Authors: Dr Shelina Visram, Senior lecturer in public health, Institute of Health & Society - Newcastle University, and Dr Stephen Crossley, Senior lecturer in social policy, Department of Social Work, Education and Community Wellbeing - Northumbria University
The asset approach does not replace investment in improving services or tackling the structural causes of health inequality. The aim is to achieve a better balance between service delivery and community building.
Health inequalities in the UK are increasing, largely due to slower or stagnating rates of health improvement in more socioeconomically disadvantaged groups (Raleigh, 2018). Much of this situation can be explained by structural factors (i.e. differences in socioeconomic position, power and status), which operate through intermediaries such as education, employment, housing, stress and lifestyle factors to create unequal health states (Solar & Irwin, 2010). The asset approach aims to address the powerlessness and low self-esteem associated with social stratification and thereby reduce health inequalities. Asset-based approaches (ABAs) are intended to be used alongside investment in services and efforts to tackle the structural causes of inequality. In reality, there is little evidence that this has happened, for reasons beyond the control of most proponents of these approaches.
The theory underpinning ABAs is closely linked to the concept of social capital, which Putnam (2007: 137) defined as ‘social networks and the associated norms of trust and reciprocity’. Social capital is often seen as an incontrovertible good, creating bonds within communities and acting as a bridge between communities. Portes (1998: 3) noted that the concept became popular quickly because it ‘engages the policy-makers seeking less costly, non-economic solutions to social problems’. Critics have noted that the potential value of social capital as viewed by policy-makers does not always match how it is used in disadvantaged neighbourhoods. By way of example, Forrest and Kearns (2001: 2141) note that the strong, informal, bonding ties associated with deprived neighbourhoods are perhaps more useful in dealing with issues such as unemployment and poverty than loose, weak ties of formal associations might be: in other words, getting by may be more important than getting ahead (McKenzie, 2015). Even where the potential for using ABAs or developing social capital exists in deprived communities, it is not always taken up, due to individual strategies for maintaining independence and avoiding being seen as a ‘charity case’ (Blokland & Noordhoff, 2008: 118).
There is often little consideration of power or politics in discussions on social capital and ABAs, or of the fact that not all assets are equal in value. For example, membership of the infamous Bullingdon Club confers a wider range of benefits than those experienced by members of the social clubs and working men’s clubs that are a feature of many UK towns. The literature on ABAs tends to emphasise the importance of psycho-social rather than economic assets (which are rarely mentioned), neglecting the fact that the two are often closely linked. Bourdieu (1986), on the other hand, suggests that economic capital is generally required to exchange or convert into cultural and social capital. ‘Time free from economic necessity’ (p246) allows people the opportunity to invest in and prolong their education and improve their health, whilst social capital is viewed as a long-term strategy of accumulation that requires effort and energy – it is not a ‘natural given’ (p249). Social capital and ABAs can therefore, as Bourdieu argued, contribute to sustaining rather than reducing inequalities, which is arguably how these approaches have been deployed over the last decade.
The contemporary context for this is the 10 years of austerity and welfare reforms imposed on the UK, and the effects these have had on individuals and communities. Programmes of austerity in Europe and the UK have ‘impacted most on those already vulnerable, such as those with precarious employment or housing, or with existing health problems [and is] associated with worsening mental health and, as a consequence, increasing suicides’ (Stuckler et al, 2017: 20). Academics have noted the ‘violence of austerity’ (Cooper & Whyte, 2017), ‘how politics makes us sick’ (Schrecker & Bambra, 2015) and how ‘austerity kills’ (Stuckler & Basu, 2013). Life expectancy amongst adults in England and Wales has fallen, while infant mortality has risen (Pike, 2019). Increasing levels of poverty and a shortage of midwives (both linked to austerity policies) have been advanced as possible explanations for the latter (Campbell, 2018; Taylor-Robinson et al, 2019)
The prevailing narrative of people living in poverty and experiencing inequality frames them as shirkers, scroungers or ‘troubled’: a general drain on resources and burden on ‘the taxpayer’, rather than people having assets and resources that are of value (Crossley, 2017). In this context the government has co-opted the asset-based way of working as a way to reduce ‘unaffordable demand’ on services, linked to public spending cuts. This is part of the broader shift from welfare to wellbeing, where dependency on services is seen as a moral failing rather than a fact of the human condition (Friedli, 2011; 2013). There are examples of local authorities trying to innovate and remain true to the participatory ethos of ABAs in the face of major budget cuts. For example, Blackburn with Darwen Council works alongside residents to deliver essential services as part of the ‘Your Call’ movement; this involves gritting pavements and picking litter as well as running libraries and community centres (LGA, 2019). The scheme is sustained through ongoing support and equipment provided by a dedicated team within the council, in recognition that volunteering is not a free resource. However, there is still a tendency to see ABAs as a cheap or quick fix, in spite of the literature emphasising the need to invest significant in time and effort in this way of working (Whiting et al, 2012).
In conclusion, while the goal may be to achieve a better balance between service delivery and community building, this has not yet been achieved in the UK at least. If ABAs are, in part, a reaction to the original welfare state view of citizens as passive recipients of welfare services, then the current context, where people requiring support from the state are portrayed as a burden on the rest of ‘us’, does not provide particularly fertile ground for these views. Many government policies implemented over the last 10 years have led to severe cuts to public services and actively worked against community building efforts. There are examples of local authorities successfully implementing ABAs in the context of austerity, but little evidence that they have had any impact on health inequalities to date. If we want to build on the strengths of local people to improve the health of the communities in which they live, we need to ensure they have a strong economic foundation to engage with programmes that are supposed to help them
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