This is for the Global Masters in Public Health, Quality Improvement in Healthcare Module. We're having a conversation today with Filsan Ali from an organization called Midaye, which works in North West London. This is to highlight how community engagement can, and is central to healthcare improvement. Filsan, hi? It's great to have you here, could you tell me about yourself? Thank you for having me. My name is Filsan Ali. At the moment I lead an organization called Midaye, that delivers service for communities that live in North Kensington. As well as surrounding areas which is Hammersmith & Fulham, Kensington and Chelsea, and Westminster. Why did you get involved in this type of work? Initially I used to work for the local authority and lead a program called Sure Start, which I used to be the community link worker, linking the community to the services. That was my first exposure of working with the community, and I really enjoyed it. I didn't know community work was this exciting and rewarding. My passion starts from there, where I connected with people, I was able to deliver and develop services. I've seen a lot of things that need change and that encouraged me to join the organization. You said it was really exciting and you also said that, things really needed to be changed. I'm just wondering, can you give examples of that? It was exciting in the sense that you're always out there helping people, trying to make a difference in their life. But then at the same time, you can see there's change that needs to happen for that to work, for any kind of service to work. When you have a say of it, of that kind of change and when you have the community behind you to make that change happen, that is the most rewarding thing you see. But, at that moment when I used to work for the local authority I knew there is lots of change that need to happen. Some of them need to come from the community, and some of them need to come from the service provider. That is what I thought would be really opportunity for me to make sure that happens and to help the community progress. Could you tell us more about what you do through Midaye? When I joined Midaye, the first project that I have taken up, it was a public health-funded project. It was a health project, and mainly health promotion and engaging the communities to raise their health awareness on certain topics. Then after a while I developed the project to engage with mental health and mental well-being, because I knew that is the area that needed a lot of work. So I applied a small pilot project from the same public health pot, and I developed a counseling group, a Somali-speaking counseling group, and an Arabic-speaking counseling group. The whole focus was that, how will the counseling group, or will the counseling work in the Somali community and in the Arabic speaking community? But I had to do interpreting training for myself, at least I would be the interpreting person for this counseling service. I recruited a psychotherapist from the local area. We set up the program but it did not really work. The third or fourth session, I realized actually doing interpreting through counseling, it doesn't really work. The only thing that helped me to realize that, is when people start to leave. Slowly the group disappeared one by one and I thought, ''What is happening?'' But it makes sense that it's really good to speak to counselor with your own language, so you can say so much about your feelings. When you have a third person in the room, it's very difficult people to express their emotions. I could understand where the difficulty is, and that was my first understanding of how difficult people find accessing mental health services. Could you tell us a bit more about what you've done since then in mental health then, and how you've tackled the problems that you've had? I went back to the commissioner and I was fairly honest and I said, I'm having a problem. The service that I have applied is very difficult for me to deliver because even though I have become an interpreter, I have tried my best to recruit clients. To engage with the community into counseling service, it's not really working for them, so we have to make a change. I asked that commissioner, there's two options. One option is just returning back whatever funding is left behind as part of the service because I'm not able to deliver. The other option is that for me to change the whole program and try to see what I can do best to deliver this counseling service. Luckily, I identified somebody that speaks Somali from the local area. I spoke to her, and I actually find that also she speaks Arabic. I felt that's fantastic, maybe it's something that I can try to see how that works. I recruited that particular psychotherapist, the counseling group started again, and it was really good. The fourth or the fifth session, people expressed their emotions because they were able to communicate their own language. There's a lot of things that was discussed. People were very expressive, a lot of issues came out. They also requested at the end of the 12 sessions to see her individually. We had to arrange appointment for her to see each individual person separately. Some of them met at the clinic, some of them met her at the GP, some of them requested to meet her at the community center. It was really successful and that was an eye opening for me. At least I'm able to change a service that doesn't work for the community to make it better for them. That's a really powerful example. I'm just trying to wonder, how did you connect with the Somali community? The reason I'm asking that is because, those of us who work in organizations, we often hear that we can't connect with these people. It's with certain groups in society that we might think are, in the UK we have this term, hard to reach and I'm trying to understand and obviously there's a group of us who are trying to break down this term because we don't think it's an accurate term. I think the example you've just given is really a useful one to