A Solution to the Home Care Crisis?

January 29, 2015 by · 4 Comments
Filed under: Design and Society, Fellowship, Innovation 

The BBC reported yesterday that spending on care is in down by a fifth.  While this puts a figure on the amount that it’s been cut over the past decade, the fact that home care is in crisis is well known.  Demand is up, money to fund it is down, too few people want to do the work and the way it’s run keeps meaningful, caring relationships from forming between workers and those they care for.

In response, Labour announced this week that if it wins the election it will integrate services ‘from home to hospital’, helping end 15-minute care slots and incentivising providers to improve social care. Not only that, they’ll also provide 5,000 more home care workers and offer all vulnerable older people a safety check.

While this is all good, there’s something not quite right about it – the whiff of advisors sitting round a table shouting out solutions to someone sticking a stack of post-it notes on the wall.  ‘A safety check for everyone’ ‘Free walking sticks for all’ ‘A 1,000 extra homecare workers’ ‘Is that enough?’ ‘Make it 5,000 then’.

Other parties will not be too far behind in their promises, which will be less or more generous, but will all share the same trait.  They will be headline grabbing, with this amount of money pledged or that policy change all that’s needed to make the difference.  It will lack the sense that they’ve thought deeply about the problem and reached a considered response working in partnership with those closest to the issues.

Here at the RSA we’ve been discussing home care rather a lot recently, more specifically a Dutch home care company called Buurtzorg, due to its pioneering organisational model.  It’s a company with 6,500 nurses and 35 back office staff.  Yes, that’s right, 35 back office staff supporting 6,500 frontline staff who in turn look after 60,000 patients a year.

The way they work is to arrange nurses into autonomous units of 12 and let them operate largely as they decide.  A strong IT system not only makes the finance, HR and other central parts of the business easy to use and efficient, it also provides strong social networking to share ideas and help each other solve problems.

This lack of hierarchical management, replaced by self-organisation and increased trust, has turned the traditional hierarchical model on its head.  Care workers decide themselves how to spend their time, choosing to spend more of it with individual clients, building up relationships and trust.  In a study of client satisfaction Buurtzorg came top out of 307 community care organisations.  It turns out to be cost effective too as the model leads to more prevention, a shorter period of care and less spending on overheads.  This is all incredibly impressive.

One of the powerful things about it is that it began with nurses themselves.  Jos de Blok, the founder, is a former nurse who didn’t like the way home care was organised in Holland, which was similar to the way it is currently organised here with very short, timed visits and no allowance for the social side of care or the development of a meaningful relationship between carer and client.

Rather than wait for someone else to fix it he decided to do something about it himself, starting his own organisation with three other nurses in 2006.  There were no special dispensations from Government, no grants to get it off the ground, he competed with everyone else on equal terms and Buurtzorg is now the leading supplier of home care in Holland by a large margin.

Something similar would be fantastic to have here, not only to improve home care in this country, but also to increase staff well-being and to demonstrate that a completely different type of organisation is possible.  You can wait to see if political parties and their pledges can make all the difference, but I wouldn’t hold your breath.  Instead, if you are a Fellow working in this area, I’d love to hear from you to see if we can start a Buurtzorg type revolution ourselves.

Oliver Reichardt is the Director of Fellowship at the RSA
Follow him @OliverReichardt

 

Creativity in public services

August 18, 2014 by · 2 Comments
Filed under: Fellowship 

This is a guest blog from London-based RSA Fellow Steven Trevillion. Steve is interested in connecting with like-minded Fellows with a view to establishing a framework for small, experimental social and community projects that could feed into the national debate about ‘welfare reform’. He is an Emeritus Professor of Social Work at the University of East London and a visual artist.

We are constantly told that public services are in a state of crisis. The NHS, social work, Children’s Services, Adult Social Care, housing and even education are deemed by most observers to be in a state of more or less permanent crisis.

The search is on not just for ways of improving existing services but for ways of transforming them. George Osborne, Eric Pickles and a number of other government ministers have made it clear that nothing less than “transformation” is their goal. And this is not just the usual stuff about partnerships and collaboration. The big idea is that public services will become innovation hotspots. And a commitment to innovation means a commitment to creativity. Our own RSA has been at the forefront in recognising this as witnessed by the title of this year’s talk by Matthew Taylor: ‘The Power to Create’. This all sounds great. Who could possibly object to creativity as the way forward for public services? Unfortunately, the evidence suggests quite a lot of people. 

