All too human: the need for coalitions across different motivations and organisations

Here’s a post I’ve written on the need for coalition building across a range of motivations and organisations if successful change is to happen in social care. This is part of the #socialcarefuture series that @mroutled has been bringing together, designed to create a space to get past just thinking about stabilising the current social care system which isn’t fit for the future. Here is the rest of the #socialcarefuture blog series.

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Much debate in public policy focuses on the “why” and the “what”. Why is this issue important? Why should it be prioritised over something else? What should be in place that isn’t? What needs to change for this to happen?

Comparatively little focus is placed on “how” – the practicalities of putting the why and what into action. The “how” follows once the “why” and the “what” have been largely agreed, and is important because it’s in this space that all of people’s experiences are generated. It’s also where good ideas can turn into bad delivery.

But below the “how” is a question even less attention is given to: “who?” Rarely is it considered: who is asking for this change? Who is the change being asked of? What are the motivations of these respective groups?

It is too easy to lament how poor commissioning and commissioners are; or how it would be so much better if only senior leaders recognised the radical difference that x or y would make. But this is to fall into the trap of “what’s the matter with these people?” rather than thinking, familiarly enough, “what matters to these people?”

This thought came home to me when, for around three years, I was simultaneously on both “sides” of a policy argument. For around half of my time I was working in a disabled people’s user-led organisation (DPULO), advocating for disabled people’s equality and rights, delivering user-led services and promoting choice and control through personalisation in social care. The other half of my time was in, of all places, the Office for Disability issues within the Department for Work and Pensions (DWP_.

What was fascinating about this was, even though I would say exactly the same things when wearing my DPULO or DWP hat, people would receive a message considerably differently depending on how they perceived me in that moment. Disability rights campaigners would broadly be ok with my thoughts when shared from a DPULO perspective. But the exact same thoughts wouldn’t be acceptable if I expressed them from a DWP platform.

In neither situation was the idea that disabled people’s equality and rights mattered to me. Nor was it recognised I was consciously choosing different means to others by which to achieve what was, in fact, a common goal.

This leads to two connected conclusions relevant for #socialcarefuture.

The first is to understand that what matters to people, matters. Motivations for engaging in an issue will differ. There will be a junior minister who wants to be promoted; there will be lifelong advocates who have dedicated themselves for 25 years to a certain change; there will be civil servants who want a pragmatic solution to a pressing problem they are facing. But all of these different motivations are as present as each other, and can be skilfully aligned to achieve a common change that works for all.

The second is to recognise that such a broad coalition of people with different motivations will be located across a wide range of organisations. Indeed, the coalition has to be widely distributed if it has any chance of succeeding: each participant will have access to something others don’t, and that is needed for the overall change. As a result, some coalition members will be “inside” the system. Some will be outside (possibly literally, chained to railings or waving placards). Some will be in the grey area that is neither inside nor outside (the voluntary sector is most often found in this space). Some may not even know they’re in the coalition.

What leads to change is consciously acknowledging and valuing the existence of such a broad coalition across motivations and organisations. Each participant – each “who”, with their all too human motivations and positions – makes a needed contribution, and it is only through this coalition that successful change will come about.

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(For those interested in the public policy theory that underpins such coalitions, this primer on Advocacy Coalition Frameworks https://paulcairney.wordpress.com/2013/10/30/policy-concepts-in-1000-words-the-advocacy-coalition-framework/ is excellent.)

The Tory answer to the question “who pays for social care?”: You!

Image via WikiHow

Two excellent responses to the Conservatives’ social care manifesto proposal: Torsten Bell at the Resolution Foundation and, of course, The King’s Fund.

It took me quite a long time to figure out the main implications of the proposals (I’m not sure I understand them even now).

We can summarise them as:

• If you have assets under £100,000, you’re a winner
• If you have assets over £100,000, you’re not a winner

In essence, the Tory answer to the question “who pays for social care?” is “you, not us”.

Coupled with the proposal to scrap the universall Winter Fuel Allowance, one argument is that the Conseratives’ proposals are progressive, redistributive mechanisms that will benefit people from lower incomes, or working-age people who have been reliant on social care for their adult lives (and are less likely to have built up assets).

The counter argument – including when comparing the proposals against the Dilnot Commission’s proposals – is that these proposals create a further breakdown in the inherent universalism and sharing of risk that only government can provide (see also: the NHS).

These proposals may provide a financial solution to the social care crisis*, but they certainly don’t shore up the idea that “we’re all in this together”.

*Though deferred payments from housing still requires large short- and medium-term injections of cash, and we don’t know how inheritance law and behaviour will respond to these announcements.

