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Evaluating the Public Health Outcomes of the Cambridgeshire Time Credits Project

Evaluating the Public Health Outcomes of the Cambridgeshire Time Credits Project

SPHR-CAM-PES-CTC

25 May 2017

01 August 2015

31 March 2017

20 months

Loneliness, social exclusion, physical activity, mental health, volunteering, co-production.

• Dr Gemma Burgess, Senior Research Associate , Cambridge Centre for Housing and Planning Research (CCHPR), University of Cambridge
• Dr Louise Lafortune, Scientific Coordinator, NIHR School of Public Health Research, University of Cambridge

N/A

• Caroline Lee, Research Associate, Cambridge Institute of Public Health, University of Cambridge
• Spice – delivery organisation, Time Credits
• Cambridgeshire County Council – funder, Time Credits
• CHS Group – funder, Time Credits

Project objectives

Key aim

To evaluate the outcomes of the Time Credit project in Wisbech, Cambridgeshire, with a focus on health outcomes.

The primary objective

To analyse the potential of Time Credits to address public health issues by:

1. Reducing loneliness and social exclusion
2. Improving wellbeing
3. Increasing community cohesion and social capital

Changes to project objectives

One issue is that we envisaged there would be a Time Credits co-ordinator who would act as gatekeeper to volunteers. This Is not the case. Instead there are 16 different organisations involved all of which act as individual gatekeepers. We have had to spend more time establishing contacts and relationships than planned.

I had hoped to conduct a national online survey of time exchange projects. Timebanking UK (TBUK), the national umbrella charity for time banks, had initially agreed to participate, as they were the best way to contact timebanks nationally. However, the Trustees for TBUK requested that we did not distribute the survey. We have already published the report on Time Credits and time banks. The resources were directed instead to producing two case study reports, agreed in discussion with Spice, CHS Group and Cambridgeshire County Council and reflecting the co-productive approach we have taken.

We used an online survey which was intended to be longitudinal. Despite offering incentives, publicising the survey through a range of mediums, encouraging partners to ask volunteers to complete it – we had few responses. On investigating this we found that the number of new volunteers in this quarter was particularly low, so we had a good response rate but from a very small sample. We balanced this with additional qualitative data.

Brief Summary

Methods

• Mixed methods research design using both quantitative and qualitative methodological tools.
• Incorporating co-production in the evaluation methodology:
  • Interviews with key stakeholders
  • Literature review, systematic review of Time Credits and health outcomes
  • Secondary data analysis
  • Developing a theory of change
  • Longitudinal survey with individual new Time Credit members
  • Face to face interviews with individual Time Credit members
  • Survey and face to face interviews with partner organisations
  • Ethnographic methods including visual ethnographies and participant observation

 Results (including findings in relation to the objectives)

Systematic review

As context to the Wisbech Spice Time Credits evaluation, the goal of this review was to identify the evidence base for associations specifically between participation in locality based community currencies and improved health of participants.

The review found a wealth of indicators reported relating to mental health, reduced loneliness and social exclusion, strengthened friendships and wider relationships, as well as employability. However, the majority of studies relied on self-reporting through questionnaires and interviews, with only a couple of studies using validated health scales or applying statistical techniques to assess strength of associations between participation and outcomes.

In terms of quality, only a small handful were judged to have high reliability, either because the study design was not robust or that the paper did not provide sufficient detail on data collection to determine whether or not the methodology was robust. A similar handful were judged to be of high/medium high ‘usefulness’ for purpose of review, either because the findings offered no new insights, the study was too small to offer any generalisable findings, or that the outcomes focused on were not closely related to the interests of this review.

We found no longitudinal studies of the impact of participating in community currencies on direct health outcomes. However, a very small number of included studies did have a longitudinal element, e.g. one study showed successful employment outcomes, and another evidence of increased community capacity to carry out larger projects meeting community needs.

With reliance on a very small number of good quality studies, there remains a significant and enduring gap in consistent evidence of effectiveness of community currencies on health and public health which is also of a reliable and robust nature.

