Thursday, April 10, 2014

Can we afford to care?

I had a harrowing day recently sitting with the top team of a really impressive local authority, trying to cut the second 40 percent out of the budget. These are good people, committed to their residents, running an efficient and effective organisation, with good performance – and they have already managed to take 40 percent out of the budget for 2010-14 without really causing much harm. It’s an ironic testimony to the competence of local councils that they managed to cut so much without residents really noticing, but of course it meant that there was nothing to stop the government from coming back for more.

But this time it will be different. This time valuable services will close. Community grants will be cut. Social workers’ jobs will be threatened.  I can’t help thinking how tragically short-sighted all this is.

We began to discuss the impact of cutting adult social care and children’s services – something councils have really tried to avoid so far, but you can’t take scores of millions out of a council budget without affecting the services that spend the most money.

We talked about how, twenty years ago, care services were run on far smaller budgets, with fewer social workers. But that was before the complex assurance systems that we now have were built up – before safeguarding systems were introduced, before everything was computerised and recorded, before regulation and inspection.  We seem to have created a very expensive, gold-plated set of care services – with highly complex accountability and reporting procedures which take a lot of time.

Participle have shown that up to 85 percent of social worker time is spent at computers or in meetings with other professionals, and only 15 percent actually with troubled families.

Eileen Munro, in her review of child protection, talked about “a defensive system that puts so much emphasis on procedures and recording that insufficient attention is given to developing and supporting the expertise to work effectively with children, young people and families.”

But now, with the cuts facing local authorities – we can no longer afford to do things in this complicated, risk averse way. We need social workers to spend far more of their time with families and children, intervening to help them rather than just assessing and recording.  Social workers will need to each carry greater case-loads, and will have to use their courage and wisdom and judgement to work out how to prioritise their work. We’ll need to spend less time feeding computer systems and more time caring for people. But at the moment, the regulatory and inspection machines don’t seem to recognise this – they are making no allowances for the scale of the cuts – and councils fear that they will be penalised if they try to reduce staffing levels or change working practice.

I had a related conversation with a young mental health care assistant, who said that now when she visits a service user with mental health problems she has less time to explore how they feel , because  she has a ‘script’ of questions to ask and  has to record everything she does.

A councillor I spoke to yesterday talked about “care organisations that don’t feel as if they care.”

The danger is that we put increasing pressure on the parts of the system that listen to service users, and respond to them, while keeping in place the control systems that squeeze the autonomy of professionals and makes users feel like cogs in a machine. The regulation and inspection regimes are going to have to respond to the fact that services can no longer be run the way they used to..

It might not mean more risk, if our social work leaders are creative, caring and wise. But it can’t mean continuing with the cumbersome processes that we established in the following years when 60 billion was pumped into public services.  Spending levels will soon be back to the levels of 2002 -3 – before we could afford this complicated assurance machine. If we can no longer sustain it, the sooner we begin talking about it the better.

Tuesday, March 11, 2014

“The NHS belongs to the people” states the NHS Constitution, but Clause 119 of the Care Bill calls this into question

This afternoon, MPs will again debate the Care Bill, and Clause 119 is the focus. (This arcane clause was previously Clause 118, for those who have been following the debates for several months – “If you can’t convince them, confuse them,” said President Harry S Truman.)

With the House of Commons rejecting earlier amendments from the Lords, the controversial clause had appeared to be put to bed, but further debate and possible cross-party rebellion is expected.

So I thought I’d reissue – and update – some of my earlier thoughts on the implications of Clause 119. 

OPM has worked hard to ensure patients and the public have a voice wherever major healthcare service changes are proposed. That’s why we’re concerned about the Clause 119 in the Care Bill. The whole narrative around why the NHS needs to change, and how, is at stake. The clause controversially and directly challenges the principles and values outlined in the NHS Constitution. “The NHS belongs to the people” – but will it continue to do so?

The bill will debated again this afternoon in the House of Commons. A straightforward reading of its language obscures the full significance of the changes should they be enacted. Why should we care? Because in the instance of financially failing acute hospitals, Clause 119 takes the power for local healthcare decisions away from clinical commissioners and the public they serve, putting it back squarely in the hands of a centralised and locally unaccountable third party – Trust Special Administrators appointed by the Secretary of State.

