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

Inheritance
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.

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#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.

change agents
Image via Helen Bevan on Twitter

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

Contributors
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?

social movements and institutionalisation

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!

Resilience is recovery

We often take a militaristic, “tough” approach to resilience and grit. We imagine a Marine slogging through the mud, a boxer going one more round, or a football player picking himself up off the turf for one more play. We believe that longer we tough it out, the tougher we are, and therefore the more successful we will be.

This from Harvard Business Review, which then goes on to note:

The key to resilience is trying really hard, then stopping, recovering, and then trying again.

I couldn’t agree more.

It’s something I’ve most explicitly learnt from running – maximum progress and improvement occurs when you push yourself at most once a week, and build in appropriate recovery runs around this, leading to strong development over time.

It’s also something I’m learning more through work. You can’t simply keep bashing away at something and wondering why it won’t give. You have to take stock, recover, reflect and “strategically stop”, in order to be able to tweak, amend and alter the intensity of your approach.

Either way, resilience is in the recovery.

People in power don’t think they have power

Power

Most people who are thought to have power don’t think themselves they have power.

Let’s look at those thought of as traditionally having power[1].

In the world of health, we hear about the “power” of the clinician over the “patient”; in care the “power” of the social worker over the “service user”. In the world of services the commissioner is the most powerful, and in the civil service we think that power resides with (Prime) Ministers or Permanent Secretaries.

Inevitably, the person at the top of any organisation is often thought to be the most powerful: the higher you go the more powerful the people get.

And, to some extent, this is true: their decisions affect larger and larger numbers, whatever those numbers happen to represent (people, staff, money).

So how can it be that the person thought of as the most powerful in the world can lament his own lack of power?

It goes back to my opening: if you ask those people listed above who are traditionally thought to hold power, I doubt very many of them would feel anywhere near as powerful as they are perceived to be by other people.

Take a social worker: from the point of view of someone who uses care services the social worker is incredibly powerful: they potentially determine what money you do/don’t get and what types of services you can access. But if we ask the social worker about their power they will talk about the pressure of their caseload, the policies they have to implement, the limited number of providers that exist on their patch, the pressure from their manager, and several other factors that all act to curtail their power to act.

Ask the social worker’s manager if they are powerful. They’ll probably laugh at you and say they have a team of social workers completely under the kosh who don’t fill out paperwork in the way they should do. They’ll be harangued by management for implementing lovely sounding changes there is actually little resource or appetite to put into practice. They’ll be getting phone calls from providers at all times about placements that are breaking down, and they’ll be pestered to complete monitoring data they’ll never see again by people they’ve possibly never met.

Commissioners in the same area will be thought of as having the power because they hold the purse strings. When they look up from reading the scant information about the latest priority they have to reflect in commissioning intentions with no new money, alongside the 78 other priorities they’ve been given, they’ll tell you that big providers call most of the shots, or that health commissioners are in the driving seat now. For what it’s worth, the supposedly powerful providers will tell you they’re being asked to do more and more for rates that are decreasing rapidly whilst under greater regulatory scrutiny.

At the top of the care staffing pyramid, the director of social care will tell you about the unrelenting pressure of upward demand, downward resources, their obligations under the Care Act, the threat of judicial review from any one of tens of families who have been treated poorly by their department, a recalcitrant workforce working in a culture that can’t be shifted, and the waffling politics of their portfolio holder and the local health and wellbeing board. They want to do good stuff in and for their local area, but the politics (big ‘P’ and little ‘p’) significantly curtails them.

And on and on it goes: “powerful” people for whom power is little more than juggling clouds.

What to do? The only reflection I can give is to try to recognise:

  • The person you think has power probably doesn’t think themselves they have power
  • Helping them in their relatively powerless position will probably help you as well
  • To someone somewhere in the system, you are the person with power.

[1] – There is, of course, a vast literature on all types of power in a variety of different settings. I’ve not gone into that at all here, but a useful starting point for the interested reader is Chapter 10 of Fred Luthans’s Organizational Behavior (pdf).

A mathematician’s view on integration in health and social care

Though the answer may be integration, we don’t always know what the question is.

Similarly, though we often say “integration”, it’s not always clear what type of integration we mean. There are at least four interpretations of what we meant when we talk about “integration”:

  • Integration across any of primary, secondary and tertiary healthcare
  • Integration across health and social care (and education and housing and etc.) boundaries
  • Integration of resources and processes
  • Integration at the level of the individual.

As a mathematician by training, integration has another particular meaning to me. I thought it would be useful to reflect on what integration means from a mathematician’s perspective and so what we might learn from this in the context of health and social care.IntegrationMathematically, integration is the reverse process of differentiation. Differentiation is all about rates of change across different variables in a system. Differentiation is a way of thinking about the world as a result of combining infinitesimally small changes at particular points in time or space.

Integration, on the other hand, gives you a bigger sense of the whole. It tells you not just about rates of change but the overall picture you have: the sum total of what exists in time or space.

Differentiation is easier. It’s exciting (think Mick Jagger swaggering around a stage) and has no room for anything but the most important stuff. If there are any ‘spare’ numbers floating around then the process of differentiation gets rids of them – they disappear.

Integration, as any mathematician will tell you, is far harder. It’s a slower, altogether more considered process that requires more sophistication (think Bjork). There are some tricks you can use to make it slightly easier – such as integration by parts – but the challenge of integration remains.

And because integration is the reverse of differentiation it adds in an unknown factor: the arbitrary constant (from which this blog takes its name). Where differentiation has no space or time for the arbitrary constant, integration very deliberately includes it and recognises it. This unknown factor – an unidentified ingredient – is a vital component of integration.

(Interestingly, the only time the added, unknown ingredient of the arbitrary constant doesn’t play a part in integration is if you explicitly define the boundaries within which integration happens. By specifying these limits so exactly the arbitrary constant is cancelled out.)

If we were therefore to try and summarise what we know about integration from a mathematical point of view we’d say something like this:

  • Integration is harder than differentiation – though there are limited tricks to make it easier
  • It gives a bigger picture across a wider area than a specific view of just one point in time or space
  • It has a secret ingredient – the arbitrary constant – which his fundamental to capturing this bigger picture
  • This secret ingredient disappears only if you define exactly the boundaries of what integration is trying to achieve
  • Integration is a subtle, complex process that takes time and understanding to do.

Thus, though you wouldn’t immediately think it, the mathematical conception of integration tells us everything we need to know about successful integration in public services, especially across health and social care and beyond.