Positive outcomes

The key positive outcomes identified are:

• Improvements in physical activity. Volunteers have seen some improvements in their physical health through earning Time Credits. Some of the health benefits come from lifestyle changes, for example, being busy through volunteering can help to reduce smoking and weight gain. Earning and spending Time Credits can boost the activity levels of volunteers. Organisations have seen volunteers develop a more active lifestyle. This is in part through the volunteering activities and in part through access to new activities by spending Time Credits e.g. going swimming.
• The combined effect of the benefits resulting from earning and spending Time Credits can be an improvement in mental health. This results from improvements in confidence and self-worth, and taking part in enjoyable activities. It also results from having greater social contact. The improvement in mood can simply be as a result of being busy and active.
• Earning Time Credits can help people to feel less lonely, which is significant because loneliness is a known key determinant of poor health. People can suffer from social exclusion and earning Time Credits is a way to get engaged with the local community and meet people. Earning Time Credits has helped some people to develop new social networks which make them feel more positive.
• Earning Time Credits has boosted some volunteers’ confidence with knock on effects on improving their mental health. Volunteering gives people a routine and a purpose.
• Earning Time Credits has had a beneficial impact on the way in which some volunteers view themselves. Volunteering has given some people a sense of achievement. Some feel differently about themselves and viewed themselves more positively as a result of volunteering. Earning Time Credits can make volunteers feeling needed and appreciated. It leads to people feeling useful and that they are making a contribution to their community.
• Earning Time Credits has helped some people to develop their skills and learning. It has given some volunteers useful work related experience and a sense of personal satisfaction. For some people, volunteering is a way to learn the culture of working, which they are not used to, and helps them to get ready for paid employment.
• Volunteering has led to the identifying, developing and strengthening of skills. This has a positive impact on volunteers, boosting their confidence and helping to improve their employability. This provides new opportunities on both sides, volunteers gain skills and improved employability, but organisations can also identify suitable employees and in some cases have supported volunteers into paid employment.
• Strengthened family and wider relationships. For some people, spending Time Credits has had a positive impact on families and children. It gives families the opportunity and impetus to do activities together. Some volunteers share Time Credits to use with other people, helping to benefit others but also maintaining social networks.
• Time Credits give people access to activities that they might not otherwise be able to afford or would not have tried. These spend opportunities have positive impacts on their health and activity levels.

Challenges and limitations

The research identified a number of challenges and limitations in securing positive health outcomes through volunteering with Time Credits. 

• Some people hoard their Time Credits rather than spend them which means they are missing out on the benefits that comes from spending Time Credits.
•  Volunteers place a clear value on the time they have spent volunteering and want to see this value reflected in the spend activities. Some organisations have offered spend opportunities, which take time and resources to organise, and had no volunteers want to participate. In some cases, this has been because volunteers felt they could get ‘better value’ on other spend opportunities.
•  Volunteers in Wisbech only use a small range of spend activities. At the moment, most volunteers spend their Time Credits on going to the cinema, going swimming, and on hair and beauty treatments, with some also spent on social events. These are very valued. However, it does mean that the Wisbech network is very reliant on three external organisations being willing to continue to accept Time Credits.
•  One of the key challenges identified by organisations in working with Time Credits has been developing spend opportunities that are internal or community based.
•  Generally, managing Time Credits within an organisation does take up staff time, most said that it took up more time than they had expected, but that it was not unmanageable.
•  The Time Credits project has a range of target outcomes. Although the focus in the evaluation is on health, the research suggests that there has been more progress in the priority areas of strengthening families and skills and employment than on engaging or having an impact on older people, particularly the ‘older old’.
•  The qualitative research identified evidence of positive outcomes for volunteers. However, the strongest benefits may be concentrated on a core of regular non-traditional volunteers. For the people who were already volunteering, but had subsequently been offered Time Credits, they were a nice thing to have, but they were not critical in motivating them to volunteer and there had been little change in their circumstances.
• It is important to be realistic about what offering Time Credits can achieve. In a place where there are fundamental structural issues of poverty, deprivation, unemployment, low levels of education, poor health and poor lifestyle choices, one community project cannot be expected to ‘fix’ these problems, particularly in a context of reduced funding for local services.

Gaps in evidence

The biggest remaining gap in evidence is that of quantification. The research has found evidence of positive outcomes for some volunteers, but it has not been possible to quantify the degree of change.

