not already in touch with services: a young person presenting challenging behaviour at the College eventually disclosed abuse to the college nurse. The nurse was able to develop a close relationship with the young person to help them develop emotional resilience and go on to access further education. The same college reported an impressive track record of help for its students including emotional support for anxiety and low mood, drug and alcohol concerns and support for sexual and physical health. Looked after children were identified and offered on-going support. The college has also provided breakfast for 679 students to combat food poverty and one to one sessions for personal advice and emotional support. Currently this level of advice and support varies in colleges and schools which is unfair.
Other comments to the Commission support the need for building life skills alongside awareness of key issues such as drugs, sexual health, alcohol, and positive mental health. Children and young people have a right to the best health education, advice and services that a state can provide and it would appear that this is not being implemented throughout Lancashire. 8
5. Raising Aspirations and Opportunities Currently a punitive approach dominates attitudes to families and children in policy and services. Children are labelled deficit because they underachieve or because they fail to behave in the way that adults would like or engage with services. This approach can appear disrespectful to children and their families and may also encourage ‘social desirability bias’.10 In other words if telling someone that you are not managing means that they will judge you as incompetent, it may affect what is disclosed and limit children and families access to the support that they need. Most services for children are not universal but based on measures of need. Hence those considered most vulnerable. However this will always mean that some children and families do not get support when they need it which is unfair. A universal approach to provide children’s and family services using a children’s rights approach that recognises that no child should have their rights taken away, regardless of their family background or income, provides a more positive route toward fairness than the deficit model. Universal services that integrate Early Years Education, Childcare and Neighbourhood support breaks the link between poverty and children’s life chances.2
Children’s Centres already provide a central resource in each area but budgets available to councils to fund children’s centres have fallen by 36% (£0.9 million) since 2010.10 There is a lack of evidence about the quality of childcare available and its subsequent link to better outcomes. Children’s Centres were set up to follow a model of proportionate universalism so that services are available to all children and families with focused services where these do not work. Funding available should return the focus to services that reach all families rather than providing an extension of free childcare places to 2 year olds. Families should have more information so that those in the most deprived areas can access the best childcare and other opportunities available and help to travel where these are not already located in these communities, thus strengthening resilience and supporting participation by more people.
Part of this is the influence of significant others in the life journey. Thus in the Early Years the importance of a key worker for children is present in policy and the assessment of services. However this does not extend through the life journey. Parents are important in providing such relationships and focus on the whole family, when appropriate is good practice. However other adults are also important in raising aspirations and significant in providing opportunities to build resilience. For example, the college nurse in East Lancashire provides a good example of the sort of human practice that focuses on young people’s health and well-being. It also illustrates the impact that such relationships can have on children’s aspirations and in negotiating difficult decisions:
A 16yr old student found out she was in the early stages of pregnancy whilst in her first year of college. With support from the college nurse and curriculum team she successfully completed the level 2 programme. However, though the student wanted to continue to a level 3 programme there were concerns that with the rigour of the programme and looking after a young baby that this could be too much. The college nurse advocated on her behalf and continued with 1:1 support throughout. The student became a committed member of the peer educator group in her second year, developing a range of high level skills. She left college in 2012 to take up her place at university studying adult nursing. She continues to be successful and focussed.
6. Multiple Issues, Joined Up Approaches The evidence submitted to the Commission highlights the need for joined up commissioning and better collaboration between services as well as the adoption of the 10-24 year life course period when considering children in line with the World Health Organisation and Chief Medical 9
Officer reports. It also suggests that through connected services the complexity of access could be reduced.
Some organisations already successfully tackle multiple issues through building people’s capacities to participate. In other words they build on people’s existing and developing assets as well as those of the organisation providing the service. The Football League Trust for example, inspires people using football to engage them and build on its four key themes of sport, education, inclusion and health to tackle social issues such as drug abuse and homelessness.
A life course and place based approach to services provides an example of good practice that recognises the complexity of people’s lives and the ongoing support that may be needed at all or different stages in life. A place based approach brings services to places that individuals and families already work in or have access to, such as schools, libraries, sports facilities and children’s centres.
