Monday, November 18, 2013
Patient experiences tell a different story about the NHS: Insights from the Commonwealth Fund’s International Health Policy Survey
Not a day goes by without another headline suggesting the NHS is in crisis. Rotating through the weekly media are debates about patients’ access to GP services, the over-use of A&E, failing trusts, and quality and safety problems. The overall impression is one of front-line services teetering on the edge of collapse, with unsustainable pressures of near apocalyptic proportions. How can we respond when the whole system seems broken?
Sometimes it is helpful to take a deep breath, step back and gain perspective on the situation by comparing the NHS to health systems of other countries. Each year, like clockwork, the Commonwealth Fund of New York releases its international health policy survey. Now covering patients’ experiences from 11 countries, the survey’s results compare access to care, affordability and use of emergency and specialist services. Comparing the NHS to other health systems tells a different story than the one playing out in the national media.
So, what can the Commonwealth Fund International Health Policy survey tell us about the NHS?
The NHS provides excellent value for money – it is among the most efficient and equitable health systems in the world. This is largely due to its universal tax-based funding. Rarely do NHS patients delay seeking necessary medical care or skip filling prescriptions because of costs. UK patients do not worry about having to pay medical bills. The only sticking point is dental care, where more limited NHS coverage translates into patients skipping visits or delaying seeking care.
Cost-sharing reduces access to care. In insurance-based health systems, where patient cost-sharing is the norm, cost-related access issues are more common place. The survey results also contain a subtle warning. As the Netherlands experience illustrates, austerity measures that result in increased patient cost-sharing are likely to result in people forgoing care. In 2010, 6% of Dutch citizens reported delays in seeking care; whereas in 2013, the figure rose to 22%. The authors of the Commonwealth Study attribute this to recent changes in the way the Dutch health system is organised and funded.
Access to primary care (e.g., same day or next-day appointments) is a problem for half of NHS patients, so strategies for improving outside of hospital care are clearly needed. We compare unfavourably to some of the other countries when it comes to primary care access, although we are doing better than Canada and the US. The survey data suggest we could learn much from the experiences of the New Zealand system, which is also a primary care-based health system.
Surprisingly, NHS patients report the best access to care after-hours compared to patients in the other ten countries, with 69% of NHS patients responding that it is “easy getting after-hours care without going to the emergency room”. That is almost twice as good as patients in Canada, France, Sweden and the US.
All health care systems face problems with the use of costly emergency care. The proportion of patients using A&E services in the UK (27% in the past two years) is similar to figures from the Netherlands, New Zealand, Norway and Switzerland. Only the US and Canada stand out as anomalies.
NHS patients are largely satisfied with the NHS (63% say the system “works well, only minor changes are needed), and very few (4%) would suggest radical changes. These results have varied little each time the Commonwealth Fund has conducted its patient survey, every two or three years. Fundamental overhaul of the NHS in the way it is funded or organised is therefore likely to prove unpopular. The view that the NHS is in crisis and about to fail is also challenged by the survey’s results.
The Commonwealth Fund survey paints a rosier picture of the NHS than the one we’re debating. We need to pay heed to the lessons from other countries, and not throw the baby out with the bathwater. Policies that focus on improving primary care and reducing unnecessary use of emergency services make sense in the near term.
What the survey doesn’t comment on is the poor financial outlook of the NHS – the key issue of diminishing resources and a lack of forward investment. How we deal with continuing austerity in the NHS will say a lot about how much we value public spending for healthcare. In five years’ time, the Commonwealth Fund’s survey could tell a completely different story about patient experiences.
Friday, November 15, 2013
If charities are increasingly playing the role of public services providers, who is left to play the role of charities?
It was amusing to note that the collective déjà vu among participants at the start of an interesting RSA roundtable discussion last week entitled “Where next for the Big Society?” While the general consensus seemed to be that people hadn’t heard the particular phrase for a while, there was also acceptance that although the term the ‘Big Society’ may have fallen out of use, its principles have not.
And so the discussion moved on to familiar but important territory: how can citizens be encouraged and empowered to do more; how can collaboration between different parties be best facilitated; and what is the role should charities (or civil society, as is the current term du jour) play in all this.
