In May 2013, the RSA and Drugscope convened a meeting of the providers that deliver the eight national ‘Payment by Results’ (PbR) substance misuse pilots. The RSA wore two hats: one reflecting our role as a think tank with a now longstanding concern for substance misuse policy and practice; and one reflecting our role as one of the providers. (As readers of this blog will know, the RSA is part of a consortium lead by CRI and including Sussex Partnership NHS Foundation Trust, which delivers the West Kent PbR substance misuse pilot.)
The purpose of the summit was to explore the provider experience over the first 12 months of operation from April 2012, and in doing so to highlight good practice and identify practical recommendations for implementing PbR schemes. You can download a short summary of the themes discussed and the learning points that emerged below:
I will not summarise or repeat the main points here, but I want to add a reflection on some conversations I had very recently about these points and what they mean for PbR. The pilots represent significant system change, that is happening within significant wider system change, that is happening within wider change still. The move to recovery-oriented systems, delivered through PbR mechanisms in the case of the pilots, is happening in the context of wider health-system change (move to public health, introduction of Clinical Commissioning Groups and Health and Wellbeing Boards, and so on), which is occurring in the context of multiple and complex changes to public services and the welfare system and wider economic stress for many groups and areas (all of which impacts on ‘recovery outcomes’ to varying degrees). Levels of public service performance can often dip after major re-organisations, so isolating the effect of PbR specifically appears difficult.
Further, it was interesting to note that when providers spoke at the summit of the ‘effect of PbR’ in terms of the value-adding change it had made to service delivery and emerging outcomes for service users, it was usually difficult to see how PbR itself had actually brought about this change. Rather, PbR had acted as a catalyst for change – something to shake up the system; a stimulus or opportunity for new thinking and innovation. It seemed that changes could have been brought about by some other catalyst (and in most cases, it seemed that these changes would have happened anyway, given local capabilities and concerns, and as the focus on recovery given by the national drugs strategy washes through the sector). Again, any change measured will be difficult to attribute to the impact of the financial mechanisms and incentives of PbR. The diversity of PbR designs in the pilot sites (and the corresponding diversity of the responses delivered by the providers), and the wider roll out of PbR into other (non-pilot) sites make comparisons across areas difficult. Even with a sophisticated realistic evaluation design, it will be difficult to take account of this much noise. The risk is therefore that we mis-interpret what PbR does (both positively and problematically), and do not consider whether there are better mechanisms for driving transformation, innovation and improved outcomes. At least the pilots are generating a significant amount of data that can help to unpick the puzzle (this is PbR without the black box in practice).
The RSA will be publishing a report in the Autumn that will explore our experience of delivering under PbR arrangements. In the meantime, one clear lesson to emerge from the summit is around the speed of the PbR design phase and the turbulence encountered in the early stage of delivery. Transforming Rehabilitation should take note.
35 social care professionals, local authority representatives and policymakers discussed reforms to the draft Care and Support Bill at an event hosted by the RSA’s 2020 Public Services Hub. Alex Fox FRSA, CEO of Shared Lives Plus, guest blogs about the event and Bill.
There can be few people unaware that there are NHS reforms afoot in the UK. Yet few are aware that the most sweeping social care reforms in post-war history are now taking place, with existing ‘poor-law’ based social care law to be replaced by new legislation outlined in the draft Care and Support Bill.
The Care and Support White Paper which preceded the Bill set out a new vision for the ‘personalisation’ of social care. This takes the idea of individuals having an individual choice of service and control over their lives as read, but recognises that even a well-funded, well-tailored service does not always add up to a good life, particularly if your support needs are social rather than entirely physical. For instance, taking a cash Direct Payment in lieu of a service to hire and manage a team of Personal Assistants can be the ideal solution for meeting physical support needs while staying in charge of one’s own life. One individual who now manages his own care said, “When I got my disability I was stuck in hospital whilst services argued over paying for adaptations to my house.” Yet if someone’s challenges involve isolation or social exclusion, the solutions are likely to lie partly in that individual’s unpaid relationships with families, friends and others in their community.
