How and why does Local Area Coordination work for people in different contexts?

Abstract

The increasing adoption of Local Area Coordination across the United Kingdom as a strengths-based approach to acting on inequalities which impact on individual health and well-being, and reducing reliance and avoidable use of health and social care services, has catalysed increasing calls for evidence to justify economic commitment. In a time of austerity where extreme pressure is on resources to prove short-term outputs, Pawson and Tilley’s realist evaluation methodology holds significant promise in asking critical questions of how and why programmes work. Ultimately, such philosophical standpoints facilitate opportunities to examine whether the sustainability of programmes are cost-effective for the system in the longer term. This article draws upon the findings of a realist evaluation of Local Area Coordination on the Isle of Wight and establishes how and why the programme works for people and local communities. A blend of realist approaches, Q-method and realist interviews were adopted within this study. The study’s sample was a cross section of 18 people who engaged with the Local Area Coordination programme across the Isle of Wight. The findings of the evaluation established that the Local Area Coordinators’ ability to facilitate a ‘golden triangle’ of listening, trust and time were factors which made Local Area Coordination work. It was also clear that Local Area Coordination worked for different people in different ways, demonstrated through the contextual differences between three subgroups who were categorised based on shared viewpoints, and presented through the holistic narratives and corroborating interview data.

Introduction

Austerity has catalysed a significant shift in the ‘responsibility’ of health and social care in the United Kingdom, resulting in a greater emphasis and investment in more person-centred, strengths-based practices to improve self-management capacity. Subsequently, communities and local systems have had to transform, reconfigure and integrate their health and social care provision to reduce the demand and reliance on services (Swansea University, 2016). Local Area Coordination (LAC) has emerged as one approach which aims to generate sustainable solutions to the current challenges experienced in health and social care. LAC was pioneered in Western Australia almost 30 years ago as a holistic approach to working alongside people to achieve their vision of a ‘good life’ (Government of Western Australia, 2003; Broad, 2012). The programme is built on the premise of an individual (local area coordinator) supporting people and communities within a specific geographical ‘community’. The key roles and responsibilities of this coordinator are to work with individuals to build and pursue a positive vision of a good life at an individual and community level and engage in practical ways to make this happen. This is achieved through a specific set of principles which include identifying gifts, strengths and needs; accessing information advice; relationship and community building; and planning for the future (Broad, 2012, 2015).

The existing evidence pertaining to LAC has supported its increasing adoption across the United Kingdom, with empirical evidence linking the responsive, adaptable, flexible and accessible nature of LAC in relation to alleviating pressures across a wide range of services, and improving individual outcomes (Billingham and Mceleney, 2016; Broad, 2012; Swansea University, 2016; Wessex Academic Health Science Network, 2018). Despite the numerous evaluations on LAC which showcase a range of different methodologies and data collection tools used to capture outcome(s) and impact, there is still limited insight surrounding how and why LAC works in specific contexts to produce certain outcomes. Therefore, this article makes the case that due to the complexity of the programme, it is important to utilise a methodology which has the capacity and capability to understand questions related to how, why and for whom does LAC works for, and under what circumstance does it achieve this.

This article begins with a brief introduction to LAC. It then provides justification for why realist evaluation was deemed an appropriate approach to assess the programme utilising Q-methodology and interviews. The findings of this article are then presented through a synthesis of the holistic narratives from the Q, and interview data to generate a series of programme theories which explain how and why LAC worked for different subgroups of people across different geographical and demographical areas on the Isle of Wight (IOW).

This evaluation of LAC on the IOW focused on the first three geographical areas in which the approach was introduced in 2016, with the evaluation occurring throughout 2018. Each geographical area had a local area coordinator who covered a population between 10,000 and 12,000 residents.

The realist approach to understanding complexity

There is indeed an abundance of evaluation work that has been undertaken in relation to LAC, with formative, impact and outcome, and economic being the predominantly favoured approaches. This is driven by the accountability culture of evaluation to prove the value and worth of new social innovations within local systems in order to obtain continued economic commitment and support. There is thus a major gap in the existing evidence base in relation to learning how and why LAC works, for different people, in different ways and in different contexts, with this type of understanding being able to better support in improving the LAC practice. It is this backdrop against which realist evaluation emerges as a suitable evaluation methodology to address this gap.

Realist evaluation is rooted in the philosophical orientation of realism. Dalkin et al. (2015) highlight that one of the key tenets of realism is the very basic idea that observational evidence alone cannot establish causal uniformities between variables. Rather, it is necessary to explain how and why the relationships occurs, that is, what it is about LAC’s principles in practice through a local area coordinator, and how working alongside an individual, within a certain set of circumstances, leads to generating change(s) in their life, as this causally links the generated change in outcome(s) to the ‘intervention’ (Pawson, 2013). The generative view of causation and need to dig beneath the observational surface level of reality (Jagosh, 2019) means that an effective realist evaluation seeks to move beyond the traditional ‘what works’ approach to evaluating an intervention to ‘what works (or not), for whom, in what circumstances, and why (Pawson, 2006; Pawson and Tilley, 1997; Wong et al., 2016).

A key contribution of Pawson and Tilley’s (1997) realist approach is the view of the mechanism (Astbury and Leeuw, 2010) which places an emphasis on understanding the interplay between the complex social reality in which different ‘interventions’ like LAC (being evaluated) are mobilised within, and how they adapt and respond to generate a change in individual outcome(s). This enables an evaluation to seek the theories which explain how and why interventions are successful in some instances, but not in others (Hewitt et al., 2012). Pawson and Tilley (1997) emphasise the importance of context in social change projects, because the conditions and environments of the participants involved in a given project will influence the project outcomes (Dalkin et al., 2015; Westhorp, 2014).