Who could possibly object to creativity as the way forward for public services?

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Pioneering social innovation in Malaysia

Genovasi Malaysia logoThis blog was originally posted on the news page of the RSA Student Design Awards website on 4th August 2014.

I am pleased to announce that nine emerging Malaysian innovators have won in the inaugural RSA Genovasi Malaysia Awards, winning a range of prizes worth a total of RM260,000. In addition, the winners all receive admission into Genovasi’s Innovation Ambassador Development Programme, complementary RSA Fellowship for a year, providing the students with access to the RSA’s Catalyst Fund and Skills Bank to further develop their projects.

The RSA Student Design Awards team partnered with Genovasi, a transformative learning institution focused on cultivating innovation skills in young people to develop and deliver the RSA Genovasi Malaysia Awards, which launching in September 2013. Genovasi offers a human-centred learning experience to learn and use innovation for social inclusion, active citizenship and personal development for future transferable skills to face challenges in life. The RSA Genovasi Malaysia Awards focused on three project briefs for this pilot year: Active Citizens, Encouraging Social Entrepreneurship, and Citizenship and Communication in a Digital Age.

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Let citizens spend tax revenues rather than the technocrats at the top

July 20, 2014 by · 5 Comments
Filed under: Adam Lent 

This post is jointly written by Director of the RSA Action and Research Centre, Adam Lent, and the Director of Institutional Reform at the RSA, Anthony Painter.

In the last century, the idea took hold that the state should expand to provide the public services and social security that the free market was unable to deliver on its own. The corollary was the need to fund this expansion through higher levels of taxation. But this conception of tax-funded services provided directly by the state is proving deeply problematic in an era increasingly defined by creativity and self-determination.

The problem emerges because the current model of the state was developed in the first half of the twentieth century when technocratic elitism was in its prime. The faith placed in the power of a small, educated set of technical specialists to deliver beneficial outcomes for any and all areas of life was enormous. Read more

Linking local growth with local politics

May 2, 2014 by · 1 Comment
Filed under: Social Economy 

Guest post by Daniel Goodwin FRSA (Chief Executive, St Albans City & District Council, 2006 – 2012)

The recent RSA conference Developing Socially Productive Places asked some important questions about the nature of economic growth and spatial development. The underlying concern being to ensure that the long term impact and social value of development needs thinking through carefully. Read more

New technology and clever people- the future?

April 3, 2014 by · 2 Comments
Filed under: Enterprise 

“Imagine being asked to chair a big organisation with a multibillion-pound turnover….you find that while you as chairman will be accountable for everything, your chief executive will be accountable for almost nothing, has little management experience, cannot be removed and – in common with the rest of the workforce – will not in fact ultimately work for you at all.”

This is how former ministers Nick Herbert (Conservative ) and John Healey (Labour) launched their new cross-party group, GovernUp, in The Times this morning. Sir Humphrey is failing his brilliant ministers. He’s not experienced enough. The machinery of government doesn’t work. He is setting a prime minister and his ministers at an immediate disadvantage. “Tomorrow’s government will need to be leaner, smarter at commissioning, better organised and more responsive to citizens.” New technology and the machine needs to be fixed. And politicians – ‘The Chairman’-  are just the people to do it.

It’s funny because it is almost as if this were a parallel world to the one written about in Ivor Crewe and Anthony King’s The Blunders of Government. I guess Sir Humphrey’s implementation was to blame for the Poll Tax, the Child Support Agency, the failure of public-private partnerships for the tube, Railtrack, and numerous other recent debacles?

Crewe and King see failure in the policy-making process. That Mr Chairman is driven by you. These failures include ‘ministerial hyper-activism’, ‘cultural disconnect’ (ie people respond very differently to new policies than expected), a deficit of deliberation (ie ministers driving forward initiatives without real consultation), a deficit of accountability (those responsible for disasters have gone by the time the disaster is clear), and operational disconnect (those who craft the policy fail to consult those who will actually be putting it into practice).

So GovernUp aims to fix the machine so politicians, who are pretty much responsible all the major blunders that we see, can become more hyper-active, less deliberative, and, in all likelihood, less accountable too.

