ADULT BASIC SKILLS IN THE WORKPLACE

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					                       LEARNING AND HEALTH REPORT


                 SKILLS AND LEARNING INTELLIGENCE MODULE,
               MARCHMONT OBSERVATORY, UNIVERSITY OF EXETER

                        SOUTH WEST PUBLIC HEALTH OBSERVATORY


                                                        February 2003




                                                                                    South West Public
                                                                                    Health Observatory




                                                  Skills and Learning Intelligence Module
                                     Marchmont Observatory, University of Exeter, St Luke’s Campus
                                  Heavitree Road, Exeter EX1 2LU. Tel 01392 264850. Fax 01392 264966
                                         Email: swslim@exeter.ac.uk       Web: www.swslim.org.uk
The Skills and Learning Intelligence Module will be part of Regional Observatory South West, a wider regional intelligence function, currently
    supported by DoH, DfES, Government Office South West, South West Regional Development Agency and the Environment Agency
ACKNOWLEDGEMENTS

We would like to thank all those who took part in the Learning Theme. This report is
the outcome of all of their contributions.

Particular thanks go to the presenters at the Learning Theme workshop: Julia Verne,
SWPHO; Cathie Hammond, Centre for the Wider Benefits of Learning; Kathryn
James, NIACE; Sheila McCann, Government Office South West; Claire Easterbrook
and Jane Ashton of P2P. Thanks also go to Brian Cooke for supporting the on-line
debate.
CONTENTS
ACKNOWLEDGEMENTS ......................................................................................................... 2

EXECUTIVE SUMMARY ........................................................................................................... 5

1      INTRODUCTION ............................................................................................................... 9

2      THE POLICY CONTEXT .................................................................................................11
    2.1 PATTERNS OF HEALTH INEQUALITY .................................................................................11
    2.2 THE POLICY CONTEXT - LINKING LEARNING AND HEALTH ...................................................14
      2.2.1 Public health policy ..............................................................................................14
      2.2.2 Lifelong learning policy ........................................................................................16
    2.3 REGIONAL AND LOCAL INITIATIVES ...................................................................................17
    2.4 INNOVATIVE APPROACHES ..............................................................................................20
      2.4.1 Examples .............................................................................................................20
      2.4.2 Good Practice ......................................................................................................21
3      THE EVIDENCE ..............................................................................................................23
    3.1 CORRELATION BETWEEN LEARNING AND HEALTH..............................................................23
      3.1.1 Literacy and health ..............................................................................................24
    3.2 FACTORS LEADING TO BETTER HEALTH ............................................................................25
    3.3 EVIDENCE FROM GOVERNMENT PROGRAMME EVALUATIONS.............................................27
      3.3.1 New Deal ................................................................................................................28
4      LEARNING AND HEALTH WORKSHOP: DISCUSSIONS AND KEY ISSUES ............29
    4.1    IDENTIFYING THE HEALTH BENEFITS OF LEARNING ........................................................29
      4.1.1 Benefits of learning ..............................................................................................29
      4.1.2 Dis-benefits of learning ........................................................................................30
    4.2 LINKING LEARNING AND HEALTH ......................................................................................30
      4.2.1 The links are complex ..........................................................................................31
      4.2.2 Need for evidence-based research .....................................................................31
      4.2.3 Beneficial approaches to learning .......................................................................32
      4.2.4 Community learning .............................................................................................33
      4.2.5 Engaging young people .......................................................................................33
      4.2.6 Peer groups .........................................................................................................33
      4.2.7 Start with the Soft approach ................................................................................34
    4.3    HOW DO WE BEST DEVELOP AN HOLISTIC APPROACH? ..................................................34
      4.3.1 Holistic approach .................................................................................................35
      4.3.2 Measuring impacts ...............................................................................................35
    4.4 PARTNERSHIPS ..............................................................................................................36
      4.4.1 Partnership the best option ..................................................................................36
      4.4.2 Changing attitudes ...............................................................................................37
      4.4.3 Primary Care Trusts (PCTs) ................................................................................38
      4.4.4 Barriers to or problems with partnerships ............................................................38
    4.5    W HAT ARE THE POLICY AND OPERATIONAL BOUNDARIES?.............................................39
      4.5.1 Research..............................................................................................................40
      4.5.2 Professional development ...................................................................................40
      4.5.3 Funding problems ................................................................................................40
      4.5.4 Targets .................................................................................................................41
5      KEY ISSUES AND RECOMMENDATIONS FOR ACTION IN THE SOUTH WEST ......43

6      CONCLUSIONS ..............................................................................................................47

BIBLIOGRAPHY .....................................................................................................................48

ANNEX A LIST OF WORKSHOP PARTICIPANTS .............................................................50




                                                                                                                                     3
FOREWORD

It has long been understood that socio-economic factors affect the health of
individuals and communities. In this learning theme we have sought to link learning
and health as a means of addressing the twin issues of health equality and non-
participation in learning.

Indeed it appears that this discussion could not have been more timely. As we
publish this report, the Department of Health (DoH) and the Department for
Education and Skills (DfES) have announced the launch of a new national
programme which aims to improve both the nation's basic skills and its health. The
programme has been launched to help more people improve their basic skills and to
link learning to health1. This reflects a growing recognition by policy-makers that
learning has the potential to secure health improvements.

When we look at practice on the ground, it is possible to identify a range of excellent
initiatives and projects which have sought to take an holistic approach to linking
learning and health. However, such practice is at best patchy and is not well
supported at the more strategic level. Agencies responsible for delivering learning
and health are not working together to any great extent and the operational
imperatives and targets of these various agencies often militate against joined up
policy and practice.

Through this learning theme, we hope to have highlighted the ways in which learning
can lead to positive health outcomes and the ways in which practitioners in these
fields can develop joint working arrangements. The starting point is to bring together
the agendas of the learning and public health systems and to get professionals and
practitioners talking each other’s language. We hope that through this learning
theme we have started to do just that.




1
 Department of Health Press Release, 24 January 2003 on
www.info.doh.gov.uk/doh/IntPress.nsf/Archive/ on 14.2.03
4
EXECUTIVE SUMMARY

The scale and nature of health inequality is a major policy issue within the UK. One
key factor indicated in poor public health is lack of educational attainment. Indeed, a
raft of recent research and policy statements highlights the strong link between poor
education and health inequality.

The implication of this, of course, is that improving educational attainment and
participation in learning will lead to improvements in health. However, there is little
clear evidence to show how education and learning can actually lead to improved
health outcomes. This in part is due to the complex nature of the processes through
which better education and learning impacts on a person’s health. The link is often
not direct and is therefore difficult to track and to measure. This presents a
significant challenge for the development of an effective public policy framework
which links learning and health.

Nevertheless, the broad range of health inequalities policy is now attracting
increasing attention from educational researchers, who confirm the need for a cross-
cutting agenda. According to the Centre for the Wider Benefits of Learning (CWBL)
at the Institute of Education, set up to analyse and measure the contribution of
learning to wider goals, there are important policy gains to be made by considering
actions in tandem. They conclude that there is much scope for exploring cost-
effective learning-based provision with positive health impacts.

That emerging research shows that despite a lack of evidence of direct causality,
education has a sustaining effect on personal lives and society by helping people to
cope with stress as well as to make positive contributions to community life.
Individual benefits accrue in psychological well-being, independent activity, improved
communication and understanding and a clearer sense of purpose and self-esteem.

This learning theme report entitled Learning and Health highlights the challenge
facing those seeking to tackle health inequality and reflects upon the policy context
at national, regional and local level. It also presents supporting evidence and good
practice gathered from discussions and experience, and makes detailed
recommendations towards improving the impact of learning upon health within the
South West region.

The fields of public health and learning have experienced significant change since
the Labour government came to power in 1997. Structural change supported by
stringent performance targets and changes to funding regimes characterise both the
learning and health fields. The recognition of the need to address underlying social
exclusion and deprivation if health inequality is to be tackled has also led to the
development of a raft of programmes and initiatives. Many of these share common
principles and values: a central emphasis on the importance of working in
partnership; the emphasis on engaging the local community; achieving sustainable
change by influencing mainstream programmes; and finally, the importance of
having a strong evidence-base on which to build activities.

At the very local level initiatives such as Health Action Zones (HAZ), Sure Start, New
Deal for Communities, Healthy Living Centres and the Neighbourhood Renewal
Strategy provide the focus for much activity to address health inequality. Within an
integrated planning framework, they offer considerable learning for mainstream
services in terms of linking health and regeneration.

The challenge is to take many of the positive lessons learned from these initiatives
and ensure that they lead to changes in policy and practice at a more general level.
                                                                                          5
Lack of communication between health and learning professionals based on lack of
knowledge currently hampers more effective joint working. Yet, as this report
demonstrates, where practitioners work closely together, the benefits for individuals
and communities can be immense and long lasting.

Key issues and recommendations

From the learning theme process emerged a range of issues and recommendations.
Many of these relate to changes in both policy and practice which participants
recognised needed to occur in agencies in the region. These recommendations are
set out below:

Recognise the Health Benefits of Learning

1.     Learning providers, health professionals and key agencies need to recognise
       and value the potential health benefits of learning.

2.     More and better quality evidence is required which demonstrates the positive
       health benefits of learning. This is likely to require more longer term,
       evaluative approaches to measuring the benefits.

3.     If health is a valued outcome of learning then changes may be required not
       only in the way that learning provision is determined, designed and
       structured, but also in the nature of the outcomes that are recognised and
       valued.

4.     There is a need for Champions to highlight the wider benefits of learning,
       including health benefits.

5.     Informal learning is as important as formal learning in the context of
       producing health outcomes. As such it needs to be valued and funded.

Links between learning and health

6.     The process through which learning leads to better health needs to be better
       understood. There is a need for more evidence-based research, both
       qualitative and quantitative, to assist in reinforcing the health messages.

7.     Social exclusion lies at the heart of health inequality. To tackle health
       inequality, it is important to address the barriers to participation in learning.

8.     Information, guidance and advice services should be targeted to those
       individuals and communities most excluded from learning. The potential
       health benefits should be stressed.

9.     A number of factors need to be taken into account in the design and delivery
       of learning if health benefits are to accrue. These include:
        User Involvement
        Learning that is tailored to the learners’ needs – choice and
            empowerment are key. Provision has to be right for the person, at the
            right time
        Providing a variety of methods of delivery which appeal to users and
            recognise the wide variety of learning skills and styles including peer
            group learning.



6
10.   The contribution of community learning, which often provides a supportive
      environment for non-traditional learners, needs to be recognised and
      supported.

11.   Schools need to offer lifeskills to encourage young people to think about their
      health and to understand the benefits of learning.

12.   Give young people the opportunity to engage in informal learning and have
      earlier exposure to vocational learning opportunities.

13.   Peer learning can provide a supportive environment for learning. Particular
      success has been noted with teenagers.

14.   Emphasis needs to be given to raising individuals self-esteem as a precursor
      to learning.

15.   The role of informal learning needs to be recognised and funded.

16.   Referral to a learning adviser should be an entitlement.

Developing an holistic approach

17.   More effective impact measures are needed to recognise the contribution of
      learning to health.

18.   Tightly drawn, specific targets can set up barriers to closer working between
      the learning and health sectors. Softer outcomes need to be recognised and
      these may only be measured using evaluative techniques.

19.   Evaluative techniques also need to be used not just to prove but improve
      impact. Evaluations of Health Action Zones (HAZ) and Education Action
      Zones (EAZ) already take this overarching approach.

Partnerships

20.   Cross sectoral/agency partnerships are critical to linking learning and health.
      Partnerships need to be formed at strategic and practitioner level.

21.   Competition for resources works against the collaborative approaches which
      may be most beneficial.

22.   There is a need for better co-ordination of information and advice across the
      learning and health arenas.

23.   Inter-professional development at all levels is critical to enabling an
      understanding of the cross over benefits of learning and health.

24.   A more structured and systematic approach to collaboration is needed which
      does not rely on the start-stop initiatives that currently prevail.

25.   Primary Care Trusts (PCTs) need to be proactive in encouraging health
      practitioners to understand the benefits of learning and promote better links
      with learning practitioners.

26.   The systems for sharing information between agencies are inadequate and
      further hampered by lack of clarity about client confidentiality requirements.
                                                                                       7
      This can lead to a breakdown in effective communications between learning
      and health practitioners.