Lancashire Cultural Services is a good example of this working with the Working Together With Families Team on an introduction to libraries, the love of reading and support and activities for families who would not traditionally think libraries are for them. Joining up such work with voluntary projects extends knowledge about what is available. Emphasis on the support of other related organisations and groups including the voluntary sector when commissioning services could further this sort of joined up work.
Across all the examples is a need to provide more access to knowledge and advice so that services and people can join up to ensure that people’s needs are more fairly met. This would aid commissioning, it would aid individual access to services and it could also provide more data on where unfairness really occurs.
Living Well
1. Impact of Austerity The median wage is 8% lower in Lancashire than the National average. There also continues to be a substantial difference between wages paid to males and those paid to females. The biggest impact of the welfare reform is the reduction in tax credits. This amounts to 1/3 of the total savings made by these reforms: £118,000,000 in Lancashire; in total 125,500 people will lose some or all of their tax credits. 125,000 of these are already in work.
The current emphasis on punitive measures for people not working is unfair and there is no evidence that it is working. Since the introduction of the new sanctions regime in 2012 for Employment Support Allowance (ESA) claimants there has been a rise in sanctions from 1,000 to 7,500 per month. Delays in benefit payments cause real distress and hardship to people:
A young jobseeker rang CaUNSS in crisis with no money and hungry. His benefit had been stopped after he had been hit by a car while cycling to a Jobcentre Plus appointment.
A pregnant young woman contacted CaUNSS for help. She had missed an Employment Support Allowance appointment, had her claim closed down and ended up sleeping in the goods entrance to a local supermarket in Burnley.
Comments received by the Commission spoke of unfairness in people’s attitudes to benefits claimants, especially those who are disabled. There was a sense from some that no-one cares about them, including the government. Austerity has placed strain on people’s finances and those in work have less available for non-essential items. However, research suggests that the 10
majority of people believe benefits are needed and are justified with 81% agreeing benefits are an important safety net and 64% that as a society we all benefit from their provision. The importance of benefits that support people to a decent standard of living is also exemplified by people living with disability. Where families cannot work because they need to care for disabled children, levels of benefit, the stigma attached to claiming benefits and the difficulty of re- entering the job market because of lack of suitable childcare, could indicate a lack of value placed on such care.11
There is also evidence that concern about benefit abuse portrayed by the media is unfounded with only 2.6% of benefits actually going to the unemployed, 42% going to pensioners and 21% the low paid. The UK spends relatively little compared to other European countries; 12% less per head than France and 19% less per head than Germany. People should have fair information about this to challenge negative reporting. UK housing costs are also the 3rd highest in Europe with 93% of housing benefit claims from working people.
There is concern at social isolation. This is discussed under Ageing Well but it is clear that it effects all ages and especially men in the 16-24 age range and those in middle age. Comments suggested that closure of local services such as shops in favour of supermarkets has also had an impact on this as people have less opportunity to informally meet other people.
People’s existing personal assets are being wasted as they take on work that they are overqualified for (around 22%)and through pressures on time as a result of long working hours and travel that stop them getting involved in the local community. People are also finding it difficult to get better paid jobs even when they try. Lack of funding for adults for courses beyond level 4 means that further education is unaffordable.
There is a suggestion that the numbers of jobs in intermediate and higher categories of pay will need to rise so that people in Lancashire can reach their full potential. However it is the lack of value placed on some work through low pay that continues to reinforce the idea that it is acceptable for some people to live in poverty. The gap between the minimum wage and the reality of a living wage further reinforces the idea that some jobs and the people that do these jobs do not deserve a reasonable standard of living.
There is some evidence that finance such as mortgages are less available. Inequalities still exist for women especially where they have split from a partner. However levels of debt are continuing to rise and much of this is associated with Pay Day lenders. For example Wonga who were criticised for not checking ability of customers to pay back what they borrow and for its roll over loans (17 in North Lancashire); their response was to increase rates from 4214% to 5583%.
