The opportunity for public services of truly engaged expert citizens

The World Wide Web was invented in 1989 and Google was incorporated as a company nearly a decade later, in 1998. AirBnB started in 2007 and Uber in 2009.

I wonder why there was such a big delay between the web and Google, and then Google and AirBnB, Uber etc., and then a subsequent delay in their reaching a tipping point in terms of awareness and use by the general public?

I ask this because there have been a very wide number of approaches and initiatives for improving public services, not least health and social care, through technology and particularly the web. For example, there have been care comparison sites a-plenty, much talk of open data and suggestions of location-based services to replace off- and online directories. And yet we see relatively little evidence of these approaching a tipping point, let alone being used regularly by local authorities, providers and the general public when it comes to health and social care.

The prompt for these thoughts is this excellent, detailed post at Policy Exchange about the rise of the citizen expert.

In it Beth Simone Noveck (former United States deputy chief technology officer and director of the White House Open Government Initiative) takes as a starting point another area of public policy – citizen engagement – and notes how the obvious opportunity to improve public services and local communities hasn’t been taken in the way it could have been.

Citizen engagement isn’t just the equivalent of technology: it’s clearly bigger than that. Beth makes clear this point by showing how better harnessing the interests and expertise of citizens can help both bridge the democratic divide and make the most of people in contributing to their local communities and society.

The internet is radically decreasing the costs of identifying diverse forms of expertise so that the person who has taken courses on an online learning platform can showcase those credentials with a searchable digital badge. The person who has answered thousands of questions on a question-and-answer website can demonstrate their practical ability and willingness to help. Ratings by other users further attest to the usefulness of their contributions. In short, it is becoming possible to discover what people know and can do in ever more finely tuned ways and match people to opportunities to participate that speak to their talents.

But she also notes the most significant barrier to this: the continued dominance / monopoly of policy- and service-elites in the work that they do:

[There is a] long-held belief, even among reformers, that only professional public servants or credentialed elites possess the requisite abilities to govern in a complex society.

Why? Because it is believed

Citizens are spectators who can express opinions but cognitive incapacity, laziness or simply the complexity of modern society limit participation to asking people what they feel by means of elections, opinion polls, or social media.

The shifting of the cause of the problem of a lack of engagement onto citizens themselves rather than the professionals asking the questions is a familiar refrain. We regularly hear laments about “the usual suspects”, limited response rates or adversarial consultation processes that create more problems than they solve.

But this characterisation of this situation only makes sense for one set of players: it suits both the technocratic elites who dominate public policy and services, and the other well-embedded elites with (vested) interests who can mobilise quickly to respond to consultation/engagement that affect their organisations.

It is, of course, a characterisation that doesn’t really stand up to scrutiny. For example, we know that (proper) co-production in health and social care has a solid evidence base in the difference it makes. But we also know it continues to be at best a nice-to-have rather than a must-have.

Thus we come back to the questions kicking about in my mind at the start of this post: if the ability to do this sort of thing exists (be it citizen engagement or technology), why hasn’t social care and the like made the most of this opportunity?

It’s largely because elites aren’t yet comfortable with distributing leadership and expertise.

One of the ways to overcome this discomfort, then, is to make it valuable and rational for the existing elites to engage in effective citizen engagement by ensuring a ‘good’ group of people are engaged and involved in public service reform in the first place.

Noveck rightly says:

To make all forms of engagement more effective, we need to increase the likelihood that the opportunity to participate will be known to those who need to participate. If a city really wants to improve the chances of crafting a workable plan for bike lanes, it should be able to reach out to urban planners, transportation engineers, cyclists, and cab drivers and offer them ways to participate meaningfully. When a public organisation needs hands on help from techies to build better websites or data crunching from data scientists, it needs to be able to connect.

To do this:

[I]nstitutions [must] begin to leverage such platforms to match the need for expertise to the demand for it and, in the process, increase engagement becoming more effective and more legitimate.

This is appealing. Citizen engagement may not be valued by elites because there hasn’t been adequate effort or ability to engage sufficient citizens to make it worthwhile enough.

As Noveck concludes:

This is about chances for civic participation; to be a member of a local community and to make a contribution based on this… It has everything to do with what it means to be a citizen in a contemporary democracy.

This is why I particularly like this: this isn’t just about technical changes around the edges of public service economies, but the broad meaningful difference it could make.

 

Advertisement

Engaging people in adult social care and co-production: what’s the best evidence?

The voice and experience of people who use services in shaping and delivering adult social care has long been a preoccupation of mine. It’s so obvious a way of working and understanding to me that even now I’m bemused and confuddled more than I should be by how ubiquitous good engagement and co-production isn’t.