27.   Time constraints and lack of funding provide a real barrier to collaborative
      working and partnerships.

28.   There needs to be more best practice sharing on how the effective
      partnerships operate.

Policy and operational boundaries

29.   The bottom-up, needs-driven approach is a precondition to developing better
      links between learning and health. The Health Action Zone approach should
      be spread more widely.

30.   Short term funding militates against those activities where the positive
      outcomes may only accrue over time. Longer time horizons are required for
      funding this type of initiative.

31.   The nature of the current performance targets in the health and learning
      fields militate against the longer term/soft outcomes approach that may be
      required if the learning is to accrue positive health benefits.




8
1         INTRODUCTION

The Learning and Health learning theme was run jointly by the Skills and Learning
Intelligence Module of the South West Observatory (SLIM)2 and the South West
Public Health Observatory (SWPHO)3. It was the third learning theme in the SLIM
series and this time we chose to focus on how learning can lead to improvements in
health outcomes, particularly for those facing disadvantage.

This report completes the learning theme, which commenced in the autumn of 2002,
and encompassed a virtual discussion, briefings, case studies and interviews with key
players and experts. The process culminated in a workshop attended by forty-five
participants from across the region and which drew together learning and health
practitioners, policy-makers, funders and researchers.

The report highlights the nature of the challenge facing those seeking to tackle
health inequality and reflects upon the policy context at national, regional and local
level. It also presents supporting evidence and good practice gathered from
discussions and shared experience, and makes detailed recommendations towards
improving the impact of learning upon health within the South West region.

The learning theme explored a range of key questions including:

     What strategies have been effective in linking learning and skills with positive
      health outcomes?

     What support and incentives do practitioners need to improve collaboration
      across the learning and health fields?

     Where is the effective practice and what lessons can be learned?

     What role can the key strategic bodies in the fields of learning and health play
      in ensuring that there is better “joining up” at the local level?

The report is presented in five sections. In Section 2 we describe the national and
regional policy context. In Section 3 we review the current literature linking
learning and health, whilst Section 4 presents the workshop discussions. Section
5 presents key recommendations for action in the South West and Section 6, our
conclusions.

The report does not reproduce the presentations made at the workshop although
the key issues raised by them are reflected in the report. Copies of the
presentation slides are available on the SLIM website, www.swslim.org.uk.




2
    For further information on SLIM visit the website www.swslim.org.uk
3
    For further information on SWPHO visit the website www.swpho.org.uk
                                                                                         9
10
2       THE POLICY CONTEXT

The scale and nature of health inequality is a major policy issue within the UK.
Attacking the root causes of ill-health lies at the heart of the Government’s recent
policy on public health. In this section we take a look at patterns of health inequality
within the UK and the public policy response.

2.1     Patterns of Health Inequality

The World Health Organisation (WHO) definition states that:

      “To reach a state of complete physical, mental and social well-being, an
      individual or group must be able to identify and to realise aspirations, to
      satisfy needs, and to change or cope with the environment. Health is,
      therefore, seen as a resource for everyday life, not the objective of living.
      Health is a positive concept emphasising social and personal resources, as
      well as physical capacities.”4

The likelihood of a person enjoying good health, however, is determined by their
social circumstances over their lifetime and in that respect the health divide in the
UK remains stark.

In 1998 Sir Donald Acheson published the report of the independent inquiry into the
causes of inequalities in health, which the Government commissioned immediately
after taking office in 1997.5 The report was the latest contribution to the health
inequalities debate which extends over more than a century and it provided a
comprehensive analysis of the evidence – social, economic and geographical –
about inequalities in health, and of the means of narrowing the health gap.

The Inquiry found that “unacceptable inequalities in health persist across the whole
life-cycle”. Although average mortality had fallen over the past 50 years, inequalities
in health were evident throughout society, from the top to the bottom of the social
scale. They also affected both sexes and the different ethnic groups.

The report primarily addressed socio-economic inequalities and showed that despite
falling death rates across all social groups over the last 20 years, the differences in
mortality across social classes had actually widened in both sexes. For example, in
the late 1970s, death rates were 53 per cent higher among men in social classes IV
and V, compared with those in classes I and II. By the late 1980s, they were 68 per
cent higher.

More recently the Chief Medical Officer’s Annual Report 20016 stated that:

      “Despite overall improvements in health the inequalities gap between
      socially disadvantaged and affluent sections of the population has
      widened.”




4
  World Health Organisation, Ottawa Charter for health promotion, (Ottawa, WHO, 1986)
5
  Acheson, Sir Donald, Independent inquiry into inequalities in health. Report to Department
of Health by the committee chaired by Sir Donald Acheson, (London, HMSO, 1998) (The
Acheson report).
6
  Chief Medical Officers Annual Report 2001 (Department of Health, 2001).
                                                                                           11
It also found that:

    some communities in England have death rates equivalent to the national
     average in the 1950s.

    men in professional occupations have rates of death which are much the same
     wherever they live, whereas rates for unskilled working men vary greatly
     between north and south. This suggests that being poor in the north is worse for
     your health than being poor in the south, whereas men in professional
     occupations seem to be able to transcend the north-south divide in health status.

    social circumstances throughout life – from birth to late adulthood – influence
     people’s health. In particular social, economic and environmental deprivation
     have a profound and overriding impact on health. Lifestyle factors such as
     smoking, diet, and physical activity are also important.

    targeting the poorest sections of the population is important to improving their
     health but this alone will not close the inequalities gap; many more people at risk
     of poor health are in manual social classes. Achieving improvements in their
     health will make a large contribution to reducing inequalities overall.

    this pattern of geographical inequalities is still present today. Most major
     diseases follow it but not all – for example, breast and prostate cancer do not.

The Neighbourhood Renewal Unit7 also cited the following evidence for a health
divide in poorer communities in the UK that, if anything, has grown worse in recent
times:

    the death rate from coronary heart disease is now three times higher among
     unskilled men than among professionals and the gap has widened sharply in the
     last 20 years

    stroke death rates in people born in the Caribbean and the Indian sub-continent
     are one-and-a-half to two-and-a-half times higher than for people born in this
     country – a differential that has persisted from the late 1970s

    children up to the age of 15 years from unskilled families are five times more
     likely to die from unintentional injury than those from professional families

    children up to the age of 15 from unskilled families are 15 times more likely to die
     in a fire in the home than those from professional families

The charts below indicate life expectancy by social class.




7
  Renewal.Net Overview: Health. Neighbourhood Renewal Unit, 2002.
(http://www.renewal.net)
12
             Chart 1:

                              Life expectancy of men at birth by social class (England and Wales)
                              Source: Health Statistics quarterly 02 tables 1 & 5


        85


        83


        81


        79


        77                                                                                                                             1972-76
                                                                                                                                       1977-81
years




        75                                                                                                                             1982-86
                                                                                                                                       1987-91
        73                                                                                                                             1992-6


        71


        69


        67


        65
               Professional           Managerial/      Skilled non-manual     Skilled manual     Partly skilled   Unskilled
                                     Intermediate




             Chart 2:


                                       Inequality: social class
              Excess death rates for men in non-professional classes

                                 I - Professional                                   280


                                  II - Managerial                                    300


               IIIN - Skilled (non-manual)                                                     426


                      IIIM - Skilled (manual)                                                        493


                              IV - Partly Skilled                                                    492


                                     V - Unskilled                                                                      806

                                                                  European standardised mortality ratio
                                                                per 100,000 population for men aged 20 - 64

               England & Wales 1991-93
                                                                                                                                   7



             Source: DoH, Government White Paper, Saving Lives: Our Healthier Nation
             (Department of Health, 1999)

                                                                                                                              13
The Chief Medical Officer’s Annual Report stated that:

        “Some of these differences in health between advantaged and
        disadvantaged areas (and individuals) can be explained by behaviour and
        lifestyle – for example smoking and dietary patterns. Some may reflect
        systematic differences in health between the health of those who move into
        or out of deprived regions and neighbourhoods and those who remain in
        these areas. However, a large part of the difference is due to more
        profound underlying social, economic and environmental factors”. 8

The 20 per cent of health authorities with the lowest life expectancy are also among
those with the largest proportion of their populations in manual social classes, in
social housing and with the highest rates of unemployment.

This link between health inequality and social circumstances has been recognised in
a range of recent government policy initiatives. They recognise that improvements in
health may only come about if more general improvements in social circumstances
take place.

So what part does learning play in improving people’s health?

2.2      The policy context - linking learning and health

2.2.1 Public health policy
The clear links between learning and health are highlighted in a number of more
recent Government policy documents. Since 1997 a number of approaches have
been used to change the emphasis of health policy from one that is primarily focused
on sickness services to one that places greater emphasis on population health
improvement. Developments post-1997 can be divided into three main categories:

     NHS modernisation;
     public health and inequalities; and
     specific initiatives and programmes including:
          Health Action Zones
          Healthy Living Centres
          NHS Direct
          Smoking Kills
          Tackling Drugs
          Sure Start
          Sure Start Plus
          Accident Prevention
          National Service Frameworks


The need to tackle health inequality through focusing on social and economic factors
is not new and it is an approach backed by a wealth of research. Research carried
out by Booth and Rowntree as long ago as the 1890s, more recently updated by the
Black report9 and the Acheson report10, propounded a socio-economic model of
public health.



8
  Chief Medical Officer’s report 2001 p 5
9
  Black, Sir Douglas, Reducing inequalities in health: an action report. Report to DHSS by the
committee chaired by Sir Douglas Black, 1980. Published as The Black Report: Pelican,
1982.
10
   The Acheson Report see footnote 5
14
As already mentioned, the most recent, Acheson report, was the result of an
independent inquiry into health inequalities. Published in November 1998, it made
thirty-nine recommendations, underpinned by a broad analysis of the social,
economic and environmental determinants of health inequalities.

The report stated that:

         “Many studies and analyses have demonstrated the association of
         increasingly poor health with increasing material disadvantage … At a
         regional level, strategic partnerships put greater emphasis on social and
         economic regeneration. Health is both a cause and a consequence of
         economic prosperity.11

Its recommendations also reflected the importance of learning as a key mechanism
for improving health, with its focus on education and early years, which included:
    Provision of additional resources for schools serving children from less well off
     groups, to enhance their educational achievement

    The further development of high quality pre-school education so that it meets, in
     particular, the needs of disadvantaged families

    The further development of ‘health promoting schools’, initially focused on, but
     not limited to, disadvantaged communities

This report also underpinned the development of the Government’s health strategy
for England, set out in the White Paper, Saving Lives: Our Healthier Nation12. The
White Paper, published in July 1999, had twin goals:

         to improve health; and
         to reduce the health gap (health inequalities).

The strategy it outlined aimed to prevent up to 300,000 untimely and unnecessary
deaths by the year 2010. In doing so it recognised that improving health meant
tackling the causes of poor health. It recognised that ill-health is caused by:

          “a complex interaction between personal, social, economic and
          environmental factors.”13

The White Paper made it clear that, because the root causes of ill-health were so
varied, it was not possible to deal with them by focusing on “health” alone. It
stressed the importance of tackling in the round all the things that make people ill.
The report therefore set out the action to be taken across Government – and through
partnerships between the various local and regional organisations in England – to
reduce health inequalities.

The White Paper acknowledged that a variety of factors influence a person’s health:

    those which are fixed - genes, sex, ageing
    those which are social and economic - poverty, employment, social exclusion


11
   The Acheson Report, p 6
12
   DoH, Saving Lives: our healthier nation, Government White Paper, (Department of Health,
1999).
13
   Ibid p 7
                                                                                         15
    those which are environmental - air quality, housing, water quality, social
     environment
    those which are to do with lifestyle - diet, physical activity, smoking, alcohol,
     sexual behaviour, drugs
    those which are to with access to services - education, NHS, Social Services,
     transport, leisure.

It recommended a number of areas earmarked for Government support, including
promotion of the benefits of additional physical activity and better diet, lower levels of
smoking and stress, with particular attention paid to mothers and young children.
Lower infant mortality and improved life expectancy are two long- term targets for the
effects of these policies.

Of particular interest in the context of this report is the emphasis given in the White
paper to the need for a co-ordinated approach and the role of education in reducing
inequalities as well as that of employment.