highlight that the communities aren't hard to reach. But I'm just trying to understand, how did you then connect with them? How did you gain their trust? Because mental health is such a huge field and there's so much stigma in every community of mental health. How did you connect with this community? I think in a way I was lucky to have the same experience, so coming from the community, it wasn't really hard to connect. But to be honest, what I realized over the years is that not only coming from the community is easier for you to connect, it's understanding people. At the end of the day, people are people. Understanding them, understanding their experience, acknowledging their needs, and try to see how I will be able to work with them. What I come across a lot of times is that a label was spot on the community like you said, hard to reach, hard to identify, hard to engage. They've got so many names it's countless. What I see is that there's a fear that created that. It was the service providers fear not able to understand this particular community. Because you build that fear, you build a wall between you and the community. You started off saying well they are hard to reach, obviously mentally it will become hard to reach, because you already put that perception and that label on the community. It's really difficult when you're at that stage to understand what you can do different. What can you make it different so that the community can understand, how can you go at their level of communication, where they are. What we come across most of the time, service providers have their own agenda. We have to deliver A and B, and C and the communities are there, so let's get them, and this is what they need to accept. Rather than coming on a set open mind say okay, what would you like to be? How would you like us to work together? We never seen a service provider having that kind of thinking. We see service providers having an agenda and target to me, and things to deliver. It's really different, it's completely two different world where the community is and where service providers are. At the end, I don't think the community is hard to reach. I don't believe that. All right. Thank you. Can you just expand on some of your examples through Midaye and Musawah I know that you have worked on female genital mutilation and you've done some work post the Grenfell Tower fire. Could you just start to expand on those two examples a bit more and tell us more about your work in those areas. Yeah. My work for FGM started off when the whole media came on the agenda of FGM and the government was putting a lot of policy in place against FGM. That policy existed many, many years ago. But it's just the reviewing that and making it tougher. People don't practice FGM in UK, that went on to media where community become really fearful about the situation. They were worried about them being targeted by the schools, by the health services, the police, the social services. Many community members that we worked with were very anxious. They come to us and they say we really need help because our worry is that now we hear what is happening from the media, so it will come to us, how can you help us? That's when we actually started arranging meetings with the community, and our main focus was that how we can engage the community into this policy arena, into these service providers, to understand where they are coming from. Obviously, they the one who practice FGM and they the one that can end FGM. We have applied a project to bring community service providers together. We're mainly focusing on schools and health and social care, which is the three areas that the community were really worried about. They all come into a room, we have done a four different discussions in four different locations where we engage hundred different woman from different ethnic minorities. As you know, FGM is practiced by many different countries. Majority of they were all present. There were discussing about their fear, they were discussing about their needs. Not only that they were telling the service providers, we the one who actually practice FGM, we the one that can end FGM. That was really educational for service providers. They learn a lot. A lot of information came out of it. We have contributed to the policy informing people how the community is feeling, what the community would like, and from there, we had been advocating the needs of the community. We have developed a service where we partner up with the local health clinics, FGM clinics, social services, and this was more about community led service. We have recruited and trained community advocates, people from the community that speak different language to advocate on their behalf, to support them. We have delivered a lot of different engagement and workshops in the community, and that become really successful. We the first pilot that started off just looking at how the service providers can work with the community. From there, we have published a report which we contributed to the policy development. We also been part of the stakeholders, organized by the home office, trying to contribute any information we get from the community, how this policy can be developed. We have done a lot of work in terms of. Then what was given to us is the DAV, funded us to deliver a model and guidance book for other service providers to come together and develop similar thing as we have developed. That guidance also was published where we engage different communities. Our model was that, we started off in the three boroughs, which is Hammersmith and Fulham, Kensington and Chelsea and Westminster. How can this can be replicated in other parts of London and UK? We have taken up this huge project where we have taken this model to different areas. We went to Birmingham, we went to Preston, we went to Wandsworth area, Ely, trying to educate the others how they can develop similar model by working with the community. At the beginning, it was more about fear, do not go, do not work with the