What does prevention mean in an ageing population?

Iriss.fm, episode 68
Published on 17 Jan 2014

Plan P: New approaches to prevention with older people, is an Iriss project which addresses the issue of social isolation and loneliness amongst older people. Each quarter the advisory group records a group discussion about a related aspect of prevention. This is the first discussion - 'What does prevention mean in an ageing population'.

Date of recording
Audio transcript

What follows is a direct transcription of the audio recording, made by Iriss specifically to assist people with hearing difficulties. Because of the differences between spoken and written English, the transcript may contain quirks of grammar and syntax.

Plan P: New Approaches to prevention with older people, is a new Iriss project which addresses the issue of social isolation and loneliness amongst older people.  Each quarter the project advisory group records a group discussion about a related aspect of prevention.  This is the first discussion – 'What does prevention mean in an ageing population?'  

Hi, my name is Audrey Taylor, and I work for NHS Education for Scotland.  

My name is Jackie Reid, I manage a programme around Reshaping Care based at the Health and Social Care Alliance.

My name is Jerry Power, I work for the Joint Improvement Team in the Scottish Government, and my responsibility is to take the lead on co-production and community capacity building within the reshaping Care for Older People Programme.

My name is Irene Wheaton, I work for Moray Community Health and Social Care Partnership, and I am a Development Officer for older people services.  

My name is Emma Collins, I am the Project Manager in the Evidence Informed Practice team in Iriss.  

And I am Derek Young, I am a Policy Officer with Age Scotland, which is the national charity for older people promoting positive use of ageing and improving later life.

EC: Thank you all very much.  So the topic we have for discussion is 'what does prevention mean in an ageing population?  What kinds of things are we trying to prevent?

JP: Well, I don't think you can prevent any of us getting older, that's to start with, so we are certainly not trying to prevent that, but I think there are consequences we all face in getting older, some of those you can delay or mitigate against, some you can't and there's an issue of how you adapt, how you become resilient, how you are able to accept that things are changing and I think that that's as much about preventing the consequences of what happens to  you as you get older, rather than simply preventing it happening to  you, because you will face challenges, I think, as you get older and it's about having the resilience to deal with that.  So I think that's about building up mechanisms which allow you to cope with the consequences, rather than simply saying it's about preventing them, because some things simply are not preventable.  That's the, if you like, the focus I would take on prevention, it's about coping, it's about developing mechanisms for refocusing on how you actually deal with things as they change and that's the big thing for me.

DY: I think you might be talking about prevention of poor outcomes and negative consequences, and obviously this group has discussed loneliness and isolation for older people, you might be considering prevention of certain health conditions such as long term health conditions, sensory impairment if you can, but you might also be talking about prevention or avoidable and costly use of public services, so there's the ... for many older people there's the decision whether to move into a care home, whereas if you adapt your home environment, A, that's more familiar, and B, the long term cost might be significantly less and they might have a higher quality of life as a result.  So I think prevention can encompass A and all of these things and we have to bear that in mind when we are having a discussion about it.

AT: I think if you look at prevention in a completely global sense as well, that sort of negative consequences, pathway thing, you know, outcomes are often based on how you are treated and how  you are perceived, so actually the Age Scotland vision of you being values as a member of your community, which sits at absolutely the core of reshaping care, actually prevention of being treated like a burden, prevention of being described as the demographic tsunami, is probably where I aspire to be in the basis that I aspire to be an older person.

EC: So rather than, what are we preventing, actually what are we trying to amplify, what are we trying to increase or support?  Which is what you have just said around that idea, and I think you said it too, about people as an asset, regardless of their age really.  So we are trying to prevent some of these negative perceptions and views of older people within our society, at the same time as kind of being aware that what can happen as people get older, as they have negative experiences in their life of what happens to them in the way that they are treated, or the services that are available or what's withdrawn from them, so how do we prevent that happening, to maintain that positive view of ageing, basically?

IW: A lot of older people are disengaged from their communities and if they can be helped to re-engage, and this has already been said, there's lots they can still offer that's a positive view for all of society because younger people can benefit from what their experiences as well as older people benefiting from still maintaining their links with their communities.

EC: The project that we are meeting about today, Plan P, is focusing on isolation and loneliness and increasing connectiveness for older people, you mentioned a few different things that prevention can mean or be about.  Where would you say the focus of this project lies within that, how important is it?