Those in work are also reporting reduced workplace benefits and problems with zero hours contracts. Those accessing work through charities who try to provide a ‘second chance’ for those who have less chance of gaining work have found that the cost of transport to work can significantly reduce income to such an extent that employees are accessing food banks. People particularly challenged by barriers to work include members of the recovery community who may be stigmatised because of their past dependency and who are faced with multiple disadvantages associated with poverty and health and this is also linked to mental health problems.
The impact of low income has been exacerbated by the rising cost of energy and food bank organisers suggest a correlation between food and fuel poverty. It is estimated that over 30,000 food parcels were distributed in Lancashire during 2013. The main reasons why people are accessing food banks are benefit sanctions and delays and increasingly low income. 11
Their latest data (for 2013-14) reveals that ‘benefit delays’ (30.93%), ‘low income’ (20.29%), ‘benefit changes’ (16.97%) and ‘debt’ (7.85%) account for three quarters of all vouchers distributed in 2013-14.(Trussell Trust)
Current figures (from the Together Lancashire research) suggest that distribution of food parcels is continuing to increase.
Bedroom tax is causing problems especially for those with disabilities. The tax is forcing people into arrears (59%) with very few moving to smaller homes. Only 6% who are affected have moved to alternative social housing. There are now more empty larger properties.
Lack of suitable as well as affordable housing is also an issue:
I pay £425 a month to live in a house with electric convector heaters that cost a small fortune to run, to have damp in some rooms and to get poor service from my landlord. It would cost too much to move to be faced with more problems with houses and landlords.
Differences also occur in how councils are interpreting payment policy for council tax bills. Most people have to pay 20% from 2013, however this is not being applied across Lancashire (as well as other counties).
The barriers restricting individual and families to move out of poverty are complex but some councils remain committed to getting people into work as the most significant factor toward change in the right direction. However the evidence suggests that paid work with the minimum wage thresholds as they currently stand, is not moving families out of poverty and is also contributing to a reduction in their quality of life. More action will be necessary to encourage work as a positive route. However punitive measures to force parents into work are unfair and the evidence does not justify this approach.
The impact on health of low income and poverty are clearly set out in the Due North2 report and the Marmot Review.1 This legacy will be felt increasingly by Lancashire in years to come whether people are in paid work or not, unless action is taken to address poverty levels.
2. Support to Build a Better Future Economic growth does not automatically benefit those on lower incomes or those who live locally. It is quantity and quality of new jobs that does. When cities talk about economic growth they need to be aware of who exactly will benefit if unfairness is to be challenged. It is also important to keep the finance generated by new business in the local economy as this directly impacts on local people.
Co-operative businesses and organisations operate under a value system that prioritises participation and democracy as well as fairer business practice. Member ownership provides employees with an interest in the success of the business as well as good working conditions. This means that such businesses and systems directly benefit the local economy as profits are not taken elsewhere. Preston County Council is seeking to promote co-operative development through 3 initiatives:
The Guild Co-operative Network, which brings together members of existing and prospective cooperatives to provide mutual support and advice; Simply Buyout, which aims to promote employee buyouts of existing enterprises, especially from owners wishing to exit their business; and the Community Wealth Building Initiative, which directly follows the Cleveland Model in aiming to increase local purchasing by anchor institutions to support the formation of local cooperative enterprises. 12
The Preston Social forum is also campaigning to encourage residents to move their money and support alternative banks, building societies and credit unions. Other ways of keeping money circulating locally are local coinage to encourage people to spend locally. Sharing information about these initiatives across Lancashire would address fairness and provide all people and businesses with a chance to get involved, which is in line with co-operative values.
However, isolated attention to the economy will not address unfairness in people’s current lives especially where they are experiencing poverty and social exclusion. Ideas to build participation across Lancashire’s population rather than for those already accessing services were under- represented in the submissions. However, these may be more apparent in the community films.
People want more advice and knowledge about services and improving their situations. They also need access to facilities to be able to access this. Rossendale Borough Council’s mobile advice vehicle STAN (Services To A Neighbourhood) has proved very successful in providing this. However former partners in Ribble Valley and Pendle Borough Councils have discontinued the service due to cuts. The Citizenzone mobile outreach vehicle also provides ICT facilities for digital inclusion. More help and advice is needed to manage debt e.g. Stepchange who help people to sort out manageable payments. CAN Help brings together 13 local advice and support agencies within the Lancaster District to form a community advice network.