Therefore, programmes like LAC will work in different ways for different people in different situations. Thus, a compelling rationale emerges for the mobilisation of realist evaluation for approaches such as LAC, because they are socially context dependent involving human volition and change mechanisms (Harris, 2018). LAC ‘may’ work for some people in certain circumstances but the question from a realist sense concerns how, and why, so that learning, explanation and understanding can take shape and be used to inform and improve practice.

Methodology

As already alluded to, realist evaluation was designed to understand what worked (or not), for people who engaged with local area coordinators across three different geographical and demographical areas on the IOW. The evaluation focused on identifying the generative mechanisms of change, that is, what was it about LAC specifically that caused a change in an individual’s reasoning which led to a change in outcomes, relative to their circumstances, at an individual level, that is, health and well-being and self-management capacity, community level, that is, connectedness within their community, and/or at a system level, that is, reducing reliance or avoidable use of services, that is, health, care and the judicial system.

Realist evaluation

According to Pawson and Tilley (1997), realist evaluation involves three key phases of first, establishing a programme theory, second, testing programme theory and finally, refining programme theory to result in evidence-informed explanations about how social innovations like LAC work, for whom, under what circumstances and why.

Programme Theories in a realist sense are made up of ‘candidate’ Context–Mechanism-Outcome (CMO) configurations (Pawson and Tilley, 1997). The key components of, and interrelationship between, the CMO are described by Harris (2018: 4) as follows:

• Context: What conditions are in place for an ‘intervention’ to trigger mechanisms to produce outcomes?

• Mechanism: What is it about an ‘intervention’ that may lead it to have a particular outcome in a given context, for example, how do resources intersect with participants’ beliefs, reasoning, attitudes, ideas and opportunities?

• Outcome: What are the practical effects produced by causal mechanisms being triggered in a given context?

Developing programme theory

Within this evaluation a series of candidate CMOs were compiled with programme staff and system-level stakeholders at the very beginning of the process to understand their preliminary theories and assumptions about LAC. This was a crucial phase as it enabled the research team to grasp a contextual understanding about the programme. Such an exercise was beneficial for gleaning what was worthy of exploration in the testing phase of the evaluation. The developing programme theory stage also consisted of the completion of a comprehensive literature review of LAC across the world as well as the grey literature pertaining to LAC on the IOW.

Testing programme theory

Following the creation of the candidate CMOs, the next phase involved testing them. Realist evaluation does not favour a particular type of data or data collection method, and has been referred to as being methodologically neutral (Pawson, 2006). Rather, what is important in a realist evaluation is that the relevant type of data is extracted in relation to the programme theory (Dalkin et al., 2015; Wong et al., 2016). Therefore, in testing a programme theory it is entirely acceptable that realist evaluations will incorporate a mixed-methods approach to capture both qualitative and quantitative data in relation to context(s), mechanism(s) and outcome(s) to enable CMOs to be tested (Pawson and Tilley, 1997; Westhorp, 2014).

The mixed methods selected for this study were made up of the Q-method (Watts and Stenner, 2012) and realist interviews (Manzano-Santella, 2016; Pawson, 1996). As stated above, these methods were informed by the programme theory development stage of the realist evaluation.

Q-method

Harris (2018) and Harris et al. (2019) draw a connection between the Q-method and realist evaluation with reference to its compatibility within the realist philosophy, that is, its contribution to understanding how, why, for whom and under what circumstances an intervention works, therefore possessing potential in the developing, testing and refining of the programme theory.

The Q-method was pioneered in 1935 by Stephenson (Watts and Stenner, 2012); it is defined by Brown (1993) as the systematic study of subjectivity through capturing an individual’s viewpoints: their opinion, beliefs, thoughts, notions and attitudes in relation to a set of statements about a topic (Stephenson, 1961; Watts and Stenner, 2005, 2012). In doing so, it establishes what does (and what does not) have value and significance from their perspective (Watts and Stenner, 2005). The Q-method sets out to quantitatively analyse the subjective viewpoints of participants, which are then qualitatively interpreted to explain the relationships and patterns emerging from the factor (quantitative) analysis of the data (Watts and Stenner, 2012).

Table 1 gives an overview of the Q-procedures (from Harris et al., 2021, forthcoming) and provides an outline of the key steps in conducting the Q-method within an evaluation.

Table 1.

Overview of Q-procedures.

Stage	Description
1. Concourse development	Q-methodology begins with the generation of a concourse, which is ‘the volume of discussion about a topic’ (Stephenson, 1982). The concourse may include text, images, media recordings and other expressions of ‘common knowledge’ about the topic of interest (Watts and Stenner, 2012: 33).
2. Selection of items	The next step is to create the Q-set, which is a representative selection of items (e.g. written statements, images) from the concourse (Dziopa and Ahern, 2011; Watts and Stenner, 2012). In practice, the Q-set usually consists of 30–80 items (Watts and Stenner, 2005).
3. Selection of participants	The P-set is a representative sample of people from the stakeholder group of interest. Q-methodology does not require a large P-set (Stephenson, 1935, 1952). However, the ratio of participants to Q-set items should be at least 1:1 (Dziopa and Ahern, 2011; Watts and Stenner, 2005).
4. Q-sorting	All participants comprising a P-set receive a condition of instruction, which is a prompt for thinking about the Q-set (Ramlo, 2015; Watts and Stenner, 2012). After participants consider each Q-set item according to the condition of instruction, they arrange all items onto the Q-sort, which is a grid typically shaped like an inverted pyramid and resembling an upside-down standard normal distribution (Brown, 1980). The Q-sort operationalises participants’ perspectives on the topic of interest along a continuum, with negative numbers on the left side, zero in the middle, and positive numbers on the right side (Brown, 1980; Watts and Stenner, 2005). Since each Q-set item is numerically identified, its rank and location on the grid can be examined within and between participants’ Q-sorts (Ramlo, 2015; Watts and Stenner, 2012).
5. Factor analysis	There are different factor analytic techniques for Q, such as centroid factor analysis and by-person principal components analysis (Brown, 1980; Schmolck, 2015). The common goal among these different techniques is to identify groups of people who ‘load’ together based on having similar Q-sorts. These groupings of people are referred to technically as factors, and each factor represents a viewpoint about the topic of interest (Brown, 1980).
6. Interpretation	Abductive reasoning is used to interpret the data; observed patterns are compared and contrasted with the prior literature (Watts and Stenner, 2012). Interviews with participants may also be conducted (Pike et al., 2015) to clarify the emerging story surrounding viewpoints within a specific factor.
7. Holistic narrative	A holistic narrative is produced to tell a story about the viewpoints pertaining to the topic of interest.