DY: Well there is some research about how being isolated and feeling lonely can have negative consequences on your physical mental health and so on, where there is less evidence, where this project might contribute is the idea of what is effective in all circumstances or many circumstances to try and address that, because there are a variety of different factors, variety of different barriers that lead to people feeling isolated, feeling lonely rather ... and one of the things that we have discussed is the difference between physical isolation and feeling lonely, because you can have a large gathering of people and an individual can feel lonely in that circumstance, equally there is some research that people in rural  areas actually feel less lonely than someone in urban environments, and that's counterintuitive, because you are more physically isolated from other people but there are suggestions that in rural areas your networks are more effective and they are designed to cope with the idea of being physically distant from others in a way that in urban environments they aren't, so because there are so many factors here in play, it's difficult to try and come up with something that addresses the universal but I think we should strive for that, so that we can tease our key messages and the factors we can apply in what's the difference in environments.

AT: I think it's quite complex, isn't it, because one way of looking at it would be to say the subject of experience of loneliness or the being isolated can be seen in a kind of reductionist way as the symptom and in fact if you address the symptom, then we are just sticking to that kind of traditional model, so we will provide something or we will layer something in that will actively address that isolation or that experience of loneliness, as opposed to sort of stepping back and going what were the conditions that create or sustain that sense and can we start to address that, so in a sense, should we actually be focusing on the people that are the ageing population or the wider society or wider group, and that can sound a little bit like ... you know, that's almost too difficult or maybe it's an idealistic kind of view, how do we stop people being excluded and kind of disconnecting ... and I suppose some of the stuff you were saying about how do we keep that kind of positive view and not necessarily just target ... 'okay, you're a lonely old person, so now we are going to come in and do something', as opposed to what happens in our communities that results in that.

JR: I suppose for many older people in terms of becoming isolated or lonely there tends to be sort of a trigger event in life, and I guess that's something that this project will look at.

JR: I think one of the other things that I hope one of the outcomes of this project will be, is about trying to provide some additional evidence which will encourage investors, and investors, I mean not just the public sector, but the private sector and the third sector, to see that it is perfectly legitimate to invest in preventative approaches, which in this particular project address, social isolation and loneliness as a means of increasing the health and wellbeing of individuals such that there is less reliance or need for a dependency type reaction, which we sometimes get with public services, certainly in the sense that we don't build up the resilience of individuals, we don't see it as a legitimate expenditure, particularly on the health service to invest in approaches which aren't seen as traditionally NHS and so on.  So I think that, I am hoping that the project will actually start to identify that there is value to health services in investing, if you like, upstream in services which actually address these issues at their core, rather than wait for a deterioration in individuals, such that we have to respond in a different and less co-productive way.

IW: I suppose for me there's something about the sophistication that sits around that as well, because actually often the standard response is something like a befriending service, which will often be measured against the number of new connections that builds for the person.  They may just be slightly disconnected from their neighbours because of that event and we have had really good relationships around the community, so the starting point needs to absolutely be bespoke and look at the assets that are very close-by that could just be very gently reconnected.  But actually often it's about new connections, not about the people I have known my entire life, because it's about new things to do, new places to go, new people to meet.  You need a particularly sophisticated view of how you think things through, and my hope is that some of the learning from the project will actually generate things that support the partners to make those decisions, to embed that sophistication in their thinking, and that means that it helps them see why a whole stack of preventative activity needs to be designed by a community for a community.  It would be really interesting to explore whether that is a community of a specific interest group like older people, or whether that's a community more globally.

EC: What other kind of things do you think are key to looking at prevention within this age group? You have mentioned before, Jackie, about enabling and hinting behaviour of practitioners?

JW: Yes, and I suppose that's I suppose not based so much on my experience of older people, but of my experience of walking alongside my son who has autism, he has significant barriers to engaging with the world, but it means he doesn't do the talking thing and doesn't really do the shake hands, engage with you if he meets  with you, and we were shopping in a shopping centre because we went out and did lots of things locally and kids from the primary school that he went to one day a week, stopped and engaged with him, because I happened to catch myself in a window of a shop, I realised I was doing the grateful smiling thing, they weren't engaging with my son, he was a really cool kind that they played with in the playground, which is how they saw him, I was re-enforcing an attitude that he was broken in some way by looking grateful.  What I realised was, I needed to control what was my natural human reaction because he had bad experience of going, yes, positive', what that did was it presented a barrier round them and I suppose because he's now a young adult which means I have walked this road for a long time, it means in my health and social care career, what I have become very aware of is actually how very small behaviours and ways of engaging with people, they create those barriers to people being seen as an asset, who immediately has a whole stack of gifts to bring to a situation, that's not meant a lot of the time, but what you need to do is almost counter intuitively respond to the way you would naturally react in a situation and I think in this context that's really important, because health and social care workers support people because they believe that people have gifts to offer the world and a contribution to make.  