3. Physical Health Access to knowledge and advice remains the underlying theme for fairness in health. A good example is the growth of Shisha cafes that are popular because young people from BME (Black, Minority and Ethnic) communities have limited opportunities to socialise. But this conflicts with the negative health impact that smoking may have and the possibility that such cafes may be contravening smoking laws. A punitive approach would be to challenge these providers. However, health information and advice may be better in protecting these young people’s rights to meet and also to build participation.
Whilst food banks are meeting the immediate needs of many people experiencing poverty alternative strategies could be identified to avoid them becoming a long-term solution. Some examples were submitted such as an organisation in East Lancashire that runs a food bank and a community cafe and provides free and low cost meals. A countywide Food Strategy has also been suggested as a way of tackling food poverty. This would need to look beyond food banks to sustainability, healthy eating and education and a focus on fairness. The sustainable Food Lancashire Steering group could look at this model as it develops its activities. Fairer access to knowledge and advice about food banks and the referral system is also needed by individuals and services.
Preston City Council’s affordable housing policy means that 30% of new homes should be affordable in developments of over 15 dwellings. However this does not address the current problems that people are facing with private landlords who do not follow regulations. There was some suggestion that measures are being taken to challenge landlords who do not comply but clearly until there is a Lancashire wide effort to do this, people will continue to be trapped in unsuitable living conditions.
There was an indication that service providers do not always understand their human rights obligations and this can leave some groups more vulnerable. There may be a need for education about human rights and services responsibilities across services (including schools). There is evidence of some concern that inequalities still exist for BME Asian women and that Councils need to be more representative of such groups. 13
4. Mental Health and Well-being 40% of people seeking help from the Citizens Advice Bureau say they cannot cope and are in crisis. 25% are seeking treatment for mental health. Connect 4 Life report a distinct lack of bereavement services in Central Lancashire. The cost of metal health issues to England is estimated at £14 billion a year.
The impact of the benefits system itself on people’s health is now also under question. There is concern that punitive measures such as removal of benefits can ‘tip clients into depression’. Those with serious mental health problems that impede capacity to work cannot always access appropriate benefits. The more vulnerable are also less likely to access JSA/ESA because they lack confidence in their ability to tackle the system. There are calls for improved administration of benefits, which has been described as ‘unfit for purpose’.
Red Rose Recovery is an example of a successful initiative to raise aspiration through volunteering and provides opportunities that can lead to employment. It is connected to Lancashire User Forum which is an inclusive forum for people in treatment and their families and provides the support they need to get through recovery. This successful partnership means that those receiving recovery services also benefit through opportunities to build their own capacities for participation and benefit the service itself through the support to each other and input on future development. Access to positive role models who are willing to share their experience is one of the successes of this project. This is a useful model for commissioning services that will have impact not just on individuals but also on future society and demonstrates the power of building capacities for participation alongside meeting people’s health needs.
Changing services from interventions that are done to people to those that build participation and values presents a big cultural change in Lancashire. However it is clear from the submissions that this is already underway. Services are responding to requests for support to access services on a human level by helping people to communicate and build their personal skills. For example through job clubs offered by churches and libraries. The building recovery in communities’ officer in East Lancashire has worked with public health and members of the community to support social prescribing and overcome barriers to engagement in positive activities.
There is significant and growing evidence to the health benefits of good quality green spaces including increased longevity and improved mental health. Bristol City Council developed an accessible green space standard: the distance people should have to walk to access green space. This is 9 minutes walk and 18 minutes to natural spaces.12
5. Raising Aspirations and Opportunities The Living in Lancashire Survey13 found that the most common response to from participants on how Lancashire could be made a fairer place was to pay a living wage. This was followed by affordability of household bills and living accommodation. However it is clear that to gain the most impact from better living conditions, people also need fairer access to social support. Living well needs to include preparation for ageing well such as planning for suitable housing, retirement and knowledge about what will be available.