The White Paper put forward a list of initiatives deployed to promote understanding
and reduce risks to health, many of which included aspects of education:

    health education
    counselling and support
    skills training
    information labelling

2.2.2 Lifelong learning policy
The Government’s consultation paper, The Learning Age, set the tone for its policy
on lifelong learning and emphasised the social and economic role of continuing
education:

        Learning is the key to prosperity – for each of us as individuals, as well as for
        the nation as a whole. Investment in human capital will be the foundation of
        success in the knowledge-based global economy of the twenty-first century.
        14



In broad terms the objective of government policy on learning and skills since 1997
has been to:

    increase participation and attainment rates among 14-21 years olds in schools,
     colleges and universities
    tackle deficiencies in basic skills within the workforce
    use educational opportunities as both an incentive for and requirement of moving
     people ‘from welfare to work’, via various New Deal initiatives
    encourage employer investment in people in order to move a greater proportion
     of the nation’s goods and services into ‘high added value’ and/or ‘quality assured’
     categories
    provide on-line learning ‘access points’, especially through the University for
     Industry.

A key document which set out the Government’s framework for post-16 learning, is
the Learning to Succeed White paper15. The White paper highlighted the failures of

14
  DfES, The Learning Age, (Department for Education and Employment, 1998).
15
  DfEE, Learning to Succeed White Paper, (Department for Education and Employment,
1999).
16
the system in addressing the needs of a significant section of the community, often
the most vulnerable and disadvantaged.
Problems included:

     low rates of learning and staying on rates at 16 - over 160,000 young people
      between 16 and 18 - around one in 11 of the age group - are neither in learning
      nor in work;

     a cycle of deprivation and disadvantage - people with low skills and poor
      qualifications are the least able to respond to the challenges of the knowledge-
      based economy. They are more likely to be disengaged or excluded from
      society. And their children are likely to follow in their footsteps.

     particular difficulties faced by people with special needs - disabled people are
      more than twice as likely to have no formal qualifications and are only half as
      likely to be in employment;

     poor levels of basic skills amongst adults - seven million adults have severe
      problems with basic skills. One in five adults have a lower level of literacy than is
      expected of an 11 year-old.

Some of the major changes to emerge as a result of the White paper have been the
institutional arrangements which have undergone radical reshaping in the past few
years with the establishment of Learning and Skills Councils and the Connexions
Service.

2.3      Regional and local initiatives

The Government White Paper, Saving Lives, recognised that communities working
in partnership through local organisations were the best means of delivering the
better information, better services and better community-wide programmes which will
lead to better health. It also recognised that the roles of the NHS and of local
authorities are crucial and that they must become organisations for health
improvement, as well as for health care and service provision.

Important messages resulted from the Saving Lives White Paper: that the remit for
public health improvement extended beyond the NHS, with much scope for
integrating central and local government services.

Indeed, joint planning within the framework of local strategic partnerships is
beginning to produce success stories throughout the UK. The Health Development
Agency is monitoring efforts to co-ordinate action on health through the development
and delivery of health improvement and modernisation plans drawing in cross-
agency activities16. Collaborative activities might include working across boundaries,
partnership and planning arrangements, community and member involvement,
setting joint indicators and targets for reducing inequalities and tackling deprivation.

The White Paper also set public health inequalities targets as a priority for cross-
departmental working nationally through to locally. Local Public Service Agreements
between the NHS and local authorities are seen as an ideal way of tackling health
inequalities for individuals and their communities. In the consultation for its delivery
plan, due by early 2003, two priorities were envisaged:


16
  Hamer, L and Smithies, J. Planning across the local strategic partnership (London, Health
Development Agency, 2002).
                                                                                         17
    the strengthening of disadvantaged communities and
    tackling the wider determinants of health inequalities through government policy.

The NHS Plan, published in June 2000, was in part about structural reform of the
health service17. It emphasised the role of Primary Care Groups (PCGs), and their
shift to Primary Care Trusts (PCTs). PCTs are at the heart of plans to modernise the
health service, as the key local commissioners and providers of care. Along with
PCTs at the centre of the service, the 95 Health Authorities have been replaced with
about 30 Strategic Health Authorities (StHA’s).

The NHS Plan specifically pledged that the NHS would play a key part in the
implementation of the National Strategy for Neighbourhood Renewal. Yet the
reforms have signified a vast structural upheaval which has limited, and will continue
to limit, the scope of these agencies to engage in wider partnerships in the short
term.18

As highlighted above, the learning system too has seen radical reform in recent
years with the establishment of Learning and Skills Councils (LSCs)responsible for
planning and funding the provision of learning within their areas. As relatively new
organisations, they are still at an early stage in developing their visions and
establishing effective partnership arrangements.

As well as structural change, the recent policy thrust has also led to the development
of a raft of programmes and initiatives which share common principles and values19.
Firstly, there is a central emphasis placed on the importance of working in
partnership. A second important feature to emerge from these developments is the
emphasis on engaging the local community in health improvement efforts. Another
objective of recent initiatives is to seek to achieve sustainable change by influencing
mainstream programmes. Finally, the importance of having a strong evidence-base
on which to build activities is another key feature.

At the very local level these initiatives - Health Action Zones, Sure Start, New Deal
for Communities, Healthy Living Centres and the Neighbourhood Renewal Strategy -
provide opportunities for more holistic, multi-agency approaches. Within an
integrated planning framework, they offer considerable learning for mainstream
services in terms of linking health and regeneration. Some of these initiatives are
described below (see figures 1-3).

Opportunities also exist for productive partnerships for those supporting learners
with a view to health improvements. For instance, local LSCs are encouraged to
include learning for mental health groups in their strategic planning and to facilitate
local collaboration and partnership working between learning providers and mental
health services. Collaborative projects could draw together colleges, local
authorities, the voluntary sector, mental health services, strategic and lifelong
learning partnerships, primary care and mental health trusts.

Local authorities are also rising to the challenge that partnerships represent20. They
recognise the need for a shared understanding of health improvement and health

17
   DoH, NHS Plan, (Department of Health, June 2000)
18
   Bauld, L, Mackinnon, J, and Judge, K, New deal for communities: the national evaluation
scoping phase, Community health initiatives: recent policy developments & the emerging
evidence-base (University of Glasgow, 2002).
19
   ibid
20
   Community strategies and health improvement: a review of policy and practice. Report by
the HDA/I&DeA/DLTR/LGA (2002).
18
inequalities, and the ways in which social, economic and environmental wellbeing
influence the health of communities.

Fig 1: Health Action Zones

Primary Care Trusts lead for the NHS in widescale implementation of Health Action
Zones (HAZs), together with partners in local authorities, the voluntary and private
sectors and local communities. Over £280 million has been spent to date in establishing
26 HAZs which address the needs of 13 million people living in deprived
neighbourhoods around the country. Aligned with new local health structures since April
2002, HAZs are introducing a range of innovative programmes aiming to promote
activities designed to boost health and well-being for individuals and their community.

In the South West, Cornwall and Plymouth are designated HAZs which are actively
working to raise awareness of health issues in their localities21.

Where the Cornwall HAZ is predominantly rural in nature and targeted to the needs of
dispersed communities, Plymouth HAZ covers a patchwork of deprived inner city
neighbourhoods which benefit from holistic approaches. The confluence of Education
and Employment Action Zones with HAZs offers an opportunity to address
neighbourhood renewal issues in tandem, linking training with employability as well as
health awareness.


Fig 2: Sure Start

The Sure Start initiative is a cross-Government programme established as
part of the drive to tackle child poverty and social exclusion. It was set up to help a
range of statutory, voluntary, community and private sector agencies to work
together to improve services focused around the specific needs of families and
children in some of the most deprived areas of England (DH, 2000b). The main aim
of the initiative is to work with parents and children to promote the development of
pre-school children – particularly disadvantaged children – to give them the best
possible start before they go to school.

An investment of more than £1 billion has been committed to Sure Start
for the period between 1999 and 2004. The programme has four overall objectives:

    To improve social and emotional development
    To improve health
    To improve children’s ability to learn
    To strengthen families and communities

As with other area-based initiatives, the Sure Start programme is based on the
principles of partnership working and involving communities. Sure Start is led
by local partnerships and works directly with individuals and communities
through a wide range of projects.

Fig 3: Adult and Community Learning Fund

The Adult and Community Learning Fund was launched by the Government in 1998 as
part of its strategy to widen participation in learning and improve standards of basic

21
  Healthy Living Initiative Programme: the Pendeen Project. Evaluation report to the
Cornwall/IoS Health Action Zone (University of Plymouth, July 2002).
                                                                                       19
skills. The Fund makes the important connection between learning and social
regeneration. While the economic benefits of learning are acknowledged, learning also
helps to promote active citizenship, to strengthen the family and the neighbourhood.

The Fund has supported community-based organisations in developing and sustaining
innovative adult learning projects aimed at adults who do not normally participate in
education and training. Often these organisations work with traditional providers. The
provision of 'first rung' and informal learning, delivered in familiar local surroundings,
has proved to be effective in engaging a range of disadvantaged or marginalised adults.

It is managed jointly on behalf of the DfES by the National Institute of Adult Continuing
Education (NIACE) and the Basic Skills Agency (BSA). As a result of the Fund, around
600 large and small projects have received sums ranging from a few hundred pounds
to over £100,000.


2.4     Innovative approaches

Moving beyond the initiatives described above, scope exists within communities for
more innovative practice in partnerships that link learning to health for all residents
as well as targeting special groups. Here we set out some examples and more
detailed good practice from within the South West region.

2.4.1   Examples

Health education in Libraries - Bournemouth University is heading up a British
Library funded project, HealthInfo4U22. The project aims to widen access to health
information held in nursing and complementary medicine databases to members of
the public and community health practitioners, using both libraries and patient
information centres.

The Guide Project – Truro College leads an ESF funded project in partnership with
other Cornish FE colleges and the Royal Cornwall Hospitals Trust to assess, guide
and retrain clients who have acquired disability through injury or illness. There is
overwhelming evidence of the benefits of learning to physical and mental health.

Big Issue Vendors – The Big Issue Foundation is training vendors as peer
educators to raise awareness of health issues amongst homeless people. Vendors
have a broad understanding, experience and visibility to other homeless people,
which enhances their potential to act as providers of information, key to social
cohesion and ‘street etiquette’.

Prison Health Promotion Development Project – the project aims to provide HM
Prison Service with advice and support to promote the health of prisoners and staff.
It surveyed health promotion resources and networks in prisons, disseminated
information, and developed further prison specific resources and health promotion
services.

Carer Training Joint Workshops – training workshops are underway in Exeter for
cross agency workers from education, health, social services and voluntary agencies
with an interest in developing the training and education of unpaid carers.


22
  Working with public libraries to enhance access to quality-assured health information for
the lay public. Bournemouth University Library. British Library Co-operation and Partnership
Programme Project 6, 2001-02.
20
NHSU – the NHS is moving forward with its own university initiative to reinforce
overall service priorities and national programmes; contribute to improved patient
care; develop staff skills, self esteem and competencies; improve staff recruitment
and retention; support learning cultures of continuous improvement; and provide
innovative learning.

2.4.2   Good Practice

Fig 4: The GUIDE Project Truro College Open Learning Centre

The 'GUIDE' project is aimed at clients who have an acquired disability through injury
or illness. Its purpose is to allow them to become more employable through
assessment, guidance and retraining at one or other of the local FE Colleges in
Cornwall. Being ESF funded, its primary aim has to be Employment but they are very
aware of the benefits of the 'soft outcomes' in terms of quality of life and they try to
be as flexible as possible when accepting people onto the Project.

Historically, its origins lie in an earlier Head Injury Project which was run in
conjunction with the Nuffield Foundation and St Michael's Hospital (Hayle) rehab
unit. This earlier project was looking into the benefits of educational courses as an
extension of hospital rehab. It was not aimed specifically at employment outcomes
but concentrated rather on the cognitive and welfare aspects of the client group.

The Guide project built on the original Hospital links and formed a partnership with
the Royal Cornwall Hospitals Trust. The Project has financed two Occupational
Therapy posts to act as liaison with the medical services, so that intervention can
occur as early as possible, preferably before hospital discharge.

