Monday, April 24, 2017

Unleash the creative potential of Social Impact Bonds

In a previous blog based on my latest advisory trip to Japan, I noted that Japan is currently ‘translating’ the SIB model in order for it to be implemented in a way that is appropriate to its specific social, economic, political and cultural context. I have encouraged Japanese colleagues not to simply think that SIBs are and always will be what they currently look like. Instead, they should approach it creatively, making it work better for all. There is a risk that an innovation, such as SIBs, may be abandoned because of disillusionment with early versions of it, which may not have fulfilled the creative potential that may be on offer. Here, I describe four reasons why I think current SIBs have only scratched the surface of what may be possible.

Outcome payers

In the UK, we have become rather lazy with our terminology. I often hear people swap ‘commissioner’ for ‘outcome payer’. In doing so, there is a real risk that we limit the way we think about who outcome payers can or should be. Apart from public bodies, who else may be interested in paying for outcomes? What types of outcomes may they be interested in paying for?

If outcome payers are ever only going to be public sector commissioners, then we need to question whether SIBs are indeed channelling ‘new’ or ‘different’ funds. After all, if all outcome payments to investors are ultimately made by public sector commissioners, then the monies will only ever come from direct taxation.

Transaction costs

Read any publication or attend any conference on SIBs, and you will head the refrain: “SIBs have high transaction costs”. Again, rather than simply accept this as an immutable fact, I challenge the market to design these costs out of future SIBs. We have good evidence that this is possible, at least for some types of transaction costs. For example, we know that vested commercial interests can cause some intermediary organisations to develop SIBs that are unnecessarily complicated. Similarly our evaluation of the Essex County Council SIB found that when the various players are more concerned about minimising risks to themselves, they can end up with a contract that is too complicated and therefore imposes ongoing costs. As our experience in Essex shows, these can be designed out of a SIB even after it has gone ‘live’.

Who bears the risks?

An attraction of SIBs is that we introduce a new group of stakeholders called ‘social investors’ into the picture, who have higher risk appetites and are socially minded. However, the fact that 7 out of the 10 SIBs in the US have over half of their values guaranteed by philanthropic organisations really causes us to question who is really bearing the risk? Are we attracting the ‘right’ types of investors into the market or are we distorting the market to suit certain types of investors? In addition, there is also evidence that some social investors can try to pass on some of the risks to service providers, for example, by providing part of the capital as a loan rather than as revenue. We must therefore be clear about who bears what risks, and whether these models are true to the ideal of the SIB aspiration.

Is it all about savings?

In a blog I wrote last year, I argued that SIBs do not have to be about savings, and showed different ways of constructing alternatives. SIBs are about social outcomes. To reduce social outcomes to only those that generate financial savings for the public purse is highly limiting. This, again, draws attention to the limitations of thinking of ‘outcome payers’ only as ‘commissioners’. Even amongst commissioners, financial savings do not have to be the only motivator. We need to ask ourselves the question: “Outcomes for whom?” when we design SIBs. If we never ask service users what success looks or feels like to them, then what message are we sending out about SIBs? Whose interests do they serve?

Conclusion

Current SIBs have barely scratched the surface of what may be possible. Rather than allowing them to ossify into what they currently look like, we should challenge ourselves to keep pushing the creative potential of the idea of a SIB. In the process of doing so, we must never lose sight of outcomes and how they can be meaningfully defined.

Dr Chih Hoong Sin, Director, Innovation and Social Investment

Wednesday, February 22, 2017

Independent evaluation of the Essex Multi Systemic Therapy Social Impact Bond

For the past three years OPM has undertaken an independent evaluation of the Essex County Council Multi Systemic Therapy (MST) Social Impact Bond (SIB). The Social Impact Bond delivers MST to children and young people at risk of being taken into the local authority care.  The Social Impact Bond has been managed by Children’s Support Services Ltd, a Special Purpose Vehicle, established by Social Finance.

The purpose of OPM’s work has been to evaluate the potential added value that can be achieved through local authority and other commissioners using Social Impact Bonds as a mechanism for financing the delivery of new services.  Specifically, whether the use of a SIB impacted on the implementation of MST and whether significant value was added to either outcomes or performance.