In relation to LAC, the concourse represented the gathering of ‘substrate’ theoretical explanations which cumulatively represented how and why LAC might work, and the different outcomes which could occur. From the concourse, a total of 35 statements were developed and linked to the initial programme theory development stage. These statements (known as the Q-set) were then ranked by participants (known as the P-set) relative to one another. The focus on the subjective viewpoints allowed a sample of participants to decide what was, and what was not meaningful to them related to LAC (Watts and Stenner, 2005). An example of the statements pertaining to this evaluation can be seen in Table 2.

Table 2.

Example of statements (Q-set).

1. The Local Area Coordinator has helped me think about my vision for a good life and how I could get there	2. Since working with the Local Area Coordinator, I am more confident and feel I can achieve what will lead to a good life for me
3. I feel the Local Area Coordinator takes time to listen to me and understands what is important to me	4. Since working with the Local Area Coordinator, I have had to use the services less often
5. Because of the Local Area Coordinator’s support and guidance, I feel I can do more for myself	6. Before being introduced to the Local Area Coordinator, I often felt isolated and disconnected from my local community
7. Since working with the Local Area Coordinator, the trust I have in the services I use has improved	8. Since working with the Local Area Coordinator, I have more trust than I had before in members living within my community that come from different backgrounds to me
9. I have a trusting relationship with the Local Area Coordinator that I work with	10. Since working with the Local Area Coordinator, I am more confident in terms of accessing, negotiating and connecting with the service(s)
11. People and groups, I have been introduced to via my Local Area Coordinator have made me feel welcome and supported	12. The Local Area Coordinator has supported me to interact with people I wouldn’t usually connect with
13. Since being introduced to the Local Area Coordinator, I feel I am managing my own health and well-being more effectively	14. I feel more confident in building relationships due to the supportive conversations with the Local Area Coordinator
15. It is important to me that my Local Area Coordinator has no set uniform and no pre-set agenda	16. It is important to me that the Local Area Coordinator is easily accessible in the community
17. The Local Area Coordinator encourages and supports me to solve my own problems	18. I feel like I need to see the Local Area Coordinator more than I currently see them

The Q-set was presented to the participants (P-set) individually and purposively during community-based sessions/activities within each of the three geographical areas where a local area coordinator would routinely connect into. Importance was raised about not ranking statements to measure the performance of their respective local area coordinator, rather to understand in more depth what was meaningful for people who had worked alongside a local area coordinator. This process ultimately helped to reduce evaluator bias.

Q-sample (P-set)

A sample of 18 individuals across the three geographical areas, who had different experiences in working with a local area coordinator, made up the participants of the research. Of the 18 participants, 11 were male and 7 were female, and aged between 18 and 74 years. The statements were then ranked relative to each other in terms of what was most important (+4) to what was most unimportant (−4) by each participant using a ‘Q-grid’ depicted in Figure 1, as suggested by Watts and Stenner (2012) to complete the Q-sort exercise.

Figure 1.

Example Q-grid.

Data analysis and interpretation

The proceeding stage focused on the analysis of the Q-sorts completed by the P-set which was conducted through factor analysis. The factor analysis involved searching for statistically significant correlations of shared viewpoints among the participants. This led to the identification of seven possible factors (subgroups of shared viewpoints) among the 20 participants. However, further analysis on the variance and numbers of participants within each subgroup led to three subgroups being selected for full qualitative interpretation.

From these three subgroups, seven participants loaded into subgroup 1, six within subgroup 2 and five within subgroup 3. The qualitative interpretation involved examining the resultant subgroup Q-sort scores in-depth. Thus, in this case three resultant Q-sorts were examined, making use of Watts and Stenner (2012) crib sheet (see below).

• Statements ranked at +4/+3

• Statements ranked higher in the factor group than any other group

• Statements ranked lower in the factor group than any other group

• Statements ranked at −4/−3

• Distinguishing statements

• Using demographical information about participants and micro–macro circumstances

• First take – (building in initial story or theory)

• Any other additional information.

The crib sheet guided the abductive reasoning in explaining the linkages between the statistical correlations between shared viewpoints. As such, a defining feature of Q-methodology is the use of abductive reasoning to interpret the results. Emanating from the work of Charles Peirce (1839–1914), abduction can be simply defined as ‘studying facts and developing theory to explain them’ (1931/1958: 90, cited in Watts and Stenner, 2012: 39). Distinct from the bottom-up nature of induction and the top-down nature of deduction, abduction is somewhere in-between because it offers both explanation and theory-building by going back from, below or behind observed patterns (Watts and Stenner, 2012). This led to the development of three holistic narratives, one for each subgroup, which are presented and discussed within the ‘Results and discussion’ section.