AT: I think that health and social care workers need to know what's going on in their communities, can I give an example?

EC: Yes, Irene is running some very successful groups with older people in Moray ... just put the context ...

AT: Okay, it's just that I went up to visit a men's group and hadn't been there for a while and the link worker was new, so I was introducing her and one of the guys there came over to us and his wife had very tragically died a few months earlier and this guy was very depressed, he had a big garden, he'd let that go, he couldn't cook, he was living out of tins.  Now the local doctor had known about this men's cooking group and rather than just giving him anti-depressants, he suggested he came there. So he was very successfully learning  how to cook, but not only that, he was linking with the other men in this village and going to different ... he was telling us about all the different events he was going to, so I think there's a really good intervention by the doctor by re-engaging him with the community.

EC: Irene, can you give us any other insights into what you think makes your groups run so successfully?

IW: The fact that they run it for themselves, they are encouraged right from the very beginning to develop their own programmes, they are supported initially, they are supported financially, a small financial outlay to begin with, but they are also encouraged right from the very beginning to become involved with the idea that these groups are self sustainable, and so they own it and that's why they have been successful.

DY: I entirely back that up, that's something that our sister charity, Age UK, did some research on a few years ago, that preventative work is considerably more effective when older people themselves are involved in designing it and developing it and delivering it themselves, and so I am very pleased to hear about the model in Moray and other member groups that Age Scotland has around Scotland, exhibit the same sort of features.

EC: Another interesting thought is lots of older people, not just in terms of designing supports and services for each other, but in terms of actually delivering supports in the community, I mean I can't remember what the statistics are, but the number of older people who are actively engaged in making a difference in their communities by volunteering is hugely significant, and actually I do wonder whether some of that is, in it's own way, a prevention mechanism, because it's a significant contribution.  In my community there are older people that if they weren't there, things that happen that make a significant difference to all of us, just wouldn't happen.

DY: Yes, I think RBS produced some figures that between 1 in 4, 1 in 5 older people over a certain age, I can't remember exactly what age it was, but spend a significant proportion of their time during the week actively volunteering in their community.

JP: I think ... I mean that's an incredible number, but I think one of the things that's important is that, as I said earlier, you can't prevent us all getting older but we all remain individuals and people and we shouldn't categorise or put into a box a category of individuals because they are over 60 for example, and I think some of the most inspiring work I have seen is intergenerational work.  I think for example with Time Banks that I have worked with, if you start to specifically categorise a Time Bank for example around a school or around an age group, you are actually losing the richness that you get from intergenerational work, so there are things that people who have lived to the age of 60, and I am in my 6th decade now, so I am rapidly approaching that, there are things in terms of that experience where people can actually pass on, give, can engage with younger people and likewise there are  younger people who have a different experience in terms of perhaps technology etc, but it's that mix of generations and experiences and skills of knowledge which is something that I think shouldn't be lost by simply focusing on how do we prevent certain conditions within older people by focusing simply on older people. We need to look at society as a whole, we need to look at intergenerational groups and we need to look at how we actually integrate all of society and recognise that we all have something to give from the youngest to the oldest.  And that's important for me as well, so as far as prevention is concerned, you can't simply focus on how do older people in the collective focus on how they prevent poor health or the impact ton wellbeing, you need to actually take a much broader view of that.

EC: What do you think of society that would be truly focused on prevention throughout the lifespan would look like then?

JP: Well that's a very difficult one, thank you for putting me on the spot there ...

EC: Anybody else is also welcome to ...

DY: I think if there were mans of identifying, because you referred earlier to significant events across the life course and that's a major factor, and again I am referring to the Age UK research, but that pointed out that loss was a more significant factor than absence, bereaved, widowed and so on, they feel more lonely than those who have lived alone throughout their lives.  Those who have children who then move away or with whom they lose contact, feel more isolated and lonely than those who have never have children at all, so significant effects are trigger points and that's often what is, what drives people to think ... I need to find something to do with my time, with my energy, but if public services and practitioners could spot these things and identify what the potential effect on peoples sense of loneliness and isolation might be, that might be a very useful trigger for them to then to start ... to find out, in fact, what's available locally.