The evaluation highlights many instances where the use of the SIB has been seen to add value to systems and processes and indirectly to overall performance.  It also draws attention to some additional costs and complexities which may result from operating through a SIB and how these can be mitigated.  Drawing on a variety of quantitative and qualitative evidence and insights, OPM have now summarised their findings and used this to inform a set of recommendations applicable to organisations that may be considering developing SIBs of their own.

In addition, OPM have drawn on the evaluation findings to develop a new guide on ‘Top Tips for developing and implementing a Social Impact Bond’ – an interactive document for commissioners, providers, funders and managers.  While summarising the Essex experience and including examples from Essex to illustrate specific points, this also brings in themes from the wider evidence base, with the aim of distilling lessons that have wider applicability.

The Essex SIB was the first local authority commissioned SIB to be established in the UK and the experience and findings reflect its innovative nature.  It was launched in 2013 and will be operational for five years, concluding in 2018. Two teams from Action for Children have delivered an MST intervention to approximately 260 young people to date resulting an in an approximately 80% rate of successful care diversion.   MST is an evidence-based programme that seeks to improve parenting and rebuild positive family relationships, enabling families to manage future crisis situations themselves.

 

 

 

 

 

Tuesday, April 1, 2014

Simon Stevens, the inherited QIPP challenge and the role of the nursing workforce

On his first day as the chief executive of NHS England, Simon Stevens notes that the NHS is undergoing the most sustained budget crunch in its 66-year history, and that navigating the next few years will be enormously challenging. The ‘Quality, Innovation, Productivity and Prevention’ (QIPP) challenge was issued by his predecessor, Sir David Nicholson, to the NHS to improve quality whilst making efficiency savings to the tune of £20 billion by 2014/2015.

Reports from the National Audit Office repeatedly questioned the sustainability of savings made to date. The NAO found that the NHS, understandably, started by making the easiest savings first through the pay freeze for public sector staff, reductions in the prices primary care trusts pay for healthcare, and cutting back-office costs.

Simon Stevens will, today, argue that only by ‘radically transforming services’ will the NHS continue to thrive in a context of austerity. Yet the NAO continues to note that the savings to date have yet to be driven by fundamental service transformations.

More worryingly, doctors and nurses across the NHS complained that front-line NHS services are being cut, while the Royal College of Nursing found evidence of nursing numbers being slashed in order to meet the ‘savings’ target.

While some, including Sir David Nicholson himself, have argued that the savings can be achieved without cutting services and staff; the reality is that navigating the transformations require not only different ways of doing things, but also demand new skills. Without these, it is difficult to see how the NHS can make the requisite savings while keeping quality as its organising principle.

It has been calculated that innovations designed and implemented by clinicians could have a value of £9 billion per year in the UK. Yet, to date, little has been done to harness this potential. Conversely, with growing pressures on the frontline, there is every possibility that innovation may be stifled.

Investing in the right skills

Efficiency without quality is unacceptable, while quality without efficiency is unsustainable. The healthcare workforce needs skills to be able to understand improvement from both the quality and the efficiency perspectives.

At risk of oversimplification, clinicians are probably more familiar with understanding how their care affects clinical outcomes and patient experience than they are with understanding the economics underpinning service design and implementation. The latter is not, to date, a skill set associated with the healthcare workforce. Yet without these skills, there are real limits as to how we can expect the NHS to achieve both quality and efficiency without simply going for the easy option of salami-slicing.

Empowering the workforce to drive forward efficiency and quality

Efficiency and quality drives that are co-produced and led by the health service workforce are more likely to be meaningful and sustained. Taking a step in this direction, OPM was funded by the Burdett Trust for Nursing to deliver a programme aimed at building the capability of nurses to assess the economic costs and benefits of nurse-led innovations, and to use this evidence to guide the continuing improvement of services. Delivered, in partnership with the Royal College of Nursing, in Scotland, Wales and Northern Ireland throughout 2012 and 2013, the programme demonstrates that investment in this skill set empowers the healthcare workforce to achieve real efficiencies while enhancing the quality of care for patients and other users of health services. The following example brings this to life.

Jayne Miller, Assistant Clinical Nurse Manager, Early Years, Children and Families Community Nursing Service, NHS Ayrshire and Arran.