There are several reasons for this. In order to measure change in people’s health, wellbeing and circumstances, a baseline is needed of these measurements before people begin volunteering, and then after a period of time to capture any change. However, the Wisbech project was quite well established by the time the evaluation began and the sample of people who joined as new volunteers during the research was not large enough to collect a robust sample of measurements. For attempts to measure and quantify change to be successful, they need to be built into a project to collect data from the beginning, rather than retrospectively. There is also a need to establish a meaningful comparator of similar people who did not join the Time Credits scheme.

There was also a degree of research fatigue amongst the study population, because Wisbech was the pilot for Time Credits in Cambridgeshire, volunteers had already been surveyed about their views of the project. There was also a reluctance to participate in some forms of data collection, such as surveys, possibly reflecting confidence and literacy levels, people preferred to share their experiences in dialogue through interviews.

Without being able to quantify any degree of positive change, it is not possible to demonstrate measureable savings to health and adult social care, which is the ultimate goal of the Council’s investment in the programme. The research has identified potential pathways to better health, but there is a lack of quantifiable evidence.

This does also in part reflect the circumstances of the particular group of volunteers active in Wisbech. Few had immediate or high level health needs, so any benefits are likely to only be realised over the long term. There are few older people who volunteer who are in receipt, or likely to be in receipt in the near future, of direct support from adult social care services. There is no direct evidence of any reduction in service use in the short term.

Benefits in terms of any reductions in the use of public services are likely to be long term. It would therefore be difficult to measure them over these time periods and to attribute them to participation in volunteering. As mentioned, there is also a general context of poverty and poor lifestyles that weighs against the immediate benefits of volunteering. Time Credits are also a diffuse intervention so establishing cause and effect between earning and spending Time Credits and the specific outcomes is difficult, particularly when there may be other types of engagement with volunteers through other means.

There is strong qualitative evidence of positive change as a result of earning and spending Time Credits, particularly amongst ‘non-traditional volunteers’, but any direct health changes have not been proven beyond the qualitative evidence. The evidence is also of positive changes in the known determinants of health, rather than in actual measurable health improvements. For example, there is evidence of improvements in social isolation, and therefore an implied potential improvement in health because loneliness is a known and proven determinant of poor health, but actual health improvement has not been evidenced. There was no direct evidence of a reduction in health-related services and this was not mentioned in interviews.

Conclusions

There is a need for further research to build on this study in order to quantify the evidence of benefits to individuals, and to meet the need for quantified, measurable proof of financial savings to public budgets. Evidencing the outcomes of prevention interventions in public health is very difficult. Cause and effect can be difficult to clearly establish as there are multiple influences on peoples’ lives. The benefits may only be evident over long time scales, but research tends to be short term. Alternatives to self-reported health, and to self-recall about service use, need to be used to develop robust measures of change.

The qualitative evidence from this research showed that earning Time Credits can have both direct and indirect health benefits for individuals. People gained a sense of purpose and felt that they were making a positive contribution which increased their life satisfaction and improved their mental health. They became more physically active and more socially connected. There is also evidence of increased confidence and development of skills and work experience to support moving into paid employment.

Spending Time Credits gave members resources to access activities and services that they would not otherwise be able to afford. Time Credits were spent on activities which lead to a more active lifestyle, such as swimming, with potential health benefits. They were also spent on family activities which may lead indirectly to positive health outcomes by improving social capital, social participation and overall wellbeing.

Time Credits are a relatively simple concept, but they are a complex community intervention with numerous interconnected outcomes and multiple pathways to positive change. They provide the opportunity to be active citizens, to share experiences and skills and make positive contributions that foster a sense of inclusiveness.

Plain English summary

The aim of the research was to evaluate the outcomes of the Time Credits project in Wisbech, Cambridgeshire, with a focus on health outcomes. In particular, to determine the initiative’s potential to tackle social exclusion and loneliness and to assess the extent to which it can improve wellbeing and increase community cohesion and social capital.

There is solid evidence that increased levels of community engagement and social participation have a positive impact on health behaviours, physical and emotional health and self-confidence, especially among disadvantaged populations. These benefits are so widely acknowledged that the National Institute for Health and Care Excellence guidance endorses community engagement as a strategy for health improvement.