On this latter point, it’s clear that charities are in something of a ‘dammed if they do, dammed if don’t’ position at the moment. An ever increasing number are delivering ever increasing amounts of public services – 20% in 2008 and 31% in 2010 according to the National Survey of Charities and Social Enterprises, no doubt much more now. On the face of it, this is no bad thing. Why shouldn’t charities put some of their specialist, some would say unmatched, knowledge, skill, and goodwill to use by becoming more directly involved in public service provision? Surely turning down the opportunity to help those they’ve pledged to would be the very definition of uncharitable?
Yet embracing this opportunity has invited challenging questions about what makes charities different from other organisations who do similar work. The Charity Commission itself warns that members risk reputational damage by choosing to deliver services previously supplied by the state: “others may now view you as being too close to the public body that funds you”. Those who subscribe to this view feel that the charities’ independence and ability to “speak truth to power” is compromised when Government contracts become a significant source of their income. As Nick Seddon of Reform has put it: “There’s a bit of a feeling of ‘he who pays the piper call the tune’.”
It is however worth reminding ourselves that many of our biggest and most respected charities significantly predate the creation of the Welfare State, and as such have been providing what we now consider to be ‘public services’ long before the Government did. Likewise we mustn’t neglect the obvious – charities are in a governance and legal sense – unique. The work they do must benefit the public. They must be registered with and regulated by the Charity Commission; and they must confirm to non-profit making principles.
Nevertheless, there are a number of legitimate concerns, both inside and outside the sector, about charities’ capability to perform their ‘core duties’ alongside the increased public service delivery role now required of many of them. Traditionally charities have been organisations that drive innovation, assess and meet emerging needs, and campaign for potential improvements in policy or practice to be made. This is as much a capacity as an independence issue, and in the current climate we should consider whether charities have the time and the resource to play both roles.
Recently OPM has been working separately with two major charities, Action for Children and 4Children. Both organisations are doing great work helping communities that have taken ownership of their local Sure Start children’s centres to deliver services. There are clear and considerable benefits to an environment where communities are able to own a public service and specialist charities provide it. However, there might also be some unintended consequences posed by this scenario. For instance having numerous providers and owners working to deliver the same services, often in the same area, could potentially lead to complicated logistical problems such as the compatibility between different training regimens or qualifications. Furthermore, this situation might be exacerbated by the resources present in different localities, as there is bound to be a difference in the quality and quantity of charitable provision from one place to another.
We must also not forget that charities are increasingly forced to compete with one another to win contracts to run public services. While competition undoubtedly drives up quality and professionalism in some cases, it can also lead to some smaller charities losing out to the big national charities who have more resources to deploy in developing high quality bids for work.
It is good to see in this instance, that some charitable grant funders – such as the Cripplegate Foundation who among other efforts, fund the innovative Islington Giving campaign which OPM recently evaluated – are deliberately trying to divert funding to smaller charities who they feel are critical for reaching disadvantaged communities but may not have the resources to compete for big contracts.
It would seem crucial that at a time when the charities face overt criticism – (for example the recent furore over chief executive pay) and possible curtailing of their political influence (as is possible under the currently ‘paused’ ‘Lobbying Bill’) – to remind the public of the sector’s very best attributes. This cause is not best served by talk of ‘scaling up’, as important as that might be, but by to excuse the cliché, getting back to basics.
As Dame Clare Tickell of Action for Children, one of the speakers at the RSA event, told OPM last year:
“One of the voluntary sector’s great strengths has always been that it doesn’t wait for commissioners to commission. Instead, it responds and demonstrates with solutions based in real time. In order to retain our independence and commitment to our beneficiaries, we need to be making sure that we are able to demonstrate that we are continuing to do this.”
Monday, October 28, 2013
Qualified or not, public services need to equip themselves to work with more volunteers and lay people to get the job done
The long running squeeze on funding is forcing public services to think very differently about their workforces. Long gone are the days when organisations struggled to recruit quickly enough to meet top down directives to increase the number of front line staff. Instead, public services now have to face up to the task of cutting the size of their workforces in response to ever decreasing budget allocations and changing responsibilities. It’s demoralising and difficult work.