Anyway, I’ve been lucky enough to be asked to write a bit about this for research in practice for adults (ripfa) as part of a forthcoming collection they’re producing. The focus is on what the evidence says about how properly involving people in the design and delivery of adult social care makes a difference (in whatever way and at whatever level).

As something of a geek I have a pretty good sense of what the best bits and sources of evidence are, but one person’s approach for this type of thing is never as good as that of the crowd. I was therefore hoping colleagues might share with me any evidence or practice they think it’s worth highlighting on engagement / co-production.

Any information is useful; if people could share any evidence in particular about the following, though, then that would be particularly great!

• How do different groups want to be involved in social care delivery and design?
• Which groups are at most risk of not having their voices heard, and how can we ensure they are included?
• What should we do when people can’t, or don’t want to be involved in their own social care?
• What’s the best evidence around on the involvement of individuals in their own care planning or assessment and general person-centred planning approaches?

Though the focus of the work is on adult social care, evidence is limited to just this area: stuff from the world of health is as useful as anything from social care.

Feel free to share via the comments here, via Twitter (I’m @rich_w) or via email (rich DOT watts AT ndti DOT org DOT uk).

Thanks in advance for anything anyone is able to share. As always, I’ll share back what is produced as a result of this work, as well as a collection of the best resources found and shared on this topic.

Should the #ILF close? Yes. But… (updated)

It’s not efficiencies. It’s not bloated public spending. It’s disabled people not being supported to meet the most basic elements of day-to-day life – getting out of bed, making a cup of tea, or going to the supermarket.

I’ve immodestly quoted from a post I wrote over 3 year ago on the Independent Living Fund, when it was announced it was closed to new applicants. 6 months later, I wrote another post after it was officially announced ILF was to close from 2015, noting responsibility was likely to fall to those well known cash-rich organisations, local councils.

Today, a court of appeal bid to overturn the abolition of the ILF has been approved. I haven’t seen the full judgment, but it seems to cite both the Equality Act (and great work from the EHRC for intervening to this effect) and that the decision to close the Fund didn’t take account of the flavour of consultation responses.

This is good news.

It doesn’t solve the problem, though, of what to do with the Independent Living Fund in the long term.

For me, the definitive report on what to do with the Independent Living Fund was written in 2006 by Melanie Henwood and Bob Hudson. It notes the peculiar history of the ILF: set up in 1988 as a transitional arrangement, a related new fund created in 1993, the original fund closed to new applications but replaced by an extension fund, all meaning there have actually been two funds operating in parallel since 1993. The report also highlights the huge number of considerations that have to be taken into account when doing anything with the ILF, not least of which is recognising the vital support it provides to 19,000 people.

And it also notes the ILF is anomalous in the long term, and that it continues to account for a large amount of social care expenditure whilst operating to different rules and remits that are incongruent to mainstream social care. It also notes ILF can result in inequity, unaccountability, duplication, arbitrary decisions and major confusion.

As such, the report concludes the ILF should close.

I agree.

But…

In closing the ILF, there are a number of points and principles which must be observed, and that at a minimum are:

• Any transition from ILF to other funded support should be slow and steady. (In the 3 years since DWP announced the closure of the ILF in 2015, I think very little activity could be detected)
• The money people received through ILF should be protected, and most definitely shouldn’t be swallowed up by local authority budgets
• The better parts of the ILF (such as a national, portable system) should influence the new location of the money, rather than these being lost.

The world since Henwood and Hudson wrote their report has changed, not least in the considerable cuts we are seeing in social care and the wider health and welfare reforms. But shifting the principles and support of the ILF into the main provision of social care is still the best thing to do, as long as the minimum points above are met.

The DWP’s original attempt at closing the ILF clearly didn’t do this; the motivation was instead to cut money, and the court of appeal has rightly picked them up on it.

Now, though, there is a chance to look again at this properly. Hopefully the DWP will do this, and do it:

1. With people from the Department of Health working on the Care Bill and the Integration Transformation Fund
2. With people driving the personalisation of health and social care
3. Most importantly, with the people who will be affected by the change.

Update: the full court of appeal judgment is here. It indeed uses the Public Sector Equality Duty as the basis of quashing the original decision.

WiltshireCIL: a #dpulo following local people’s prioirities

WiltshireCIL was supported through the Facilitation Fund of the Strengthening DPULOs Programme to explore the issues local disabled people wanted to focus on, and so enhance their sustainability. Below, Clare Evans – the Chair of WiltshireCIL – shares some reflections on their recent work.