JR: And this is absolutely anecdotal, just based on my experience of working with people, but actually at that point in time, people will often say that they don't need help and they don't need support, and for me, the gift of preventative service, particularly if they are based around that model of being co-produced, what they say is ... can you offer us something, and people will find it much easier to make an offer than to accept something. And I think that's true of all of us, I mean people say it's older of the older population, I think that's true of the world, most of us will say, you know, we need help, it's very difficult to ask, but if you knew someone else needed help, you would immediately want to step alongside them and do what you could.  And I think it's an interesting approach to think about how you model that practice because often there is a group you might be interested in joining down the road, is very difficult from, you know ... now that your wife is not here and you are not managing to cook, maybe you should start coming to the day hospital once a week.  And they're a very different way of engaging me in how I am going to engage with that process.

AT: I think as human beings though we respond, or usually to a request for help, so I agree it's very different saying 'would  you go to this group or would you do that', to saying ... I don't know, ... 'the high school is doing a project on something, could you please, we need your experience to come and tell them about whatever that is', and that request for engaging or help or support with something is very, very powerful and I think ... back to  your question about what would a society look like ... I  hope it doesn't sound too naive, but it something about where people can actually ask for what they need and think but it's here, you know I don't have to go and look miles away or I don't have to make this a very complex response, I can look in my local community and I can say I am a primary school teacher and I am going to be doing something around ... whatever it is, then I can look in my community for resources and assets around that, and that will be within the people ... and then get over the barriers that might be, oh you can't do this because of that or the health and safety rule will say you can't bring ... I don't know, an older person into the school for some reason, but somehow a society that has the ability to kind of flex around that or work around that, so that we do say well, what we need is there in our community, we just need to ask for it and someone will respond to that. 

EC: And that goes back to I think what you were mentioning earlier regarding services that focus specifically on isolation and loneliness aren't likely to have that affect, it's services that give people other things that will have the knock on effect of making sure people stay connected and involved.

AT: Well arguably it's a secondary focus but it's possibly the primary gain in a sense, because yes, for me there is something about saying yes, now we are going to provide a service that will make you feel less lonely that for a lot of folk, myself included, would have me running for the hills going, 'don't come near me with that'.  But something that was around, okay we want to help build your physical fitness or some other aspect, then I think for a lot of folk it's much easier to engage with.

DY: People like to participate in culture and the arts for example ... 

AT: Yes

DY ... and one of the things Age Scotland is involved in is Illuminate Festival, which is the creative ageing thing, based on the ... the biggest one in the world is the Beltane one in Dublin, which a quarter of the Irish population participates in over a length of time, and at the last one in Scotland we had 350 different events over Scotland, so that's something that you don't have to be particularly physically active to be able to participate in,  you can pick up new skills,  you can form social networks and so on, and all of that is tremendous and doesn't make people feel that they are needy, which there's a huge resistance to and I think part of it is a Scottish aspect to that too, but I don't want to dismiss befriending, because it is of value and as long as people can access it differently, so there are telephone befriending services for example, including one that ... first shameless plug ... Age Scotland has just arranged with the Silver Link Charity set up by Esther Rantzen of the National Telephone Helpline ...

AT: Have you got the phone number there?

DY ... it's 0800 4 70 80 90 ... there's a wee jingle I could sing to ... but as long as there are a variety of different options because of ... something Jerry has mentioned before, people have different needs and wants, so having a variety of different options available which people can access which they feel are appropriate to them and their circumstances, that is ... it has to be a multi layout approach to try and achieve, prevent ... for different people ...

JR: Choice is important

DY: Absolutely

JR: Going back to your question about what a community that absolutely has prevention embedded in it looks like, for me in terms of the touch and feel at the very essence of it is people know who each other are, because prevention is about connections, because either in order to know where to go if you do need a bit of support or have someone to talk to, or if you aren't well and would require ... you know like, say you fall in the house, actually your neighbours knowing that they haven't seen you and they wouldn't normally see you go past for your paper, those are the things that most preventative interventions are coproduced more than one person, that's for me the common thread, so for me the difference is connection.

IW: Can I give another example?  There's a group of people called 'Be Active life' in Birkhead and we were interviewing them recently and what they said was valuable is that when they went down the street, they went down the street they would meet people they knew and when they went into the shops, people would speak to them which they didn't have before, and then somebody would say, 'would you like to come for a coffee?' so it's not just the once a week, it's all the knock on affects and in Hopeman, which is a little village down the road, there was one of their members who was in hospital and what they did, the group did, they took it in turns to go and visit her and they had shopping for her when she came out of hospital and it was ... all this support that cannot be cost ... so that would save a lot of money for the services, and this person feels valued, they feel valued, they are not being done to, it's their friends helping and supporting them.  So it's really a very valuable way of doing it.  And another woman in another group in Elgin had fallen, so the group there, this was a sheltered housing group, and they would go round and visit or phone or one of the members, who actually is a wheelchair user, he used to take soup round to her. So it's all this informal network of support that's very valuable from something that is set up from the once a week projects.  So there's loads of anecdotal comments I could make, but this is just a few.