It is in this context that the current war of words on whether teacher’s need to be qualified or not – between Nick Clegg, Labour and teaching unions on the one hand, and Michael Gove and Boris Johnson on the other – is taking place. But, whilst interesting to watch, this discussion is actually something of a distraction from the broader changes that are happening elsewhere across public services.
In a climate of providing more for less, public services need all the help they can get – and often this means pulling in volunteers, parents, community organisers or other willing local people to help them run services, whether this is a local library, care home or youth service.
Of course certain jobs – such as teachers, doctors, nurses, and social workers to name but a few – will quite rightly remain the preserve of those with the requisite qualifications and experience. There are also many skilled and important roles discharged by non-qualified staff that are critical to the successful running of public services which it would not be appropriate for volunteers to deliver. These also need to be protected. But, in order to help these professionals do their work as effectively as possible a number of support positions exist, which increasingly are being carried, or are able to be carried out, by a cadre of highly capable and enthusiastic volunteers in receipt of the necessary support and training.
Several of the programmes OPM has been working on recently are heavily reliant on such voluntary staff, many of whom do not have formal public service qualifications. The National Citizen Service for 16 year olds for instance – which OPM helped to evaluate – involved local voluntary sector bodies drawing in help from volunteers to run everything from outward bound trips to the country side to supporting social action projects in the community.
The evaluation found that providers of NCS need to change the way they worked in order to recruit, train and support good volunteers to help them provide the service. Those that did it well were adept at communicating and selling the benefits of being involved; supporting volunteers with excellent induction and training, linking involvement to career development and skills acquisition, and providing good supervision and support throughout.
Another project we’re evaluating – the Sure Start Programme delivered by 4Children and funded by the Department for Education – aims to get parents and community groups involved in taking over ownership and management of children’s centres. In this case, 4Children needed to provide a substantial amount of training and support to parents to give them the necessary grounding they needed to take on formal roles and responsibilities, such as help with understanding governance, legal frameworks and engaging with communities and the local authority. In doing this, they also had to be very flexible, providing advice at times and locations that suited busy parents who often had full time jobs.
Whatever the outcome in the battle over whether teachers need to be qualified or not, it will not stop the wider drive to involve more unqualified (at least in terms of formal public service delivery roles) people in the public sector service delivery.
This is not about pitting qualified staff against unqualified volunteers, rather, it is a recognition that in cash strapped world of public services, increasingly non-statutory positions will be supplemented (as opposed to substituted) by lay people in either paid or unpaid roles – as a pragmatic way of ensuring services run efficiently and effectively. The public sector needs to be at the vanguard of this movement – encouraging and enabling those who are willing and able, to contribute on delivering services to the public Learning about what works in recruiting and supporting these people will be an important skill of anyone who wants to lead and manage public services in the future.
Monday, October 21, 2013
Shades of Grey – towards an integrated model of care
It is always a privilege to spend time with clients in a transformational environment, but it’s especially rewarding when passion and commitment lead the way. Earlier this week, I was delivering a training workshop with front-line staff in Merton about integrated care. OPM is working with Merton Council, Merton CCG and local health and social care providers to implement a model of integrated care that rests on multi-disciplinary teams operating in three localities.
My learning from the workshop confirmed that making integration real is easier said than done. Integrating health and social care provides the vehicle for transforming service delivery, but to make it work, we also tackle some shades of grey to get front-line professionals working more effectively together (there are, no doubt, more than fifty!).
Senior managers and commissioners are driving this large-scale change, whilst practitioners on the ground are making integration real. This top-down-bottom-up approach should prove fruitful, as Merton’s practitioners’ desire to improve client outcomes is in abundance.
The participants at the training session included social care managers and brokers, occupational therapists, physiotherapists and GPs. It was evident that they were eager to grapple with the practicalities of multidisciplinary working towards creating the best outcomes for clients. They identified the key factors in making integrated care work:
- Strong leadership,
- Good relationships,
- Shared values,
- Engagement and communication, and
- Education and training.
