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.)

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Another cross-party commission on health and social care?

Andy Cowper is most probably right that there won’t be another cross-party commission on health and social care:

A cross-party funding commission on health and social care might get traction if funding issues represented an imminent and significant political challenge to the Government.

Thanks to The Fixed Term Parliaments Act and the tacit, uncivil war within the Labour Party, this does not seem likely.

Andy also makes another vital point: the Treasury doesn’t think there is an NHS financial crisis, let alone one that can be fixed by investing more in social care.

(As an aside, can someone explain to me why ex-Ministers seem to be more proactive in a policy area than they were when actually Minister for the relevant portfolio? This, of course, is a rhetorical question, but doesn’t make the situation any less frustrating.)

 

Four lessons for political reform

1. Reform is a profoundly political process, not a technical one
2. The political coalition favouring reform has to be based on groups that do not have a strong stake in the existing system
3. While government reform reflects the material interests of the parties involved, ideas are critical in shaping how individuals see their interests
4. Reform takes a great deal of time.

These lessons are from Francis Fukushima and how to reform patronage-based political systems to modern, merit-based ones, but I’d say they’re equally applicable to most public service change processes – including, of course, personalisation across health and social care.

If we were to apply the four lessons to how things have gone with personalisation so far, I’d suggest the following:

1. Personalisation has focused too much on technical changes (e.g. Resource Allocation Systems, online directories of support), and not enough on political ones (including attitudinal and cultural)
2. There has been a coalition of people wishing to change the social care and health systems through personalisation. This coalition, however, hasn’t been sufficient, and certainly hasn’t yet engaged enough with groups that have a strong stake in how things currently are (particularly social workers, who broadly remain wary of personalisation)
3. The idea of personalisation is a strong one. Indeed, it’s probably driven reform in other areas of public services
4. Even if we took 1996 as the starting point for personalisation, we’re still only 20 years into this journey. 2007 is a more realistic starting point (with the advent of Putting People First), and for the scale of political, cultural and attitudinal change we know personalisation requires, a decade is nowhere near enough. If this is in doubt, ask any race, gender or sexuality equality campaigners in the UK, US or beyond.

If we looked at the topic of social care funding, I suspect we’d find even less evidence on each of the four lessons for political change.

“Personalisation is just a cover for cuts” – debunked

If there was a pound for every time someone has said that personalisation is just a cover for cuts in adult social care, then we could pay off the national debt.

For a moment, though, let’s assume that personalisation is just a cover for cuts. What would this actually involve? I think there are three things:

1. Personalisation would have been introduced deliberately to achieve/deliver cuts to social care services
2. Further, personalisation would have to have been introduced at the time the need for cuts was identified
3. We wouldn’t see cuts in services that aren’t personalised or have the option of Personal Budgets.

Let’s look at each of these in reverse order.

No cuts elsewhere

Is it true to say that there haven’t been cuts in services that aren’t personalised?

Below is a table that captures social care expenditure over the last 9 years [1], including for different types of services – “personalised” (incorporating Direct Payments and homecare services) and “non-personalised” (Nursing care, residential care, supported/other accommodation, equipment and adaptations, meals, “other”) [2].

Figure 1 below charts gross levels of adult social care expenditure for all personalised and non-personalised services.

Figure 2 charts year-on-year changes in levels of adult social care expenditure for the same.

What the table and figures 1 and 2 show that little distinguishes levels of spend or year-on-year changes for personalised and non-personalised services. Or, put another way, the data doesn’t show that personalised services are more likely to be cut that non-personalised services.

Timing

If personalisation was a cover for cuts, it would have to have been introduced at the time the need for cuts was identified.

It is agreed the financial crisis hit in 2007/08, though public sector spending increased from 2007/08 to 2009/10. Since the General Election in 2010 we know that public sector spending as a proportion of GDP has decreased, and that there have been real-terms cuts in local authority budgets.

Personalisation would therefore need to have been introduced in at least 2008, and certainly by 2010, were it a mechanism for delivering cuts.

