The process evaluation focused upon the design, development, scope, intended purpose and implementation of the Breathing Space programme. To this end it used a range of qualitative data collection methods, including: observation (at programme meetings and key events); in-depth interviews (with key stakeholders including programme managers and workers); focus groups (with programme implementers and young people); and examination of official documents (minutes, reports, budget statements, policy documents and key correspondence) and monitoring of local newspapers and community publications.
Analysis of the process data was informed by a grounded theory, constant comparative approach. Interview transcripts were read and re-read by members of the process evaluation team in conjunction with data obtained from the other process evaluation research methods. Thematic categories were identified in the combined datasets and explored in order to ascertain which aspects of the intervention enhanced or hindered the successful design, development, implementation and receipt of community based programmes. Reliability of coding procedures was established through frequent meeting of team members. The robustness of both pre-identified and emergent categories was tested by reference to the individual cases, and conditions and circumstances of these formulations were compared and contrasted. A qualitative software package (NUD· IST) was used to assist in the management and combination of the combined datasets (from observation, mapping of community activity and interviews).
Extracts from data presented in the paper are prefixed by a letter which identifies the type of intervention participant: 'M' signifies manager, 'I' signifies intervention team member, and 'CP' signifies intervention member from the local community group.
Findings
Managing change
While change is an anticipated component of community based programmes, the level of change associated with Breathing Space far exceeded planned resource provision. Respondents described these changes as imposed upon the programme from outside and as impacting negatively upon the programme in a number of ways.
Staff turnover and attrition constituted a major issue for respondents. Over the lifecourse of the programme, the number of individuals associated with the design, development and implementation of Breathing Space decreased considerably. While respondents acknowledged that "things are always going to happen within a project that's spanned over such a long period of time" (CP3), by the end of the programme they lamented that there were "few members of the original team left" (I13).
Attrition was ascribed to several factors, of which the most important was organisational change within the programme's partner organisations, both locally run and external public organisations. The local area had experienced ten years of an extensive urban regeneration funding that was coming to an uncertain end. The withdrawal of significant urban regeneration partnership personnel and resources that supported local people had serious repercussions for the Breathing Space project. This insecurity was further compounded by re-structuring in the Health Board. Of six original intervention team members employed by the Health Board only two retained involvement throughout the three year initiative. Moreover, of three original community intervention team members (employed by the local CHA and URP) all were either on long-term absence or resigned during the course of the programme. At a managerial level, two managers at the CHA, two at the URP and five different Health Board staff had responsibility for Breathing Space during its lifetime. All these changes were exacerbated by uncertainties over core funding in the partnership and associated staff cut-backs in all three partner organisations:
"Each agency has transformed completely. (Health Board) went through restructuring. The Partnership (URP) is winding down towards closure and the Health Agency (CHA) have got staff shortages and are now completely, well until recently out of the loop" (I10).
As a result of these changes, funds were not available to replace staff on long term sickness, posts were frozen and/or part-time workers replaced full-time workers. While the reasons underpinning staff turnover are important, in this paper we focus upon the implications for the integrity of the programme of the loss of these very different, and often key, contributions.
Programme ownership and control over decision-making
Staff turnover served to undermine the sense of control over the programme among programme staff and local people. This, in turn, eroded key stakeholders' sense of programme ownership. The significant changes in the programme managers meant that Breathing Space found itself without the authority to make and act upon decisions. Under these circumstances, key decisions relating to the programme often lay outside the control of key programme workers and local people, and programme staff frequently had to await decisions from others in the parent organisations:
"I suppose bureaucracy, big organisations being what they are, they think, they obviously feel that they've got to make their own in-house decisions" (I10).
Even when new members of management were appointed to fill the vacant posts, they did not share the same programme history. Thus, intervention team members were required to refer to line managers who did not necessarily have in-depth knowledge about the programme. Respondents reported being unsure as to which manager was responsible for what, while lacking the authority to make their own decisions.