The reorganisation of social care around promoting wellbeing is a radical and welcome vision. But there is concern that the draft Care and Support Bill will not fully enable this vision in practice. Five pioneering community support organisations -Community Catalysts, In Control, Inclusion North, Inclusive Neighbourhoods, Partners in Policymaking, Shared Lives Plus, as well as a leading Director of Adult Services – have argued in a briefing on the draft Care & Support Bill that the Bill needs set out a different route into – and out of – social care to achieve an affordable, more empowering and more successful care system.
In particular, the care organisations argue that eligibility tests should not be the first conversation which people have when they encounter social care. Instead, they should be offered support with life-planning as the first intervention. These personal planning discussions would look first at the individual’s strengths and skills, rather than considering only their needs; then at their existing supportive relationships with family, friends and the wider community; and lastly at services. The wellbeing principle should be developed to set out in plain English a minimum acceptable level of wellbeing to replace the current Fair Access to Care Services (FACS) eligibility criteria.
The recommendations are based on the care organisations’ experience of how people are changing lives and communities for the better, often with less money than has been spent on traditional services. At a recent roundtable hosted by the RSA’s 2020 Public Services Hub and chaired by Paul Burstow MP, who currently chairs the Joint Committee scrutinising the draft Care and Support Bill, one participant said that the current system intends to be empowering but “drags us back” into a deficit-focused model and “dependency culture”. In contrast, when disabled people and family carers themselves are involved in explaining support options to others, there can be a more honest conversation. A parent said, “When I had my daughter in the 1970s it felt like I’d fallen down a rabbit hole into a world I didn’t know existed. I had no support strategies and was battling every day to get simple things. Other local parents were holding on to what they knew and were wary of change.”
Likewise, Partners in Policymaking runs citizen leadership courses for disabled individuals and the parents of disabled sons and daughters, and brings families together for peer support and to influence decision makers. Before the courses participants say that they would often “just talk about their problems, not about what would make things better”. After completing the courses, many people get jobs and some set up groups or social enterprises to tackle the challenges they have experienced: “I would have been one of those parents who wrapped my daughter in cotton wool, but I started to see her as a citizen of this world with the same rights as others and now she’s done two degrees. We learnt to ask for what was needed, not what was on offer and we built a community. One young man would have gone into residential care when his Mum went into hospital, but with support from the network he is still living at home after seven months.”
Moving away from the mindset of “These services are what we have on offer” towards “What would you see as a good life and how can you move towards living it?” represents a huge culture change, particularly at a time when many services are in crisis mode. Mechanism changes such as personal budgets, implemented in the aim of personalising care, have not always created change of this kind. Though some councils, providers and professionals have implemented personal budgets, these are still used to buy the same old services staffed by the same people. In contrast, two social entrepreneurs described how they had built upon the skills and insights they had gained working within public services to identify a gap in current provision, going on to set up their own small enterprise which provides transition support for young disabled adults which is tailored to their goals in life. They are just one of around 800 micro-enterprises known to the partner organisations.
A new social care law cannot legislate for culture change of this kind. But, while Direct Payments remained little used for a decade after they were introduced into law, the cultural shift towards individual control which eventually followed them would not have happened without the original legislative change.
Some councils are already trying to make a change of this kind, even within the present system, with FACS tests replaced by questions which could be used to define acceptable wellbeing such as: Are you safe? Can you live with dignity? Do you rely upon services for personal care? Are you connected to those around you? Are you able to be an active citizen in your community? A personal planning approach which helps people to find, recognise and use all kinds of resources and relationships, including family care, community groups and new links to people in similar situations, will often find ways of improving wellbeing without relying upon services.
However, developing a different approach to care with local spending cuts of up to 40 per cent is clearly a challenge: “we are reneging on the welfare state commitment made in the ’40s, with no evidence that the taxpayer will step up. So we either abandon those goals, put our hands in our pockets, or take collective responsibility and have a new public discourse on care.” Or as one council representative said, “it’s not ‘doing more with less’, it’s doing ‘different’. We need to remember that we are often the minority partner in the provision of care and to be careful about where we are putting our big feet. The economy of regard doesn’t function in ways in which we always understand.”