But what was also evident was that the boundaries between professional remits are not always clear – in fact, several grey areas persist, and these ambiguities interfere with the delivery of care and thwart practitioners’ ability to progress client referrals. For example, a client who has both physical and mental health needs can be “handed off” to one organisation, rather than “handed over” meaning that essential client information is not communicated.
Other grey areas relate to the current system’s complexity. One scenario raised is the Friday afternoon crisis, when a client who needs either an emergency package of care or medication is often admitted to hospital because the social care/primary care avenues have been exhausted, or the decision about whether the client “belongs to” health or social care has not been determined. Practitioners were also concerned about clients who have been diagnosed with dementia whilst in hospital and who, upon discharge, are then advised to access primary care. In some cases these clients cannot access primary care before their next spell in hospital, which means that they “bounce” around the system.
At the session, participants offered some practical solutions for tackling the grey areas – a willingness to wade into the uncertainties across health and social care, and working jointly rather than individually. A major recommendation was much more investment into practitioner training as well as team development.
Perhaps the best barometer of organisational success is its employees’ ability to learn and deliver new ideas and fresh thinking. I came away from the workshop inspired. I was reminded that putting client outcomes first always renders the best results and that by supporting the frontline workforce to perform their best will mean fewer shades of grey.
Friday, September 13, 2013
The more people know about the Prevent strategy, the more they are likely to support it
The recent attacks in once again Woolwich reminded us about the threat posed by violent extremism (a subject which we have written about recently). In response to these events, the Government has convened a new Tackling Extremism and Radicalisation Taskforce to consider how best to prevent radicalisation taking root within Britain’s communities. Its report – expected in December – will have significant implications for how Prevent – the policy intended to stop people supporting or becoming terrorists – is delivered in the future.
One problem which has plagued the Prevent strategy since its inception in 2008 (and revision in 2011) is the lack of trust many people have in the policy. The Taskforce would do well to address such questions such as: why are people mistrustful of Prevent?; what concerns do they have that need to be allayed?; and how can the strategy be more positively communicated? The Prevent strategy itself was honest about this problem, stating that “Trust in Prevent must be improved”
A lack of support and buy-in for Prevent directly impinges on its ability to be successful, because those who don’t believe the strategy’s stated intentions are unlikely to help contribute to its success. Prevent is reliant on good community engagement for a number of reasons: to help people spot those who are vulnerable; to access hard to engage communities; to ensure that local communities play their part in challenging and deconstructing extremist narratives; and to provide support with specific projects, e.g. in schools and universities.
A recent research study for Hackney (a Prevent funded priority area) is typical of many. It describes a number of people either lacking awareness of the Prevent strategy, or worse, being very mistrustful of the agenda. One participant told the researchers:
‘Prevent will always have a stigma attached to it. There have always been questions about whether it is an honest process, whether it’s intelligence gathering or mapping or monitoring and Hackney has the same questions. ‘
Other respondents told Hackney of knowing little, or nothing, about Prevent, even though they did hold some concerns about extremism.
Our own research on prevent tells a similar story: a small minority of people are very distrustful of the agenda, while others are simply unaware of what Prevent strategy is all about.
So what can be done to help build trust?
Firstly, I think improvements could be made in making basic information about Prevent available, including publishing action plans and any research. Whilst some of these papers may contain some uncomfortable information, they do provide a clear rationale for why Prevent is doing what it is doing. Bradford (another Priority Area) has published its Prevent action plan, in an effort to become more transparent and I think this is a good step to have taken.
Secondly, there should be better and clearer messaging about Prevent. Our research for two London Borough’s recently found that most people would more likely relate to and support Prevent, if the messages were clearer about the end-goals of the strategy – i.e. that it is about tackling a minority of dangerous people and stopping criminality. Complex messages about Prevent that overuses terminology like ‘ideology’, ‘values’, ‘radicalisation’, and ‘sectors and institutions’ can confuse and put people off. Simpler messages about tackling all forms of violent extremism are much more likely to resonate.
Thirdly, dispelling myths and distrust about Prevent is better done face to face. Holding events and forums where people can raise concerns openly, and learn about different sides of the argument, can be good for building understanding. In terms of techniques, we would recommend deliberative engagement – a technique we have written about extensively – as an effective way of building understanding and support for an idea through a two-way engagement.