Time Credits are a way of recognising the time people spend volunteering with a local organisation, community group, volunteer group or statutory sector service provider. In exchange for their contribution, volunteers ‘earn’ a Time Credit note, one for every hour they give. These can be ‘spent’ on a range of leisure and other opportunities, typically donated by organisations, local businesses and corporations to allow the community members to take advantage of their spare capacity. They can also be spent on activities run by other community members.

There are 16 active local organisations where people can earn Time Credits in Wisbech. These include schools, homeless hostels, children’s centres and an adventure playground. Volunteers can earn Time Credits by reading with children, running after school clubs, gardening, office work, working in a café and kitchen and litter picking. Volunteers can spend Time Credits on activities such as the gym, swimming, the cinema, beauty and hair treatments, attending social events and going to the theatre.

The research used a mixed methods research design that included both quantitative and qualitative methodological tools.

The findings indicate that Time Credits have been particularly successful in engaging with ‘non-traditional volunteers’ (a term used by local organisations). These are people with little or no history of volunteering and who tend to be unemployed or on very low incomes, are in receipt of state benefits and may have long-term physical and mental health issues. They may be socially isolated and have previously had little engagement with local community organisations.

The research found that for this group the experience of earning Time Credits was overwhelmingly positive, with evidence of both direct and indirect health benefits. The key pathways to better health for this group are associated with improved confidence, community and social participation, and a reduction in loneliness.

Dissemination

Academic conferences

Lafortune L; Burgess G. The Time Credit Programme in Wisbech, Cambridgeshire: assessing impacts on health and social wellbeing. Sharing our learning from the Public Health Practice Evaluation Scheme (PHPES), ScHARR, Sheffield. 25/01/2017

Lafortune L; Burgess G. The Time Credit Programme in Wisbech, Cambridgeshire: assessing impacts on health and social wellbeing. SPHR Annual Scientific Meeting, London, March 24 2017.

Durrant, D. and Burgess, G. (2017) Time exchange and austerity: The role of social enterprise and civil society in local economic and community development. AESOP. (Academic conference - talks)

Burgess, G. (2016) Public health outcomes of complex community interventions: volunteering and Time Credits in the UK. July 2016. International Public Health Conference. (Academic conference - talks)

Burgess, G. (2016). Health outcomes of place based approaches to building community cohesion: Time Credits in England. Presented at Association of American Geographers and International Society of Urban Health Conference April 2016 (Academic conference - talks)

Burgess, G. and Lafortune, L. (2016) Evaluating the Public Health Outcomes of the Cambridgeshire Time Credits Project – Presented at SPHR Conference March 2016 (Academic conference – posters)

Full reports (web access)

Louise Lafortune, Caroline Lee, Gemma Burgess, Andy Cowan, Isla Kuhn. A systematic review of the effect of time credit systems on public health and economic outcomes. PROSPERO 2016:CRD42016051615 Available from: http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42016051615

Burgess, G. (2017) Evaluating the Public Health Outcomes of the Cambridgeshire Time Credits Project: Final Report.

Durrant, D. and Burgess, G. (2016) Using Ethnographic Methodologies to Evaluate Time Credits. Cambridge: Cambridge Centre for Housing and Planning Research.

Durrant, D. and Burgess, G. (2016) Time Credits in Wisbech. Cambridge: Cambridge Centre for Housing and Planning Research.

Burgess, G. (2016) Evaluating the Public Health Outcomes of the Cambridgeshire Time Credits Project: Interim Report. Cambridge: Cambridge Centre for Housing and Planning Research.

Burgess, G. (2016) Wisbech Time Credits – partner organisation case studies. Cambridge: Cambridge Centre for Housing and Planning Research.

Burgess, G. and Markkanen, S. (2016) Wisbech Time Credits – individual member case studies. Cambridge: Cambridge Centre for Housing and Planning Research.

Markkanen, S. and Burgess, G. (2016) The potential for Time Credits to generate public health outcomes – a conceptual model. Cambridge: Cambridge Centre for Housing and Planning Research.