Current service provision across all ages targets certain groups or conditions. This excludes some people from services because they do not fit ‘neatly into a box’. There is some evidence that labelling of health conditions may in effect exclude others who may also have health and social care needs. This is particularly the case for long term health conditions such as mild to moderate mental illness. Lack of life-course attention to such people’s needs may also result in unfairness when people have to meet the criteria and join waiting lists for age defined services. 14
It also means that people struggle to find out what is available because there are so many different services and no entry point open to all. Capacities to access knowledge about such services is then impeded by lack of access to specialists who know about services, or access to information and the technology to access digital services and social isolation.
A West Lancashire resident summed up this complex issue in their comments:
I get no support at all from any agency. I've been physically and mentally disabled since being injured in combat in 1986, anything I've had like benefits I've had to find myself. My GP helped me once with bathroom accessories. I have no idea what agencies can help me, because organisations like local and county councils offer no help at all. And to be honest, they're a real hindrance. I'm now 58, in an electric wheelchair and waiting for an emergency move which has taken the WLBC 18 months so far. The move should be to a bungalow, but at this rate it'll be a pine box first.
Because I'm also hard of hearing, the telephone is useless and any web addresses I've tried tend to give me misleading information. If you don't fit into square box, and know the right people you get nothing in this country. And that's before Labour and Conservatives demonise you for being a disabled parasite, that's been going on with the help of the press for 15 years now. Lancashire is a bad place to live if you're getting older or disabled, I often call it Lancashi*e.
Universal services or proportionate universalism where services are offered to all with more specialised services available as an extension of these would work towards alleviating such problems.
Adult education is associated with improved social capital and connectiveness, health behaviours, skills and employment. All these have an effect on health. There is also some evidence that it has a direct positive effect on mental health.11 Investment in adult learning also has good returns on investment. Barriers include lack of access, confidence and finance. Those out of work are less likely to participate.
6. Multiple Issues Joined Up Approaches Co-operative business and systems bring individuals and smaller producers together to work more effectively and also so that they can compete with larger organisations. Local food and milk producers are already adopting this model. Sharing information would enable other groups to understand this approach and local institutions may be able to support this. Whilst no evidence was submitted to the Commission regarding schools, the co-operative model has also been adopted by schools with some success in other parts of the country which provides a fairer model for children and families as well as promoting their participation. Again sharing of information and research is essential if Lancashire residents and businesses are to have a fairer understanding of the opportunities and approaches available to them.
Partnership working may be difficult because institutional loyalties can obstruct this. However, a real effort to focus attention on what works and the values underpinning such services and projects shifts the emphasis to fairness and beyond meeting limited goals.
Preston city Council presented many examples of collaborative working and it is the sharing of such practice that may be most beneficial in acting on this commission. Other services such as the Red Rose Recovery (see above) demonstrate the positive benefits of services that look beyond corrective intervention to building capacities for future participation and it is this that is 15
key to joined up approaches that really put Lancashire’s people and future at the forefront of what is delivered.
However, the current emphasis on tackling deficit when it appears rather than prevention means that families may already be facing multiple complex needs and stigmatisation before services are offered. Lancashire Constabulary highlights the importance of ‘Early Action’ to reduce vulnerability and address members of the community with the most complex needs.
Alongside the work provided by specialist services are the self-funding and voluntary community groups that exist across Lancashire. This includes religious groups and spaces that not only matter to communities but also have assets including people who are often sensitive to local need. Some groups are very good at going out into communities and promoting ‘neighbourliness.’14 The formation of the Church Urban Fund’s Together Network is a good example of building upon assets through greater collaboration.
Ageing Well
1. Impact of Austerity Physical health is at risk from austerity, particularly the culture of ‘eating or heating’. Lack of resource is also leading to people not maintaining what they have, for example having boilers serviced. Age Concern has worked with Lancashire County Council and Preston City Council and South Ribble Borough Council initiatives to offer free checks and assistance to vulnerable older people.
Alongside risks the effects of austerity are the increasing needs of a growing ageing population. This includes dementia and the need for more services to support people with this and their families and carers.