Fourthly, efforts should be made to try to build community leadership over Prevent, e.g. by letting local people become advocates for the programme, rather than leading through institutions, such as the police, which some people may already mistrust. One London Borough for instance has started encouraging a cadre of young people to speak out against extremism, in schools, social clubs and in friendship circles. These people are not coerced or paid to do this, they have bought in to the idea that tackling extremism is their problem, as much as the police’s problem.
Of course none of this is easy to do – but there are benefits to be had if some of the above, and other, steps are taken. As the Taskforce contemplates where to go next with Prevent, a clearer strategy on building trust should be on their list of priorities.
Tuesday, August 27, 2013
How can we make integrated care affordable?
Integrated health and social care was the hot topic at this year’s LGA conference. The government announced plans! Labour announced plans! the LGA announced plans!
Pioneers are to be established. Pilots are to be set up. In the face of a demographic time-bomb and cuts in social care – integration is everyone’s solution.
But we also have learnt the hard way about what happens when carefully designed, locally adapted, well-led experiments are ‘rolled out’ to places where none of the right starting conditions exist. There are no ‘magic bullets’ here and suddenly everyone is peddling computer systems, risk-stratification models, IT integration packages, project management systems, pathways diagrams….
And there’s a bigger issue… we know from the evaluation that has been carried out of all the pilots so far, that while integration is popular with both clinicians and with service users – it hasn’t reduced unplanned or emergency admissions to hospital. The savings haven’t yet materialised. Now this may not be a problem in the long-term. Most system redesign experiments fail to work well at first. But what if the system pressures are strong enough to prevent savings being made?
As always, the devil will be in the detail. But there are some important lessons from previous ‘whole system’ change such as Total Place and Community Budgets which helps to inform the work that OPM is doing in a number of places making health and social care integration work. These include:
- Without firm, skilled system leadership, organisations won’t be able to make new arrangements stick. The shared sense of purpose is critical – and the agreement to make life better for service users.
- Commissioners and senior managers are too far away from what really happens to know what will and won’t work. It’s the users, the GPs and the front-line staff that need to co-design new ways of working.
- Just because a system has been designed to function in a certain way, there is no guarantee that it will. Most system failure happens because people don’t behave in the way that the system engineers intended. They’re not components, they’re people. Winning hearts and changing mindsets is more important than drawing diagrams.
- Unless the whole system is part of the change – people will fall through the gaps. For example, unless the out-of-hours GP service is connected into new arrangements – they will continue to call ambulances and send people to A and E in the middle of the night!
- Different players in a system need different results – and the most successful change may involve navigating between the different needs of users, clinicians, acute hospitals, social care providers – system leadership is making sure everyone stays on board so that plans turn into action. That means making the time for leaders to come together to understand and reconcile their different perspectives.
- The most ambitious, comprehensive approach may not be the most effective. Some obstacles can be worked round. Start small and follow the energy. Find the people who want to make it work and liberate them. Demonstrate success – and learn from it. It may not be necessary to invest millions up front in new computer systems and new organisations. What matters to the service users is practical change on the ground. It may not cost much.
As we implement exciting new preventative programmes, and experiment with ways to reduce hospital admissions, we also need to recognise that there are some longer-term, more fundamental issues to be addressed.
First, we need to think hard about who integrated care is for. Merging a universal health service with a means tested social care service raises important questions about the limits of state help. Trying to reduce preventative services to save money has resulted in growing demands on the emergency and acute sectors. What is the way forward?
Second, many would argue that cashable savings from the acute sector are not achievable. It may be possible to improve the quality of care, and user satisfaction, but without necessarily reducing the pressure on hospitals. Integration is about managing increasing demand, and given the growing population of frail elderly people and those with dementia, integrated care is unlikely to solve the financial problems of either local government or the NHS. So if it isn’t the ‘magic bullet’ many expect – we may need to be cautious about ambitious ‘invest to save’ plans. Cheap and practical solutions reduce the scale of up-front investment and make it easier to create benefits that offset costs.