#peoplepoweredhealth: how to make it stick – in one minute

As promised, here are my reflections on “how to make #peoplepoweredhealth stick”, which I shared at Nesta’s People Powered Health event. For context, I was given one minute and was speaking alongside some terrific speakers, so decided to offer a particular angle on what I thought might work…

• There are limits to progress that can be made through hard levers, like policy, regulations, guidance, draft contracts
• Policy makers, commissioners providers, practitioners – i.e. people – are rarely motivated by efficiencies and technical
• They are motivated by good relationships, happiness, positive contact, seeing the difference they make, feeling like they are good at what they do
• My reflection on making people powered health stick is to support people to come together as people, rather than in the roles they have, so that they can directly and personally experience what it is that motivates people
• Part of making it stick is trying to move beyond our protective labels and roles, and emphasizing our common human bond.

 

We can’t all be change agents

Around 16% of people in an organisation are change agents. About 50% of people are late adopters or laggards.

Image via Helen Bevan on Twitter

Similarly, around 13% of employees are engaged contributers in the workplace:

Image via School for Change Agents

All the rest are compliant – disconnected from the purpose of their organisation, controlled by performance management and procedures, largely resistant to change.

An idle thought: though we’d all dearly love to be change agents and contributors, by definition, we can’t all be change agents; we can’t all be contributors.

Half the battle – actually, over 80% of the battle – may be recognising our place in the organisational picture.

The institutionalisation of successful social movements: peril or pragmatism?

Nesta’s #peoplepoweredhealth event earlier this week was hugely enjoyable. It built on the vast range of work Nesta has done on this topic over the last few years, and brought together a wonderful and diverse range of people.

“Work” shouldn’t be this much fun.

It was a privilege to be part of the session on “People powered health: how to make it stick?” I’ll write up what I said another time, but wanted to share something else that occurred to me through the discussion and after reading this excellent related report on health as a social movement (pdf).

It focuses on the question of what success looks like for innovative approaches:

What if social movements were so successful that what they advocated for was completely taken on by institutions (such as the NHS)? What if people powered health became so sticky that the NHS completely appropriated it?

If this happened, would this count as success? Or would it represent too much of a compromise or dilution of what the pure approach was when it was outside the grip of a big institution?

We don’t need to look very far for examples of where this has happened before. In social care, Direct Payments in 1996 were an innovation proposed and owned by the disabled people’s movement. Fast forward to 2014 and personal budgets are the default delivery mechanism for all community-based social care. Along the way, many disability campaigners have become anxious about the compromise of notional budgets or the use of resource allocation systems.

More recently, social prescribing could be argued to be an example of an innovation whose adoption by the formal health system has meant it has moved away from what it was originally intended to be.

And yet in the case of both personal budgets and social prescribing, their ultimate net benefit is greater for their adoption by large institutions than if they’d have stayed as small but perfectly formed innovations.

I wonder if most social movements start out with the hope of what they advocate for becoming part of the system? And I wonder if the inevitable pragmatism that’s needed to reach that point imperils the very value such approaches represent?

My personal view, as I’ve written before, is that if such appropriation makes things a “bit” better for a “few” more people, then it’s worth doing. But it would be fascinating to know what you think!

Avoiding a hierarchy of equalities

There was a major general election announcement over the weekend that focused on mental health policy. Whilst this is great news in itself, I’ll bet someone, somewhere, has written that there should be an equivalent for people with learning disabilities, or for people with sensory impairments, or for carers, or for older people with x condition etc. etc.

This is not where we want to be.

As I’ve written before:

Whilst there are arguments which could be made for each [impairment group requiring something separate], to my mind there is no overarching framework within which all of them hang together. There is no agenda around which all people with a commitment to disability rights and equality for all disabled people can coalesce.

In the absence of an overarching disability rights and equality framework, what we end up with is a hierarchy. In such a hierarchy, mental health is currently doing (relatively) ok, but learning disability less so. And if learning disability ends up with a new cross-government strategy then what about… and so on. Goodness knows what happens if you’re a person who happens to tick more than one box.

The point can also be extended to other equality groups: there is common cause, for example, in closing the gender pay gap and the disability employment and pay gaps (as exemplified by the nonsense suggestion that people with learning disabilities should be paid below the national minimum wage).

Insteaf of separate policies we should be calling for a reignited overarching disability equality strategy, which builds on the heritage of the Life Chances report, the Independent Living Strategy and Fulfilling Potential. Underneath this could easily lie dedicated action plans and analysis that relate to particular impairment groups, and so still taking account of the specific barriers some groups face. Such a strategy would clearly link to a general equalities strategy, showing common cause across all protected characteristics. This should all be backed by a strong central government presence, including through a significantly rejuvenated Office for Disability Issues, through the Government Equalities Office or, perhaps, through proper resourcing and respect for the Equality & Human Rights Commission.