Jayne and her team developed an electronic Child Health Record to support professional record keeping and information sharing by a wide range of practitioners who provide care and support to children. Having participated in the OPM-RCN programme, Jayne was able to calculate direct and indirect costs associated with setting up and running the system and to compare these against the financial benefits resulting from the current pattern of usage of the electronic record. Jayne estimated that the electronic record system contributed to efficiencies amounting to around £85,000 per year.

By having clear evidence about the financial benefits experienced by different partner agencies, Jayne and her team have been able to persuade an increasing number NHS children’s services to use the system; and have been widening access to local authorities and social workers. These developments will generate further efficiencies within and beyond the healthcare system.

In the throes of its most sustained and challenging budget squeeze, the NHS will need to raise its game by being clear about how efficiencies may be secured while protecting quality. This vision can only materialize if everyone working within the NHS not only sees that they have a role to play, but also know how they can fulfil this role. This requires investing in the health service workforce to equip them with the skills vital for securing a positive future for the NHS.

Dr Chih Hoong Sin will be speaking with Jayne Miller, together with Dr Ann McMahon from the RCN at a symposium on 2nd April 2014 as part of the International Nursing Research Conference

OPM has published an edited volume, Valuing Public Services, that offers practical ideas about how we measure and demonstrate the value of our public services, based on our real life experiences of working with a broad range of public organisations, including charities and professional bodies.

Tuesday, March 11, 2014

Helping disabled people’s user-led organisations to demonstrate the added value of their work

Background

User-led organisations (ULOs) are led and controlled by disabled people, and their services are run for disabled people by disabled people. There are more than 120 ULOs in London, many of which are small voluntary organisations, and most employ between 1 and 20 staff, mainly part-time. As well as providing services, these organisations act as a voice for the concerns of London’s 1 million Deaf and disabled people.

The current fiscal climate means that the future of many ULOs is under threat. The majority have already experienced cuts in funding, and most expect further funding cuts.

In order to survive in this challenging climate, these organisations must be able to demonstrate their impact and value to funders and stakeholders. In particular, they must provide robust evidence that being user-led adds social and economic value above and beyond that which other providers can achieve.

OPM worked with Inclusion London, a second tier organisation working to support ULOs in London, to develop a prototype tool kit that will help them demonstrate their added value. This project is about organisations taking the lead in producing their own evidence to influence funders and other stakeholders.

What we did

Our approach is underpinned by the following four key principles:

  1. Empowering and collaborative
  2. Pragmatic
  3. Accessible
  4. Robust

Working with Inclusion London, we recruited ULO leaders to take part in developing the prototype tool kit. We then conducted an initial scoping phase, through brief conversations and reviewing key documents, to explore ULOs’ priorities for demonstrating their value; understand their services, key stakeholders and ways of working; understand their experience of this type of work; be aware of the kinds of evidence they currently produce; and explore the types of information they routinely hold, or could secure access to, which could potentially show impact.

From this scoping phase we designed a prototype tool kit which contained a written guide, a workshop and ongoing OPM support. At the start of the guide is a bespoke process model, or framework, taking the user through four straightforward steps to demonstrate value. This systematic approach is designed to help the user meet HM Treasury requirements for economic assessment.

The model is supported by:

There are tailored sections around 5 priority areas for demonstrating value:

Each has a tailored ‘sample’ version of the model, with more specific prompts and references to other sources of information, as well as social and monetised values where available. In appendices to the guide are further references for social and monetised values from the wider literature and, for each service type, examples of suggested approaches and possible benefits to funders and the wider system.

The tool kit is supported by workshops and ‘light touch’ support to help participants develop confidence in applying the tool kit in practice.

Impact

Participants in the programme have reported immediate impact. Crucially, they found that local authority commissioners have been responding positively to the approach set out by the tool kit, noting that it is systematic and transparent.

Participants reported feeling empowered to apply the approach and have been able to use it flexibly to meet their needs. They have been telling us that the tool feels entirely relevant, and is accessible and straightforward in practice. A service delivery manager of an independent living service told us she feels confident to share her learning with colleagues and hopes that together they can demonstrate value more widely across their organisation.