This week the 2020 Public Services Hub at the RSA and the Social Market Foundation (SMF) launched a new report on the scale of the challenge for public finances ahead of this year’s Autumn Statement, and what this will mean for public services. The figures, based on Office for Budget Responsibility (OBR) projections and analysis by the SMF, suggest that an additional £48bn of tax rises or spending cuts will need to be made by 2017-18 in order for the Coalition Government to meet its aim of eliminating the structural deficit within five years.
The implications for public services are grim. If health, education and international development continue to be protected, we are looking at cuts of 23 per cent across remaining government departments – on top of the cuts that were already planned by 2014-15. For the Department for Work and Pensions, this would be the equivalent of cutting half of its spending on Job Centre Plus and all employment programmes.
In the report, 2020PSH argues that we need a new approach to public services to meet the challenges ahead. The pressures on public finances will remain even when there is a return to economic growth, as a result of an ageing population and rising demand for services. 2020PSH argues that more strategic spending, rather than unsustainable cuts and short term fixes, can alleviate these. We need real devolution of power from Whitehall to localities, alongside a serious attempt to manage demand for public services and smarter use of public spending and commissioning processes to catalyse social and economic growth. Legitimacy and consent are vital – without effectively engaging with citizens, policy changes on this scale are not possible.
A further three key points emerged from the event’s public launch at the RSA, at which the report authors were joined by public service veteran Lord Michael Bichard:
1. The scale of the challenge ahead has been understated. The dire state of current and medium-term public finances is troubling enough, but the long-term pressures of rising demand are even more serious. Lord Bichard argued that we are not taking this challenge seriously enough and are ignoring the “gaping hole” in the current public service model. There needs to be a far more serious effort at reconfiguring services around early intervention and prevention. We should be managing demand by creating services that strengthen the self-help capacity of citizens: not a smokescreen for cuts, as this has been interpreted, but to enable individuals and communities to take greater control of their lives and meet their personal and collective aspirations. The funding model for services also needs to be transformed, so that social investment and the mobilisation of new forms of social and economic resource are part of a new, more diversified spending model.
2. Localism and social equality can go hand in hand. One question raised in the audience discussion was whether centralism stifles local attempts to address the big issues facing communities. The argument runs that because local councils are assessed based on centrally-set targets, they are less accountable and responsive to local need.
Yet the central-local debate is often focused on the trade-off between localism and equality. There is an explicit or tacit assumption that greater devolution would produce unequal outcomes between different places – the ‘postcode lottery’ effect.
Instead, and as Lord Bichard and Ben Lucas both argued, perhaps the centre should give local government the capability to focus on issues such as inequality and economic stagnation that matter to local people, and which centrally set policies do not effectively address.
3. What type of growth is desirable? What was arguably missing from the discussion was the ecological component of future challenges. Everyone agreed that a return to economic growth was desirable, but there was no discussion of what type of growth this should be. It is clear that traditional consumption-based GDP growth is environmentally and socially unsustainable. To consider the long-term future of public services in the UK, we need to address the viability of the economic model which underlies them.
For this reason, 2020PSH’s argument for an integrated fiscal, economic and public service reform strategy is crucial. It highlights the need to think about growth not for its own sake, but in terms of how it can support and respond to the aspirations of citizens and the needs of society. We make this point in more detail in 2020PSH’s Business, Society and Public Services report on the productive potential of collaboration between businesses, public service providers and civil society.
As the fiscal outlook worsens and our policy options narrow, it is vital that we explore these issues now.
Many have spoken of the potential value of social investment, or investments that include both financial and social returns. Building on initiatives from the previous government, the current government has articulated a vision and strategy for growing the social investment market. The Big Society Bank (now renamed Big Society Capital) forms a core part of this, but the underlying aim is to provide the infrastructure and support necessary for the social investment market to overcome various barriers to its growth. While social investment has been growing, there are several problems that limit its potential scale, such as a lack of investment readiness on the part of social ventures, lack of market information, and cultural and behavioural barriers among both those running social ventures and potential investors. This is why much of the debate on the feasibility of social investment has revolved around the importance of ‘social market intermediaries’ that are able to provide the expertise and infrastructure required to connect funds to appropriate social ventures, and to enhance the market readiness of social ventures.