MPs should pay heed, for these new powers are fraught with danger. Clause 119 prioritises financially-driven solutions to health system failures, something which Robert Francis warned about in his landmark report on Mid Staffordshire NHS Foundation Trust. It enables the TSA to reconfigure services across whole health economies – creating winners and losers and potentially compromising patient care in order to create financial balance.

The clause also renders absurd the strategic planning efforts that have exercised Clinical Commissioning Groups over the past several months. For why bother setting out plans for improving local health services (both 2-year and 5-year plans) if an unaccountable administrator can unravel them in 40 days?

If I’ve learned one thing about reconfiguring local hospital services, it is that the process can be lengthy, laborious and full of setbacks. But handing the process over to an unaccountable third party, putting arbitrary time limits on the process, and disregarding both clinical expertise and the will of local people is unlikely to produce satisfactory outcomes.

Areas that have succeeded in reconfiguring services are few and far between, but they offer some helpful lessons about what it takes for successful results. A few examples come to mind: London’s reconfiguration of stroke services and Manchester’s “Making it Better” reconfiguration of maternity, neonatal and paediatric services. Their success stories have several important characteristics in common:

None of these factors is supported by the proposals in the Care Bill. In fact, they would be over-ridden quite easily by the TSA. Never mind that focusing on financial sustainability might limit patients’ access to care, adversely affect the quality and nature of local healthcare services, and produce greater health inequalities among vulnerable patient groups. Unfortunately, we cannot know the full impact of TSA-directed changes if local people aren’t involved in the decision-making.

As Clause 119 is debated today, MPs should re-read the NHS Constitution, particularly the seven key principles intended “to guide the NHS in all that it does”. If the NHS is to “put patients at the heart of everything it does” and to remain “accountable to the public, communities and patients”, these legislative proposals for addressing financially failing healthcare trusts need fundamental re-thinking.

Thursday, February 20, 2014

Breakfast Seminar: Commissioning social care for older people in a post-Dilnot world

Join us for the launch of a new guide to self-funding for older people, where you will hear from leading experts about how health and wellbeing boards and health and social care commissioners can tackle the self-funders challenge.


In response to the Dilnot report, the government has committed to introduce a cap of £72,000 on total self-funder care costs and to increase the upper means test threshold to £118,000 from April 2016. Now, local authorities will need to work with people who previously would have been off the council’s radar and new mechanisms will have to be developed for councils and individuals to work together to agree care needs and costs.

Legal obligation, the risk of avoidable health care costs, and the need for synergy between personal budget holders and self-funders are just some of the reasons why health and wellbeing boards and health and social care commissioners should put self-funders at the top of their priority list. At this seminar, you will hear about the different ways in which leading local authorities and others are working with self-funders to enable them to best meet their own needs. We will also discuss the key areas that commissioners should focus on to enable people to move from self-funding to being partly, or wholly, state supported.


More info

The seminar will be held at Body & Soul, with breakfast served from 8.00am (for an 8.30am start) and the event will be finished by 10.30am. If you have any special access or dietary requirements, please let us know and we will do our best to accommodate them.

For more information please email or call Rosie Keefe on 020 7239 7816.



Wednesday, February 19, 2014

Bath and North East Somerset CCG simulation of the urgent care system


Bath and North East Somerset (BANES) CCG asked OPM to design and deliver a simulation of the urgent care system as part of their planning for winter 2013/14. Senior leaders in the area were aware of the need to establish fundamental change across the whole health and social care system that would help to meet the challenge of rising demand for emergency care in a climate of limited or reducing resources.

A process for thinking creatively, holistically and collectively was needed – where current services and delivery practices would be challenged and ways of improving patient experiences and flows could be explored. To meet these requirements OPM designed a behavioural simulation exercise of the whole urgent care system from primary care, ‘blue lights’ and A&E, to discharge and social and community care services.

What we did

Following desk research, scoping work with CCG and RUH colleagues, a simulation was developed. The event held on 23 July in the centre of Bath, brought together local stakeholders from across the health and social care economy, collectively fast forwarding the local health and social care system. Simulation constructs a plausible but simplified version of reality, sufficiently developed so as to create a clear sense of what a place is like and how different events will impact, but simplified enough to be manageable in a compressed timeframe.

Fifty-one people participated in the event, drawn from across the health and social care system in BANES and Wiltshire.The simulation was designed to provide participants with the opportunity to shape and influence plans for the management of urgent care, and to ensure that the system can respond quickly and effectively to urgent care challenges when they arise.


