90. Use zero-to-ten scale questions to assess wellbeing

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Scaling questions ask people to assess how close they are to a self-identified preferred future using a zero-to-ten scale.  The technique is used in solution focused brief therapy but I am suggesting that it can be adapted for the process of producing a well-being assessment.  The purpose of this post is to set out how.

Well-being Assessments in Wales

One of the things that local partnerships have to do to comply with the Well-being of Future Generations (Wales) Act is produce a Well-being Assessment.  Guidance here if you like the detail.

It is different from the needs assessments that have been required in the past in a couple of important aspects.

First it is based on an asset rather than a deficit model ('what’s good and how can we have more of it?' rather than 'what’s bad and how can we fix it?').

Second there is an expectation that the assessment will be linked logically to an analysis of the likely response (see my post on Driver Diagrams for an example of what this might look like).

These two points, plus the emphasis on achieving a ‘preferred future’, suggests to me a big overlap with solution focused approaches (see my previous post about this) of which scale questions are an established part.

Scale Questions 

Scale questions are not a research method nor are they a scientific tool.  What they are is a way of framing the conversation about a particular outcome and, most importantly, a way of making the link between assessment and action.

Within the therapeutic context, Ratner et al describe it like this:

A solution focused scale is a way of enabling a client to focus on the degree of progress towards their preferred future; it has nothing to do with assessing the extent of their problem. After a client has explored how they have got to where they are on the scale, they can be invited to consider what will tell them (and others) that they have moved to a point further on.  It is important to remember that the scale is the client’s subjective view of the situation.  It is not a scientific assessment! [1]

So, answering a scale question is a matter of judgement and perception not mathematical certainty.  This is of course true of any assessment particularly when a number of different sources of evidence are involved. There is no way, for example, of drawing together quantitative and qualitative research other than by an informed judgement.

In the context of a well-being assessment the appropriate point on the scale can be debated with a view to reaching a consensus.  This is no different from the assessment process that an interview panel goes through to agree a mark for a candidates question or that a tender panel goes through to assess a presentation from a perspective contractor.

The second point that can be drawn from the quote above is that the scale question technique calls for a focus on what positive things have got us to the score that we have agreed.  So, for example, we might think about the outcome; ‘Children have a good start in life’ and agree that it is a ‘5’ for the local area.  Considering what makes it a five may draw attention to excellent play schemes or Flying Start provision – assets to be developed rather than problems to be fixed.

The next step then is to ask ‘Ok, if we are a ‘5’ now, what would get us to a ‘6’?

Hence the technique moves quickly from ‘situation’ to ‘response’.

Applying the Technique to Well-being Assessments

So, what would a well-being assessment, based on scale questions look like?

The first step is to be clear about the preferred future that is being assessed.  This is likely to mean a set of outcomes, broken down into sub outcomes perhaps, that describe the future conditions you want to see.  These are set locally; as with the therapeutic context, the fact that they are 'self-determined' is really important.

The Well-being Assessment will then be structured around those outcomes providing a one-to-ten score for each based on the available quantitative and qualitative evidence.

Here is my suggestion of what each section might look like.

1. The evidence will be summarised for each outcome starting with "One a scale of zero to ten, where zero represents the worst things can be and ten the best they can be, we gave this an 'x'"
2. Next, under the heading “‘Why we gave it an ‘x’”, for each outcome the assessment will discuss “What makes it an ‘x’?”  This will highlight the assets that contribute to the score whether, physical, cultural, services, initiatives or otherwise.
3. The next question is ‘How would we know if we had got one step higher?’  Again, this is a matter of judgement to be negotiated collectively.  The answer might point to the evidence that would be required to push the score one point up the scale.
4. Finally the assessment should propose, for each outcome, “What would make it an ‘x+1’?”  This might point to an extension of existing schemes or approaches that have worked elsewhere.

Benefits of the Technique

Approaching the assessment in this way has a number of advantages:

• As a solution focused approach it places attention on assets rather than problems
• The scale questions allows us to be both ambitious about the future AND realistic – while the statement that ‘children have a good start in life’ may be a desirable if ultimately unachievable in full, the focus on ‘+1’ ensures that the conversation remains manageable and practical.
• Scale questions move us quickly from an assessment of the current situation to what the response might be
• Partnerships will be required to identify a small number of ‘well-being objectives’ and to address them within Well-being Plans.  Using scale questions provides allows progress against different outcomes to be compared (remembering that the scores represent judgements not facts).
• The scale question technique can be more widely used for research and engagement outside of the well-being assessment process - a new tool in the engagement toolbox.
• It is easy to explain and to get people engaged – it lends itself easily to public involvement – a public survey can be fed in, or conducted in parallel, for example.  Public results can be reported separately and compared to the partnerships' scores - big differences will provide an interesting topic for debate!

[1] Ratner, H, George, E and Iveson C (2012) Solution Focused Brief Therapy:  100 Key Points and Techniques P115.

85. Driver diagrams

Driver diagrams are logic charts with three or four levels.  They are a neat way to capture the links between strategy and action.  They provide a one-side-of-A4 description of what you are trying to do and how you are planning to do it.  They also show how different services contribute to broad outcomes and how all these contributions link together.  Driver diagrams are now at the heart of our One Swansea Plan (the overarching strategy for the area).  We rather like them so I thought I would share.

We got the idea of using driver diagrams from health, specifically our local public health team who use them in the Public Health Strategic Framework.  The idea of including them in the One Swansea Plan then came ‘bottom up’ from various partnership and policy coordinators who saw the approach and really wanted to use it.

In our plan we have six population outcomes – conditions that we want to achieve – for example Children have a good start in life or People learn successfully.

For each of the population outcomes we have produced a driver diagram that includes:

• The Population Outcome 
• Primary drivers that describe what needs to be in place for the outcome to happen
• Secondary drivers that describe the most important things that we need to do to achieve the primary drivers 
• Key Indicators to help track progress

For example, for the Population Outcome ‘Children have a good start in life’, a primary driver is ‘Babies are born healthy’ and a secondary driver that contributes to this is ‘Improve the health and safety of pregnant women’.

This example could also be written like this:

Children have a good start in life when babies are born healthy so we need to improve the health and safety of pregnant women.

While not included in our current plan, each diagram can also include tertiary drivers; a fourth column that covers the services, projects and other activities that contribute to the secondary drivers.  We will be adding these as we develop the driver diagrams further.

Each diagram has been developed through our Multi Agency Research Group by subject experts and through wider consultation.  In June 2015 we held a workshop to refine the diagrams.  We know that the diagrams will not be perfect and we intend to update and improve them every year as part of updating the plan.  

Our strategic partnership (Swansea Local Service Board) will use the driver diagrams to set their priorities for each year.  If you are working in Wales then you might like to know that this approach is entirely compatible with the Well-being of Future Generations Act and that the secondary drivers can be used as well-being objectives.

Looking forward we will continue to develop the approach. The one area that we definitely need to explore is how the driver diagrams can be used to get the public more involved with the strategy.