From the point of view of hard evidence of a positive link between learning and
health, a report was produced following the Head Injury Project based on
questionnaire and structured interview techniques. Recorded outcomes from the
present project are more focused on employment owing to the nature of the project.
However there is overwhelming evidence of an anecdotal nature of the benefits of
learning to physical health including improved stamina, lower perceived pain levels,
and lower incidence of infection. In addition from a mental health perspective,
improved confidence and self-esteem, lower levels of anxiety, greater emotional
resilience, improved concentration and memory also resulted.


Fig 5: Case study: Barne Barton

Barne Barton is part of St Budeaux ward, in the bottom 10% of wards in the UK in
terms of deprivation. In Plymouth St Budeaux scores bottom in numeracy amongst a
population where 25% have numeracy, and 24% literacy, needs. In 2002 a
successful Neighbourhood Renewal Fund bid set up a learning centre on the estate
and also formed the nucleus of a wider network, which now includes health visitors
as well as the Sure Start Tamar FOLK project.

Clients living on the estate are helped through acute problems as they arise and into
longer term learning opportunities. Courses in basic and life skills are offered in a bid
to raise self-esteem and help people into jobs. The scheme links education with
health issues and improves quality of life for clients, providing support that sustains
interventions.

The programme runs in tandem with a Money Advice information and guidance

                                                                                        21
project that is targeted towards Sure Start clients. Money Advice aims to remedy
deficiencies in numeracy with long term basic skills courses and engages with
external agencies on behalf of clients. It provides guidance on welfare benefits,
debts and housing, employment and training, financial and social exclusion and
offers grant support. Many clients suffer with long term illness or disabilities needing
complex financial advice, often unavailable through conventional channels. Positive
outcomes include debt clearance, better housing and uptake of training and
education.


Fig 6: Case study: Learning to Feel Better

The Learning to Feel Better project was launched in several towns in Somerset in
early 2002 by a partnership of senior health and educational professionals. The
project involves the provision of expert learning advice services to adult patients at a
medical practice, following referrals by GPs or other health workers including a
health visitor, practice nurse and counsellors.

Forty referrals were made in the first part of the year for learners of mixed ages and
backgrounds for vocational and job related courses, as well as those for education
and personal development. Many of those who attended were looking for paid
employment and keen to follow up practical learning opportunities. Early successes
have reflected the perception of the practice as a ‘safe place’ to receive advice, the
proactive skills of the learning advisor, and the ownership of the initiative by all
practice workers.

Fig 7: Case study: The Pendeen Project

The Pendeen Project is one of three Community Health Development projects
funded under the Healthy Living Initiative in Cornwall, to reduce health inequalities in
local communities, enhance their quality of life and provide opportunities to progress.
The Project aims to improve health, offer information and advice, and support its
home community by:

- Addressing the health and social needs of the target area
- Improving access to services by providing a signposting service linking local people
to voluntary and statutory providers of health related services
- Involving local people as key partners in assessing need and identifying solutions
- Supporting local people in building networks and social support mechanisms to
enhance pride in the community
- Working with a partnership of agencies to build capacity of the community.
Local activities have included a Quit Smoking campaign, drop in health visitor clinics,
training in first aid, food hygiene, IT and personal/community growth.




22
3        THE EVIDENCE

Whilst there is much evidence pointing to poor educational attainment as an
indicator of health inequality, what has been lacking has been any real evidence that
learning can positively benefit health and if so, how. Part of the problem lies in the
fact that the inter-relationships between learning, health and other variables are
complex. According to the Learning to be Healthy report by the Centre for the Wider
Benefits of Learning (CWBL), understanding these inter-relationships is further
complicated by the fact that the processes through which learning affects health cuts
across traditional academic disciplines23.

Nevertheless, the broad range of health inequalities policy is now attracting
increasing attention from educational researchers, who confirm the need for a cross-
cutting agenda. According to the CWBL at the Institute of Education, set up to
analyse and measure the contribution of learning to wider goals, there are important
policy gains to be made by considering actions in tandem. Researchers there
conclude that there is much scope for exploring cost-effective learning-based
provision with positive health impacts.

They point to:

     a major preventative role for education in combating ill health, which deserves far
      greater support
     the need for new or refined methodologies to consider the impact of learning on
      health
     excellent opportunities for a genuinely inter-sectoral approach to the
      effectiveness of learning as part of health policy.

3.1      Correlation between learning and health

The CWBL has been surveying quantitative and qualitative evidence that years of
education have positive effects upon physical health outcomes and protect against
the development of depression.

They have been monitoring longitudinal studies of British cohorts born in 1958 and
1970 and have found the following correlations:
     Amongst the 1970 cohort, degree level qualifications improved reports of good
      health at age 26 (by 6 percentage points for men and 11 for women) compared
      with those with no qualifications.

     At age 26, those with no qualifications were almost four times as likely to report
      poor general health; a similar pattern occurred in the 1956 cohort at age 40 (only
      17% of unqualified people reported good health, compared with 35% of those
      with degrees).


     Having above Level 1 numeracy skills reduces the likelihood of a long term
      health problem by 6% to 9%, even allowing for individual educational level and
      family background.24

23
   Hammond, C, Learning to be healthy. Report to DfES by the Centre for the Wider Benefits
of Learning (London, Institute of Education, 2002)
24
   Feinstein, L. Wider benefits of learning. Centre for the Wider Benefits of Learning (DfES
Research Digest 2002)
                                                                                          23
In their Learning to be Healthy study, the CWBL also investigated the relationships
between health and formal education and how these varied across health conditions,
learning experiences and context. Evidence was found from a number of studies
worldwide that levels of education and qualifications link positively with physical and
mental health. The effects of education on health also interact with the following:

    Economic factors, such as occupational self direction, personal fulfilment, and
     financial security
    Adoption of positive health behaviours, supported by empowerment,
     socialisation, and raising awareness
    Development of resilience, including autonomy, problem solving skills and social
     competence
    Social cohesion, promoting social responsibilities, values and skills at community
     level
    Improved access to and take up of health services, including quality of
     communication with health professionals

In a survey of learners participating in Adult Learners Week, NIACE sampled active
learners for their views on the impact of learning on their personal health.

Key findings included:

    The greatest general benefits from learning are confidence, increased social
     contacts, direct health benefits, and new employment or voluntary work.

    A number of learners were surprised by ‘unexpected’ benefits; others
     experienced ‘dis-benefits’, which were offset by improvements in other areas.
     Almost 90% reported benefits to physical, emotional and mental health. 25

    NIACE also targeted learning for people with mental health difficultiesas a key
     area for further work, particularly by local Learning and Skills Councils26.
     Learning concerns of these groups may include extra anxieties about access or
     ability, poor concentration and fluctuating attendance levels.

    There is also an additional need for flexibility in provision to reflect the great
     diversity of personal circumstances of these learners. Sensitivity to needs
     extends to considering ‘softer’ measures of achievement as positive outcomes to
     retain and foster motivation.

3.1.1 Literacy and health
In Canada, the Centre for Literacy of Quebec has been co-ordinating resources,
training and research since 1989 on the links between adult literacy and health. They
are currently involved in a health literacy project that conducted a recent assessment
of health education and information needs of hard to reach patients27. The survey
began by mapping the OECD’s International Adult Literacy Survey findings for
Canada with functional requirements for an individual’s effective health behaviours.
Measures were made of the reading skills needed by individuals to make sense of
health education and promotion resources. These were found to be pitched at


25
    Aldridge, F and Lavender, P. The impact of learning on health (Leicester: NIACE, 2000)
26
    James, K. Learning and skills for people experiencing mental health difficulties: briefing
sheet. (Leicester: NIACE, 2002)
27
    Centre for Literacy and Health, Health Literacy Project, Phase 1: Background document on
literacy and health (Montreal, Canada: Centre for Literacy and Health, 2001).
24
literacy levels too high to reach a significant cross-section of the Canadian
population.
The following direct effects were noted:
     Individuals with low literacy cannot read medication labels and sometimes take
      medication incorrectly.
     Compliance with medical directions for treatment is often a problem for those
      with low literacy.
     Parents with low literacy skills have difficulties in reading instructions to prepare
      baby food and may feed infants improperly.
     Individuals with low literacy skills may not understand workplace health and
      safety regulations and requirements.

Related US research has shown that individuals with low literacy:
     cannot read written instructions for preventative, self-help and follow up care
      after illness or injury; and
     have problems with appointment slips, informed consent forms, discharge
      information and oral instructions.

And further indirect effects of low literacy were found:

     Those individuals are more likely to live in low quality housing in unsafe areas,
      with greater pollution and environmental hazards.
     People with low literacy are less likely to request care early in the course of an
      illness.
     Those with low literacy smoke more, exercise less and have poorer nutrition.
     Those with low literacy are less likely to conduct individual health monitoring
      procedures.

The report cited US research that noted:

        “There is considerable research demonstrating the links between low
        literacy, poverty and ill health. Therefore, groups that most likely need
        health education and promotion the most are the groups least likely to
        benefit from the current practice28”.


3.2      Factors leading to better health

Benefits to individuals’ health and the factors at play, figure prominently in a recent
report by the Centre for the Wider Benefits of Learning. The report, Learning,
continuity and change in adult life, considers a number of themes which each impact
on individuals’ perceptions of learning:

     School and initial education
     learning contexts and experiences
     adaptation and change
     family lives
     health
     social capital and cohesion.29
28
   Hohn, M. Empowerment health education in adult literacy: a guide for public health and
adult literacy practitioners, policy makers and funders (US National Institute for Literacy,
1998).
29
   Schuller, T, et al, Learning, continuity and change in adult life. Report to DfES by the
Centre for the Wider Benefits of Learning (London, Institute of Education, 2002).
                                                                                               25
The report concluded that, despite a lack of evidence of direct causality, education
has a sustaining effect on personal lives and society by helping people to cope with
stress as well as to make positive contributions to community life. Individual benefits
accrue in psychological well-being, independent activity, improved communication
and understanding and clearer sense of purpose and self-esteem.

On a wider level, learning promotes networks and social activities and builds shared
values. To achieve these, the report proposed that community development and
neighbourhood renewal initiatives include clear links to educational progression
routes.

Specific findings in relation to health were that different kinds of health effect overlap
and interact and that there was more evidence about mental and psychological
health effects than about physical ones.

The report found that learning aids both protection of and recovery from mental
health through:

providing distraction from problems;
providing a vehicle for self expression;
re-establishing the ability to relax;
providing a structure;
building self-esteem;
developing a positive sense of identity;
fun and enjoyment;
mental fitness;
building self-efficacy;
developing a new sense of role and social identity – or replacing the one that the
individual had before their breakdown;
helping people to identify their direction and goals;
giving people confidence in relation to others;
helping people to feel part of the social world.

NIACE has also been examining the benefits of learning to health in terms of existing
provision, successful approaches by learning and health professionals, and
innovative partnerships, such as the Prescriptions for Learning initiative.30

The idea of Prescriptions for Learning is the basing of a learning adviser in a GP
surgery. GPs and other healthcare staff can then refer individuals to discuss access
to learning and the support that they may need with their learning.

Prescriptions for Learning was originally set up in Gloucester and Nottingham
respectively, the former by Gloucester College of Arts and Technology jointly with
the NHS South West, the Local Education Authority Adult Education Service, and
Social Services.

The project involved the placement of community learning advisors in health centres
in and around Gloucester and surrounding towns. They targeted, surgeries in areas
of disadvantage, poor health and low participation in learning. Guidance officers took
referrals from healthcare staff and patients with an interest in learning, developed
individual learning plans, liaised with appropriate training providers and monitored
follow-up and progression31.

30
   James, K, Prescribing learning: a guide to good practice in learning and health (Leicester:
NIACE, 2001).
31
   James, K. Prescriptions for Learning [Nottingham] evaluation report. (NIACE, 2001).
26
The Prescriptions for Learning Report highlighted five approaches to learning and
health:

    Learning about health
    Learning that occurs though involvement in an activity for a specific health
     purpose and outcomes, usually physical activity.
    Learning that occurs through involvement in an activity that allows individuals to
     explore and express feelings, to express creative potential, and to promote a
     positive sense of mental well being.
    Building self-esteem learning for a more general health outcome that enables
     individuals to explore how they feel about themselves, and which could impact
     on behaviour and lifestyle, such as self esteem raising or assertiveness.
    Learning whatever an individual is interested in, or wants to achieve, which,
     where this is a positive experience, has physical or mental health impacts such
     as Prescriptions for Learning. 32

3.3 Evidence from Government Programme Evaluations

Given current Government policy’s emphasis on supporting locally-based initiatives
and programmes, it is worthwhile taking a look at some of the issues emerging from
the evaluation of these initiatives and programmes.