The simulation succeeded in galvanising the entire system to take more concerted action to improve urgent care planning in Bath. It also confirmed in the minds of all parties that it is the CCG that, as system leader, has the responsibility for making this happen.

Overall there was clear evidence of a wish to move beyond any version of ‘awful is normal’. Escalation processes are of course essential to manage immediate pressures but they do not in themselves establish action plan to manage pressures in the whole system more effectively in future. However, the strong sense that all members of the health and social care community need to work together, with clear leadership, to deliver sustainable hospital occupancy levels, was increasingly evident as the simulation progressed. As a direct result of the exercises a number of tangible improvements to plans have been made.

Working with the whole health and social care system in a local area together for a day, participants are able to explore and shape their plans for the management of urgent care in a way which effectively speeds up the usual processes of arranging meetings, building better working relationships based on an understanding of each agency’s contribution and limitations, and using that time together to challenge the usual ways in which seemingly ‘stuck’ problems may be addressed. While the central focus is on urgent care provision, it is no coincidence that other aspects of integration and improved patient experience also receive valuable attention. We wrote about we learned from the simulation in the Health Service Journal: How simulations can help develop new thinking to tackle winter admissions crises.

Tuesday, February 11, 2014

Helping NHS London managers to coach across the capital


Following our work with the SHA in 2009 to help establish a capital-wide board level coaching resource, OPM was commissioned the following year to run two ILM Level 7 Certificate in Executive Coaching and Leadership Mentoring programmes to increase the number of senior NHS managers equipped to provide coaching across the capital as part of their role. The successful delivery of these programmes led to us being asked to provide a series of advanced skills CPD workshops for registered coaches.

What we did

From 2011 to the present day we have worked collaboratively with learning and organisational development managers to create a strongly practice-focused approach to enabling the coaches to build their portfolio of coaching techniques. Themes for the one-day workshops, delivered by David Love and Helen Brown, have included:

With each workshop we have located the topic firmly within the context of the current challenges in the capital’s heath service so that coaches have had opportunities to explore ‘live’ issues that take account of the realities and pressures faced by their coachees (and indeed themselves, as NHS managers). During each workshop participants have opportunities for coaching practice, which is supported by structured observation questions, feedback from peers and feedback from the workshop facilitators.


All the workshops we have delivered to date have been extremely well received by participants, whose confidence and skills have been strengthened through their involvement.

Tuesday, February 11, 2014

Evaluation of the NHS Patient Feedback Challenge


The Department of Health funded the £1 million NHS Patient Feedback Challenge to support the spread and adoption of innovative approaches to involving patients and carers, capturing their feedback and using this to inform service improvements. NHS organisations submitted applications to take part in the programme, and nine projects were funded across England, all adopting different approaches and forming partnerships with other NHS, social care and commercial organisations.

The NHS Institute wanted to learn about the various approaches to adoption and spread employed by the nine projects – what worked, in what circumstances, and for whom? They also wanted to capture evidence of the impacts emerging, including those generated within programme timescales as well as longer term anticipated outcomes, and assess the extent to which the programme offered value for money.

What we did


As a result of emerging insights from the evaluation, the NHS Institute commissioned a series of evaluation webinars, to support project leads to develop their own plans for monitoring the impacts arising. This included an introduction to economic assessment, helping project leads to assess the financial impact of their initiatives.

The NHS Institute was able to use the evaluation report to make recommendations for future work in this area.

The case studies and brochure will be used to encourage others to adopt the approaches embedded in the project sites, and to foster further linkages between NHS organisations and others with an interest in health and social care.


Tuesday, February 11, 2014

Measuring the economic impact of care homes wellbeing programme


In spring 2012 OPM carried out research into the care homes sector in the UK, on behalf of the NHS Institute. This research informed the development and marketing of the NHS Institute’s Care Homes programme, a service improvement package aimed at residential and nursing care home providers, owners and managers.

The NHS Institute worked with several care homes across England to test and refine the programme’s service improvement tools. The NHS Institute wanted to know about the effectiveness of using the tools in care home settings, the critical factors underpinning successful implementation, and the challenges encountered by staff and managers.

The evaluation was commissioned to generate evidence of impacts emerging – including impacts on residents, staff wellbeing and retention, safety and efficiency. The NHS Institute also wanted evidence of the financial savings arising, to enable potential purchasers to assess the programme’s value for money.