Eligibility criteria have been tightened for the Fair Access to Care Services so many older people are no longer eligible. The North of England is not being able to support this through retention of business taxes as the benefits of the recovery are less than for those in the South. There is some evidence that less people are accessing day care provision because of austerity including closure of day care centres and increases in the cost of attending. More older people are requesting help to apply for financial support and for help to manage debt. Rates of Help Direct transactions are highest in Burnley, Pendle and Rossendale. Service delivery is higher for people in Ribble Valley than in Wyre and Fylde even though they have a similar economic and social profile.
Knowledge is a problem. Often people do not know what is available unless they are already accessing a service because of crisis or hospital attendance. Further to this, older people do not always have the communication necessary to access services such as transport to hospital and need support to do this.
Whilst older people prefer face to face contact, digital provision is a useful way for families to keep in touch. There was little indication of whether older adults have fair access to digital technologies or whether they have the knowledge about how these can support communication with families and the skills to use relevant applications. The increase in digital procedures in services is also disadvantaging those who do not have access to computers. The Promoting Independence Service is trying to address this; however clearly more use could be made of facilities already available. 16
Lack of planning and education about older age may mean that there will be increased problems as adults under retirement age reach this. There is currently a large difference between the median sum of property, physical and financial worth of those on higher incomes with private pensions in place (£160,000) and those without a private pension plan (£23,900). In 2010-2012 45% men and 49% of women did not have any private pension savings and there are variances in uptake depending on the type of work engaged in. There are also variances in pension tax credit across Lancashire’s districts.
Anecdotal evidence points to better subjective well-being in those who are economically better off in older age:
"I am happily married to a wonderful man. We both have health problems but have easy access to a doctor, plus we are fortunate enough to have private health insurance. I cannot think of anything other than getting younger, which is impossible, that would make our lives better."
However, caution must also be taken in considering today’s examples of lifestyle for older people as a good indicator for the next generation. The effects of changes to pension funds, contributions and the underperformance of private pensions that adults were encouraged to take out in the 1990s are still to be seen. Comments from today’s pensioners cannot be used as a guide to the future:
"We both paid into good pensions for all our lives. Now we are reaping the rewards."
2. Support to Build a Better Future The most common responses to the Living in Lancashire Survey12 to how Lancashire could be a fairer place to age well were more support to live at home, affordable bills and accommodation.
Age Concern Central Lancashire Community Support and Information Service is responding by supporting people to maximise their income by looking for better energy deals, insurance products and budgeting for household bills. The Promoting Independence Service is supporting older people to make appointments and arrange transport.
However support to continue living at home is also entwined with available health and social care services. Submissions suggest that better access to information for people is required and better communication by all involved. This means attention to the human elements of services available as well as maintenance of economic need through benefits.
3. Physical Health Dementia is an increasing problem in the UK. There are 835,927 people with dementia and this number is set to grow to over one million people by 2021.15 There are concerns about the level of diagnosis and available information to people who may have dementia in Lancashire. Screening may not always be offered to older residents (over 75) and some GPs lack awareness around diagnostic support in the community.
Across Lancashire numbers of residents registered as having dementia is highest in Lancaster, Wyre and Fylde. However the Alzheimer’s Society estimates of how many people are thought to actually have the condition show that diagnosis rates across Lancashire may be less than half of actual rates. Lancaster appears to be diagnosing more reliably but the scale of the actual 17
problem may be much higher. In Wyre if the diagnosis rate of 37-40% is correct then this may actually be the area with the most cases.
There is a need for dementia informed services and awareness across services and communities to improve diagnosis and provide a fair standard of life for those with the condition. This includes carers and families.
Many older people are engaging with Help Direct and there has been a very marked increase in numbers accessing the service and issues resolved.
One comment also raised the issue of the well known health risks associated with lead pipes that still connect many older properties in Lancashire to the water system. Whilst limited schemes were available to have these removed, home owners have to pay for the work on the property (i.e. under the house wall) which is not affordable for all.