Realist interviews

Harris (2018) draws a connection between the values of interviews following Q-methodology to follow-up, clarify and consolidate why a participant ordered and ranked the statements the way they did. This is of relevance when requiring data which explain gaps or questions arising from the holistic narrative based on the researcher’s interpretation. This supports the researcher to ‘dig deeper’ (engaging in retroduction) to corroborate their qualitative interpretation of the subgroups.

A realist interview is generally semi-structured in nature, though different to a conventional interpretivist interview as it is not focused on exploring the constructed meanings based on an individual’s experience in relation to a particular topic under investigation. Rather, a realist interview following an intervention is focused on ‘testing’ and ‘refining’ programme theories as a result of the ‘real’ effects caused by the intervention relative to the participant.

To guide the realist interview, Manzano-Santella (2016) outlines a ‘teacher-learner cycle’ approach, whereby the realist questions are designed around the stakeholders’ awareness and experience of the programme, including their reasoning (Dalkin et al., 2015) about specific propositions which relate to the research questions/objectives. Therefore, programme theories are the subject matter of the interview and these are hypotheses that need to be elicited, developed, refined and tested (Pawson and Manzano, 2012). This is achieved through the interviewer (researcher) sharing the programme theories verbally or through use of visualisation techniques with the interviewee (stakeholders) who having learned the theory under test, then teaches the interviewer about components of it, that is, how and why aspects of LAC did or did not work for that subgroup (Harris, 2018; Manzano-Santella, 2016).

In relation to the research study, a purposive sampling method was used and a sample P-set from each subgroup. In total, six participants were involved in this phase, with two participants from each of the three subgroups. The interview schedule was informed by clarifying gaps in understanding, while remaining open to the notion of emergence being applied, with the interviewers being planned for the unplanned, ready for the exploration of unexpected (not previously hypothesised) CMOs (Pawson, 2013).

As a result of the interviews, data were transcribed, and analysed through coding, extracting and synthesising the data using the CMO as an analytical framework (Oatley and Harris, 2020). To simplify explaining how LAC worked to generate certain outcomes, Dalkin et al.’s (2015) disaggregation of ‘mechanism’ was adopted to illustrate how specific resources (MRES) provided by local area coordinators generated certain reasoning responses (MReas) in relation to certain outcomes. As such, we present our programme theories as Context–Mechanism Resource–Mechanism Reasoning–Outcome (CMMO) patterns. This empirical data corroborated and refined the holistic narratives from the Q-method. In doing so, it provided scaffolding to support the Q-method findings.

Refining programme theory

The data generated were synthesised in relation to refining the initial programme theory produced. To achieve this, the CMMO was utilised as an analytical unit to code, analyse and identify CMMO configurations informed by the holistic narratives and realist interviews. As such, the analysis was ‘intraprogramme’ in its focus, as it sought to establish inter-group comparisons through CMMO configurations, illustrating the different ways in which LAC worked (or not) for people relative to their circumstances (Gilmore et al., 2019; Jagosh et al., 2012). To assist this phase, the researchers engaged with the data retroductively to theorise the relationships within the data to explain the identified patterns within (Gilmore et al., 2019; Greenhalgh et al., 2015; Jagosh et al., 2012; Wong et al., 2016).

Results and discussion

The findings of the evaluation established that the ‘golden triangle’ of listening, trust and time were consistent mechanisms which led to outcomes being achieved. This aligned to other evaluations such as the Wessex Academic Health Science Network (2018), which found that the unrestricted nature (time) of LAC compared with other services led to a wide range of impacts being achieved, built on the foundations of a trusting relationship between the local area coordinator and an individual. However, it was also quite clear that LAC worked for different people in different ways, with the Q-method creating three different subgroups of end users experiencing LAC. There were also key contextual factors, which influenced the degree to which broader LAC outcomes were achieved.

The findings from each of these subgroups are illustrated below through a holistic narrative, data from the realist interviews which are then synthesised to provide key CMMO configurations for each subgroup. Each holistic narrative is displayed below, in present tense with the support of statement rankings (Watts and Stenner, 2012). For example, in group 1, ‘5 + 4’ would indicate that participants within this group ranked statement 5 at ‘+4’ on their Q-sort, whereas they ranked statement 9 at ‘−4’. Each ranking and score acts as a supporting reference to justify the narrative.

Subgroup 1: ‘I know you are there and that means a lot, but I’m building my own social networks’