What we did

We carried out two strands of work:

  1. We carried out fieldwork with three homes that tested some of the tools in the Care Homes Wellbeing programme. This included visiting homes to see the changes made, interviewing staff and managers about the processes they went through, and capturing evidence of outcomes achieved. Following this fieldwork, we developed three in-depth case studies outlining the test site experiences and impacts arising as a result of the programme. The case studies explored the impact of the tools on reducing falls and accidents within the home, saving staff time by re-organising systems and tidying shared spaces, and introducing ‘resident summary at a glance’ boards to enable all staff to quickly see the status of all home residents.
  2. We developed a ‘ready reckoner’ economic assessment tool, to enable care home owners and managers to assess the potential financial benefits and costs associated with the Care Homes Wellbeing programme. We reviewed programme documentation, cost data captured from case study sites (including staff time spent on implementing the tools) and secondary data from other sources in order to populate the ready reckoner.

Our understanding of the care homes sector, and the challenges it faces in realising service improvements, enabled us to explore the crucial issues in depth with care home staff and managers. The work also built on our experience of producing economic assessment tools for the NHS Institute High Impact Actions in Nursing and Midwifery – The Essential Collection, enabling us to employ a similar methodology to developing the ready reckoner tools.


The project enabled the NHS Institute to assess the effectiveness of the tools when employed in care home settings. We provided evidence of impact as well as insights regarding some of the challenges experienced and critical success factors.

The ready reckoner tools enable care home owners and managers to assess the value for money of the Care Homes Wellbeing programme before taking purchasing decisions, and provide a resource to assess the impact of the tools in different contexts (e.g. homes with different staffing structures or with residents with particular needs).



Thursday, September 19, 2013

Councils must get to know their self-funders to contain mounting care costs

Self-funders make up approximately 45% of residential care home places, 48% of nursing home placements and 20% of home care support. They may be unaware or unable to plan for their care and support needs; they may be making decisions at crisis points that are costly, or choices that are financially unsustainable; and they may not be fully aware of the full range of care and support options.

As such they have the potential to become very costly to the state and to local authorities in particular. However, the support provided to self-funders to enable them to secure effective and financially sustainable care varies widely form one area to another, is often of a very general nature and can be difficult to access. Only around half of local authorities even have estimates of the number of self-funders in their area.

Read the full article on the Community Care website.

Monday, September 16, 2013

Older people who self fund their social care: A guide for health and wellbeing boards and commissioners

Working with Sitra, OPM has produced a free guide to help local authorities consider the needs of self-funders and plan for the new social care system.

Designed to be used by health and wellbeing boards and commissioners, with engagement from self-funders, the guide aims to raise awareness, improve strategic planning and system design, and provide commissioning advice. The guide also includes a commissioning scorecard, which offers an at-a-glance tool for mapping current provision for self-funders and for determining future priorities.

Both an executive summary and full version of the report are available for free download.

Friday, May 17, 2013

Changing Times with Lord Victor Adebowale

Today’s Changing Times interview is with Lord Victor Adebowale, Chief Executive of Turning Point a social enterprise, focused on the issues of mental health, learning disability, substance misuse and employment.

 If you compare today’s society and the society into which you were born: what’s most strikingly different, and what’s most surprisingly similar?

Well I was born in 1962 at a time when racism was pretty much casual and politicians thought it was okay to get elected on a platform that was, to a greater or lesser degree, racist. It pretty much remained that way throughout the 1970s and 80s, when racism was a popular pastime and even created some pretty good television series.

I think one of the things that I’ve noticed now is that there’s more shame around racism, more embarrassment and a greater sense of disgust. That isn’t to say racism is a thing of the past at all, it clearly isn’t, but I think it’s certainly less obvious. I think that multiculturalism is an accepted norm now in a way it just wasn’t before.

What’s similar? I think the class system. Although it is expressed in a more sophisticatedly now, it remains remarkably resilient to change. There are certain rules that money cannot break and as such having money doesn’t necessarily make you of a different class. But being of a certain class gives you access to privileges and opportunities that others are denied, no matter how much money they have. The professions and politics in particular have remained remarkably static.

I think the class system is expressed more subtly today than in the past, but in a way this also makes it more solid. There’s more of a pretence that class discrimination doesn’t exist.

Given difficult choices have to be made, what one public service or source of support do you think we should prioritise most highly, and why?