The best thing about a strengthening DPULO grant is that you can apply for funding to meet disabled peoples’ agenda and not have to fit into funders’ agenda.

WiltshireCIL got a grant to reach more disabled people by involving members as volunteers in meeting the needs of others.

We started by inviting any disabled people from our mailing list of several hundred to come and discuss how the project should develop.

Four areas came up as priorities:

• Informing disabled people about social policy to enable them to influence it
• To provide disabled people with learning IT opportunities
• Investigating how to assist self funders on social care
• Supporting disabled people influence locally and gain skills targeting Salisbury area of Wiltshire

As we draw to the end of our year long project we can see that some areas have been followed through successfully while others not so.

First the “not so” ones! We advertised widely an opportunity to learn IT skills from scratch and had 5 people enrol but only 2 finished the 4 sessions and there’s been no demand for more despite extensive advertising. It’s a bit worrying when you know the Welfare Reform changes are based on everyone getting online to fill in forms, but somehow people don’t perceive local organisations as being able to support them with this.

Secondly we had plans with a local access group to develop some sessions in Salisbury but their leader became hospitalised and plans are on hold.

However what did work beyond our expectations was putting on an information session about the Welfare Reform changes – we are now planning our third conference; also similarly for ILF users.  A combination of speakers, presenting the facts clearly and an opportunity to discuss in groups in a safe place has met peoples’ needs though they remain anxious about the future. For self funders, we first contacted those who attended our Self Funders Forum for their ideas and then carried out a survey. We are now producing a signposting guide and Wiltshire Council has asked us to work with them on the issue to ensure we’re both as effective as possible.

We’re in touch with many more disabled people and are building systems to ensure we can publicise ourselves to them and others again.

Look out for the formal evaluation we’re preparing for the spring!

New consultation principles in practice (updated)

When the government’s new consultation principles were introduced last summer, it was noted that, though potentially good in principle (ironically enough), we’d have to wait for government to use them in practice to see what sorts of effect they would have.

A great post from Mike Harris on the Open Policymaking blog has summarised nicely what’s happened since.

At the time the new principles were announced, a few people called for some analysis on how long consultations lasted for under the new principles compared to the old rules. Mike’s post has an answer:

Between January and July 2012, 56.5% of the 253 government consultations held lasted more than 12 weeks, but between July and December 2012 only 26% of the 207 consultations did so.

Though a headline figure, that strikes me as worrying. It would be useful if more detailed figures were available on how long the 74% of consultations that were under 12 weeks lasted.

(Just because I’m that way inclined, I’ve submitted an FOI request to the Cabinet Office to ask them that exact question – will keep you posted with the results.)

Update: the data was actually in one of the Appendices to the Committee’s report on this topic! I should’ve read the appendices! Here’s the data, which I’ll analyse at a later date.

HealthWatch: Good in principle, worrying in practice

This was posted as a guest blog on the always insightful Health Policy Insight, run by the always amusing (in a good way) @HPIAndyCowper, who has kindly allowed me to re-post it here.

Criticisms of the reforms of the health system have focused primarily on shifting £80bn of public expenditure to GP commissioning consortia.

Much less attention has been paid to the issue of patient/user voice and representation in the reformed system, something this post aims to address (building on two posts at the time of the White Paper, here and here and one just before the Health & Social Care Bill was published).

The White Paper contained proposals for the creation of both HealthWatch England and local HealthWatch – building on the work of existing Local Involvement Networks (LINks) – in each upper-tier local authority area.

Local HealthWatch will essentially be the local “consumer champion” for health and social care users, promoting choice and control, influencing the shape of services, and highlighting issues in service delivery, including through advocacy.

HealthWatch England will provide support to local HealthWatch and synthesise the issues they highlight at the national level, working with the NHS Commissioning Board and the Care Quality Commission.

In principle, the introduction of HealthWatch based on the work of LINks is a good idea (though there is a question over how effective LINks have been); what’s more, there is “extra” money being made available for both local HealthWatch and HealthWatch England to carry out their roles.

In practice, however, there are 3 significant areas of worry about HealthWatch arising from the Next Steps consultation response and the Health & Social Care Bill and its associated Impact Assessment.

The first is money. Though there will be “extra” money for local HealthWatch, this is being taken from existing services.

In 2009/10, £27m was allocated for LINks. For local HW, the funding that was used to fund the Independent Complaints Advocacy Service (£11.7m) and PALS (£19.3m) is being handed to local authorities to commission local HW, meaning there will be £59.1m in 2010/11.

HW England will also have £3.5m of its own funding (figures from Impact Assessment, para D42).