By avoiding a hierarchy of equalities, the common cause of everyone will be improved.

Hypothecation, hypothetically speaking

Would you be prepared to pay an extra 1p in income tax if it was guaranteed to go to the NHS?

Pls RT to increase the sample size#VoteNHS

— NHS Million (@NHSMillion) May 6, 2017

This won’t be the last question about hypothecated taxes in this general election, nor in elections for the rest of time.

Hypothecation is the process of assigning tax revenues to specific areas. The debate about it has a long history in the UK – see this House of Commons Library research paper (pdf).

In health, a little nugget to consider is that National Insurance raises roughly how much the health service costs. NI receipts in 2016/17 were £126bn and the NHS budget for 2016/17 was £120bn. But if you follow where those NI receipts go, I’d be surprised if they go directly to the NHS.

There’s a nice paper from the World Health Organisation (pdf) that I’d recommend reading on this thorny topic. I like it because it digs behind the economics of hypothecation and examines the reasons for and against it. The reasons given for hypothecation include:

• Trust
• Transparency
• Public support
• Protecting resources.

You can therefore see why @NHSMillion would be keen on hypothecation – particularly looking at that last point: the lack of trust that appears to exist is exactly why people want to protect NHS resources.

This said, I’ve never been a fan of hypothecation. Whilst it would be foolish to argue against trust and transparency in particular, I’m not sure you need hypothecation to ensure trust and transparency. The other cons of hypothecation also point to my reluctance to embrace it. They include:

• Undermining solidarity
• Exemption from review
• Inappropriate funding levels
• Tying the hands of government.

It’s coincidence that funding levels and NI receipts are roughly similar in health. But controlling for this,  my worry with hypothecation is that we quickly undermine solidarity for tax revenues and public services. Hypothecation opens the possibility of people saying “yes, I’ll pay tax for x” and so potentially “no, I won’t pay tax for y.” I fear it would exacerbate what we already see in areas like welfare support and social care.

Whilst hypothecation isn’t an answer, I think it at least helps us pose the right sorts of questions: how do we ensure transparency in how public money is spent, how do we debate the right balance between different types of services, and how do we build trust between those who make these decisions on a day-to-day basis on behalf of the electorate.

“Become what you are”

There are two broad interpretations of this imperative, originally found in Pindar, and discussed in The New Atlantis.

The existentialist view, epitomised by Nietzsche, is it means:

Become what you happen to be, not what you think you should be.

Don’t pretend to be something you aren’t or can’t be, don’t strive to be an ideal version of you, and simply go with who or what you are.

The essentialist view, more in line with Plato and Aristotle, is to:

Become such as you are, having learned what that is.

This is the opposite of Nietzsche. It suggests you find out who you really are and then work towards this, and don’t be sidetracked by your baser drives.

There is also the argument made by Josh Cohen in The Private Life: that we can’t actually ever know our own, unconscious selves. Even if we could know what our true self is, Cohen’s suggestion is that we can only ever know the bit above the surface – we can never understand, perhaps in a way a friend can, why we pursue doomed relationships or reach a self-limited plateau in our work.

I tend to fall more towards the existentialist view here. Even if I could identify what my true self was, I’m not sure I would either, first, know when I’ve reached that state, or, second, not be diverted away from reaching it by how I am.

“Constrained by the limits of your own mind”

This is about baseball:

[N]o matter how much will and determination you might muster, you will always be constrained by the limits of your own mind. Ankiel doesn’t know why he can’t pitch anymore. All he knows is that he can’t.

It is also about a lot more than baseball.

Are you feeling lucky?

We tend to remember the obstacles we have overcome more vividly than the advantages we have been given.

This quote comes from an article about what this tendency (or cognitive bias) to remember how we overcame adversity instead of remembering the easier times might imply for public policy to try and make things more equal for people.

I found myself agreeing with this on at least two fronts:

1. “Hard” levers of change, such as legislation, regulations and targets, focus much more on addressing obstacles than they do on creating better opportunities to address equality issues
2. I’ve often thought of my own luck at various points in my life (making a good friend, having a good teacher, having a godparent who was very interested in sharing books).

We can easily translate this into the “luck” of having a good social worker, doctor, employment adviser etc. and ensuring the opportunities and experiences that public services provide are equally available and good to everyone. I have always been motivated by ensuring that this luck (or “luck”) systematically comes the way of as many other people as possible.