Holistic Narrative This subgroup represented a total of seven participants of which six were male and one was female. Three males were from the freshwater area; one was aged 35–44, one was aged 45–54 and one was aged 65–74. In addition, one female was from Freshwater, aged 65–74. In contrast, three males were from the Shanklin area; one was aged 18–24, one was aged 25–34 and one was aged 55–64. Two of the participants introduced themselves to the local area coordinator, one found out by being approached by the local area coordinator, one found out through services, one through the local health advisor, one through the Freshwater food bank and one through a conversation in the doctors’ surgery waiting room. Seven out of seven participants identified as White/Caucasian. The strong representation of Freshwater and Shanklin participants in this factor could be significant for micro-level CMMOs. Like every other subgroup, due to the local area coordinator’s ability to take time to listen and understand what is important to each person (5, +4), this subgroup felt the local area coordinator had the knowledge and understanding to directly support them and connect them to someone who could help (33, +4). Moreover, due to the easy access of the local area coordinator within the community (26, +3) and the trusting relationship which had developed (15, +2), individuals felt like they could contact the local area coordinator when support and guidance was required (31, +3). Interestingly, however, this subgroup did not feel like they needed to see the local area coordinator more than they currently saw them (32, −4), instead, when they did see the local area coordinator, they were encouraged and supported to solve their own problems (34, +2). This shows evidence of this subgroup aligning to the LAC intended outcome, centred on reducing dependency on the system and building personal resilience among community members. Furthermore, the ability to recognise the local area coordinator as a first point of contact within their local community (35, +3) could show further evidence of reducing pressure on the system. Although this subgroup did not feel overly confident in building relationships (23, −1), they had taken initial steps to becoming more involved in the things they like to do in the community (2, 0), demonstrated through the ability to take opportunities in introducing themselves and interacting with people they wouldn’t usually connect with (22, +2); furthermore, these people had brought enjoyment to their lives (24, +1). These items were ranked higher than any other subgroup which demonstrates further evidence of individual and community resilience and social capital (bonding) increasing. However, in contrast to any other subgroup, individuals ranked building trust in those from different backgrounds as somewhat important (14, 0), demonstrating some aspects of social capital (bridging). More than any other subgroup, it was significantly unimportant to receive support in mapping out their vision for a good life (3, −3) or to increase their confidence in achieving a good life (4, −1). This could be because the participants in this group already had a clear vision of what a ‘good life’ looks like and instead utilised LAC for small-scale support (occasionally) and to access interaction with other people. Interestingly, despite there being several younger individuals within this subgroup, the group did not see it as important to be made more aware of opportunities to develop their existing skills set (18, −3), and thus it was relatively unimportant to develop their employability skills (19, −1). The younger age and mobility of older individuals within this subgroup could explain why accessibility (in terms of transport (9, −4) and geographical location (10, −3) were not barriers to attending events in their local community, arranged by their local area coordinator.

Overall, it appears this subgroup are more casual users of LAC (specifically) than subgroups 2 and 3. However, they utilised LAC to build and sustain social connections with others. Like other subgroups, the personal traits of the local area coordinator are most important. On the contrary, for this subgroup, the individual benefits of being able to access the LAC at their own discretion is very important. The participants in this subgroup are not, however, as dependent on LAC or the service(s) (27, 0) like subgroup 3. Instead, building trusting relationships and socialising with likeminded individuals has brought enjoyment to the individuals’ lives (24, +1) and they are more aware of what there is to do (1, +1) in the community since being involved with LAC. This could be because they were socially disconnected from their community before being introduced to LAC (11, +2).

Interview data to support narrative: subgroup 1

The interviews supported the notion that this group was mostly capable in their everyday lives, though they needed some support. Introduction to other individuals through the local area coordinator had provided participants with a friend, as well as giving them the opportunity to receive help or advice from the local area coordinator. Those in this subgroup use the local area coordinator casually for minor things, such as setting up a mobile phone. These small actions seemingly have a big impact on this subgroup’s lives. Where this subgroup does not have close family or friends on the island, the casual use of LAC is important to them. When an incident occurs that would cause disruption to the individual, the local area coordinator is a mechanism for emotional support and actions are collaboratively set to reassure the individual:

When something goes wrong, I look forward to the coffee morning where I get to speak with the Coordinator, it gets me through the week. (Participant 1)

This indicates that they continue to require access to the local area coordinator to prevent greater use of services or a reliance on LAC. The value of keeping casual contact through LAC aligns to findings from Swansea University (2016), which underlines the challenges which can emerge in making positive individual, societal and financial benefits if problems are not identified and addressed through the earliest possible intervention.

It is suggested that the participants do not worry about developing their employability skills as they already hold a good level; however, their mental health has caused them to stop working or being confident to continue working. This also affects taking up any volunteering opportunities. It is not that developing employability skills is not important, rather their involvement in LAC is to get the specific help they need when they need it:

The local area coordinator has shown me where I can volunteer and get involved in different things, but I am not at a stage where I take these opportunities. (Participant 2)

Interaction via interviews would indicate that members of this group have a higher potential to generate social capital than other subgroups, allowing greater interaction with new people; they are, however, still relatively isolated. The relationship with the local area coordinator was still a large contributing factor to these participants taking the next steps in improving their lives:

My mental health has really suffered, and I have struggled recently, especially with the stress it has caused. I’m going to be moving closer to my daughter who can help me. Adam has helped me realise this. (Participant 2)

The listening skills, trusting nature and openness of the local area coordinator have helped the individuals to collaboratively outline the next best steps to achieve a good life. These individuals are not reliant on LAC; however, this does not mean that they are completely free of their use of services.

Sample of overarching key programme theories for subgroup 1

The variation of ways in which an individual can be introduced to LAC (MRES) enables individuals with a range of different needs (C) to come into contact, access and utilise the support of a local area coordinator (MREAS), who is not available through any other service (MREAS) to address personal issues which can reduce systemic barriers (O).

The accessibility to the local area coordinator in the local community (MRES) facilities opportunities for individuals who need casual, but specific support, (C) to contact with the local area coordinator when required (MREAS) at a time convenient to them (MREAS) to access support and guidance (O) before issues become greater systemic problems (O).

Individuals who lacked trust in other people (C) through conversations with the local area coordinator (MREAS) gained trust and confidence in others (MREAS), leading to increased confidence in connecting with people who could help them (O).