But the major issue – and the number one risk identified by the DH itself – is that this money won’t be ringfenced. Instead, since the money will be allocated to local authorities under normal LA funding arrangements, Councils can choose how to spend it.

In 2009/10, although £27m was allocated for LINks, Councils only spent £24.3m of it on LINks – they effectively creamskimmed 9% off the budget. There is no guarantee they won’t do the same for local HW.

The second issue is independence. Local HW will be “contracted by and accountable to Local Authorities” (Impact Assessment, para D34). This does not make them independent in principle; nor, potentially, in practice.

More worrying is that HW England will only be a statutory committee of the CQC. Despite the Next Steps consultation response suggesting this means HW England would be “independent” (para 2.59), the Impact Assessment formally recognises (para D24) that

setting up HealthWatch as a statutory committee of CQC [means] it would not be formally independent of the NHS and social care system.

Furthermore, HW England’s funding will need to “maximise synergies” with roles within CQC (para D28) to ensure its funding of £3.5m goes as far as possible. No “independent” committee should have to rely to this extent on staff within its host body.

Even more significantly, the Chair of the Committee will be appointed by the Secretary of State (Next Steps, para 2.59). The Health & Social Bill also stipulates that some members of the Committee will be appointed and others elected (Impact Assessment, para D27), but with no details about the blend of appointed and elected members or the process for elections (D26) – this is to follow in further regulations.

None of this sounds particularly independent, and there have to be worries about how this will operate in practice. Anyone who knows how the statutory disability committee within the EHRC has operated in practice – a very similar set up to that proposed for HW England within CQC – will rightly be concerned.

The final issue is advocacy, particularly complaints advocacy, in which confusion reigns. Next Steps suggests (para 2.43) that local HW should have a role in NHS complaints advocacy, but that Local Authorities will now be responsible for commissioning it and that this may or may not be through local HW.

Conversely, the policy summary signed by Andrew Lansley as part of the Impact Assessment says that HW will bring together patient voice and complaints advocacy. It won’t – especially since advocacy in social care is not mentioned a single time anywhere in documents relating to the Health & Social Care Bill.

Unlike much of the rest of the proposed health reforms, the suggestions for HealthWatch were actually quite good in principle.

In practice, significant questions about money, independence and advocacy as one of the new, key functions of HW means the end position for HealthWatch is much the same as everything else associated with Lansley’s reforms.

LINks annual reports 2009/10

The annual reports of Local Involvement Networks (LINks) for 2009/10 makes for interesting reading. This is particularly in light of the fact LINks will become local HealthWatches under the proposed reforms of the government’s White Paper, and will be the major vehicle through which patient/user representation will be secured.

LINks are membership organisations which empower people in the community to have their say or influence local health and social care services. In 2009/10 there were 150 of them, with a total spend of £24.3m.

The numbers in terms of people engaged aren’t, I’ll be honest, particularly good. Even then, the data collected probably represents a slightly rosy view: as the report highlights:

Many LINks were not able to provide details of their finances, membership, activities or their effects.

It doesn’t inspire confidence, does it? Even so, we will plough on with what the annual reports tell us.

Across all LINks, the average number of members (both individuals and organisations) was 489. In total, around 192,000 people were engaged in their activities (of which 42% related to social care). Given the population of Essex alone, for example, is 1.4m, this doesn’t strike me as a great number. Nor does the number of LINks that report engagement directly with people from a BME background or disabled people: less than 60 and just over 50 respectively.

If the engagement numbers don’t grab you, then potentially of more interest is the headline finding that LINks provided a net return on investment of £4.10 for every £1 invested.

I’m afraid to say the data behind this is optimistic at best. On the basis of the average benefit for 4 – just four – case studies being of the order of £270k, someone has simply multiplied this benefit by the number of changes that were “inspired” in services by LINks in 2009/10 – some 463. This gets you to a figure of £126m gross annual benefit.

Whilst the veracity of the 4 case studies seems reasonable, it’s a leap of faith to suggest the same financial benefit applies on average across each of the service interventions LINks achieved, wouldn’t you say?

My overall impression of the report is that there are undoubtedly some LINks making a positive difference through engaging their local communities in issues relating to health and social care services. However, the level of this engagement isn’t particularly deep, isn’t particularly innovative and is really quite limited. Nor can the level of financial benefit accrued from changes made by LINks be considered realistic.

At best, the report reads as if the most optimistic of civil servants has written it, looking for good as a whole where it only exists in patches.