A fundamental shortcoming is the lack of a focus on giving citizens a greater stake in social investment. Social investors are predominantly rich individuals (such as philanthropists) or large organisations, and social investment is typically associated with social enterprises
But it might also be argued that an even more fundamental shortcoming is the lack of a focus on giving citizens a greater stake in social investment. Social investors are predominantly rich individuals (such as philanthropists) or large organisations, and social investment is typically associated with social enterprises. In comparison, citizens have very limited opportunities to become social investors, which isn’t helped by the lack of engagement with social investment by institutional investors such as pension funds.
This absence of a democratic space for citizens to develop a greater stake in social investment has led Bristol City Council to pursue its forward-looking Building a Better Bristol programme (which 2020PSH will be assisting), which is working on developing credible investment products and governance structures to support ‘socialised investment’ – getting the wider public, businesses and institutional investors involved in investing in the social and economic development of the city while ensuring financial feasibility and investor confidence.
Bristol City Council’s Building a Better Bristol programme is working on developing credible investment products and governance structures to support ‘socialised investment’ – getting the wider public, businesses and institutional investors involved in investing in the social and economic development of the city while ensuring financial feasibility and investor confidence
At a time of austerity and debates about how public services and economic and social development can become more sustainable, productive, and locally relevant, ‘socialised investment’ raises some very interesting long-term opportunities for local government, including:
- A new role for local government. As localism becomes more embedded in statutory and policy frameworks, local government can carve up an enabling local leadership role (possibly having a ‘social market intermediary’ role of its own) to catalyse social change and public service reform.
- Public money can be combined innovatively with pooled socialised investment funds and leveraged to collaboratively finance services and developments, which could also help relieve pressure on cash-strapped local authorities.
- The commissioning and delivery of services will theoretically be more intertwined with what citizens want from their services. While tax is a legal obligation, social investors will expect not just a financial but also social return – and this will need to be negotiated with citizens. Expectations of social returns will also have implications for the degree to which commissioning is based on the generation of social value. It will also have the potential to reshape how we should think about productivity in public services – something 2020PSH will be exploring soon.
- Greater local accountability and transparency, and greater local distinctiveness.
2020PSH has long argued for social productivity as an organising principle for public services – that is, public services should be judged according to the degree to which they help citizens, society and local communities achieve the social outcomes they desire. If it works, and if it is able to successfully scale out across the country in the long term, ‘socialised investment’ could be a fundamental part of socially productive public services. While it certainly is at its very infancy, the potential is also great.
Blog by Henry Kippin, 2020 Public Services Hub at the RSA
Confirmation that the UK is now officially back into recession must be pretty shattering news for a government that has based a big part of its political strategy on avoiding a double-dip. Statistical confirmation merely supports what many in the construction, manufacturing and high street sectors already knew – that we are now in a sustained period of low-to-no growth. The Guardian today talks of ‘little sign of recovery before 2014’.
The blame game is in full swing. Opposition blame the Coalition for a rapid adjustment policy that has stripped demand and stunted recovery. Coalition blames Labour for the inheritance of a huge debt burden and an economy in decline. Both blame the Eurozone economies – but at different times, and for different reasons. Both are stuck between fingering blame on the financial sector and hoping it will drive economic recovery, and the green shoots of a more sustainable and collaborative growth model risk being trampled by the urge to create quick and effective economic incentives.
Buried under the economy and Leveson this week was a report from the Public Administration Select Committee , which called for an annual ‘statement of national strategy’ in the absence of a ‘critical and unfulfilled’ strategic direction for government. The implication being that – in the rush to decentralise, liberalise and retreat from clunking fists and deliverology, there is little coherent thinking on the long term direction for the economy and public services.
There has certainly been a lack of coherence (from both government and opposition) in this area. As we write in a forthcoming report, “public services need to be reformed to meet the demands of the long-term, under the fiscal constraints of today. Economic growth needs to be re-kindled – but in a more sustainable form that carries public confidence and delivers fairer returns. These are the two big policy challenges of our time. Yet they are not being considered together, and risk pulling in conflicting directions.”
In a new 2020PSH report (launched on 10th May at the RSA) we suggest a few ways of pulling these agendas together. But a vital part of this is taking a view of the public sector and public services as an intrinsic part of the growth strategy – not as a structural barrier to be peeled back. This means thinking hard about public service productivity: what we mean by it, and how we can use public spending to drive sustainable growth and employment in future. We think our social productivity approach (which emphasises strong public-private-social relationships) is a way in to this, and will be picking this up in a new programme on public service productivity in the summer.