One theme beginning to emerge from these evaluations is the complex nature of the
evaluation process itself. Writing in the Journal of Health Services Research and
Policy, Professor Ken Judge points to the fact that given the complexities of these
initiatives, traditional evaluation approaches are often inappropriate and there is a
fundamental problem of attribution33. With so many interacting factors impacting on
the programmes and activities in many local areas, it is almost impossible to focus
attention solely on the mechanisms or interventions of interest and to assume that
contextual factors can be ‘controlled for’ in some way. New approaches to evaluation
are required.

This is further highlighted by the authors of the National Evaluation of New Deal for
Communities: Community Health Initiatives.34 They point out that the review of
recent policy developments and the emerging evidence-base reveals some
important lessons for policy-makers and NDC partnerships.

The report pointed to problems arising from the lack of firm evidence of effectiveness
of health interventions in deprived communities in the UK, and the need therefore to
ensure that health-related activities and any health benefits (both subjective and
objective) of the initiative were captured.

It also pointed to methodological challenges and suggested that the evidence-base
was weak in relation to a number of health interventions often because the methods
selected for evaluation were insufficiently rigorous. The authors suggested that
emerging experience from both the HAZ and Scottish health demonstration project
evaluations suggested that theory-based evaluation was most useful at the
beginning of an evaluation, and as an overarching framework for research within
which a range of methods could be employed.


32
   Prescriptions for Learning, NIACE
33
   Judge, Professor K, Testing evaluation to the limits: the case of English Health Action
Zones, Journal of Health Services Research and Policy Vol 5, no 1 (January 2000)
34
   National Evaluation of New Deal for Communities: Community Health Initiatives
                                                                                             27
The report goes on to say that at the same time, there is a need for well-designed
cohort and panel surveys to develop the evidence-base further. These need to
include intermediate measures of health change, as substantive health outcomes (in
terms of population health change) can literally take decades to be realised.
Intermediate measures such as changes in lifestyle and particularly self-perceived
health questions (which are an important predictor of improvements in health status)
need to be included. Secondary benefits of health interventions should also ideally
be tracked.

In terms of lessons for partnerships the authors suggest that despite significant gaps
in some aspects of the evidence-base, there are important messages for NDC
partnerships in terms of which types of health-related activities are most likely to
yield benefits for communities. They pointed to the fact that ‘comprehensive’
interventions were more likely to be successful than those focusing on one particular
issue or population group with specific types of services being offered.

Below we look at the evaluation of New Deal for unemployed people and the impact
that this has had on the health of participants.

3.3.1 New Deal
The New Deal programmes for unemployed people have formed a key part of the
Government’s welfare to work strategy. They aim to increase the employability of
participants as well as helping them move into jobs more quickly.

New Deal for Young People was rolled out in 1998 and targeted young people aged
18-24 who had been unemployed for at least six months. As part of the
Government’s commitment to assess the health impact of major new policy
initiatives, the Department of Health set out to examine whether the New Deal for
Young People had had a direct impact on participants’ health. The study examined
both the direct impact on health, through opportunities that were open to them whilst
on the programme; and the indirect impacts through accelerating progress towards
employment35. It found that 18 months after entry to New Deal:

    participation in the New Deal Options appeared to have a beneficial impact on
     general health, compared with remaining on an extended version of the
     Gateway;
    participants in the Education Option appeared to be doing generally well in terms
     of their mental health. The education option seemed to have an impact on mental
     health not related to positive job outcomes, ie they related to the process and
     context of learning;
    the Employment Option had the most beneficial impact on self-efficacy;
    participants on the Employment and Education Options had the lowest level of
     experiential deprivation, suggesting that social contact, taking responsibility and
     respect were good sources of experience.

The results were not able to show whether health impacts arose from the activities
undertaken in the options or from the options’ effectiveness at moving people
towards more rewarding labour market outcomes.




35
  Lakey, J. and Bonjour, D, Health Impacts of New Deal for Young People (Policy Studies
Institute 2002)
28
4    LEARNING AND HEALTH WORKSHOP: DISCUSSIONS AND KEY
ISSUES

The learning theme culminated in a regional workshop which attracted forty-five
participants from a wide range of stakeholder organisations including national,
regional and strategic agencies, learning and skills providers, health professionals,
trades unions, and local initiatives (see Annex A for the list of participants). The aim
of the workshop was to provide a platform for the sharing of ideas and the
development of recommendations for the improvement of policy and practice in the
South West region.

Speaker sessions were aimed at stimulating issues for debate and included well-
received presentations from:

     Julia Verne, Director of the South West Public Health Observatory;
     Sheila McCann, Government Office for the South West;
     Kathryn James, NIACE;
     Cathie Hammond, Centre for the Wider Benefits of Learning; and
     Claire Easterbrook and Jane Ashton, P2P.

Discussion groups provided participants with the opportunity to share views,
examine issues and develop recommendations for actions in the region.

The issues explored by delegates through these discussions were those highlighted
by practitioners in a preceding online debate on the SLIM Website (accessible under
‘Learning Theme’ at http://www.swslim.org.uk).

Key issues for discussion were:

1.       Identifying the health benefits of learning.

2.       Making the links between learning and health.

3.       Developing an holistic approach to learning and health.

4.       Forging better partnerships between learning and health professionals.

5.       The policy and operational boundaries linking learning and health.

Set out below are the key questions followed by the key points to emerge from these
discussions. Recommendations relating to these may be found in Section 5 below:

4.1      Identifying the health benefits of learning

What are the health benefits of learning? What can learning contribute to reducing
health inequality? At the level of the individual, what are the key health benefits of
learning and can these be measured? Are there health dis-benefits of learning?
What aspects of learning are most likely to produce positive health outcomes and
how can these be built into learning provision?

4.1.1 Benefits of learning
At a very basic level, participants agreed that learning enables people to change
their lives. What is more difficult is pinning down the precise outcomes of learning,
particularly in relation to health.



                                                                                         29
The emphasis of Government policy in relation to learning is about getting people
into jobs. However, if improving peoples’ lives, including improving their health, is
also important, then new approaches to learning may be needed. Changes may be
required not only in the way that learning provision is determined, designed and
structured, but also in the nature of the outcomes that are recognised and valued.

Practitioners at the workshop were keen to stress the importance of learning in
raising self-confidence and enabling people to improve the socio-economic position.
Once again, and as already discussed, anecdotally it was known that these led to
better health but it was often difficult to track the direct links.

Moreover, participants felt that it was time to highlight the wider benefits of learning,
that it was not just for work but to enhance life as a whole. ‘Champions’ will be
important in making this case, to promote benefits to professionals and recipients
alike.

For this to happen, it was recognised that a better understanding was needed about
exactly how learning promotes better health and well-being. There are undoubted
personal benefits from achievement in learning. Formal learning is important, but
unaccredited, more informal learning is just as beneficial when taking into account
the health benefits.

4.1.2 Dis-benefits of learning
Whilst participants were keen to stress the potential benefits of learning, they wanted
to acknowledge that for some individuals there were dis-benefits. The wrong learning
in the wrong environment can cause stress. Learners can be made to feel
inadequate by poor quality learning provision.

As one contributor to the online discussion highlighted:

      … simply putting people in a learning situation is not necessarily going to
      improve their health. There needs to be some form of direction and
      purpose to the learning process for it to be of benefit, and learners
      themselves also need to be aware of this. To avoid unsuccessful learning
      attempts, people entering a learning situation benefit from guidance and
      support to ensure the level is appropriate for their ability and the subject of
      the learning is relevant to their life goals. Ongoing monitoring is also
      extremely valuable. In this way it should be possible to maximise the
      chances of people maintaining motivation and confidence whilst on a
      course. This is just as true for adults as it is for children, and especially true
      for anybody who could be considered as one of a vulnerable group.
                                                                                  David Hill

4.2    Linking learning and health

How do we make the links between learning and health? Does there need to be a
change in the ways that learning and health are understood? What are the most
effective ways of linking learning with positive health outcomes? Can learning
provision be designed to lead to better health outcomes? What key lessons to
emerge from this? What does this mean for the ways in which we organise the
learning environment? What opportunities/challenges exist from the expansion of the
health infrastructure in the region to build on the links between learning and health?




30
4.2.1 The links are complex
Workshop participants were clear that learning and health were mutually beneficial.
Yet the picture is hugely complex because of the nature of the socio-economic
factors which interplay across these areas.

This complexity has meant that hard evidence showing the links between learning
and health is lacking. The links are mediated by other factors between learning and
health. There is no one direction of causality and that in turn makes the link appear
vulnerable. As a result it is hard to develop a clear public policy response.

At one level participants were keen to stress the importance of educating people to
build healthy life practices into their daily lives, how if you walk to the bus with your
kids they will become accustomed to walking to the bus, eating vegetables etc. Many
poor health practices arise from the general fabric of social existence, peer pressure
etc. Education (broadly defined) was the process through which they could be
challenged.

As one on-line contributor stated:

      The government holy grails of health and education are inextricably linked.
      Wealth on its own isn't much use. I guess one of the questions in my mind
      is the extent to which we can sign up to the WHO definition and look at how
      education in its broadest sense influences health. The better the education,
      the more likely we are to be employed, and those in employment are
      healthier than the unemployed. So education is good for your health.

      Education about health probably has much less effect on health than
      general education. It's probably good to have some health education, but
      it's not very important in the grand scheme.

      The issues are simpler in less developed countries. Education has much
      more lasting effects on population health than any medical intervention.
      The interventions are good, but generally a little late.
                                                                         Brian Cooke



4.2.2 Need for evidence-based research
This led to a debate on the need for more evidence-based research to assist in
reinforcing the positive health benefits of learning, of a qualitative as well as
quantitative nature. It was also agreed that the research and evidence which does
exist had not been widely disseminated.

It was important to establish the direction of causality. Is it education to good health?
Or education to better socio-economic group to health? There are other links with
family, support and expectations.

Fundamentally the key issue remains tackling social exclusion. Those excluded from
learning are those most likely to suffer ill health. We need to focus upon tackling
exclusion from learning and seek to include health within that.

Yet it was recognised that change takes time. There is a continuing need for
evidence-based research and case study style guidance to assist those facilitating
positive health messages.



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This evidence-base is important if professionals, communities and individuals are to
be empowered and given the confidence and skills to behave differently.

4.2.3 Beneficial approaches to learning
Participants discussed approaches to learning that were most likely to be beneficial
in terms of positive health outcomes.

Firstly, participants stressed that it was never too late to use learning to change
attitudes. But there existed a learning and guidance divide: people are much less
likely to receive guidance post-45 if they are less well educated, and are more likely
to be dissatisfied. Initiatives are needed that pull together learning/health benefits for
individuals and communities. Just getting people to first base was the greatest
hurdle.

Other key issues highlighted were:

    Involvement of users of services is key.
    Being treated as an individual. It is what the learner wants that is the issue. Help
     learners to take control and give them choices – empower them. It is important
     to build up a trusting relationship.
    Providing a variety of delivery methods which appeal to users and recognise the
     wide variety of learning skills and styles including peer group learning. Learners
     need choice and realistic expectations.
    People need the skills they want - demand-led provision, not institutionally
     supply-led provision. Inappropriate provision leads to negative experiences that
     could prevent those people from learning in the future.
    Provision has to be right for the person, at the right time.
    There is a need to listen actively and carefully to learners so that provision can
     match what they want. Some people are resourceful, some are not.

One contributor to the online discussion stated:

       My work has indicated two issues perhaps of relevance to 'how do you
       design wellbeing into learning provision?'

       Some research I did back in '95 and '98 indicated that the conditions within
       optimal learning relationships in the lives of learners were those that Carl
       Rogers had deemed essential to effecting change in counselling and
       learning. Such relationships were learner-centred, empathic and authentic.
       The spin-offs for learners were increased self-esteem, and a sense of
       agency. These relationships were also stated to be essential to learners’
       well-being and mental health. In effect, they felt more able to control their
       environment and make choices. So a 'relational way of knowing and
       learning' is perhaps something that could be more recognised as a process
       within education of any type.