Due to the infrequent, but effective meetings with the local area coordinator (MRES), individuals who were not confident in solving specific problems (C) were supported to collaboratively solve these problems (MREAS) leading to increased understanding into how to deal with these problems independently if they were to come up in the future (O)

For individuals who were disconnected from the community (C), conversations with the local area coordinator (MRES) means they feel more understood (MREAS) and the local area coordinator’s knowledge of likeminded people within LAC (MREAS) has allowed individuals to know more about opportunities which allow them to interact with people they wouldn’t usually connect with (O) and they have brought enjoyment to their lives (O).

Since being introduced to local area coordinators (MRES), individuals that were unclear about which service to use for support (C) have approached the local area coordinator as a first point of contact in the community (MREAS), mitigating pressures on the system (O).

Subgroup 2: ‘thank you for your support, I’ve come a long way’

Holistic Narrative This subgroup represented a total of six participants of which four were female and two were male. Three females were from the Freshwater area; two were aged 35–44 and one was aged 45–54. In addition, one male was from the Freshwater area aged 65–74. In contrast, one female was from the Ryde area aged 45–54 and one male from the Ryde area was aged 45–54. Four of the participants found out about LAC through the services. One introduced themselves and one found out through being approached by the local area coordinator. Six out of seven participants identified as White/Caucasian. One participant preferred not to say. The strong representation of the Freshwater participants in this factor could be significant for micro-level CMMOs. The local area coordinator’s personal traits of taking time to listen and understand the individuals’ needs (5, +4) is consistent as the most important item across all the three subgroups. This is symbiotic with the trusting relationship the individuals have with the local area coordinator (15, +3) because of their ability to directly support them and/or connect them to someone who could help (33, +2). Similar to the first subgroup, this subgroup has also moved beyond benefitting from the one-to-one relationship with the local area coordinator and due to the supportive conversations with the local area coordinator, relationships have been built with others (23, +1) as people and groups that they have been introduced to via the local area coordinator have made them feel welcome and supported (17, +2). Furthermore, individuals know more about what there is to do in the local community based on their interests (1, +4) and have taken opportunities to be more involved in the things they like to do within the local community (2, +2), thus becoming more socially connected. On the contrary, unlike subgroup 1, individuals’ engagement with LAC has not led to wider integration with people they wouldn’t usually connect with (22, −3). Contextually, the individuals do not feel they have developed more trust than they had before in members living within the community that come from different backgrounds (14, −2), and people that they wouldn’t usually connect with have not brought enjoyment to their life (24, −3). This could show that despite outcomes in line with social capital ‘bonding’ being achieved within this subgroup (i.e. bringing together people with similar beliefs), the context for ‘bridging’ (i.e. bringing people together with different beliefs and from different backgrounds) has not been achieved. This could align to the deeper class divisions on the IOW and the limited ethnic diversity. Interestingly, very similar to subgroup 1, accessibility is not an issue for the individuals from this subgroup. Indeed, poor accessibility in terms of geographical location (9, −4) and poor accessibility in terms of transport (10, −4) are not barriers. In addition, like every other subgroup, developing employability skills since being introduced to my local area coordinator (19, −3) was again ranked of little importance compared with the other statements. This shows that developing employability is a very niche outcome and could be a wider contextual factor with the older population and high volume of people with mental health issues accessing LAC on the IOW. Individuals are more confident in terms of accessing, negotiating and connecting with the service(s) (20, +2) and despite its relatively low ranking, it could appear that the usage of the services has decreased somewhat (8, −1), especially in the context of these two statements being ranked more important in this subgroup than any other. This could show that LAC has eased systemic pressures. On the other hand, the trust individuals have in the services has not improved (16, −2) and could show the local area coordinator is limited when trying to rebuild this relationship once it has already been broken. Overall, like subgroup 1, this subgroup is further down the path of being individually resilient and in control of their own lives when compared to subgroup 3. They feel less isolated and disconnected from the local community (11, +3) due to taking opportunities to do thing I like to do in the community (1, +4) and from this meeting people that have made them feel welcomed and supported (17, +2). However, unlike subgroup 1, they are also more confident in accessing, negotiating and connecting with the services because of the support from the local area coordinator (20, +2). The local area coordinator’s ability to help individuals think about their vision for a good life and how they could get there (3, +3), but also the longer term outcome of achieving this vision (30, +1) supports the justification for resilience increasing. Furthermore, individuals generally have the viewpoint that it is not important that they see the local area coordinator more than they currently see them (32, −2), and it is not important to access them easily (26, −1); this could demonstrate that power has been given back to the people to solve their own problems.

Interview data to support narrative: subgroup 2

The local area coordinator is instrumental in supporting the participants with small achievable tasks in this subgroup to improve their lives. These tasks ranged from supporting the application for benefits, to providing information on volunteering and skill building opportunities (cooking), to conversations in terms of local affordable activities for family members:

The local area coordinator has been vital to developing a community spirit inside me where I want to give back to others and help them. (Participant 3)

The introduction to community life is an important factor, with the local area coordinator a key instigator to encouraging them as a trusted friend. This trust has been built up through the caring actions of the local area coordinator, which is extoled by those who frequently get to see the local area coordinator on a weekly basis.