Henry Kippin @h_kippin
Three of the most intractable problems in the field of mental health services are stigma; isolation and disempowerment.
Stigma can be partly be combated through educating the public and through marketing campaigns. But there is very little that is better at dispelling stereotypes than direct contact.
Isolation and loneliness can be addressed through neighbourhood activities and institutions that bring people together.
As we recently argued, disempowerment can partly be understood as having a lack of resources in your social network. If you do not know people who can help you to get things done then you are much more likely to feel like you cannot control the forces that act on you. Part of empowering people, therefore, is sustaining and developing their social networks, for example introducing them to people who might be useful to them in the future.
In short, part of the solution to all three of these problems must involve talking about people’s relationships. This can be a tricky subject for mental health professionals and for service users.
I recently chaired a panel discussion around this topic at the One In Four conference.
There was no shortage of at the conference. People were discussing how personal budgets, micro enterprises, co-production and network weaving could all be ways of supporting and developing people’s social networks.
It struck me that this would require a quite different role for the state. Rather than delivering solutions to service users the state would be supporting and sustaining an environment in which people are able to develop their own social networks. If you want a practical example of what this would look like you might have a look at the Southwark Circle project that Participle started.
One of the many reasons why I do not think we are going to see this type of culture change within mental health services is our own ambivalence towards the state. One the one hand there is huge mistrust of the state; we are sceptical on the efficiency of the government (“waste”) and often on the motives of government (e.g. “stealth taxes” or “big brother”). On the other hand there is a strong belief that the government is largely responsible (see this report especially from page 12 onwards) for bringing communities together. This “ambivalence gap” leads to a type of risk adverse paternalism from public services.
Worryingly this means that changing the way public services are delivered means changing ourselves.
Apparently the Chief Executive of Nokia has written an internal memo to his staff likening his firm to a “burning platform”. He argues that the introduction of the iPhone and Google’s own mobile phone platform has had such an impact on his industry that Nokia must adapt or die.
For me the key quote is
“Apple disrupted the market”
The idea of “disrupting the market” is at the core of Apple’s approach to developing new technology. Steve Jobs once said that his purpose was “to put a dent in the universe”.
Within business and technology literature the idea of a “disruptive technology” (when a new and unexpected technology arrives on the scene and changes everything) is well established. So too is the idea of “creative destruction”. It would be fair to say that this approach has not been tried or particularly welcomed within government, which has often proved to be ‘path dependent’.
But is this all changing?
Some have argued that the current government are undertaking such a broad reform of public services that they can be described as “Maoists”. Steve Hilton, the government’s Director of Strategy has said he wants to “change everything”. I think that the government’s approach to changing things borrows quite a lot from the idea of disruption.
Everyone knows that the government is cutting funding to public services and reforming them at the same time. The way they are reforming them is, I would argue, an attempt to add disruptive elements into communities to shake up the way public services are delivered. They are adding elected police commissioners, GP consortia, and giving community groups the ‘right’ to bid to run services. All of these reforms, and many more, can be seen as adding assertive, challenging new presences that will be fighting their own corner.
This is quite a contrast to the previous government’s approach, which was typified by (forced) partnership working whereby a range of different local agencies had to sign up to grand plans and strategies for their area.
There would be very few people who would march to save Local Strategic Partnerships. You can hardly imagine people chanting “What do we want? A Sustainable Communities Strategy! When do we want it? After the statutory consultation has been undertaken!”
However, the question does spring to mind, who will bring a diverse range of neighbours, businesses, government agencies and charities together to agree a common vision for an area?
Perhaps you think that this will be a role for the government’s new ‘army’ of community organisers. However, as Toby Blume has persuasively argued, the community organisers will in fact be another disruptive element. They will “offer a challenge to all those who hold power, whether in local government, the private sector or the voluntary and community sector”.
The gains from having “disruptive technologies” introduced into communities include; innovation, challenging old and tired ways of doing things and, potentially, a better service for users.