It’s very convenient for politicians to lay the blame at the feet of Sir Humphrey but it is also a tad too easy. It also happens to miss the point.

What is needed is not a better machine with better drivers, engineering and technology. Actually, there needs to be a complete rethink for how Government works. State economic command was abandoned because it is impossible for Government to see and respond to trillions of pieces of real time data. So it is with public services. There are no people clever enough or technology smart enough to replace the adaptability of direct contact with those who need, use and want public services. It requires constant interaction with people, between institutions, and a capacity for flexible adaptation.

Without a real distribution of power to creative institutions and communities of support then clunky, ill-adapted, systems will remain. We use machine metaphors when describing the state. Instead, there is a need for cultural metaphors. If we were to see the state as an untold number of complex interactions then we might begin to engineer it around people’s real complexity of needs.

Elsewhere today, the Commission on the Future of Health and Social Care in Britain has published its interim report. It demonstrates how the two systems of health and social care, each with a different logic, funding methodology, and entitlement rules, work in friction. It shows how our demand for health and social care is already escalating and will continue to do so. The notion that Government will be able to do anything other than set the basic rules of the game – entitlement, standards, and resourcing – for a combined health and social care system is in the realm of fantasy. These enormous systems will need to be completely reconfigured around the needs of the individual rather than the system. It is about both quality and efficiency of care.

It is through professionals interfacing with individual needs and having the freedom, motivation and power to adapt that we have any chance at all of improving standards and not swamping ourselves with an unfundable burden.

This is the real debate we should be having: how do we create cultures around people that enable them to better meet their needs? Who has more control between Jim Hacker and Sir Humphrey entirely misses the point. It is convenient for ministers of all parties who want to have it slightly easier when it comes to having their way. But as Crewe and King show, that will just lead to even bigger blunders. Instead of GovernUp, how about PowerUp for all those involved in providing public services and those who rely on them? That is how to make the governance of Britain better in the future. It will also make lives better too.

How do you feel when you see the police?

March 7, 2014 by · Leave a Comment
Filed under: Social Economy 

When you see a police officer do you feel safer, or less safe?

This is the half-serious test that the anthropologist and activist Prof. David Graeber uses as a metric of whether somebody has a middleclass ‘mind-set’ or not. It is also a distinction that threatened to expose some social divisions in Brixton, where I live, yesterday.

Brixton Underground Station, Thursday 6th March. Photo by Tom Johnson for Vice: http://www.vice.com/en_uk/read/the-police-swamped-brixton-yesterday

‘Brixton Unite’ was, depending on which side of this social divide one situates oneself, a community-outreach day coordinated by a coalition of Lambeth Council, the police, and Job Centre plus to ‘reduce the harm caused by gangs’ to the community, or a huge display of force by the Metropolitan Police and British Transport Police to intimidate, harass and inconvenience as many residents as possible.

As I got off the Tube at Brixton station on my way home from work, a man was shouting a warning to everybody as they approached the escalators, ‘Loads of police upstairs! Watch out! Undercover police, filth everywhere!’

Commuters chuckled dismissively over their smartphones, shaking their heads at this noisy man who was making a scene with his paranoid ranting. One man tutted and made eye-contact with me, a white man in office clothes and – so he seemed to think – a natural ally with whom to share his amusement. But my personal experience of the police has not always been pleasant, and as I reached the top of the escalator and saw scores of officers in hi-vis jackets, a man being searched by the ticket machines, black-clad plain clothes police scanning the crowds, and sirens screeching up and down the road outside, I felt uncomfortable at seeing a place that looked under siege.

Outside the station a small group of activists waved placards protesting the heavy police presence, and tried to direct people’s attention to the front page of the Evening Standard, which coincidentally carried new allegations of police misconduct in the Stephen Lawrence case. There were raised voices and mini-clashes as accusations of disrupting or supporting police activity were traded. Elsewhere in Brixton people made their displeasure at seeing such numbers of active police officers known in various ways, as detailed in reports by Channel 4 and Vice online.