Staff turnover/attrition was also described as impacting on the relationship between the three main partner organisations. From the outset the Health Board was perceived as the most powerful player in Breathing Space, with more staff and heightened visibility, particularly in the early stages of the programme. As the community regeneration partnership wound down and key community workers on the programme were absent on long term sick leave, decisions were increasingly perceived to come from the Health Board. This had implications for maintaining community involvement:
"The partnership were the link to the people locally. They were the link to the other work that was going on. They were integrating the sustainability of the initiatives. And basically they were to take forward the community setting, which just hasn't happened" (I5)..
Knowledge and expertise
As participants of the programme left and/or were replaced, knowledge and expertise which they bought with them or acquired through familiarity with the programme, were forfeited. Theoretically, new participants drafted on to Breathing Space, to replace those who had left, could be initiated into the programme. However, respondents perceived this as a less than ideal solution for a number of reasons.
First, those involved in the initial design and development of the programme were considered to be 'visionaries' whose intensive association with Breathing Space was perceived as necessary for the programme to realise its objectives. The loss of these key players was felt deeply by respondents:
"...we've not had (visionary X) there, who we can get instant answers from, about Breathing Space , and about our interventions and things, so there's been a lack of direction" (I7).
"They were the key people that, if there was anything I wasn't sure about, I was able to ask. So, in these terms, in terms of sourcing information...it's a bit more difficult, I now find, to clarify things for myself. You know, other than reading through past papers" (I4).
Second, the early stages of Breathing Space involved the identification of useful community local contacts and the development of local networks between these individuals. However, because these networks remained at the individual level, and were not institutionalised at programme level, the support which they provided was forfeited when the key contacts left:
"...she would build up networks and contacts just by doing that. So we've lost that. We've definitely lost out by the fact she is moving" (M1).
"It's difficult for somebody else coming in who has not had the leads created" (I2).
Third, specialist skills deemed necessary to the successful working of the programme were lost. Staff members who had "worked that way before" and who were felt to have "particular community development skills" were particularly missed:
"I think her particular community development skills will be, she has worked in that way before, her understanding of that will be a great loss, actually" (M1).
As original members left, information about the programme became increasingly difficult to source. A member of the intervention team who came on board during the last year of the initiative explained:
"... it has taken me a long time, a good while to get my head around what it's all about. And I think there have been difficulties in people informing me about things because there are so few members of the original team left" (I13).
Loss of continuity and loss of momentum
Respondents expressed concern that staff turnover had implications for sustaining the ethos of Breathing Space in its original conception:
"...new people come in and they are picking up and they are bringing their own approach to things. But I don't think that's been maybe so significant as the fact that, because of absences in other people, even just people stepping in for a short term isn't the same for momentum as people being consistent and believing in the ethos and continuing it right the way through" (CP1).
Furthermore, the theoretical direction of the programme became diluted and the understanding of the new programme leaders was not always consistent with the original programme objectives. The original commitment of working in and with the community was transferred to the more traditional primary care models of smoking cessation.
"One of the big objectives has kind of almost been forgotten about... is about changing perceptions, and that we've concentrated very much on primary care and not the community. And I think that's partly through the coordinator when he took over post maybe not being given a fully accurate understanding of what the project was about and then maybe lost it again with someone else. A bit like Chinese whispers: you start off and you end up with a very diluted message" (I6).
For the most part respondents understood these changes to be a function of the lack of programme continuity:
"Not only (were there) not enough people but not the continuity. There's huge, huge numbers of changes from the beginning to the end. I mean, with all the people who are not involved now but were at the beginning for various reasons" (CP1).
Loss of continuity was, in turn, associated both with staff departure and with the unequal inputs from, or the perceived value of, those contributing from different organisations. The implication here was that, if input into the programme had been more equal, then staff losses from one quarter may have been more easily accommodated.
Restructuring and associated financial cutbacks in Breathing Space's partner organisations, which impinged on the amount of funding available for programme work, were also associated with a loss of momentum. Respondents talked about a "failure to follow through" on original pledges, noting that the ability of local community organisations, in particular, to execute their agreed programme of work was adversely affected.
"It's hard to look forward because people pull the rug from under your feet all the time. One year they want a four year business plan and the next year they will be cutting twenty percent off your money" (M5).
While community partners acknowledged their inability to fulfil the contribution they had agreed during early programme planning, they were resentful when others (particularly Health Board staff) stepped in to carry out work on their behalf.