However, Putting People First – the key policy document that heralded the formal introduction of Personalisation – was published at the end of 2007. Before this, there had been the Individual Budgets pilots which ran from 2005 to 2007, as well as the Personal Health Budgets pilot that ran after, from 2009.

More pertinently, personalisation has a long history. Quite aside from campaigning efforts, Direct Payments legislation was first introduced in 1996 through the Community Care and Direct Payments Act 1996 and 2001’s Health and Social Care Act made it mandatory rather than discretionary to offer direct payments to those with an assessed need.  (See both the King’s Fund and SCIE’s excellent timelines of adult social care.)

What these timings therefore show is that personalisation, as enacted in legislation, pre-dates the financial crisis by at least 10 years, and that the introduction of the existing policy framework, Putting People First, pre-dates public sector spending cuts by 3 years.

A deliberate plan?

The final piece of ensuring personalisation is a cover for cuts would be for it to have been introduced deliberately to achieve/deliver cuts to social care services.

Anyone who has worked in government, in local government or in provider organisations – actually, anyone who has worked for any large-ish organisation at all – knows that the gap between what’s asked for and what’s delivered can be large. This is especially so if what’s asked for challenges existing behavior / culture.

In the case of personalisation we know the benefits of it haven’t flowed as far and as fast as people would like, mainly demonstrated by ongoing debates about how well it has been implemented and how true it is to any original vision.

Such a debate highlights to me there is simply not the level of command and control through the adult social care system – with its national policy from DH, distributed through 152 local authorities with their own local policies, decision makers and workforces, and 1000s of provider organisations supporting people on the ground – that can deliberately do anything very easily, quite aside from use personalisation as a means of achieving cuts.

Conclusion

I can understand why people think personalisation is just a cover for cuts in adult social care. This is especially the case for anyone who doesn’t have a more detailed, perhaps professional interest in the issue.

But, as demonstrated by this post, anything more than superficial thinking on the topic shows that saying personalisation is just a cover for cuts is wrong.

I close with the best observation I’ve seen on this topic:

Although the implementation of Self-Directed Support will be affected by funding cuts, personalisation brings challenges regardless of the financial context; cuts bring challenges regardless of the model of social care.

[1] – Gross social care expenditure, excluding Supporting People. Since SP couldn’t be personalised (see [2] below), these figures possibly favour non-personalised services

[2] – These are categorised according to what, in theory, can or can’t be personalised through a Personal Budget or Direct Payment.

Integration Transformation Fund: Robbing Peter to pay Paul?

Despite what my wife says and what my schoolteachers used to say, my natural state is not one of being a pain in the arse.

I’m at risk of seeming like this, though, when it comes to the integration in health and social care.

I say this for two reasons:

1. Last week, I blogged to note that integration in mental health hasn’t had the most positive effect on personalisation, and to ask how we can work to ensure the same doesn’t happen more generally
2. After reading the most recent announcement on the Integration Transformation Fund (see here – pdf) I’ve noticed that part of the Fund in 2015/16 will be made up of c£220m of Disabled Facilities Grant funding and £130m Carers’ Breaks funding.

We knew that the Integration Transformation Fund wasn’t going to be new money, and we knew Paul (aka integration of health and social care) needs the money. But Peter (aka disabled people in their inaccessible homes and carers) isn’t exactly rolling in it at the moment.

Just to prove my wife and schoolteachers wrong (always a strong motivation, that), let’s end on two positives:

1. Integration across health and social care is absolutely something to aim for, for all the reasons people highlight (including the money and the currently artificial divide between health and social care that affects people more than it affects budget lines)
2. Without a doubt the most successful integration will be done at the level of the individual, for example (but not only) bringing together Personal Budgets and Personal Health Budgets. As much as possible should therefore be done to enable this (but without, I’d suggest, nicking money from where there already isn’t very much!)