For some, Brixton Unite was conceived to intimidate and unsettle people, the latest stage in what they view as a deliberate ‘gentrification’ of Brixton amid a context of rocketing private property rates, evictions, the proposed sale of a community college and an influx of symbolically high-end business such as Champagne & Fromage and Foxtons estate agents.  The perspective of those commuters I saw who seemed unconcerned by the police presence – the ‘If you’ve got nothing to hide you’ve got nothing to worry about’ mentality – doesn’t wash with everybody, as the political commentator Stephen Bush (who is black) illustrates vividly:

When I think of the police, I think of being stopped-and-searched, aged 15, on the Embankment in broad daylight with everyone looking at me, an experience as humiliating as if I had been stripped naked right there on the Strand. That’s the part of me that gets nervous when I see police officers at Highbury and Islington Station of an evening, or quickens my pace around the Palace of Westminster.”

(http://www.newstatesman.com/politics/2014/01/its-all-other-police-deaths-should-really-trouble-our-politicians)

If we take Lambeth Council at their word and accept that Brixton Unite was a well-intentioned attempt to engage with the community and reassure residents that problems with gang violence are being tackled, then the episode demonstrates some of the difficulties faced by public services when they attempt to engage with their communities proactively. Communities, perhaps especially urban communities, are not made up of people who think and experience the same things, as my colleague Jonathan Schifferes blogged yesterday. Some people are reassured by the sight of police officers proactively keeping the peace; others see an invasion of authorities attempting to ruin their day. In a place like Brixton where there is an ongoing debate about gentrification and, for some, a perceived divide between working class long-term residents and well-heeled newcomers attracted by the city transport links and trendy market, then tensions can arise such as those I observed at Brixton underground station yesterday.

‘Relational’ public services that productively engage with communities are difficult to achieve – as recent work by the IPPR has discussed and the RSA’s public services and communities action and research strand continues to explore. Yesterday’s events in Brixton demonstrated this further; the same actions by public services can alienate some and reassure others. It is a conundrum that the authorities in Lambeth will have to work out, but on yesterday’s showing it seems unlikely that the mass appearance of ‘bobbies on the beat’ is really the thing that will see Brixton unite.

 

Power to the people requires a strategy for reform

February 17, 2014 by · Leave a Comment
Filed under: Social Economy 

After nearly four years of silence on the issue that divided the Blair and Brown governments, Ed Miliband has set out the direction he wants to take Labour on public service reform.

It is a radical one. His Hugo Young lecture marked a departure from both Labour’s statist point of view and its more recent embrace of ‘new public management’. We have already heard about his Theodore Roosevelt inspired anti-trust approach to markets – breaking up large concentrations of uncompetitive market power in banks, energy companies and elsewhere in the economy. Now Miliband has signalled that he wants to take the same approach to breaking up concentrations of power in state institutions.

The language of power to the people is strong and the policy nuggets are good. But this is clearly still a work in progress. Jon Cruddas’ speech went much further in fleshing this out. He was very clear that a future Labour government will not have the money to spend on public services that its predecessors had. And he argued that Labour should drop its institutional conservatism and instead follow the collaborative, small scale, localist and mutualist route mapped out by Michael Young as long ago as 1948; but that is ignored by Labour’s mainstream because it didn’t fit with their Fabian managerialism. Cruddas identified the key features of this power shift as devolution to cities; co-operation as the mode of public service production; and collaboration to achieve whole system change.

Labour should be under no illusion about the size of this task. This is a challenge as big as Clause 4, and in some ways even bigger. With Clause 4 the issue was whether to drop a theoretical commitment to public ownership that the Labour Government had no intention of enacting in practice. Confronting Labour’s institutional statism is different. This is about Labour’s culture and practice, not just its constitution. Centralisation, mass universalism and deliverology have been hard wired into Labour practice for decades.

If Labour is to build on the promising start that Miliband and Cruddas have made, then further substantial work will be needed in three related areas: the reform narrative; the theory of change that will need to underpin this; and the policy mechanisms that can enable people power.

The narrative for reform needs to be more compelling in two respects. First, Labour needs to be crystal clear about the fiscal and demand pressures facing public services. Politicians cannot promise to spend more or deliver new solutions – instead they have to be open and honest with voters about the need for a new social settlement, in which citizens and the state will have to share responsibility for generating the social productivity that can tackle loneliness, provide better social care and improve public health and wellbeing. But as importantly, this narrative needs to be rooted in modern times. This is not about harking back to a sepia tinted Britain of social solidarity and sacrifice. It is a recognition that the new social, economic and technological forces driving change in society all pull in the opposite direction to centralisation and mass standardisation. A new global picture is taking shape in which urbanisation, city led growth and local innovation are the dominant characteristics. Horizontal organisations, small firms and social networks are increasingly what define our work and social relationships. And vertical, bureaucratic organisations are struggling to keep pace with this.