       … recent research with 197 adults (age 30 to 80) who were on the margins
       of society, poorly educated but who had been given grants of relatively
       small amounts of money to change their lives,(by going on courses, or
       whatever they chose)… has indicated that friends and partners can also
       provide much needed support through learning events and transformations
       of any kind. It also reinforced the issue of increased agency as a motivator
       for people to take control of their circumstances and deal with difficult
       patches. Participants described a better 'quality of life', improved health,
       and changed perspectives and attitudes brought about as a spin-off from
       formal and informal learning in adulthood.
32
      Perhaps when designing a learning environment, some thought could be
      given to motivating learners by enabling opportunities for solving everyday
      problems within groups initially, with an aim to increase autonomy within
      mutually supportive interdependent relationships. There were of course
      some other factors which arose but to include them here would make this
      e-mail too long.

      To sum up, I'm not sure that we can design for wellbeing, but I think there is
      much we can do to increase and maximise the learning environment so
      that wellbeing becomes an outcome.
                                                                   Christine Bennetts


4.2.4 Community learning
High on the agenda is the need to recognise the importance of community learning,
which often provides a supportive environment for non-traditional learners.

The approaches adopted in community learning allow interventions to follow the
needs of the learner, rather than expecting learners to fit the requirements of the
programme.

Many participants felt that real progress was only possible when it arose from the
community. However, there was disagreement about what was needed to make
community learning work. Some were clear that 'it's not about money, it's about
people'. Whilst others argued that money was a 'facilitator' as it makes it possible for
communities to understand and realise their inspirations / desires / visions. The
problem really is that for many communities and individuals, there is a lack of
inspiration and vision of what life might be like or what is possible.

4.2.5 Engaging young people
The initial engagement of young people in learning was considered important.
Schools should offer lifeskills as this was essential for empowering young people to
believe that they can change their destiny.

Ultimately young people place a high value on work. To that end, offering earlier
vocational experiences ie before 16, might help. Young people with low levels of
education believe they cannot do a lot about it or change their life. It is important to
make them believe that they can and that they can look after themselves. Showing
them that learning can be informal may be a first step, for instance drawing out what
they have learnt in something they enjoy like skateboarding.

4.2.6 Peer groups
Peer group attitudes to education is important when engaging young people and
adults alike. Peer learning – eg TUC learning reps – where peers learn from each
other fosters empathy with others and shared experience.
.
Participants felt that amongst teenagers in particular, peer group learning should be
considered – as with successful examples of peer tutors amongst teenagers.

Such approaches need “social time” so that effective relationships between peers
can be fostered.




                                                                                      33
4.2.7 Start with the Soft approach
For those who have not participated in learning, the first step is engaging them. A
good place to start is non-accredited learning. This often leads to them wanting to
follow up with further learning.

For instance Raleigh International's Plymouth based Youth Development
Programme, works with 'Youth at Risk' to enable individuals to participate in Raleigh
International expeditions. Each individual is supported through various activities
which prepare them for expedition. During this process there are opportunities to
work towards various other goals or accredited learning activities such as Duke of
Edinburgh, First Aid or Open College Network. Whilst these are not the initial hook
to become involved in the project, and are not always apparent to the individuals
themselves, they are supported through the realisation that the training and
development that they undertake as a core part of preparation for expedition can
assist them in achieving other accredited learning. These 'fringe benefits' can
contribute to a greater feeling of self-worth and themselves lead to further learning

However, whilst the experience may be positive for some, it can deter others if they
think there is a hidden agenda. Images of learning can frighten people off, so people
may need to be allowed to learn without knowing it. Learning can be almost
unconscious particularly when people are doing something they already know they
enjoy, such as playing the guitar. What is learnt is not necessarily the obvious, and
friendship-building may be more important than the acquisition of technical know-
how at a motorcycle maintenance class. It may be difficult to persuade someone
who has a low self-image and poor mental health to learn. Great skill is required to
inspire such a person, to prevent them from getting the message that they need to
learn because they are not good enough at the moment, which simply reinforces the
downward spiral of inadequacy.

There is a key role to play in raising people’s self-esteem so that they can make
decisions about learning. The emotional precursors to learning need to be
recognised. Non-accredited learning is important in raising self-esteem yet it can be
hard to attract funding. Non-traditional learning environments should be supported,
and a broad definition of learning is also needed.

It is important to dissipate the anger from people who feel isolated and are therefore
defensive. They fear the unfamiliar and failure. Non-traditional environments can
present people with a positive view of learning.

People need help in assessing their needs and abilities before attempting formal
learning. They need to be given a soft, informal approach as a stepping stone, so
that it becomes a positive experience. If not, there's a danger of reinforcing the
negative perceptions of education. It is important to recognise what the learner
needs at a given time in their life, rather than what is provided by institutions and
curricula.

It is also important to bring people to a point where they can engage in learning. As
such, a starting point might be the soft issues including building self-esteem, worth,
life and home skills [and again control], having a broader impact on social capital,
and linking learning to positive health impacts, so that more formal learning becomes
a natural progression.

4.3    How do we best develop an holistic approach?

Do we have much evidence of holistic approaches developing which link learning
with positive health outcomes? What lessons are emerging about the effectiveness
34
of these approaches? If effective, how can such initiatives best be supported
(resources, operational issues etc)?

4.3.1 Holistic approach
Participants raised the issue of how best to support people with multiple problems
such as alcohol abuse and mental-health related difficulties who could not return to
learning without support. The complexity of dealing with some of these problems
means that many agencies need to work together to achieve an holistic approach.
Participants felt that at some point the referral to a learning adviser will become an
entitlement in the same way as referral to counsellors.

4.3.2 Measuring impacts
Key to the development of a more holistic approach is the need to measure the
impact of learning on health. However, the different ways in which the learning and
health fields current measures impact provides a barrier to such an approach. The
development of more rounded measurement might provide a solution.

The field of learning is characterised by a high level of reporting. Yet much of this
relates to specific, measurable outputs such as qualifications or jobs gained. If health
and learning are to work more closely together then this needs to be recognised in
the way their impact is measured.

Yet participants recognised that this may be difficult. Measuring the health impact of
learning may take time and the processes are complex. An individual may derive
benefits from learning such as more social contacts, improved confidence and self
worth, which over time may mean that they are less likely to succumb to illness and
haunt their GPs surgeries. Such a link is long and perhaps tenuous. It would be good
to evaluate the impact but it would have to be done in the long-term. If it were to be
channelled into health, then impacts/assessments may be more visible.

There was considerable discussion of ‘soft’ outcomes and the big question for
participants was how to measure them in an environment obsessed with measurable
goals and targets? It was noted that the Open College Networks have done some
work on this. Professional measures can skew progress e.g. procedures used by
consultants – evidence-based assessment shows over time. Tight and specific
targets create problems, not only in and of themselves, but if working in partnership,
each partner has different targets.

One contributor to the online discussion noted:

      … (is) anyone else concerned over the way funding is now tied up with
      formal qualifications in many ways? I think this is relevant to the discussion
      because people are being forced to build projects that fit in with funding
      requirements, rather than the other way around. One of the projects I work
      with helps people with learning disabilities or mental health issues build
      self-esteem and confidence by a variety of means, be it voluntary work
      and/or arts and crafts activities. We have countless problems getting
      funding for this because, despite funders saying they recognise soft
      outcomes we are consistently turned down because we cannot guarantee
      that people will achieve NVQs. Money to support people in their first steps
      to learning by using arts/crafts etc as a stepping stone is hard to get. Apart
      from that, the need for a qualification may put too much pressure on
      someone who needs to discover that learning can be fun, what better way
      than by the arts?
                                                                         Mary, Plymouth


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Some sort of assessment is needed of the potential for a more evaluative approach
to interventions. There is a need to do evaluation, not just prove but to improve. The
impact that learning has on people’s lives is multi-various. For instance the HAZ/EAZ
evaluations are overarching.

For health, ward-level data is patchy and provides at present a much more unequal
picture than when aggregated at local health authority level. The aggregation can
conceal small pockets of deprivation, even within individual villages, which are then
overlooked. This can be particularly true of the links between crime and community
safety.

One participant to the online debate commented:

      The other difficulty is that I think we expect health outcomes too quickly -
      again perhaps because we are so funding driven. Many people have health
      difficulties that have developed over many years, and they are not going to
      be solved over night. Benefits may take years to show, or may not even
      occur for them but for their children.

      The issue of self-esteem is useful I think though because it affects us all
      regardless of our health status. An interesting project in Leicester has been
      using recognised self-esteem.
                                                                         Kathryn James

4.4    Partnerships

How do we forge better partnerships between learning and health professionals?
What evidence is there of effective joint working between health and learning
practitioners? What are the main barriers to effective joint working? What good
practice exists? Do we need to build capacity of practitioners to work jointly? How
well equipped are learning practitioners to understand and meet the desire for
positive health outcomes?

4.4.1 Partnership the best option
The need for better partnership between health, education and social services is
overriding. Partnership yields the best for the client, and has the advantage of
allowing practitioners to see things from different perspectives. It is important to
build up relationships cross-sectorally and with the learner, empowering people to
understand their needs better and building up vital trust.

Cross-agency partnership needs to be collaborative, integrating aims and
approaches. Partnerships can help in securing funding which is essential for
maintenance and development. But here is where problems arise. The nature of the
resources and of the competition for them often acts as a deterrent to collaborative
working.

Participants particularly noted the need for better co-ordination of information, advice
and guidance.

Partnerships and practice also need to join up at an appropriate level. It was
common for practitioners to develop close working relationships only to feel that they
were not supported by the right policy context and funding.

Conversely, joined up policy does not necessarily lead to joined up practice on the
ground. The whole process needs to be reviewed to ensure fitness for purpose.


36
In conclusion, participants called for the abandonment of the endless short-term
funding sources and competitive bidding for them in favour of more collaborative and
planned working arrangements.

4.4.2 Changing attitudes
Participants recognised that significant cultural barriers existed to collaborative
working between learning and health professionals. People simply do not “speak
each others language”, either in relation to organisational ethos or indeed jargon and
terminology. Inter-professional development is needed at all levels to understand the
cross over benefits of learning and health.

Partnerships provide a vehicle to allow professionals an alternative to the way they
may have behaved traditionally. For this to be most beneficial, partnership
arrangements need to change from being solely strategic to ones in which there is
greater involvement of practitioners and opportunities for cross professional
development. Secondment between agencies can help to encourage culture change
ie between learning and health providers. There may also be a need for new, more
innovative approaches.

This is well illustrated by one contribution to the online discussion:

      Here in Devonport regeneration company (New Deals For Community
      Plymouth) we have … a health facilitator and a life long learning co-
      ordinator (are) now working side by side in the same office. I would say that
      working together is beginning to pay off and we recognise that social
      exclusion, health and learning are inextricably linked. As we work through
      our project cycle management process (this is a tool for identifying issues
      /problems, developing solutions, designing and commissioning Services to
      resolve issues and problems) we are not separating issues out but
      clustering similar ones together which affect all aspects of life and look for
      solutions which will impact across the board as well as on single themes. I
      would say that there have been greater links between health and learning.
      This has been particularly beneficial between parents, nursery teachers,
      health visitors, parenting support and basic skills providers in our area. I
      would say that the focus here on the community taking control particularly
      of the new deal process is starting to have an affect on agencies and how
      services are provided. Time and evaluation will tell.
                                                                          Liz Mawhinney


Top down – bottom up communication is essential to developing links. The common
needs of communities, government and individuals should be the drivers.

Plenty of examples exist of specific cross-sectoral initiatives but this ethos is not
mirrored within the mainstream health and learning infrastructures. Yet, the
“initiative” driven nature of much of the existing collaboration is not necessarily the
most effective or efficient way of building links. A rethink of approach is needed.
Many participants felt that the good practice that had emerged at practitioner level
had done so despite the existing structures.

A contributor to the online discussion noted:

      Gloscat (Gloucestershire College of Arts and Technology) ran some
      awareness-raising sessions a couple of years ago for groups of front-line
      staff in non-education sectors, such as housing association and district
      council reception staff. It's surprising how often people seeking help are
                                                                                          37
      referred by busy staff to a poster, or sent home with a leaflet, or asked to
      put their comment in writing, fill in a form, etc.