The participants still rely on services such as a social/support worker as well as various health supports, a mental health nurse or psychiatrist. However, since the introduction to LAC, they have built confidence and reduced their reliance on some of these services due to the guidance and support from the local area coordinator, a factor which is key to avoiding costs (Swansea University, 2016). Listening and caring skills shown by the local area coordinator has proved important to the participants trusting the local area coordinator’s advice and helping them to shape a better life:

The local area coordinator advised me to take up opportunities [a cooking class] which I would not have taken if I did not trust the local area coordinator. They show they care and explain the how these things can help me, and it did help me. (Participant 3)

The reliance on the local area coordinator has stabilised; however, the local area coordinator is still an important part of the participants’ lives. The time taken up by participants in this subgroup ranges from 2 hours a week individually to conversations when they come across the local area coordinator via different engagements (Sports Centre, Our Place, Food bank, etc.):

My partner did everything, so when she passed away, I did not know how to pay the bills, how to cook. The local area coordinator was great, just sorted everything out for me and got me to come along to Our Place. (Participant 4)

The participants tended to rely more on the local area coordinator after an incident (bereavement, issue, with child behaviour or mental health issue). The local area coordinator was a support mechanism in their time of need:

The local area coordinator comes over for an hour a week, we talk, and he chats with my son. They get on very well, and he’s supported him loads with his anger issues. (Participant 3)

The local area coordinator appears to have enough time to work with participants in the way they need them most. As more participants come into LAC, it is likely to decrease the time each local area coordinator can spend with each participant individually.

Sample of overarching key programme theories for subgroup 2

Due to the LAC’s ability to invest time in each participant (MRES), those who are most vulnerable in the local community (C) can build or rebuild self-confidence through working with the LAC collaboratively (MREAS), leading to increased individual resilience in the longer term (O).

Due to the LAC’s ability to invest time in each person (MRES), those who were previously isolated and disconnected from the community (C) are heard, and their specific interests are understood (MREAS), leading to the LAC introducing them to other members of the community with similar interests (O) and thus building community resilience (O).

The LAC’s knowledge of the services (MREAS) takes away some of the systemic challenges (C) by supporting individuals’ capacity to understand each service and what they can provide (MREAS), leading to more efficient use of the services (O).

Individuals have been involved with LAC for a long period of time (C); through access to the local area coordinator (MRES), they have built a relationship centred on mutuality, understanding and trust (MREAS), leading to a clear vision of what a good life looks like to them (O) and the participants taking ownership and working independently towards this (O).

Due to the individuals being disconnected from the community (C), weekly drop-in centres were provided (MRES) where members of the community would attend (MRES); this provided an opportunity for interaction with people with similar interests (MREAS), building social capital among people from similar backgrounds and with similar interests through bonding (O) and reducing social isolation (O).

Individuals were disconnected and had little idea about what there was to do in the community (C). Voluntary networks such as clubs and community groups (MRES) worked closely with the LAC (MRES) to build community networks and promote during coffee mornings (MREAS), leading to participants knowing more about what there is to do in the community based on their interests (O) and becoming more involved in the things they like to do within the local community (O).

Subgroup 3: ‘I’m moving down the path, but I still need your personalised support’

Holistic Narrative This subgroup represented a total of five participants of which three were male and two were female. Two females were from the Ryde area; one was aged 35–44 and one was aged 45–54. In addition, two males were from the Ryde area; one was aged 35–45 and one was aged 55–64. In contrast, one male was from the Freshwater area aged 45–54. Two of the participants found out about LAC through being approached by the local area coordinator. One introduced themselves, one found out through the service and one through a family member. Five out of five participants identified as White/Caucasian. The strong representation of participants from Ryde in this factor could be significant for micro-level CMMOs. Like every other subgroup, it appears that the most important items are those which are built around the personal traits of the local area coordinator. The participants have a trusting relationship with them (15, +4), because they take time to listen and therefore understand what is important to each person (5, +4). This has ultimately led to the belief that the local area coordinator has the knowledge and understanding to directly support or connect the participants with someone that can help (33, +3). Within this subgroup, due to this support, individuals not only have a vision for a good life and how they could get there (3, +2), but are more confident in achieving what a good life looks like to them (4, +3). This item is ranked considerably more important than any other subgroup and could be because the group are happier than any other group to share their goals and targets with the local area coordinator, and feel they are supported to achieve them (29, +3).

Before being introduced to the local area coordinator, the individuals in this subgroup were not as disconnected from the local community (11, −1); subsequently, it is not important to know what there is to do in the local community based on their interests (1, −2) or to be more involved in the things they like to do within the local community (1, 0). Significantly, this item is ranked more unimportant than any other subgroup. On the contrary, this group remains dependent on the services and the local area coordinator has had little impact on this (27, −3). This is supported by the limited impact in line with reducing the frequency at which individuals use the services (8, −4). Subsequently, rebuilding a broken relationship between the individuals and the services is once more beyond the local area coordinator’s capacity (16, 0). However, similar to every other subgroup, the individuals do not see it as significantly important for the local area coordinator to have a role in ensuring that the services talk to each other more frequently (6, −1). This could show that this is a management-level intended outcome and is not recognised as much at the delivery level. Within this subgroup, the dependency on the services also extends to the local area coordinator. More than any other subgroup, individuals feel that they need to see the local area coordinator more than they currently see them (32, +1). This could explain why it is important for the local area coordinator to be easily accessible in the community (26, +2) and why they are recognised as a first point of contact (35, +2). On the contrary, the support and guidance has started to show signs of the participants doing more for themselves (7, +2) and thus moving along the pathway towards individual resilience. The general lack of importance when it comes to anything outside the remit of the local area coordinator and participants’ personal relationship show further evidence that this subgroup utilises LAC predominantly at a personal level. This is shown through the insignificance of the local area coordinator supporting them to interact with people they wouldn’t usually connect with (22, 0), and the people and groups they have been introduced to have made me feel welcome and supported (17, 0). Once more this group has not gained trust in those that come from different backgrounds (14, −3). The geographical location (9, 0) and poor accessibility in terms of transport (10, +1) are more of a barrier for this subgroup than any other subgroup. This could show that accessibility is more of an issue for participants in Ryde. Moreover, more than any other subgroup, participants suggest that they are aware of opportunities to develop existing skill sets (18, +1). However, developing employability skills is once again ranked as significantly unimportant (19, −4). Overall, this subgroup is the most dependent of all the other subgroups on the services and show some dependency on the support of the local area coordinator. On the contrary, individuals are starting to show some evidence of doing more for themselves and are also the least socially isolated subgroup. The participants are at the early stages of engaging with their local area coordinator, though they already have a strong relationship with them, which may lead to the participants becoming more in control of their own lives.