community, they are the target element, they are the one who's causing the problem. Over the years, people seem to be understanding. Unless they support this agenda, it will be hard for the FGM to end. I'm so glad to say that now, the model has been taken up by Department of Health, and this is replicated in different parts of London as I know now. I think in UK as well, where they developed community midwifes actually run clinics in the community. They work with the community organizations as well as the social services and the health are working together jointly. I'm so glad not only have we created a model, we were able to educate others so they can develop similar models. I find it really interesting, Filsan, because this example you've just highlighted has a lot of the core elements of quality improvement. In quality improvement, there is always a collaborative approach, it's really important to engage people, and you always have to think about the sustainability. How are you going to scale this? How are you going to spread it to other areas? It's really interesting to hear that, without a specific quality improvement background, you've embedded this type of thinking and this type of process, I'm finding that really interesting. Could I just ask you to expand on your work that you're doing with Musawah, how that came about? What's happened? We have been involved a lot on Grenfell and the reason is that we are located near Grenfell. We're about 10 minutes walk from Grenfell Tower, and we have been supporting communities around the area. Also, some of the communities who lost their lives in the building. We have been offering a lot of community service where they were engaged with our trips. Other community activities we deliver, and when Grenfell happened, it was really a shock for everyone. It was difficult for us because we knew there's some members of our community who lost their lives in the building. We've been approached by different funders, different officers, that they really needed our help. They want us to engage with the community because that was the only thing that was there for the community at that time because of that anger, frustration, the mistrust that was happening within the community. We were able to design a big program which engaged a lot of community members. I think we have engaged almost 950 community members in a very short period of time. I would say a month, and that was only the people that we engaged. But in addition to that, we have been supporting a lot of funeral services, supporting communities to connect with their other members of the community. Try to give them a space where they can mourn, help each other in a culturally appropriate way. Seeing that and being part of that situation, we thought really what is needed is Musawah, which is a group of community organizations that wanted to come together, give a voice, and provide a surface that is culturally appropriate. It was really difficult moment for us, but what comes out of it was the learning that there's a need to collaborate in a bigger agenda as a community organization. Because we operate in a very diverse area where different ethnicity, different language people speak, they come from different countries, unless people work together and come together, it would be hard for us to resolve a lot of issues, and that was a really great learning. We published a report which is about community needs assessment of the local community just informing others what the needs are. These needs were not new needs but it was exposed more and it came out more after Grenfell Tower happened. But I think it was really a great learning for us and a great opportunity to come together and to help the community in a bigger way. Filsan, that's really interesting and incredibly powerful and a really good example I think of the value and importance of engaging communities when we're aiming to either deliver or improve health and care and also the wider determinants of what makes people healthy in their communities. Could you just tell me a little bit more about what you mean by needs assessments and how did you carry out this needs assessment? Okay. What we did is that actually evidence the needs of the community. Some of them existed before and some of them were extra needs that was added after the Grenfell Tower fire. What we did is that we interviewed, and engaged, and created a focus group in different community organizations that speak different languages, so there was involvement of different community members, all sections of the community, adult, young people, old people, different sections of the community came together. It was mainly focusing on what their needs are at that moment in terms of their education, their health, their housing, so many things came out of that. When we looked at the needs, we collected on the surveys, and the interviews, and engagement that we have done with the community and that carried on for about three months. It came out actually some majority of the staff at the community are saying their need are, it was something that existed but not actually dealt with because why? The community where found to be hard to reach, so I think there is understanding and learning that came out from that. That was also become part of the public health agenda of moving forward and looking at how they can improve the lives of communities in North Kensington, so that was part of that as well our research became part of that. It was a learning that we presented to the local council, what the community needs are, how the community want services to be delivered, what kind of change that they are requiring or requesting, so it was very successful meetings that we had, and at least we have better understanding and people do have better understanding, which we share widely the needs of that North Kensington community. Thank you. I'm going to flip the questions now, I'm going to ask why those people working in organizations that are aimed to improve health and care, how are we hard to