Personalisation and funding cuts

This is a really neat way of putting things when it comes to personalisation and funding cuts:

Although the implementation of Self-Directed Support will be affected by funding cuts, personalisation brings challenges regardless of the financial context; cuts bring challenges regardless of the model of social care.

From IRISS’s insight on Self-Directed Support: preparing for delivery.

It’s an important observation, and we should always be careful not to conflate personalisation and funding cuts – either as commissioners or as campaigners.

Spending in mental health: 80% in and out

In 2011/12, the total spend on Direct Payments for Mental Health was £30.5m. This was 0.56% of all mental health spend.

Of the total mental health spend, over 80% (83.3%, in fact) is spent in the NHS. However, when someone with a mental health condition is given money to spend to meet their mental health outcomes, over 80% (84.5%, in fact) is spent on non-statutory providers.

That is, when there is no choice for mental health services users, over 80% of mental health spend is in the NHS. When there is choice, over 80% of mental health spend is outside the NHS.

What does this tell you?

Payment by Results in mental health: introduction

By themselves, the topics of Payment by Results or mental health services are pretty complicated, but when you combine them the complexity more than doubles.

As a topic I’m interested in – both for work and personal reasons – I’ve brought together a series of blogposts intended to provide a brief introduction to Payment by Results in mental health.

These posts are by no means comprehensive, but hopefully provide a useful overview for anyone generally interested in this topic.

A bibliography / reading list of the documents used to inform this overview is included as a separate post, and will provide the interested reader with much more comprehensive and detailed information on the topic of Payment by Results in mental health.

The posts in this series are as follows:

• What is Payment by Results? – Introduction, Growth and scale of PbR, PbR in other policy areas
• How PbR works in practice – Fundamental features, Currencies, Tariffs
• The impacts of PbR in health
• PbR introduced in mental health: background
• Differences between PbR in acute health care and mental health
• What is the international evidence for PbR in mental health?
• Practicalities of introducing PbR in mental health – Clustering and initial assessment
• Practicalities of introducing PbR in mental health – The care clusters
• Practicalities of introducing PbR in mental health – Defined interventions and packages of care for each cluster
• Practicalities of introducing PbR in mental health – Transition protocols, National / local tariff, Data quality, Link Payment by Results in mental health to social care
• PbR and personalisation in mental health
• PbR and mental health: Bibliography and further reading

Payment by Results and mental health: bibliography and reading

This post is one in a series on Payment by Results in mental health, written for both professional and personal reasons. The full series is introduced and linked to here.

Association of Directors of Adult Social Services (ADASS) (2009), Payment by Results for Mental Health as a driver for personalised services: Joint ADASS and DH position paper (available via here)

Association of Directors of Adult Social Services (ADASS) (2011), Position Paper: Recovery and Payment by Results in Mental Health (available via here)

Centre for Health Economics (CHE) (2009), Payment by Results in Mental Health: A Review of the International Literature and an Economic Assessment of the Approach in the English NHS (available here (pdf))

Department of Health (DH) (2010), Practical Guide to Preparing for Mental Health Payment by Results (available here (pdf))

Department of Health (DH) (2011a), A simple guide to Payment by Results (available here)

Department of Health (DH) (2011b), Payment by Results: Draft 2012-13 Mental Health Guidance (available here)

Department of Health (DH) (2012a), Draft Mental Health Payment by Results Guidance for 2013-14 (available here)

Department of Health (DH) (2012b), Mental Health Clustering Booklet v3.0 2013/14 (available here (pdf))

Department of Health (DH) (2013), Key steps for successful implementation of Mental Health Payment by Results (available here (pdf))

King’s Fund (2012), Payment by Results: How can payment systems help to deliver better care? (available here)

Mental Health Network, NHS Confederation (MHN) (2011a), Payment by Results in mental health: a challenging journey worth taking (available here (pdf))

Mental Health Network, NHS Confederation (MHN) (2011b), Mental Health Payment by Results Readiness Review (available here)

National Development Team for Inclusion (NDTi) (2012), Getting it together for mental health care: Payment by Results, personalisation and whole system working (available here)

Royal College of Psychiatrists (RCP) (2012), Payment by results for mental health (England): Position statement PS02/2012 (available here (pdf))

Sitra (2013), Report: Payment by Results (available here)

Payment by Results in mental health and personalisation

This post is one in a series on Payment by Results in mental health, written for both professional and personal reasons. The full series is introduced and linked to here, including a post with all references in it.