EC: That's really helpful and it's useful that we are going to be picking up on case studies later in the project. It was interesting what you said about the fact that ... it was kind of a welcome home service from the hospital, which is something that people look at as statutory services would save a lot of money.  I know that we have touched briefly on the kind of economic argument for prevention, how important is that aspect to this project, do you think?

DY: Well the challenge always is if you can demonstrate savings because of the policy architecture that surrounds this, I mean there are always challenges to try and overcome the short term and political cycle in national decision making and the national performance framework is an attempt to try and do that in saying, well look we are trying to reduce the number of avoidable hospital admissions and delayed discharges and so on, but it's very hard to make the connection although there have been lots of attempts to try and do so, between giving advice on insulating your  home or setting up a book club or day centre to try and say, how many hospital admissions have we saved this month out of this quarter? I mean that's very hard line to draw in a convincing way, and I am sure Jerry has mentioned this before,  you know, if you work for a local authority, for and NHS board, you know, if  you are not concentrating on delivering your heat targets and your single outcome agreements, then your job is at risk, so there has to be a kind of push towards valuing and measuring what we can in preventative work, so that we can then plug that into the wider discussion we are having about improving services and achieving better outcomes for people.

IW: It's always more difficult in evaluating the qualitative aspects than it is statistics for how many people attend or whatever ...

EC: Jerry, you had said earlier that one of the things you were hoping from this project was some element of convincing evidence, can you elaborate on what you think would be seen as convincing?

JP: There is an issue in terms of connecting this into the investment that you would make in preventative services and how that impacts upon the targets that health boards and councils need to make or need to achieve.   The fact that the intent of government is to achieve a model of care which actually focuses on a shift to prevention and if you look through a lot of the policies the government have produced over the last 2 to 3 years, you can see that that's clear. We have also heard around the table a number of specific examples of where that is happening on the ground but there is this edifice, if you like, in the middle of NHS Boards of Councils, who because of the targets that are set for them, find it difficult to legitimately invest what is a diminishing resource for them in aspects of care which are not immediately connected with delayed discharges or prevention admissions, so for example around hospital beds etc, and that's where the investment continues to be made.  Now if the investment is to shift in real terms from providing a reactive service to one that is around participatory care and prevention, then it's not simply about having the evidence that I think this project will bring forward, there is evidence, there is a logic to the fact that preventative interventions will have an impact, but I think that there is a need for a shift in that interface between government and public sector organisations which give legitimacy to the measures which this particular project can work with.  So that if you are actually having that conversation with government or if public sector is having that conversation with government, it's seen as a legitimate shift in resources.  Now again, that's very difficult because the other conversation that needs to take place is between government and society in terms of what the expectations of society are, because we have developed a dependency type culture over the last 65 years in the health service and in welfare and that model is not easily changed over a very short period of time. So I think that conversation remains to take place between government and society about what their expectations are and government then needs to support public sector organisations and society move to a position where it's about how we actually facilitate our own healthcare and our own wellbeing, being supported by organisations, not just in the public sector but the third sector as well.  And I think that once that conversation and once that recognition takes place that we do need to shift the way we actually see how we support ourselves and how public services and the third sector can help us, support us, facilitate that, rather than do it for us, then I think we might come to terms with a recognition that the evidence that comes out of this type of project is a legitimate form of evidence which allows us to shift actual resources from reactive care to more preventative care, but within an economic context that we have got at the moment, that is very difficult.

JR: I would also argue, however, that the project itself needs to deliver balance.  Because there are many different weavers that need to change that conversation between citism and government and there are many different decisions at a strategic level that need to be taken to create weavers in the system to make that happen.  The programme needs to simultaneously generate information that helps individual practitioners and local managers figure out how they do what they do better and how they stop doing the things that get in the way, so that actually simultaneously, the on the ground delivery continues to evolve in a sensible way.  There is a pragmatic financial concern here doing things really well, because each of us should be able to live a good life interdependently with the people that we walk on this planet with is as important.