However, there are downsides. Unlike in the private sector, people are loath to allow public services to fail and disappear. Nothing brings a community together better than a campaign to save a hospital which is threatened with closure. The possibility of organisations failing is an essential part of creative destruction.
From a communities perspective it is vital to recognise that certain issues can only be solved by bring people together. If we want to improve race relations, reduce isolation, or promote more trust between generations then we need to bring people together.
The Prime Minister has made it clear that his vision of the Big Society is one whereby “neighbourhoods who are in charge of their own destiny, who feel if they club together and get involved they can shape the world around them”. In this description, clubbing together is clearly a precursor to getting involved. The concern must be that rather than clubbing together, people will splinter into competing groups.
Tessy Britton has written of her worries that community organisers might be one degree of disruption too much. Instead she calls for “people that bring people together in positive ways that change and improve their communities”. The key point that she makes is that these “social artists” seek to create emergence, when new and coherent structures come out of complex systems.
If we accept that there will, in the future, be a lot more disruptive elements acting in communities, then there is a strong case to be made for the need for organisations and individuals that can act as conveners; bringing people together and facilitating cooperation and mutual action. This convening role should not be bureaucratic or controlling. It should be creative and fun and allow for the possibility of emergent phenomena.
Christakis argues that obesity spreads from person to person, like cholera.
People who have lots of social connections are more at risk of obesity just as they are more at risk of cholera. Those in the periphery of the network are less likely to become obese.
This might seem strange to viewers of Channel 4s Britain’s Fattest Man, which followed Paul Mason, a man who is noteworthy for being both obese and having very few friends.
I think Paul’s story tells us a lot about the types of problems we face as a society and give us a glimpse of how reformed public services could better solve these problems.
As the candid consultant observed in the documentary, most of the people he sees who are very overweight have some underlying problems with relationships. In Paul’s case, his main problem was that he did not have any relationships.
Paul’s weight was average as a teenager but then, in quick succession, he broke up with his girlfriend, lost his job and his father died. His mother then became unwell and he moved in with her to be her sole carer.
Faced with this strain he started to eat. You can easily imagine other people in similar circumstances turning to drink or drugs, but Paul turned to food.
He ate so much that he needed to re-mortgage the family home. His sisters promptly disowned him for squandering their inheritance. His mother then died. He was acutely isolated and ill-equipped to deal with this.
He continued to eat. He was eating 20,000 calories a day, 10 times the recommended amount.
Eventually, the public purse started to support him in more and more dramatic ways. He was provided with a carer who supported him for 12 hours a day. He was given money in the form of benefits. He was given special equipment. Eventually, he was brought into hospital for a series of operations to reduce the size of his stomach. He is now of a size where it is possible for him to move around on a specially designed wheelchair, and he receives fewer hours of support.
We might be tempted to argue that the huge cost to the taxpayer (over 100,000 a year in care costs alone, the Daily Mail estimates) do not represent good value for money, we might even be tempted to agree with Paul himself, who is suing the NHS for allowing him to get so overweight.
These are both interesting points. I am reminded of Cacioppos work on loneliness and Smalls work on the role of institutions in building our social networks. I think it would be fair to sum up their arguments by saying that loneliness has a very negative effect on people and that institutions can build peoples social networks through placing obligations on people.
How might this apply to Paul Masons case?
As things currently stand Paul’s isolation was partly remedied by paying a care worker to visit him for 12 hours a day. The medical consultant obviously did not consider it anything to do with him that Paul was isolated. Neither, presumably, did the Job Centre when they assessed him for his benefits.
However, the relationship Paul had with his care worker was not of the type that exists between friends and family. There was nothing reciprocal about it. He was in receipt of her presence as long as the Local Authority deemed him entitled. This type of relationship infantilizes and breeds dependency.
A different approach might have been to require and support Paul, when he first appeared to the authorities as being severely overweight, to undertake activities which might grow his social connections. He could have been moved in the direction of the local timebank or a local sports club that needed volunteers.
At present the rights and responsibilities approach to benefits emphasises the need for applicants to look for work or to attend courses to help them find work. Perhaps it is time to consider other types of responsibility being placed on benefit recipients. This would have the dual advantage of growing individuals social networks and saving the public purse since people will be less likely to need the very expensive downstream treatments such as stomach staples and liposuction.