Oh, and one more thing. There was a lot of discussion at LGA conference about the problem of young inexperienced care workers on zero hours contracts. We do know that only happy, unstressed, empowered staff will treat service users well. The Cavendish Report suggests that many care workers feel they are being asked to perform the tasks of nurses (and in some cases doctors) without adequate training. Until we make sure that care workers themselves are cared for, properly trained, and truly valued, we are unlikely to create the care that you or I would want for our own parents.
Tuesday, July 16, 2013
Woolwich – Community relations under strain, but some are showing the way forward
There is a real danger that the terrible crimes committed in Woolwich will contribute to the breakdown of community relations. For extremists of both a far right and intolerant Islamist persuasions, the attacks in Woolwich have been a boon and an opportunity; for the rest of us, they are a tragedy and present a really worrying trigger for the deterioration of community relations.
We have seen a small number of attacks on Islamic community centres and Mosques, and a re-emergence of the English Defence League at a point when some were arguing that it was beginning a slow decline. To counter this group, a new organisation – the Islamic Emergency Defence – or IED – has been established to protect Muslim communities from attack through vigilante action. The fact that Anjem Choudary – a prominent extremist – has hailed this group is cause for concern in itself. Sections of the media have also been less than helpful by giving these groups prominent platforms from which to broadcast their pernicious and marginal perspectives.
This is all very worrying. However, look beyond the escalation in tensions and there have also been some glimmers of hope. In areas where strong inter-community relations have been nurtured and built over many years, people have come together to confront extremists and portray their shared commitment to keeping their community united.
In the London Borough of Barnet for example, the reaction to an arson attack at a local Islamic centre became the focus of a combined effort between two different faith communities to show that this kind of incident will not be tolerated and that communities can stay together in the face of divisive actions. The attack triggered a wave of support from residents, local businesses and other faith groups, with the council quickly offering the use of a local library so that the activities of the centre could continue. Particularly notable were the immediate messages of support and solidarity coming from local Jewish groups. Instead of dividing this community, the attack served to cement a positive relationship between the many different groups which comprise it.
More recently, a small group of EDL protestors gathered outside a mosque in York. Instead of allowing this protest to sour community relations, members of the mosque were able to diffuse the situation, inviting protestors to share tea and biscuits with them. It is likely that the frank conversations and the game of football that followed this invitation did an incredible amount to promote mutual understanding, as the individuals present were able to air their views and develop a better understanding of one another’s positions and concerns. The conversations also sent out a wider challenge to those seeking to incite tensions between community groups. By highlighting the ease with which good natured dialogue can be achieved, they undermined the case for more divisive ways to express concerns, such as rallies or violent acts. These conversations also present a strong challenge to the ‘us versus them’ rhetoric which often seeks to emphasise the apparent incompatibility of different community groups.
In Tower Hamlets, when the EDL was planning to march two years ago, the community was mobilised on a massive scale to reject the march and show that it stood together. Whilst some of the marchers from the EDL were embroiled in trouble with the police, the counter protests were peaceful.
These types of positive community responses can arise quite by chance, but they can also arise because the foundations of good community relations have been laid over many years, nurtured by the local authority and others and kept alive through a strong commitment by local community leaders and activists. It is important, therefore, even in the context of ever more severe cuts to funding, that these relationships are sustained and enhanced. Not all of this requires money, it mainly requires strong leadership and encouraging local groups to offer their time and efforts for free.
Tuesday, July 9, 2013
Stop and Search: the misuse of these powers undermines more than just confidence in the police
“If stop and search is being used too much or with the wrong people, it is not just a waste of police time, it also serves to undermine public confidence in the police” (Home Office spokesperson)
As the Guardian reports today, a recent Her Majesty Inspectorate of Constabulary (HMIC) report, commissioned by Theresa May to understand the use and effectiveness of Stop and Search in England and Wales, reveals that too few forces are collecting sufficient information to assess whether it has been effective. It reports that 27% of the 8,783 stop and search records examined by the HMIC show insufficient evidence to justify the lawful use of the powers. This finding, combined with the fact that black people are seven times more likely to be searched than white people, implies that people are being targeted on the basis of their racial profile. As such, misuse of Stop and Search is not just ineffective and undermining of police trust, but it is also a gross misuse of power.