Labour will also have to develop a credible theory of change. Merely stating an intention to decentralise power and to invest in the networks and new social institutions that could collaboratively produce public services is not enough. There needs to be an appreciation of the barriers that stand in the way of this, and of how systemic a change this would be. Everything mitigates against change of this type, from the form and culture of Whitehall spending departments, to the Treasury frameworks for revenue, growth and risk. A strategy for change would have to be based on reforming central government, changing Treasury spending frameworks, opening up policy making and pursuing devolution to city regions as an economic and fiscal priority.

At the same time, Labour will need to develop new policy mechanisms to enable its power shift. For example, shifting the focus to prevention will require re-profiling expenditure. The Scottish and Welsh Governments have both taken some steps in this direction. But a future Labour government would have to go further. This is partly about longer term funding settlements, but it is also about creating an investment and business case for demand management. And for city devolution, it may have to look at different models for sharing risk between central government and cities that are more akin to PFI deals than the tame substance of the Coalition’s City deals process.

Miliband’s new public service approach is very welcome. But the real test will be in how much Labour recognises that it will need to work with social networks, local government and civil society organisations to open up government and deliver this power shift to people and places.

Ben Lucas

RSA, chair of public services

Decentralisation is no longer a question of ‘if’ – it’s a question of ‘how’

February 17, 2014 by · Leave a Comment
Filed under: Enterprise, Social Economy 

Last week in Greater Manchester, the City Growth Commission welcomed a dozen individuals from academia, businesses and local authorities to publicly share their thoughts on the role of cities in stimulating economic growth. On the heels of the Commission’s first report, Metro Growth: The UK’s Economic Opportunity, the Commission is seeking to identify the main factors limiting cities’ growth and the policy levers needed to maximise growth potential.

Manchester Town Hall (image by Thomas Barnes)

Manchester Town Hall (image by Thomas Barnes)

Those providing evidence were incredibly forthcoming in their analysis of what was holding cities back, but also optimistic about the ability of cities to overcome these barriers in future. The consensus in the room was that while there may be specific issues with skills, connectivity, and housing for example, problems in these areas continue to persist because ‘one-size-fits-all’ policies are rolled out across the nation to address differing needs locally. Autonomy at a local level is denied because, as Lewis Atter (who leads on Infrastructure Strategy at KPMG) explained, “Central government doesn’t have a view at all on local growth. There is only a cost side, scorecard and resource capture. There is no sense of how interventions contribute incrementally to national growth.” For instance, cities would be better equipped to raise qualification levels and tackle worklessness if they could oversee skills provision, which is a prospect the Commission will be exploring in our next report.

Where efforts have been made to decentralise power, government should still be cautious about claiming success. Eammon Boylan, Chief Executive of Stockport Council, warned that there is danger in seeing combined authorities and elected mayors as a panacea. What may work for one city is not necessarily right for another, a point which also clearly emerged from a retrospective of the past 30 years of attempts to devolve power to the UK. The Institute of Government categorised the success of combined authorities and elected mayors as ‘mixed’, concluding that the limited adoption of such evolutionary or ‘opt-in’ models of reform signals that the shift in power has yet to be embedded.

It’s not that Whitehall is oblivious to calls for decentralisation. When Lord Heseltine proposed devolution of funding from central government to Local Enterprise Partnerships (LEPs) in 2012, heads in government were quick to nod along in harmony, although hands unfortunately didn’t loosen up on the purse strings of the Treasury – fiscal devolution creates anxiety at the centre. Drawing on her experience from local government, Lorna Fitzsimons of The Alliance Project and former MP of Rochdale, explained to the Commission that while central and local government may agree on the outcomes they want to achieve and roles they each play, but the centre often has difficulty letting go. The Treasury in particular needs to feel that the risk of relinquishing control is minimal, which is why phases or pilots should be seriously considered as devolution is pursued.