      Basic assumptions about numeracy are also common. With some
      sensitisation to basic skills issues, they might be able to spot that the real
      problem is not so easily 'sorted', and take the time to deal with the query in
      an appropriate way. It would be good to roll out such a programme with
      other frontline health (and other) staff, such as health visitors, district
      nurses, etc. Improving the leaflets and instructions on the bottle is only half
      the battle - the staff who are in direct contact with the public need to know
      when even good, written material is inappropriate.
                                                                             Pamela Reay

4.4.3 Primary Care Trusts (PCTs)
PCTs were felt to hold out the possibility of greater collaboration. They employ
nurses, and they are currently becoming the employer of large numbers of GPs,
particularly young ones who want to be able to move from surgery to surgery, which
they cannot easily do as partners and part-owners of a GP practice. The PCT as
employer will have increasing scope to influence what GPs do. This may be
important in encouraging them to see the wider benefits of learning, participants
having highlighted that they currently tend not to be lifelong learners in the way that
Health Professionals are.

Participants also suggested bringing health into centres such as Connexions – they
offer universal service to all young people. Connexions has been good for bridging
gaps between learning and health, particularly in rural areas, as it already operated
within schools and had personal advisors. Young people were not keen on referrals
from GPs on health/social issues but may rather go to Connexions and speak to
someone there. They do not often want medical help and the Connexions people are
already skilled in this area.

4.4.4 Barriers to or problems with partnerships
Information mechanisms remain a critical issue for partnerships. For instance,
confidentiality requirements, particularly in relation to mental health problems, can
cause barriers to partnerships. People may be reluctant to pass on information in
case they are wrong or breaching confidentiality. This also raises the issue of
professional boundaries and professional rivalries. There needs to be clarity about
referral information. People also need to be able to access education without
necessarily having to go through the referral process. Good practice in relation to
confidentiality issues is needed – at the moment this is a barrier to access to
services.

Time constraints and lack of funding are other barriers. Funding problems in
particular can lead to problems with the credibility of a project. As already noted, the
short-term nature of the funding time horizons acts as a deterrent to ongoing
partnership development. Funding structures need to be reviewed and both
streamlined and simplified.

Partnerships can be reliant on champions – people committed to the project.
Working with different agencies can be problematic but can provide opportunities too
for organisations to talk to each other. The challenge is to keep the individual central
to all this rather than subordinate.

Knowledge of good practice and what other partnerships are doing is also very
important. There are many benefits to working in partnerships but it is necessary to
break down the language barriers. The eventual goal may be the same but the
38
language may look different and thus create problems. What about a “Rough Guide”
to PCTs?

Partnerships are meant to solve the problem/danger of replication – but do they?
Messages can get diluted in partnerships. Mechanisms are therefore needed to
reinforce the messages.

Perceived cultures are a barrier. Professionals tend to work in silos. We need to give
professionals permission to select alternatives and take a more flexible approach to
developing solutions for individuals and communities. Learning practitioners,
although competent, are often too target-driven. The health field is dogged by
paternalism. A fear of change pervades many professions and fears and insecurities
can be compounded when working outside their own spheres, existing working
practices and structures is suggested to professionals.

4.5    What are the policy and operational boundaries?

Are there significant policy and operational boundaries surrounding the areas of
learning and health? Do the current funding mechanisms and programmes support
or inhibit better links between learning and health? What roles should the key
agencies within the region and locally play in improving the links? What scope is
there for pooling resources?

Many of the activities required to link learning with positive health outcomes are
simple. Yet implementing even simple solutions can be difficult because of the ways
that monolithic delivery structures (NHS / Education) work and the type of
institutional thinking that they set in train.

Participants noted attempts at 'joined up policy' such as the Neighbourhood Renewal
and Social Exclusion Units’ approach and suggested that there were possibly two
types of delivery structure in operation:

a) the monolithic, target-driven type approach
b) the bottom-up, needs-driven approach that you can get in area-based initiatives
   where the ethos is on empowering communities, regardless of the institutional
   boundaries etc.

There appears to be confusion within government over which approach to
governance it favours. However, it was clear that participants felt that the bottom-up,
needs-driven approach was a precondition to developing better links between
learning and health.

The review of Area Based Initiatives taking place at the moment was noted and the
fact that HAZs will be mainstreamed. Whilst mainstreaming was good in theory,
unless there was a real commitment to it, all the good local work could all too easily
be strangled by institutional constraints or stifled by disinterest once pushed into the
monolithic structures. Hence real care would be needed to ensure that
mainstreaming happened in a way that was beneficial to all.

One contributor to the online debate stated that:

      Whilst many micro-initiatives can provide much needed solutions, we must
      be mindful not to lose sight of the macro-level picture. To my mind, we
      must be aware of the need to take fuller advantage of economic
      developments within the health sectors and place learning at their core. In
      this way, we have the basis for a much more prosperous region as well as
                                                                                      39
      the skills and people in place that will, hopefully, provide more tangible
      improvements in health and wellbeing…
                                                                          Salinder Supri

It was also noted that cultures within LSCs varied considerably, with Somerset
being held up as an example of a very liberal, free thinking, innovative LSC
compared to some others.

There was a real need for Champions for these kinds of approaches, both within
communities (demanding joined up approaches) and in the professions (pointing out
the logic, simplicity of providing them).

4.5.1 Research
Linked to the discussion on the need for research and joined up thinking, a barrier to
establishing the 'legitimacy' of this type of inter-institutional collaboration arises from
the way in which the case for public expenditure on health and learning is usually
made.

Medicine and medical research has a fairly concrete methodology for assessing
clinical outcomes from certain types of intervention. State-sponsored learning tends
to be legitimated as either being 'education' or as having an economic rationale
(market failure etc). As such, legitimating state funding of learning for its health
benefits tends to fall outside the traditional health and education paradigms.

4.5.2 Professional development
There was a sense that some GPs could be resistant to allowing non-health staff to
work from surgeries and other health settings. Some 'conservative' GPs tended to
think that they knew best, mainly because their professional experience was
somewhat narrow.

There was also a sense that GPs could think that health and education / learning
had different cultures and values which may be hard to marry up. This was
considered to be mainly due to a lack of exposure to the aims and working practices
of the other sector and may only be problem of perception.

It was felt that there was a big job to be done in educating GPs and that, if there was
evidence, the argument that 'this will save you time and money' could be a powerful
one with them. Just getting people from different professional backgrounds to spend
time on each other’s premises would also be a big help.

To date GPs have run their own practices like independent businesses and been left
very much to their own devices. As described above, this is changing with more and
more GPs becoming employees of PCTs rather than independent contractors to the
NHS. PCTs are also gaining more power to set GPs targets (though they may not be
called targets), ie they are provided with research on average 'success' rates for
various types of interventions and agree with practices what their outcomes should
look like.

Perhaps the corollary of the above, some GPs / health professionals can feel
insecure about prescribing learning.

4.5.3 Funding problems
Funding, as always, was problematic, with participants complaining of the continual
chasing for money to support worthwhile initiatives. There were a number of facets
to the problem.


40
There was the practical difficulty of working with groups in a community, either
getting them all to the same stage at the same time, or getting them all to want to do
something in order to get the funding which also took time and resources that often
were not available.

As already discussed, there was the short-term nature of the funding. It tended to be
for initiatives, not for long-term in-depth changes. There was the pressure of having
constantly to chase money; having to tailor projects to the funding rather than vice
versa; and letting people down if money did not come through or stopped mid-
project. Participants described the effect on morale for those living in an almost
constant state of uncertainty over the future of their projects, and the danger of
raising aspirations and hopes among learners only for them to be dashed when
money was either not forthcoming or not renewed.

Finally, there was the learning itself. It was acknowledged that most funded learning
was accredited whilst participants felt the need for more funding for non-accredited
and even informal learning.

A contribution to the online discussion highlighted the problems of funding what were
essentially cross-sector activities:

      The original Prescriptions for Learning (PfL) project in Nottingham was funded
      through a mixture of Health Action Zone (HAZ) money, Regional Development
      money and ESF money. When that funding ended it was funded by the local
      Learning and Skills Council (LSC) Local Initiatives Fund money and now that has
      ended it is funded through the LEA Adult and Community learning Fund. They are
      now waiting to see if they are successful with a LSC co-financing bid, which will
      give it two years funding.

      As you can see funding for such projects is short-term which make the
      projects very precarious. NIACE is now funded through the DfES to support
      a consortium of PfL projects - there are about 50 projects nationally, and all
      funded differently. Some are learning provider funded, some LSC, some
      Information Advice and Guidance, some through the Primary Care Trust
      (PCT). All are short-term funded. And of course the funding route affects
      the emphasis of the work and the required/ desired outcomes of the work.

      Without wishing to state the obvious, projects such as PfL which cut across
      sectors find it hard to get sustained funding because despite
      government/policy makers directives to work collaboratively, think joined up
      etc there is no funding that reflects that directive. HAZ's were a wonderful
      initiative to start that process but what will happen when they are
      mainstreamed remains to be seen. Will the fact that they are PCT owned
      as it were mean that they will be 'used' to address short-term health driven
      targets such as waiting lists rather than longer-term social goods like
      lifelong learning or building social capital?
                                                                         Kathryn James


4.5.4 Targets
Participants were of the view that the targets that were set often ran counter to the
outcomes that people wanted. Current government targets were seen as
compounding inequalities, sending out mixed messages.




                                                                                        41
Target-setting could lead to economies of scale which themselves do not tackle
inequalities at local level; they will not achieve targets and are too expensive to
implement.

Quality is often compromised and the choice becomes one between “cheap and fast”
and “good and quality”, where the latter is more difficult to measure. Performance
measurement is skewed to that which can be achieved in the short term resulting in
the problems for practitioners highlighted in the previous section.

Much of course depends on what you are evaluating; everyone has different ideas of
what constitutes success. Many operations are less effective, procedures become
ingrained and are continued despite having reducing value. Financial benefits can
encourage and mask ineffectual practice. Consultants follow their own practice,
specialisms and incentives.




42
5    KEY ISSUES AND RECOMMENDATIONS FOR ACTION IN THE SOUTH
WEST

From the learning theme process has emerged a range of issues and
recommendations. Many of these relate to changes in practice and we hope that the
discussion, debate and case studies provide enough food for thought. However,
participants in the learning theme recognised that there was a need for agencies in
the region to make changes to their policies and practice. These recommendations
are set out below:

Recognise the Health Benefits of Learning

1.   Learning providers, health professionals and key agencies need to recognise
     and value the potential health benefits of learning.

     Action: Learning providers, lead agencies, health professionals.

2.   More and better quality evidence is required which demonstrates the positive
     health benefits of learning. This is likely to require more longer term, evaluative
     approaches to measuring the benefits.

     Action: Researchers, funders, health and learning practitioners.

3.   If health is a valued outcome of learning then changes may be required not
     only in the way that learning provision is determined, designed and structured,
     but also the nature of the outcomes that are recognised and valued.

     Action: Government, Learning and Skills Council and local LSCs, other
     strategic agencies, learning providers.

4.   There is a need for Champions to highlight the wider benefits of learning,
     including health benefits.

     Action: Information, Advice and Guidance staff, learning providers, health
     professionals, Connexions service.

5.   Informal learning is as important as formal learning in the context of producing
     health outcomes.

     Action: Learning and skills council, learning providers

Links between learning and health

6.   The process through which learning leads to better health needs to be better
     understood. There is a need for more evidence-based research, both
     qualitative and quantitative, to assist in reinforcing the health messages.

     Action: Researchers

7.   Social exclusion lies at the heart of health inequality. To tackle health
     inequality, it is important to address the barriers to participation in learning.

     Action: Strategic agencies, learning providers, local authorities.




                                                                                         43
8.    Information, guidance and advice services should be targeted to those
      individuals and communities most excluded from learning. The potential health
      benefits should be stressed, in formats appropriate to the intended audience.

      Action: Health practitioners, IAG staff, Connexions service

9.    A number of factors need to be taken into account in the design and delivery of
      learning if health benefits are to accrue. These include:

         User Involvement
         Learning that is tailored to the learners needs – choice and empowerment
          are key. Provision has to be right for the person, at the right time
         Providing a variety of methods of delivery which appeal to users and
          recognise the wide variety of learning skills & styles including peer group
          learning.