I think health and social care is most important. You only have to look at the newspaper to see the panic – and it is panic – at the possibility that your kids might catch mumps. 30, 40, 50 years ago diseases like mumps, measles, rubella and croup were all common. And people died. People died of diseases we can now cure. And people didn’t get access to a GP. Nowadays people expect to see a GP, like they expect to go to A&E. 65 years ago you didn’t. If you couldn’t afford it, that was it. That literally killed people’s life chances. So having a universal health and social care system that people can plug into, stay healthy and make the most of their life chances is absolutely vital. Without that I think they would question whether we had a civilised society.

Of course the challenge is for us now is to make changes to the system in line with the changes that are and have taken place in demography life expectancy, expectations, and resource. There’s no doubt that this will be a difficult, but I think it’s important to note that these challenges are partly due to the success of the health and social care system. They are not challenges of failure as many commentators suggest.

After all, it’s a good thing that people are living longer or that people’s expectations have raised. But the system can’t exist in the abstract. The system starts to fail when we have a romantic view of it, which prevents us from making pragmatic decision in light of what we know about expectation, resource, and demography.

If you could choose one person to be the Prime Minister’s adviser, who would that person be, and why?

I would say that whoever it is needs to come form outside the usual suspects and needs to have something that is hardly mentioned these days: wisdom.

So for that reason I would choose Doreen Lawrence. I’m not saying this because of the terrible tragedy that has happened to her, but because of what she did with that tragedy. She used it to gain masses and masses of wisdom. She has changed the way the nation thinks about itself, not just in terms of race, but also it’s relationship with power.

I think one of the things that Prime Ministers need is to be aware of is the human impact of their policies. That’s not because the PM should go to bed in tears every night, but I think power has a tendency to weaken the humanity of the powerful.

The scandal following the murder of Stephen Lawrence was so shocking that it almost transcended the event itself. It led us to ask whether we can actually trust the institution we rely on most to keep us safe.  Doreen’s work created a paradigm shift in how we question our institutions and how we hold them to account. How transparent are they? How open are they? How do they learn? How do they engage with the public?

She rose above the personal tragedy to become a genuinely wise person with the ability to shift public opinion and she did that through sheer tenacity and the refusal to be ignored; qualities which you’d also need as a Prime Ministerial adviser.

Public services rely on voluntary support more than ever: is this to be welcomed?

It always makes me smile when people say we need more volunteering in this country, because actually the country is pretty much run by volunteers. But the problem with volunteering is that it isn’t distributed equally across the country and therefore doesn’t lead to equitable outcomes for all.

This makes for a poor substitute for services to the public and it’s one of the reasons why companies like Tesco don’t use volunteers. People need their services to be reliable and available on an equal basis everywhere. You don’t want to go to Lincoln and be told: “Sorry there’s no social services because people are doing three jobs”.

I think you would get all kinds of unintended consequences with that kind of approach to public services. Apart from anything else, I think it also undermines the very principal of public services.

There are people, not many, but there are people who think that if it’s not run by the private sector it should somehow be run by volunteers. And of course they are forgetting that it’s not that one sector is more important than the other, they both rely on each other. So it’s a “both/and” issue, not an “either/or”.

In the best case scenario, what will public services be like by 2023? What about the worst case scenario?

In the best case scenario you would have bespoke services. That means personalised and driven by the values of transparency, access and outcome, that isn’t the same as a post code lottery, bespoke means individuals and communities get services that meet their particular needs. In fact you wouldn’t really call them public services; they’d be services to the public, because I think people would genuinely question what a public service is.

In this scenario, the idea that a private company can establish itself as having a right to make outrageous profit from public money would be seen as laughable. But that doesn’t mean that a private company should be stopped providing services to the public, as long as the public can see a value.

The inverse care law would also be something that all providers of services would be aware of, and unless they were driving out the inverse care law, they wouldn’t get public support to provide anything.

In the worst case scenario I think you can almost reverse what I’ve just said! It’s almost not worth thinking about, what you would have is the smell, sight, dangers and outcomes of a corrupt and corrupting failed state.

But I think the truth probably lies somewhere closer to the best than the worst of these scenarios. There’s an inherent sense of fairness in the culture of the British people.

Previous Changing Times contributors

Matthew Taylor, Chief Executive of the RSA.

Professor Kate Pickett, epidemiologist and author

Carolyn Downs, Chief Executive of the LGA

Professor Chris Drinkwater, President of the NHS Alliance