The feeling in the room was that in spite of previous setbacks, devolution of political power to the local level is inevitable. Sir Richard Leese, leader of Manchester City Council, highlighted the recent lecture given by Ed Miliband, committing to a reimagining of public services which aims to put power back in the hands of people and their local government. Leese felt that Miliband made it clear that politicians had not only been listening to arguments in favour of devolution, but are now ready to respond in a meaningful way. If the next election hinges on who can be the most radical on this front devolution will certainly be back on the table. The most pressing question is how powers should be best distributed at different scales. In making the rhetoric a reality, the economic outlook for cities will improve as cities are allowed new freedoms to pursue their growth agendas.

Follow #citygrowth and @CityGrowthCommission on Twitter for updates.

Metro Growth: the UK’s economic opportunity

February 10, 2014 by · 1 Comment
Filed under: Enterprise, Social Economy 

Today marks the launch of the first output of the City Growth Commission, featured on www.citygrowthcommission.com. Building on feedback from our launch event at the RSA in October 2013, the report takes on a striking infographic-led template to deliver the message.

Report thumbnail

We argue that the UK’s opportunity for strong economic growth – which addresses wider long-term challenges – requires strengthening our urban system. Our scale of analysis starts with looking to the 15 areas with the largest population, which we term ‘metros’. The Commission will consider the potential of UK cities large and small.

In Metro Growth: the UK’s economic opportunity, we argue that a new global picture of growth is taking shape. This is not about a transfer of economic power from North to South, or West to East. It is about the rise of cities.

Global growth

The UK is home to one of the world’s truly global cities. But too many of our urban areas outside London are failing to achieve their growth potential. We will explore what political powers and governance arrangements are needed to deliver this; and how public service reform can improve fiscally sustainability in all UK cities. The report highlights that public spending Greater Manchester exceeds tax take by £4–5bn – equal to roughly £2,000 per person per year, yet metros have little power to change this: over 90% of all tax is collected by central government.

Led by renowned economist Jim O’Neill, the City Growth Commission will argue that UK cities have the potential to foster higher, more sustainable productivity, growth and living standards. Metro Growth sets the scene for the Commission’s work.  It explains why ‘metros’ not only drive most of our economic activity, but shape how nearly all of us live and work.  Cities, and their economic success, matter to us all.

Manchester-Liverpool population 1981-2011The data tells us that we need a sophisticated understanding of the dynamics of population. For example, while both Manchester and Liverpool grew over the last decade, Manchester added 11,000 young people (under 15) while Liverpool lost 9,000 young people.

Focussing on skills, infrastructure and devolution of fiscal and policy-making powers, Metro Growth makes an early exploration into some of the factors currently limiting UK cities’ growth. The report found that:

Skills are consistently identified by businesses as a big barrier to growth. Whilst universities play an important role in developing skills and clustering talented people, graduate retention and attraction strategies are relatively unexplored aspect of economic development.

Pennines commutingAlthough many UK cities are close in distance, weak infrastructure links between regions mean that potential economic relationships are under-developed. Despite the 22,000 commuters that cross the Pennines every day between the largest metros of Yorkshire and the North West, the economic relationships between Manchester and Leeds are less strong than might be expected for cities of their size.

Qualifications ratios

There remain large differences between metros in qualifications. South Sussex Metro (Brighton, Hove, Worthing, Littlehampton and Shoreham – combined population of half a million residents) was found to have 23 residents who are university graduates for every 10 who have no qualifications. By contrast, the Potteries Metro is home to 22 residents with no qualifications for every 10 university graduates.

Metro Growth concludes by looking at the wider conditions in which people are able to contribute economically. The social context matters – for example health and well-being varies greatly between and within metros. Having people will low mental well-being, and poor physical health, limits the opportunities for productive participation in the economy.

Limiting long-term healthAs we develop more in-depth research over the next eight months, important areas of investigation remain for the City Growth Commission. Most fundamentally, how can we ensure that the case for metro growth is connected to salient issues for citizens – how to improve living standards – and for government – how to reform public services in light of long-term challenges.

The City Growth Commission runs for 12 months and will seek to influence all political parties in the run up to the next General Election, and make the case for cities to take a new role in our political economy. Following an open call for evidence which ran from October 2013 to January 2014, the Commission will host its first evidence hearing on Tuesday 11 February in Manchester Town Hall.

Follow #citygrowth and @CityGrowthCommission on Twitter for updates.

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