      Action: Learning providers, LLSCs.

10.   The contribution of community learning, which often provides a supportive
      environment for non-traditional learners, needs to be recognised and
      supported.

      Action: Local authorities, LLSCs.

11.   Schools need to offer lifeskills to encourage young people to think about their
      health and to understand the benefits of learning.

      Action: Schools, LEAs.

12.   Allow young people the opportunity to engage in informal learning and have
      earlier exposure to vocational learning opportunities.

      Action: Schools, Youth Service, Connexions, learning providers, LLSCs.

13.   Peer learning can provide a supportive environment for learning. Particular
      success has been noted with teenagers.

      Action: as above.

14.   Emphasis needs to be given to raising individuals’ self-esteem as a precursor
      to learning.

      Action: Learning providers

15.   The role of informal learning needs to be recognised and funded.

      Action: LLSCs

16.   Referral to a learning adviser should be an entitlement.

      Action: Government, LSC.




44
Developing an holistic approach

17.   More effective impact measures are needed to recognise the contribution of
      learning to health.

      Action: Government.

18.   Tightly drawn, specific targets can set up barriers to closer working between
      the learning and health sectors. Softer outcomes need to be recognised and
      these may only be measured using evaluative techniques.

      Action: Government and strategic agencies.

19.   Evaluative techniques also need to be used not just to prove but improve
      impact. Evaluations of Health Action Zones and Education Action Zones take
      this approach.

      Action: Researchers, funders

Partnerships

20.   Cross sectoral/agency partnerships are critical to linking learning and health.
      Partnerships need to be formed at strategic and practitioner level.

      Action: Strategic agencies, learning and health practitioners.

21.   Competition for resources works against the collaborative approaches which
      may be most beneficial.

      Action: Government, strategic agencies.

22.   Information and advice across the learning and health arenas need to be better
      co-ordinated.

      Action: Regional Observatories, strategic agencies, professional bodies.

23.   Inter-professional development at all levels is critical to enabling an
      understanding of the cross-over benefits of learning and health.

      Action: Government, strategic agencies, professional bodies.

24.   A more structured and systematic approach to collaboration is needed which
      does not rely on the start-stop initiatives that currently prevail.

      Action: Government, strategic agencies.

25.   Primary Care Trusts need to be proactive in encouraging health practitioners to
      understand the benefits of learning and promote better links with learning
      practitioners.

      Action: Primary Care Trusts, learning providers.




                                                                                        45
26.   The systems for sharing information between agencies are inadequate and
      further hampered by lack of clarity about client confidentiality requirements.
      This can lead to a breakdown in effective communications between learning
      and health practitioners. There needs to be greater clarity in the systems so
      facilitating partnership.

      Action: learning and health professionals.

27.   Time constraints and lack of funding provide real barriers to collaborative
      working and partnerships.

      Action: Strategic agencies and funders.

28.   There needs to be more best practice sharing on how the effective
      partnerships operate.

      Action: Professional networks, Observatories, strategic agencies.

Policy and operational boundaries

29.   The bottom-up, needs-driven approach is a precondition to developing better
      links between learning and health. The Health Action Zone approach should be
      spread more widely.

      Action: Government, strategic agencies.

30.   Short-term funding militates against those activities where the positive
      outcomes may only accrue over time. Longer time horizons are required for
      funding this type of initiative.

      Action: Government, strategic agencies.

31.   The nature of the current performance targets in the health and learning fields
      militate against the longer term/soft outcomes approach that may be required if
      the learning is to accrue positive health benefits.

      Action: Government, strategic agencies.




46
6      CONCLUSIONS

Learning has the potential to impact beneficially on an individual’s health and can
contribute to reducing health inequality. However, the process of translating learning
into health benefits for individuals and the community is a complex one.

Throughout this learning theme we have identified a range of effective practice which
demonstrates how learning and health practitioners are working together to achieve
results. Yet many barriers continue to exist to joint working.

At the same time, all-too-often, the requirements of publicly-funded health and
learning programmes focus on that which is measurable in the short term. Too often
they militate against those activities whose impact may take more time to realise or
whose outcomes are ‘soft’ and by definition difficult to measure.

As our understanding of the positive benefits of learning improves, so we also need
to improve understanding across the professional divide. We also need to get better
at evaluating these activities and sharing what we have learned.

It is widely believed that learning has the potential to impact beneficially on an
individual’s health. By extrapolation, it thus has a part to play in reducing health
inequality where research already shows that those with low educational attainments
enjoy poorer physical health. However, the process of translating learning into health
benefits for individuals and the community is a complex one and at present it is not
well understood. Much of the evidence to support the belief in the link between
learning and health is anecdotal. Moreover, much learning that is beneficial to
health is in fact informal and ‘soft’, particularly in its initial stages, and not easily
susceptible to measurement or quantification.

There are, as a result, a number of conundrums which the learning theme brought
into sharp focus.

There are many good examples of effective practice where learning and health
practitioners are working together to achieve results. Yet many barriers to joint
working exist. These may be summarised as ethos, vocabulary, and competition for
scarce resources both within and across sectors.

Then there is the short-term nature of much of the funding itself. Whilst applauding
the Government’s emphasis and commitment to tackling social exclusion, including
poor health and educational attainment, the existing funding is largely for initiatives,
not long-term sustainable projects. The result is that a lot of good work is started,
and then efforts diverted to obtaining further funding to continue the work.
Uncertainty affects the morale of staff, and those the projects are designed to help.

The learning theme as a whole, and the workshop in particular, provided an
opportunity for professionals from both sectors to meet and understand each other’s
points of view. It demonstrated vividly how much was shared in terms of good
practice, and belief, and how much was unintentionally frustrated. As our
understanding of the positive benefits of learning deepens, so we also need to
improve understanding across the professional divide. Our recommendations are
designed to tackle that divide and improve practice.




                                                                                       47
BIBLIOGRAPHY

Acheson, Sir Donald, Independent inquiry into inequalities in health. Report to DoH
by the committee chaired by Sir Donald Acheson, (London, HMSO, 1998)

Aldridge, F and Lavender, P, The Impact of Learning on Health (Leicester, NIACE,
2000)

Bauld, L, Mackinnon, J, and Judge, K, New deal for communities: the national
evaluation scoping phase: Community health initiatives: recent policy developments
& the emerging evidence-base (University of Glasgow, 2002)

Black, Sir Douglas, Reducing inequalities in health: an action report. Report to DHSS
by the committee chaired by Sir Douglas Black, 1980. Published as The Black
Report, (Pelican, 1982)

Centre for Literacy and Health, Health Literacy Project, Phase 1: Background
document on literacy and health (Montreal, Canada: Centre for Literacy and Health,
2001)

Chief Medical Officers Annual Report 2001 (Department of Health, 2001)

DfEE, Learning to Succeed White Paper (Department for Education and
Employment, 1999)

DfES, The Learning Age, (Department for Education and Employment, 1998)

Department of Health Press Release, 24 January 2003 on www.info.doh.gov.uk/
doh/IntPress.nsf/Archive/ on 14.2.03

DoH, NHS Plan (Department of Health, London, June 2000)

DoH, Saving Lives: Our Healthier Nation White Paper (Department of Health, 1999)

Feinstein, L. Wider benefits of learning, Centre for the Wider Benefits of Learning
(DfES Research Digest 2002)

Hamer, L and Smithies, J, Planning across the local strategic partnership (London,
Health Development Agency, 2002)

Hammond, C, Learning to be healthy. Report to DfES by the Centre for the Wider
Benefits of Learning, (London: Institute of Education, 2002)

Hohn, M, Empowerment health education in adult literacy: a guide for public health
and adult literacy practitioners, policy makers and funders (US National Institute for
Literacy, 1998)

HDA et al, Community strategies and health improvement: a review of policy and
practice. Report by the HDA/I&DeA/DLTR/LGA, (2002)

Healthy Living Initiative Programme: the Pendeen Project. Evaluation report to the
Cornwall/IoS Health Action Zone (University of Plymouth, July 2002)

James, K, Learning and skills for people experiencing mental health difficulties:
briefing sheet (Leicester, NIACE, 2002)


48
James, K, Prescribing learning: a guide to good practice in learning and health,
(Leicester: NIACE, 2001)

James, K, Prescriptions for Learning [Nottingham] evaluation report, (NIACE, 2001)

Judge, Professor K, Testing evaluation to the limits: the case of English Health
Action Zones, Journal of Health Services Research and Policy Vol 5, no 1 (January
2000)

Lakey, J. and Bonjour, D, Health Impacts of New Deal for Young People (Policy
Studies Institute 2002)

Renewal.Net Overview: Health. Neighbourhood Renewal Unit (2002)
(http://www.renewal.net)

Schuller, T et al, Learning, continuity and change in adult life. Report to DfES by the
Centre for the Wider Benefits of Learning. (London, Institute of Education, 2002)

Sheffield Hallam University, Determinants of health inequalities in the East Midlands,
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World Health Organisation. Ottawa Charter for health promotion (Ottawa, WHO,
1986)




                                                                                     49
ANNEX A         LIST OF WORKSHOP PARTICIPANTS



Surname           Forename    Position                   Organisation
Alderwick         Jillian     Consultant                 Evaluation Trust

Ashton            Jane        Health Visitor             The Surgery, Stonehouse

Astin             Lizzie      Speech & Language          Bridgwater Education Achievement
                              Therapist                  Zone
Barkle            Linda       Adult Learning and         Somerset County Council
                              Leisure
Bennett           Simon       Research Assistant         Cornwall Health Research Unit

Bennetts          Christine   Lecturer                   Research Centre for the Learning
                                                         Society
Bird              Emily       Lifelong Learning and      South West RDA
                              Information Manager
Brain-Gabbott     Lucy        Researcher                 SLIM/Marchmont Observatory

Chapman           Philippa    Consultant                 Evaluation Trust

Cooke             Helen       Public Health              SW Public Health Observatory
                              Information Specialist
Cooke             Brian

Dare              Dominic     Learning Gateway           Connexion
                              Personal Adviser
Dean              Andrew      Co-ordinator               Marchmont Observatory

Dove              Margaret    Public Health Scientist    Central Cornwall Primary Care Trust

Easterbrook       Claire      Nursery Headteacher        High Street Primary School

Elliston          Kevin       Public Health Specialist   Plymouth PC & Public Health Dev
                                                         Unit
Evans             Chris       Director                   Marchmont/SLIM

Griffiths         Karen       Development Worker         Connexions Cornwall and Devon

Hammond           Cathie      Research Officer           Centre for Research on the Wider
                                                         Benefits of Learning
Henwood           Rebecca                                Cornwall County Council

Jane              Hicks       Head of Adult &            St Austell College
                              Community Learning
James             Kathryn     Development Officer –      NIACE
                              Learning & Health
McAdie            Susan       Network Coordinator        Plymouth Business Health Network


50
McCann      Sheila    Public Health            South West Public Health Group,
                      Development Manager      Directorate of Health & Social Care
Memon       Bilquis   Family Learning &        Sure Start Exeter
                      Information Officer
Morison     Judi      Adult Learning           Adult Learning and Leisure
                      Development Manager
Neild       Ben       Manager                  SLIM

Plumb       Graham    Project Development      HOPE (Plymouth) Credit Union Ltd
                      Manager
Powell      Gary      Training and Resources   Community Council of Devon
                      Co-ordinator
Pratt       John      Regional Development     Edexcel Foundation
                      Adviser
Pye         Jo        Researcher               Marchmont Observatory

James       Hawkin    ‘Fit for Life’ Project   Pentreath Industries
                      Manager
Saunders    Val       Adult Learning Manager   Somerset County Council

Singleton   Sue       Development              Taunton Deane PCT
                      Officer/Mental Health
                      Promotion
Smith       Laura     Labour Market Analyst    SLIM

Stone       Adrian    IAG Network Co-          North Somerset IAG Network
                      ordinator
Todd        Hilary    Secretary                Marchmont/SLIM

Turner      Mary      Outreach Worker          Exeter College

Turner      Richard   Head of Adult &          St Austell College
                      Community
                      Development
Verne       Julia     Director                 South West Public Health
                                               Observatory




                                                                      51

				
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