reach? What are the key challenges of working with organizations like ours and people like us who work in Health and Care Organizations? I think you're coming from a side of that I want to meet a target, I have an agenda, I have a funding behind me because that's what they want me to meet, so how can I get engaged with the community? I think it's seeing the community as a product rather than they're actually human beings, and they have needs, and they have demands, so they come in in a way that okay, I have to deliver this project and I have to get the right people on board. That doesn't really work properly because if it comes from a place where you engage with the community first, let's build something together, let's do something together, let's do it the way that you think would be done. Can you be part of that? Giving the community the ownership, that would be working really well, that would work very well but what we see most of the time is something that was thought about before even engaging the community. There's a target, there's figures, there's some plan, there's a surface developed already that the community is not even aware of it, so it's all complicated because it would look and it would translate it or try to interpret it in a wrong way. For us, the difficulties we have is that when we get this service providers approach us, we have to understand first. If we don't understand, it would be difficult to actually make sure the community do understand. That is the difficulties we have. Sometimes, we find our-self in the middle, not understanding what the service providers want to deliver. For example, we have developed a parenting group, a family support project. Our project, the way we develop is that, we said, we're going to have women that have children between the ages of zero, a new born mother to the age of 19. People were like, "Well that's impossible." Either help early years or you help the young people. Before us, this is our community dynamic. A mother could have a new born baby, but then she can have a child that is 19,18 years old and the whole family needs help. This was created as a holistic sort of service. People, do not understand that it took them many years to understand. But luckily, our own local council now, is actually developed a similar model. Which they understood is really important to see that journey and offer holistic service for the community. That kind of service, it developed from the community. Without understanding the needs of the community, we can't go and develop services and bring it to the community. The good thing, the position we are in now is developing something from the community and giving the ownership to the community, rather than bringing them what we feel is right for them. That's what we see from many of the services at the moment. Great. Thank you. To end on a positive, you've touched on this slightly already. But what do you think are the key ways to ensure that people who work in health and care and work to shape health and care can work meaningfully with their communities? I think the most important thing is that they have to be open-minded. They have to be able to understand the community. I mean, without to understand it's very difficult to develop services. Yes, you do have your figures, you do have your numbers, you want to do certain improvement. But also educating the community and understanding them at the beginning where they are, is really important. One of the things that I come across recently, is that a group of health professionals want to improve child obesity. When you work with the community that do not know if their child is going to come back safe or not, whether they're going to be alive or not tomorrow and they're living in an area that they are really fearful. They are unemployed, financially struggling. The last thing they want to hear is to sit down and say, "Okay, you need to listen how you can improve your child obesity." That is really way off. It's understanding the way people operate and then getting the place that you want them to. I think that's really important. The other thing I would say, I hear a lot of co-production. Every meeting you go, when it comes to how it's done, we open to co-produce with the community, we doing co-production. When you really look at it deeply and understand the whole concept, you find that they already know what they have to deliver. This is not co-producing, no. You want to improve that. But rather than asking the community, educating the community, trying to get their ownership from the start. You know exactly what you're doing, you see you're not co-producing. That word, I don't trust anymore. I don't know if others do, it's a word to be said rather than an action that is behind it. I think co-production need to be improved maybe, reworded in a way that maybe the community can understand or maybe reword it in a way that is genuine. I think it needs to be genuine rather than just a word that need to be said. The other thing I would say, what is needed is a model of care. Definitely, when it comes to mental health, mental health is huge struggle. I mean, I'm already involved, I'm currently training as a counselor. I could see there are difficulties, there are huge barriers. Definitely, what is needed is model of care, of engaging certain community, looking at where they're coming from, their own experience. What is the best way for them to engage, if they don't want to talk about mental health. Mental health an issue, we know that one in four people is affected by mental health one way or another. But community is not being very involved and not use mental health until it is too late for them. It's really difficult and they will cost the health service a lot of money. There's need to be a development of new models of mental health care, definitely. Right, Filsan, it's been fantastic talking to you. I think we've learned so much. I really appreciate your time and I really appreciate you sharing your experience of community engagement. Thank you.