In theory, PbR should support personalisation and the introduction of personal health budgets. Early on in the process of introducing Payment by Results, some of those responsible for its implementation were positive that the clustering process gave them new information about the people they were treating, leading to a better understanding of where quality and outcome improvements could be made. Similarly, the currency model is focused on paying for individuals, not individual services, and so means that delivery may be provided by different organisations, such as those in the voluntary and independent sector, rather than “just” NHS providers (DH, 2013:18).

In the early days of PbR in mental health, it was noted that implementation needed to support the adoption of best practice in the delivery of outcomes, as set out in No Health Without Mental Health. Similarly, ADASS amongst others noted that PbR in mental health needed to take a whole-systems approach to mental health needs, or otherwise risk “unwittingly undermine some of the innovative partnerships, services and associated health and social care outcomes for people” (ADASS, 2009).

The potential was clear:

“The Care Pathways and Packages approach that is being used for mental health Payment by results has the potential for embedding personalisation into mental health services. By focussing on individual needs it potentially lends itself to commissioning for outcomes and this will be developed further. The “results” should ultimately be more personalised services and improved outcomes.” (ADASS, 2009)

However, people have felt unclear how PbR fits with personalisation and some concerns about PbR have been expressed about whether or not it will be a systems change that will in practice lead to real improvements, choice and control for people (King’s Fund, 2009).

These worries have included whether PbR may perpetuate a medical model of mental health rather than taking into account a range of social care outcomes. Similarly, by taking a deficit approach to mental health – through, for example, using HoNOS measures – the tools of PbR may not be geared towards promoting recovery-based approaches and increasing social inclusion (ADASS, 2011). The language currently used in the PbR Clusters and the allocation tool tends to focus on symptoms and problems” (NDTi, 2012:13). This is a concern echoed by the Royal College of Psychiatrist:

“The College recognises that social, economic and cultural influences will have a large impact on outcomes… Likewise, the College’s determination to support recovery principles and service user empowerment emphasises a focus on patients’ strengths and skills which are currently absent from the care clusters.” (RCP, 2012)

There is a concern that the Care Pathways and Packages approach reflected in the PbR currencies focuses on intervention and treatment (ADASS, 2009) and so potentially misses the opportunity for PbR to be an:

“added ingredient to make it possible to achieve a culture that embraces personalisation, recovery and a whole systems approach, with person-centred integrated planning, easily accessible personal budgets for health and social care, whole system creative commissioning in partnership with people and communities and recognising the contribution they make, and a personalised PbR system that will reward recovery and inclusion as well as activity and efficiency.” (RCP, 2012)

Currently, PbR is felt to be more about contracting, rather than commissioning mental health services (MHN, 2011b:15). For it to be successful it needs to evolve from “being an essentially ‘payment by activity’ model, to becoming a true ‘payment by results’ approach” (RCP, 2012:8).

Clearly, PbR in mental health is still a work in progress, and its impact on personalisation will be more apparent as PbR, and the framework to measure outcomes, begins to be further developed and implemented (ADASS, 2011).

As NDTi notes in its paper on PbR in mental health and personalisation:

“As with any development in public services, raising key questions in the development stage may avoid the danger of disappearing down a rabbit hole of systems development without coming up to see that on the surface nothing much has changed, and the burrowers have lost sight of important values and principles.” (NDTi, 2012:15)

As such, it is important to check the extent of understanding of those developing and delivering PbR in mental health care about personalisation in practice, and the culture, attitude and systems changes that it brings, and not leave this to chance (NDTi, 2012:13).