Given this forms the foundation for patient and user enagement under the new health reforms, I draw the following implications for HealthWatch:

• Engagement is actually very low. LINks may have improved from 2008/09 to 2009/10, but the base was incredibly low in the first place. In particular, disabled people and people from a BME background were evidenced to be poorly engaged in LINks as a whole. HW will have to do much better than this.
• The report indicates that the money allocated by DH for LINks was not ringfenced within LAs: £27m was allocated by DH to LAs, £24.3m was allocated by LAs to LINks. Will the DH require money allocated for HW to be spent only on HW?
• The performance of LINks was patchy, but no enforcement mechanism seems to have been in place to address this. How will this be dealt with under HW?
• Data collection for LINks was quite poor. Given it underpins so much of the work HW do, will there be standards and requirements that are enforced in order to understand the work HW do?
• The annual report seems very keen to attribute financial benefits to the work of LINks in order to justify their works. Will a cost-benfit outcome be a key driver of HW, or is their value recognised as being one of engaging local communities in decision making on health and social care?

Reflecting on HealthWatch in the Health White Paper melee (updated)

Whilst the pandemonium about various changes proposed by the Health White Paper continue (rightly so, by the way), the issue of patient and user voice remains as high up the agenda as it usually does.

That is, not at all.

I’ve focused on this area in two previous posts – one on patient voice in the White Paper and another on the question of democratic accountability.

I have to confess I’ve not had chance to read the government’s response to the White Paper consultation (“Next Steps“) and what it says or updates about HealthWatch (HW). As far as I can tell, it’s strengthened issues around advocacy (particularly by saying advocacy services can still be contracted for directly by LAs, rather than sitting within HWs), strengthened HW representation on Public Health and Wellbeing Boards, and generally reduced the need for overview and scrutiny.

Of course, I’ll blog on what Next Steps actually says about HW when I’ve read it.

But in the meantime, today saw an event in the area I work on the establishment of a local HW. Here are some quick and dirty observations of the day:

• The level of understanding of what the Health White Paper is seeking to achieve is low
• The level of understanding of what HW England and the local HW will do is low
• The level of understanding of the relationship between HW England and the local HW is low
• There is a significant divorce between health and social care in the views of service user “representatives”
• “Entrenched interests” doesn’t come anywhere near explaining the problems facing commissioners of local HW over the next few months
• If today was anything to go by, the profile of people directly engaged as “representatives” and volunteers in LINks at the moment can be summed up in two words: (1) old; and (2) white
• Partnership working between organisations who are or will be relevant to the local HW feels a long way off
• For areas where there are unitary and county councils close together, the question of whether there is a joint Health and Wellbeing Board across all of them or a separate one for each is a very, very thorny one
• This said, the question of whether there is one local HW per council or a local HW operating across several is a bit easier – it’s only a very thorny question and not a very, very thorny one
• No one knows what money will be available to commission the local HW, or whether it will be ring-fenced. I’m guessing not, since it will sit in LA budgets. (As a comparison, in 2009/10, the DH awarded £24.3m across all 150 LINks.)

This may all sound like doom and gloom, and at least in that regard it’s similar to most other proposals in the Health White Paper.

But it’s not.

All the government needs to do is create some clarity soon on the topic of HW England and local HW in order to allow commissioners to demonstrate the local leadership they are hugely capable of.

Next week’s Health and Social Care Bill may give us this, so amid the tumult of discussion about the big ticket items, remember to keep an eye out for what the Bill says on HealthWatch.

Update: Of course, I forgot to mention whether social media was mentioned as a means of engagement for HW. Apart from the most cursory of mentions – a gesture towards Facebook – it wasn’t. A few of the kool kids at the back of the room whispered about it away from the more vocal participants in the day, but it was a useful reminder of how little wider awareness social media there is amongst parts of the population and as part of the debate/solution to engagement.

It would be great to have the opportunity to change that.

More positively, there seems to be some excellent LINks work at the moment on Twitter – see this list from LINk East Sussex and this nicely chirpy stream from Somerset LINk.

Government websites cost gazillions

I was struck by this comment made by David Cameron during his Skype call with Mark Zuckerberg:

Normally if Government wants to engage with people we’d probably spend millions of pounds, even billions, on our own website, and with your help we’re basically getting this public engagement for free.

This is revealing in two ways:

1. Making Facebook the government’s “primary” communications method for debating with the public is being driven by the fact it’s free, not because it will actually result in anything useful.
2. Cameron seems to think it could cost the government “even billions” of pounds on a website to engage the public.

That last point is demonstrably untrue.

Notwithstanding Cameron getting a bit carried away because he was talking to one of the kool kids, and therefore exaggerating in a playground-like manner, it does hint at Cameron’s mindset when it comes to whether government should or shouldn’t be leading debates with the public, or whether other providers (probably private ones) could be doing it for them.