Undermining trust in police and wider democratic institutions
We have recently completed various research projects with different groups of young people including a focus group with Somali boys in North London. During this session they talked about their own experiences of Stop and Search which, depressingly, echoed the HMIC report findings. The boys had both first and second hand experience of being stopped and searched in their day to day lives and felt it had made a huge dent in their trust with police. They accepted they had to show willingness to engage with the process but it meant they were less likely to go to the police with future issues or information or confide in them in general.
Moreover, the police represent not just their own forces but also the wider pillars of democratic society. Therefore, misuse of powers such as Stop and Search has an impact not just in terms of trust and confidence in their processes, but also in terms of other institutions including schools, healthcare, housing, the legal system, press and media and in local and national government. We have found that young people, including the North London Somali boys, were also less likely to engage in a range of these public institutions due to low levels of trust they placed in the system.
How mistrust becomes disengagement
Last summer saw a number of public and peaceful demonstrations against a range of austerity interventions. I asked a young, black, male friend whether he was planning to go on a march. He laughed at the suggestion. Despite sympathising with several of the causes he didn’t want to be seen anywhere near the events. His reason was because he would get into trouble, even if there was no trouble. My friend’s fear of racial profiling means that he distrusts policing at large, which effectively excludes him from engaging in many forms of democratic activity which are his right. And then the London riots kicked off and a bad situation just got worse.
Many of the young people we have spoken to, and particularly those from BME or Muslim faith groups, have reported increasing frustration at how they are negatively portrayed in the media. Misuse of powers such as Stop and Search means that we’re left with a situation where those who are most targeted due to their racial backgrounds are also those who feel most powerless in changing their situations. At worst, this leads to complete disenfranchisement with society and our democratic institutions. At best this leads to disengagement, like my friend, who is happy to keep his head down and get on, although that should not be good enough for anyone.
Thursday, July 4, 2013
Why empowering the public service workforce is key to improving quality and efficiency
As is well known, the NHS is facing one of the most significant financial challenges in its history, with the need to secure £20 billion of cash releasing efficiency savings by 2014/15. Against this backdrop of austerity, there is a risk that resourcing decisions will be taken purely on the basis of driving down cost without due consideration of how this affects ‘value’. Not all cuts will lead to savings. Cuts to specialist nursing aimed at helping patients stay at home for example, can lead to greater demands on hospitals. There is an urgent need to be clearer about how we measure the social and economic value of health services as a means to justify or rationalise their actual financial cost.
There is a further risk that austerity can stifle innovation. It has been calculated that innovations designed and implemented by clinicians could have a value of £9 billion per year in the UK. Through the Royal College of Nursing’s (RCN) Frontline First campaign, for instance, we have been made aware of the numerous ways through which nurses add value to patient care while generating efficiencies through new and innovative ways of working. They, and others, have a key role to play in realising the cash-releasing efficiency savings in the NHS.
To empower the health service workforce to understand how they can contribute to realising cash-releasing savings while maintaining high quality care, OPM designed a programme of training and support in the use of a bespoke and accessible Economic Assessment Tool (EAT).
Thanks to funding from the Burdett Trust for Nursing, this two-year programme has started to be delivered to nurses in Scotland,Wales and Northern Ireland since 2012.
This programme equips nurses with the relevant skills to assess the social and economic value of nursing services and to use those skills to guide the development, improvement and delivery of services. More critically, the programme can help unleash the potential of the health service workforce to contribute proactively to the quality and efficiency agenda, by demonstrating where real efficiency savings are being made as well as highlighting areas where there is further potential for savings. If this is scaled up, it could make a significant contribution to national efforts.
For example, one nurse stated that:
“In the course of conducting my economic assessment, I also came to realise that an understanding of these economic benefits can influence the way we plan for future activities and developments to improve the service.”
Another nurse remarked that:
“The OPM programme offered a unique opportunity to engage in a process that not only sought to identify the economic value of the service model but also empowered practicing clinicians to develop new skills that were sustainable. This has laid the foundations for thorough assessment of cost, value and worth to be incorporated into future service design and delivery. There has been a real culture change that supports a systematic and consistent approach in clarifying costs, value and quality.”