4. Mental Health and Well-being The greatest numbers of people living alone are in the 75-85 age bracket. Many are women whose partner has died. People over 75 also experience the greatest levels of social isolation. Men are at greatest risk but but fewer men than women access services. Social isolation or loneliness increases with age but it is not an inevitable consequence of old age. It is driven by factors such as poor health and low income.16
Age UK have a ‘loneliness scale’ to help identify people and signpost them to support. Services should share knowledge about this. Age UK Lancashire has set up ‘Promoting Independence Service’ funded by Lancashire County Council with 21 groups across Central Lancashire which have grown very rapidly. However other services are reporting that there are not enough befriending services in Central Lancashire where people have long term health conditions and that criterion for entry to such services excludes some conditions. There are long waiting lists for services that are available (e.g. Silver Line is about 6 months). Age Concern has seen an increase in the numbers of people accessing their service due to low mood, bereavement or mental health problems. Around 62% receive emotional support from staff.
Social isolation is exacerbated by lack of transport particularly in rural areas. This was also suggested by responses to the survey.
"A bus service would help Arriva have recently withdrawn the 300 bus service passing through Shirdley Hill, leaving lots of elderly people totally isolated"
Bus routes that are not profitable are being withdrawn. This raises a question about the availability of free bus passes and payments made to bus companies where there are no services to use them. The effect is compounded when there are other needs to such as disability:
"I have a disabled bus pass but no bus services near to me, there used to be lots of busses but none I can get to now without having to walk nearly a mile."
Lack of transport also contributes to self-funding services not be able to run properly because they need people to attend to be able to afford to run. This is detrimental where friendships have already been made.
Service users report that they get great benefit from attending groups including learning new skills, and making friends. 18
Men over 50 appear to be experiencing more affect on their mental health and well-being with increases in social isolation reported and increases in suicide (measures recorded using the Warwick Edinburgh Scale for older men). For some men this is attributed to lack of paid work for several years , low self-esteem and negative attitudes to the future. There are inequalities in social support between people from different socio-economic groups with those from professional and managerial groups perceived to have better experiences.
Successful practice with men in tackling isolation and improving health includes opportunities for social activities such as walking football, walking rugby, Men in Sheds, Veterans Groups, cookery for men and men’s social groups. Men’s Sheds provided a ‘lifeline’ for early stage dementia sufferers and their families: “The fact of being wanted and of making a real contribution to something feels really important not just to the men, but also to their wives.
5. Raising Aspirations and Opportunities There is less evidence about the impact of austerity on LGB&T people or the sort of support they may need although they experience social pressures that differ greatly from heterosexual people. They are more likely to be single and many experience barriers to seeking help because they expect poor treatment or discrimination. Age Concern provides the ‘Older & Out’ service which prevents isolation and help to be more involved in the community. Training and awareness across services is important such as awareness training about LGB&T for care providers.
Factors associated with whether people seek help include lack of knowledge about services and what is available. This is pronounced in BME communities where concerns about whether day care are culturally sensitive have been raised as well as stigma among men about accessing such services. Language was also suggested as a barrier along with availability of transport. Women may be very isolated because of the reliance on male members of the household for information.
Good practice includes taking an asset based approach to members of vulnerable groups and supporting them to support others. For example, training men to be ‘Older Men’s Champions’ and provide support to groups and motivation for other men. Broader research also suggests that this sort of user involvement is beneficial.15
There was a suggestion that for day care to be more fairly accessible, it needs to be close by and cater more for individual needs. This should include bigger spaces for parties and physical activities. Central information hubs need to be created so that everything that is available is easily accessed and can then be more easily shared with those needing advice and services.
People not using Adult Social Care Services need more knowledge and advice about services and these need to be available in languages such as Urdu and Punjabi. Situational advice is also important, for example through local mosques and churches to enable word of mouth rather than reliance on digital materials which do not reach everyone.
6. Multiple Issues Joined Up Approaches Partnership work is being utilised to make older men more aware of the health issues that can affect them such as Diabetes. In Central Lancashire the NHS partnered with Edge Hill University to map out food assets in the area, including organisations providing training, support and education (from accredited food growing qualifications to cookery clubs and food growing skill sharing; healthy eating and related support and education; support for food premises, e.g. local 19
markets), networks and funding, and food projects including allotments and targeted growing projects, and food banks.