Other ULO have already applied the learning to secure new funding, with impressive results.

Monday, March 3, 2014

Building capacity among the nursing workforce to conduct economic assessments

Background

OPM developed an Economic Assessment Tool (EAT) in 2010 to help generate evidence to sustain efficient and high quality public services in financially uncertain times. Driven by our conviction that people do not have to be ‘experts’ to understand the key issues and to engage, we designed an innovative programme around the EAT aimed at building the capacity among workforces and organisations to be able to start demonstrating the value of public services, and to use the intelligence to continuously transform and improve services.

What we did

We were awarded grant funding by the Burdett Trust for Nursing at the end of 2011 to deliver this programme of training and support to frontline nurses, and to facilitate the spread and adoption of EAT by the nursing workforce. This two-year funded project commenced in Scotland in January 2012, and is being rolled out to Wales and Northern Ireland in 2013. We are working with the Royal College of Nursing to deliver this programme. Two cohorts of up to 20 nurses in total are being trained in each country. Trained nurses have been and will be producing an economic assessment output each, with light touch support from OPM colleagues. Outputs have been and will be validated and quality assured, before being made available via the RCN’s website to the wider nursing workforce.

A dedicated Wiki page enables individual nurses to stay in touch with co-trainees as well as with colleagues from OPM and the RCN. The Wiki page has been supporting the sharing of resources, collective problem solving, sharing of experiences and sense-making. Trainees have also been using the Wiki page as a platform through which they provide encouragement and support to others. Earlier cohorts act as mentors to subsequent cohorts.

Impact

To date, evaluations have found that all nurses reported acquiring new skills, and that they have developed confidence in conducting economic assessments. The experience of undergoing the training has affirmed their conviction that understanding the economics underpinning their services is an integral part of their role. Feedback also shows that nurses have started using the intelligence generated to improve their own practice and to mobilise others to transform services collaboratively.

The programme has achieved endorsed award status from the ILM in July 2012. It is the only programme of its type in the UK that has gained such recognition. All trainees will be presented with a certificate upon successful completion of the programme.  Independent evaluation by the ILM concluded that the programme: “generated high quality work from the learners”.

“There is now a business case for service expansion to improve patient referral, thus improving wider patient symptom burden and ultimately reduce unnecessary admissions further. The project supported potential further savings hence managerial interest.”

Jill Nicholls, Heart Failure Nurse Specialist, NHS Tayside

“I have been able to analyse our service delivery and analyse outcomes to ensure an improved balance between patient and organisation.”

Lee Cowie, Nurse Consultant, Acute Services, Fife CAMHS

 

Tuesday, February 18, 2014

Building Capacity on vInspired’s 24/24 programme

Background

The 24/24 programme is managed by vInspired and funded by the Department of Education (DfE). It is designed to give young people a qualification, work experience and experience of volunteering with the aim to get them into education, employment or training; and to increase their confidence, raise their aspirations and build an attainable and long-term personal development plan.

As part of this package of support, vInspired seek to offer providers a range of relevant training options, to help build capacity both within programme timescales and ultimately to help ensure the longer-term sustainability of the provider organisations.

In order to design and shape this package of support, vInspired asked OPM to work with all the 24/24 providers to undertake a needs assessment of their organisation across three areas: evaluation, fundraising and social media.

What we did

The focus of the capacity building was to support partners in demonstrating the impact of their work, effectively communicating the difference they made and to develop this into an effective case for financial support. To do this, OPM designed three short diagnostic online surveys to identify providers’ priority areas for additional capacity building in:

OPM then worked with external experts commissioned by vInspired to develop bespoke training and support that would enable providers to meet these key developmental priorities.

Impact

The feedback from partners involved in OPM’s capacity building programme was extremely positive. 100 percent of participants said they felt OPM’s capacity building work improved their overall understating of economic assessment, likewise 100% of those involved felt the training provided had improved their evaluation planning.

Overall, OPM designed training and support programmes to help providers include skills in five key areas:

Saturday, June 16, 2012

Fairness and Equality – Leading in London

OPM completed a two year London Councils programme to build the capacity of local authorities across the capital to respond to the challenge of improving fairness and equality. This final report focuses on key learning points and good practice examples.