Interview data to support narrative: subgroup 3

Interviews highlighted how the participants in this subgroup were the most reliant on services and were dependent on others, including the local area coordinator, social/support worker for many things. The relationship with the local area coordinator is very important to them, as is seeing them more often and relying on them for greater, more time-consuming support when compared with the other two subgroups.

The local area coordinator is helping me to get another flat, my old social worker was rubbish and left me in a bad area, but the local area coordinator and my social worker are trying to get me out of there. (Participant 5)

This indicates the difference in support provided by the local area coordinator. Rather than small interventions that build up to make a greater difference, there is a different level of reliance on the local area coordinator. It also shows how participants feel they have been let down by services in the past, with little done to reassure that faith.

The local area coordinator continues to provide support with the little things; the listening skills and time provided by the local area coordinator is vital for the participants, while with one participant the local area coordinator provided emotional support that had been absent throughout their life.

The interviews also illuminated how differing participants viewed the importance of developing new relationships. The participants were not socially isolated, so they did not feel that developing new relationships through LAC was important:

I’ve got lots of mates from different things, and I come to this church because of the people. They are sound Christians who care about others, and I will care for them too. That is what I want to be involved in. (Participant 5)

The participants do not struggle with social interaction in this subgroup; however, their dependence on services and the local area coordinator does not seem likely to change in the short term:

I would like to see the Coordinator more than I currently do, he’s really great when I get to see him but he’s a really busy man. (Participant 6)

This statement emphasises the current workload for the local area coordinator, showing that the participants who currently access LAC within this subgroup require more time with them. Due to the demanding nature of participants in subgroup 3, it is clear that the complexity of LAC means that it is difficult to measure and evaluate workload and could result in local area coordinators’ capacity becoming unmanageable if they are working with too many people from subgroup 3 at one time.

Sample of overarching key programme theories for subgroup 3

Individuals initially had low levels of personal resilience (C) to the local area coordinator, and the time they can provide (MRES) enables opportunities to listen and understand the needs and interests of individuals (MREAS), fostering a feeling of being valued (MREAS), leading to higher sense of self-worth and personal resilience (O).

The local area coordinator’s knowledge of the services (MRES) supports individuals with a range of personal issues and a lack of knowledge in accessing services (C) to connect with someone that can help (MREAS) navigating systemic barrier by making sure individuals are contacting the right service provider (O).

The open access to the local area coordinator within the community (MRES) and the non-targeted focus (MRES) enables a range of different individuals with different requirments (C) to access the local area coordinator whenever required (MREAS), and by viewing them as a first contact point within the community (MREAS) supports individuals with personal issues in a timely and efficient manner (before they become widder systemic issues) (O).

Due to the local area coordinator’s ability to take time to listen (MRES) to those who are dependent on people and services (C), the local area coordinators are able to understand and speak positively of the individuals’ existing skill set (MREAS), and by working collaboratively with the local area coordinator (MREAS) they are able to develop resilience, so that they can start to do more for themselves (O).

The local area coordinator’s ability to listen (MRES) to individuals that are unclear in terms of what they would like to achieve (C) facilitates a comfortable environment in which the individual can share goals (MREAS) leading to increased confidence in achieving what a good life looks like to them (O).

Conclusion

The findings have demonstrated how a realist approach to unravelling the complexity of how and why LAC works for different people, in different ways, is possible through Q-methodology and realist interviews, and illustrated by the three distinct subgroups. The holistic narratives of each subgroup also demonstrate that key outcomes centred on individual and community resilience, social capital and mitigating systemic barriers were being achieved, though the time it takes for different individuals to become confident to work independently towards their vision of a ‘good life’ will vary. It was clear that all three subgroups were on their way to achieving a ‘good life’ and were supported in different capacities. The complexity of individuals accessing LAC means that LAC will continue to be an asset for the services, particularly in supporting those hard-to-reach individuals.

Overall, the ‘golden triangle’ of listening, trust and time are pivotal and these were confirmed as the most important mechanisms to every subgroup. The ability to ensure that marginalised voices are heard through listening and understanding the needs of every individual they work with, is vital, and provides the basis for a wider scope of outcomes to be achieved. Alongside this is the knowledge and understanding the local area coordinator has of the services and indeed the assets and resources available within the community, such as community clubs. However, undoubtedly, the infinite time the local area coordinator can spend with every individual (within reason) is the most important mechanism. Moving forward, these factors should continue to be considered through the recruitment and managerial process.

Importantly, the evaluation highlights some crucial aspects in terms of the local area coordinators’ capacity within their role and demonstrates that while individuals from subgroup 1 will require casual support, subgroup 3 requires a lot more support and, therefore, this could become problematic when managing workloads of local area coordinators. Furthermore, like the findings of Swansea University (2016) and Wessex Academic Health Science Network (2018), the success of LAC will be dependent on developing a reciprocal relationship with other services, such as developing an awareness of strategic positioning, boundaries and the role of local area coordinators among key stakeholders to avoid the replication of roles and responsibilities. In addition, a monitoring approach (which tracks the usage of services by those who access LAC) will support evidencing the impact of LAC on whether the participants are changing their usage of services because of being involved in LAC.