The Lancashire Health & Wellbeing Board, through its Ageing Well programme has made 'dementia' a significant priority for action and is working toward Lancashire becoming a Dementia Friendly County. Dementia-Friendly Communities (whether cities, towns, parishes, neighbourhoods or streets) do as much as possible to remove the barriers to everyday living that people with dementia and their carers face. They also help people with dementia to make the most of their own capabilities, encouraging them and including them in what is going in the community. Lancashire County Council launched its Dementia Friends Action –'Our Corporate Social Responsibility' -Be a dementia friend campaign 2014. This programme is to Support the national campaign to create 1 million Dementia Friends. Adult Social Care has rolled out the 'Life with Dementia' programme in Central & West Lancashire. A new website and 4 short films titled 'Life with dementia' in Central & West Lancashire the films have been developed to showcase and to provide information about the range of supports and services available.17
Lancashire Cultural services also provide links to other services that work around dementia across the county as well as providing a collection of books selected by a specialist dementia panel. They offer outreach sessions that can be delivered in care homes and day centres. They are also exploring other ideas such as Dementia Cafes, Dementia Friendly Communities Partnerships, Reading and Art groups. Targets to address fairness include consistent access to memory boxes across the county, to be more dementia aware across the organisation, challenge stigma and develop a range of socially inclusive services for those with dementia and their carers.
Lancashire Library Services offers free use of the internet and computers and are focusing on more services for digital inclusion especially for older people.
Where services are made available for people with disability, criteria may be excluding some people in need. For example dementia is not classed as a disability so sufferers are not entitled to a ‘blue badge’, disadvantaging some families and carers. A joined up approach to such assessment could be more positive.
References
1 The Marmot Review (2010) Fair Society Healthy Lives, The Marmot Review. Available from http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review
2 Inquiry Panel on Health Equity for the North (2014), Due North: The Report of the Inquiry on Health Equity for the North, Liverpool: University of Liverpool and Centre for Local Economic Strategies
3 Save the Children (2014) A Fair Start for Every Child, London: Save The Children. Available from http://www.savethechildren.org.uk/resources/online-library/fair-start-every-child
4 United Nations (1989) United Nations Convention on the Rights of the Child (UNCRC), Geneva: United Nations
5 Nutbrown Review (2012) Foundations for Quality: The Independent review of early education and childcare qualifications, Final Report, Runcorn: Department for Education
6 Grauberg, J. (ed) (2014) Early Years: valuable ends and effective means, London: Centre Forum
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7 Lancashire Children and Young People’s Trust (2014), Lancashire Children and Young People’s Plan 2014-2017, Lancashire Children and Young People’s Trust. Available from [email protected]
8 UCL Institute for Health Equity (2014) Local Action on Health Inequalities: Adult learning services, Health equity briefing 4: September 2014, Public Health England
9 Newman, T. (2004) What Works in Building Resilience, Ilford: Barnado’s
10 Roberts, J. And Donkin, A. (2013) Measuring What Matters: A guide for children’s centres, UCL Institute of Health Equity
11OCC (2013) “We Want to Help People See Things Our Way”: A rights-based analysis of disabled children’s experience living with low income, London: Office of the Children’s Commissioner
12 UCL Institute for Health Equity (2014) Local Action on Health Inequalities: Improving access to green spaces, Health equity briefing 8: September 2014, Public Health England
13 Lancashire Fairness Commission (2014), Living in Lancashire Survey, Preston: Lancashire County Council
14 Bickley, P. (2014) Good Neighbours: How churches help communities flourish, Church Urban Fund and Theos. Available from http://www.cuf.org.uk/sites/default/files/PDFs/Research/Good%20Neighbours%20Report-CUF-Theos- 2014.pdf
15 Dementia UK Second edition, http://www.alzheimers.org.uk/infographic
16 Beach, B. and Bamford, S. (2014) Isolation: the emerging crisis for older men. A report exploring experiences of social isolation and loneliness among older men in England, ILC-UK and Independent Age
17 (www.lifewithdementia.org)