Markkanen, S. and Burgess, G. (2015) Introduction to co-production in research: summary report. Cambridge: Cambridge Centre for Housing and Planning Research.

Markkanen, S. and Burgess, G. (2015) Introduction to co-production in services: summary report. Cambridge: Cambridge Centre for Housing and Planning Research.

Markkanen, S. and Burgess, G. (2015) Introduction to time banking and Time Credits. Cambridge: Cambridge Centre for Housing and Planning Research.

Summary report (paper)

Burgess, G. and Lafortune, L. (2017) Evaluating the Public Health Outcomes of the Cambridgeshire Time Credits Project: Summary and Conclusions.

Academic journals

Burgess, G. (under consideration) What is the potential for community currencies to deliver positive public health outcomes? Case study of Time Credits in Wisbech, Cambridgeshire, UK. Journal of International Community Currencies.

Burgess, G. and Durrant, D. (under consideration) Reciprocity in the co-production of public services: the role of volunteering through community time exchange? Social Policy and Society

Practitioner dissemination

Within the partner organisations we have used newsletters, blogs, social media, emailed dissemination of reports at regular intervals, given presentations and participated in workshops. Members invited to launch event. We held regular face to face discussion meetings (monthly) throughout the project.

We met on the Monday of every month to discuss the research and outputs. They were sent drafts of all outputs for feedback and comments to be revised and agreed before publication. The strategic group met once a quarter and a section of the meeting was devoted to discussing the research, members include Cambridge County Council community engagement team and public health team Cambridge City Council public health, Fenland District Council, CHS Group, Spice.

Within the public health practice (and policy) community we held a launch event to promote the research. We have disseminated three short films to make research findings accessible. We have participated in practitioner workshops, distributed reports and outputs via email networks and held regular face to face discussion meetings.

Project website

http://www.cchpr.landecon.cam.ac.uk/Projects/Start-Year/2015/Evaluating-Public-Health-Outcomes-Cambridgeshire-Time-Credits-Project

Launch event May 18^th, University Centre, Cambridge

Event open to public

Burgess, G. (2016) Time Currencies in Cambridgeshire: Exchanging Time, Connecting Communities - Public health outcomes in Wisbech. Festival of Ideas, October 2016, Cambridge.

Workshop with practitioners

Policy seminar to local public health practitioners August 3^rd 2016, Cambridgeshire County Council.

Other

We are very proud of the three short films made co-productively with research participants to make the research findings accessible and easy to disseminate to a wide audience:

• Cambridgeshire Time Credits – an overview of the public health outcomes: https://www.youtube.com/watch?v=YXlw-dVeQss
• Cambridgeshire Time Credits - the benefits of volunteering: https://www.youtube.com/watch?v=wulsKngZIs8
• Cambridgeshire Time Credits - a volunteer's story: https://www.youtube.com/watch?v=t84UQ9PgsQU

Blogs

http://www.justaddspice.org/blog/evaluating-public-health-outcomes-cambridgeshire-time-credits-wisbech

http://www.justaddspice.org/blog

http://www.justaddspice.org/blog/cambridge-centre-housing-planning-research-launch-reports

http://www.justaddspice.org/blog/cambridge-report-in

http://www.justaddspice.org/blog/connecting-communities-cambridge-festival-ideas

Public involvement

We held a steering group meeting three times during the research with people in Wisbech. Members included organisations and volunteers. This was very useful throughout the research, enabling us to test out our understanding, revise the theory of change, test and amend fieldwork tools, discuss contacts and research approaches, and discuss findings. It meant that we were sure that the final outputs reflect the experiences of participants.

We held an event open to the public as part of the University’s Festival of Ideas. It was well attended and provided useful feedback about how we might present and shape the outputs, target the dissemination, and what to focus on for future research.

Impact

Cambridgeshire County Council are investing further in Time Credits. They are looking to link with wider partners in public service provision. They are building Time Credits into all of their contracts as a KPI.

Spice have responded to emerging findings with on the ground change to practices and project delivery, particularly around spending Time Credits.

This project was funded by the National Institute for Health Research School for Public Health Research (SPHR-CAM-PES-CTC) 

 Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Public Health Research, NIHR, NHS or the Department of Health.

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