We firmly believe that workforce-led quality and efficiency drives are more likely to be both sustainable and successful, and therefore that it is important to invest in the workforce sufficiently.
It is with this in mind that we are convening our next seminar in our Valuing Public Services breakfast seminar series in partnership with the Royal College of Nursing, and with participation from the MS Trust. This event, on 5th July 2013, showcases two innovative programmes aimed at developing the capability of the nursing workforce to demonstrate their impact, and their social and economic value. Frontline nurses, who have undergone the programmes, will be sharing their experiences and learning, as well as discussing the impact of their work. Although the case studies originate from the nursing profession, the lessons learned also have wider applications across the public services workforce.
For those unable to make the event in person, we will be tweeting throughout the seminar using the #valuingps hashtag. There will also be a live Twitter chat led by the RCN (@thercn) following the event this Friday at 12.45pm, which uses the hashtag #RCNchat.
Monday, June 24, 2013
Greater demand for personalisation necessitates further changes in supply
A new Respublica Green Paper by Alex Fox argues that the personalisation agenda must go further than simply enabling personal budget holders to choose between the limited range of supports that exist. The supply side, it says, must also change. The constraints on the current industrial scale provision of care homes and domiciliary care mean that whilst they are able to meet the physical care needs of older people they many of them as, if not more, isolated and lonely as before.
The report points to Joseph Rowntree Foundation research which says that older people aspire to living the ‘good life’ rather than managing their decline. Critically this includes: keeping up existing, and building new, relationships; being able to help others as well as receive support; and living in appropriate housing. Given this, we need new human scale, micro-approaches that enable older people to be part of their local communities and build on their strengths whilst meeting their needs. These approaches also enable a much wider range of informal and professional relationships to work alongside and enhance one another in a ‘networked’ model of care.
Fox shows that thanks to the work of Shared Lives (where he is also CEO) and other organisations new forms of housing and support are already emerging. Shared Lives matches older people to families with whom they can either live full time or during the day. Micro social enterprises, formed by domiciliary care workers enable them to provide personalised care at a pace and scale that puts relationships first, links the older people they care for into their communities and also delivers the personal and other care that is required. Leeds Council, supported by the Stamford Forum, has enabled old people to pool personal budgets to buy new types of services that reduce isolation and build mutually supportive friendships. Hanover Housing is working with local people to set up an inter-generational co housing cooperatives that are designed to actively enable community support between residents. In the Isle of Wight, Care4Care is a timebank which enables more able older people to care for other older people who require support. The ‘hours of support’ that they contribute can then be drawn on by the current carers when they in turn require support in the future.
The Paper points out that whilst knowledge of these and other micro developments is becoming more widespread, they are still seen as interesting but essentially niche adjuncts to the mainstream housing and care industry. The big issue for interested commissioners is how to commission the large volumes of services that would be required if these new approaches were to replace existing domiciliary and residential care. Respublica put forward a commissioning approach that focuses on market shaping rather than block commissioning. They envisage the franchising of models of care, such as those developed by Shared Lives and Community Catalysts, to support local micro developments. The franchise would provide a basic specification for the service that can be ‘scaled out’ through supporting local based service development, a regulated rather than a tightly specified ‘scaling up’ approach to franchising.
Alongside changes in local commissioning Fox proposes provider developments including redesign of services to blur the boundaries between formal/informal, paid/unpaid. An example of this is the way that Community Catalysts was invited by the care provider MacIntyre to work with its staff to encourage them to develop its services by acting creatively and with autonomy at the micro-level. Nationally, the Care and Support Bill regulations should include market shaping to support micro services development and the Department of Health should remove the existing barriers to commissioning these types of service. The role of mutuals in providing the new services should be supported by the Cabinet Office’s Mutuals Task Force and by making creative use of the provisions of the Public Services (Social Value) Act.
The approach that Respublica advocate fits well with that of the National Collaboration for Integrated Care and Support that aims to make integrated care both person-centred and asset-based. However if these aims are to be met complementary changes must be made which also build the principles and practice of coproduction into existing core services in both health and social care.