AT: One of the things that's just sort of occurred to me, and I can't really believe I am going to say this, but is ... you know in all this conversation we haven't really talked about the private sector or employers and kind of their businesses, local businesses, kind of their potential place in all of this. You know because we talk about the public sector or the third sector, social care sector  ... and it's almost as if we have kind of gone, okay this is our business, sort of some how or other there's a danger we will own it, and when I think back at my experiences in mental health and I think back to 20 years ago when someone said to me,  you know, suicide prevention should never sit in health, because if we take it on and own it, we will only do it in a public sector kind of way, and there is something for me, and I am thinking of just small examples in the village where I come from, the local businesses do a number of different things and I am sort of thinking, do  you know what, why are we not working with them a bit more and saying look what's ... I know money is tight and .. but this is just in a very small way, and the local businesses that are really seeing that they have a role to play and that they can contribute.  And I guess if we are thinking we are all going to be working until we are a lot older, so there is something about kind of ... employers role in this or businesses role in this that I kind of think maybe ... I don't know, could do with a bit of exploring.

JR: I think that's happening but it's just not formalised.  I suppose I have a tendency to end up in conversations with complete strangers in an ongoing basis, and I had an engagement with a taxi driver who was telling me, who asked me what I did and I mentioned it was around reshaping care and he started telling me the story of his father, who lives in a high rise flat in Glasgow and his mum has passed away and he is much more isolated because the high rise flat means that the neighbours change a lot and they don't really have the same connection with one another.  Where he goes for his tea now is a very large business, tea room in a large department store and he has Parkinson's disease, so he has a bit of a tremor and they intentionally only ensure that his cup is filled to the right level, they just discreetly carry it over to the table with him, he knows about their families because they share that interaction, they put aside his favourite cake if it looks as if they are going to be all sold out before he comes in, he wasn't well and hadn't made it in one day, when he was better he went back in and actually they now have the son, the taxi drivers phone number, because they were so concerned because they noticed his absence, and immediately were concerned that something had happened to him.  Now that's in a very large urban environment that's not based on that engagement being between neighbours, but it was just one of those stories that captured, for me, that people want to reciprocally support one another and actually will naturally mould and evolve to make it work if actually they are given the opportunity, and that was just one story, there must be hundreds of stories of that happening across Scotland.

EC: And it's very aspirational. I want to rap this discussion up by asking you, as people who have become interested in this project, what your particular hopes are for its outcomes?

DY: Well I think we discussed before, a society in which older people feel valued and feel that they have a role to play in society, because that ... in many instances is what separates actual physical isolation from a sense of loneliness, is the feeling that there's no place for you any more, there's nothing productive or valuable for  you to do.  So people do have that kind of dignity, self respect and to have communities that encourage that, that would be a tremendous outcome to achieve.

IW: I would agree, because the way the press are portraying older people is as if they are a burden on society and a number of older people have made that comment to me, so if  we can change that, the culture of thinking, that would be great.

JP: I think I'd describe the current model of care we have as a deficit approach or an edifice that we need to break down and one of the things I hope will come from this project is a contribution to the body of evidence that preventative approaches are a legitimate area for investment and will contribute to actually breaking that edifice down.  So I am hoping it will make that significant contribution.

JR: I think alongside that there is the ... which I suppose sits with Derek's point, which is about changing the narrative, I think case studies and evidence are all really helpful for me as a professional, what often changes the world is the stories and the descriptions people use, if some of the richness of what happens and how  that happens is captured, then actually there will be more of those stories and the stronger that narrative becomes, the nearer we get to the tipping point of that just being the way business is done.

AT: Yes and for me it's just slightly expanding on that, if it can articulate the benefits of that ... so these stories that are emerging, these bits that come up, and there are a lot of stories out there but it's that next bit about how you then say, and this is the value to our .. the social value, but also there is an economic value in allowing these things to emerge as opposed to coming in with an engineered solution ... so it's that sort of bit that Jerry was talking about as well, about this has economic sense, of course we can see the power of the social side of it, but it also has economic and there's almost like this imperative ... so that it gives mangers or whoever, people that are making these decisions in our public sectors or in our other sectors, it gives them that little bit ... another string to the bow basically, that they say, 'look, there is a reason we are doing this, and it might be a bit messy but it might not be very easy to articulate in the way that we might have traditionally done it, we might have to work in a bit of murkiness occasionally, but we will get to this place in the end and that place is a better place.'  That sounds a bit over the top, but you know what I mean.

EC:  I think that's a really good note to end on.  Thank you all very much for  your contributions. 

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