#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.

 

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!

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.

It’s person-centred, Jim – but not as we know it

We all have our favourite “I can’t believe that actually happened” stories in social care.

Mine relates to care and support planning: whilst observing a panel process (error number 1), a Head of Social Care instructed a social worker (error number 2) to change a support plan so that all sentences were “I” statements (error number 3) from the point of view of the patient [sic] (error number 4), without going back to the person themselves (error number 5).

It would be funny if it weren’t so normal.

But we hear variations of this all the time, summarised in the line:

Of course what I do is person-centred care – it always has been

If we are honest, relatively little of what currently happens in the care and support system is person-centred (though we’re definitely moving in the right direction).

This being the case, we should ask ourselves: if it isn’t person-centred, then what is it? I think there are at least four alternatives:

  1. Money-centred care: where what people get is what commissioners can either afford, currently buy, or have always bought
  2. Provider-centred care: where the primary objective is to ensure the ongoing feasibility of an organisation rather than the people it serves
  3. Process-driven care: where filling out the paperwork or keeping the IT system happy is the main driver
  4. Professionally-driven care: where the professional knows best and tends to think of the person in front of them as another one of their caseload or a walking set of conditions

Thinking of it in this way shows why the drive to person-centred care has been so difficult: it requires significant change on a number of major fronts – the flows of money, the role of providers, the supremacy and comfort of process, and the culture of professionals.

It’s why I’m personally so excited about person-centred care and what it means for the future. It isn’t just an optional variation of what we’ve always done; it flips public services as we know them on their head. To make this happen, though, we need to be clearer on the alternatives that being person-centred is replacing.

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.)

 

Wicked issues and constructive conversations in health and social care

wicked-musical-movie1
Image via Screenrant

The Social Care Institute for Excellence is working with the Health Foundation and Institute for Government on a fascinating project about how “constructive conversations” can help with “wicked issues” in health and social care.

I was lucky enough to be invited to a discussion about the project and hear a wonderful summary of the literature on both constructive conversations and wicked issues from ICFI, and wanted to quickly reflect here two key parts of the useful information that was shared.

(I stress that the information below is taken directly from the really excellent work by ICFI, to whom all plaudits should absolutely go!)

First, what is a wicked issue?

The concept is taken from social planning (Rittel and Webber, 1973) referring to problematic social situations where: there is no obvious solution; many individuals and organisations are involved; there is disagreement amongst the stakeholders and there are desired behavioural changes. Public policy problems are ‘wicked’ (Clarke and Stewart, 1997) where they go beyond the scope of any one agency (e.g. health promotion strategies) and intervention by one actor not aligned with other actors may be counter productive. They require a broad response, working across boundaries and engaging stakeholders and citizens in policy making and implementation (Australian Public Services Commission, 2007).

Wicked issues therefore have the following typical characteristics:

  • Are multi-causal with connections to many other issues
  • Are difficult to define – so that “stakeholders understand the problem in different ways and emphasise different causal factors… The way the problem is approached and tackled depends on how it is framed, so there may be disagreement about problem definition and solution.”
  • Are socially complex – “Decisions about how to tackle them are unavoidably political, values based and may raise moral dilemmas. They cannot be tackled as technical challenges with scientific solutions; there is no point at which sufficient evidence will be gathered to make a decision.”
  • Require a whole system, multi-agency response – they do not sit within the control or authority of a single organisation, making it difficult to position responsibility.
  • Have no clear or optimal solution – they are not right or wrong, but better, worse or good enough
  • Have no immediate or ultimate test of ‘success’.

Against these characteristics, questions of social care, health, promoting disability equality, and public service reform are all obvious wicked issues.

Second, what is a constructive conversation?

The phrase “constructive conversation” itself is perhaps not well known, but its attributes are becoming increasingly familiar since they reflect much of what the approach to system leadership calls for.

A constructive conversation engages in what area known as “clumsy solutions”:

  • Questions not answers: seeking a deep understanding of the problem
  • Relationships not structures: engagement as the primary vehicle of change
  • Reflection not reaction: resisting the pressure for decisive action at too early a stage
  • Positive deviance not negative acquiescence: ignore, or look beyond, conventional culture and wisdom
  • Negative capability: the ability to remain comfortable with uncertainty
  • Constructive dissent not destructive consent: seeking consent is often destructive and illusory
  • Collective intelligence not individual genius: WPs are not susceptible to individual resolution
  • Community of fate not a fatalistic community: collective responsibility to underpin action which is likely to involve risk-taking
  • Empathy not egoism: seeking to understanding how other people see the problem, and the wider context”

As a result, a conversation is constructive if the following are in place:

  • A commitment to be open and honest
  • A conscious effort to foster and maintain trust
  • Clear information, provided at the right time
  • A focus on relationships not methods, underpinned by the goal of collaboration
  • Well-defined roles and clear expectations
  • The involvement of all stakeholders, fostering a whole-system approach
  • The ability and willingness to be flexible, wherever possible”

What a wonderful though subtle rejection of “heroic leadership” or CEO-itis this is, and what an obvious parallel with co-production it produces!

As I read through the slides of the summary on wicked issues and constructive conversations I found myself scribbling “YES!” and “Absolutely!” all the way through, so well did the findings tally with my feelings about what’s needed for change, especially in health and social care, and disability equality. They clearly tally with the ideas of system leadership and collective impact we’ve written about here before on many occasions (1, 2, 3). Though I could understand it if people were to tire of yet another set of terms that could be used and abused, for me the value of the above is in having something further to point to, consistent with what we’ve been talking about before, that further articulates the how I feel we need to go about change.

What can we learn from the Right to Control?

The Right to Control was a new rights-based approach to support and services for disabled people. It brought together a range of government funding streams across social care, housing and employment with a view to improving people’s experiences across these funding streams and, ultimately, improving people’s lives.

I write about it in the past tense because the Right to Control is no more. The pilot ran for two years from December 2009 with a further extension until the end of December 2012. A Ministerial decision in 2014, however, decided not to roll-out the Right to Control any further.

The decision was based in large part on the findings of a formal evaluation (pdf). This

did not find any evidence of the Right to Control having a positive impact on customers, either in terms of their experiences of applying for and organising support or services, or in terms of their day-to-day lives, including employment outcomes.

The evaluation notes, however, this lack of evidence is most likely due to the fact people did “not experience the intended Right to Control customer journey” and that the short space of time for which the pilots existed may not have been sufficient for the full effects of Right to Control to be felt.

What was unique about the Right to Control, compared to pilots regarding Individual Budgets (as were) and Personal Health Budgets (as are) was its attempt to unify – to integrate – funding streams around an individual. It was therefore similar to parts of what the Integrated Personal Commissioning programme is seeking to achieve.

The question is this: What can we learn from the Right to Control? From my reading of the evaluation, other documentation available around the Right to Control, and from conversations with colleagues who were heavily involved in several of the pilot areas, I would suggest eight (by no means comprehensive) things we can learn*.

1. Create demand from the bottom-up by building the understanding and expectations of people who could benefit from the change. There is no point having new rights or the potential for more choice and control if the people these are intended to benefit aren’t aware of them or equipped to expect them. This isn’t just limited to people who use services, either: carers and staff are also important to focus on. For example, employment support in a northern pilot area worked so well under the Right to Control because there were two Disability Employment Advisors who were looking for a way to change a system they saw every day wasn’t working for the people they supported. The Right to Control gave them a vehicle to change things.

2. To build meaningful demand, market development must start as soon as possible. The Right to Control evaluation notes the following specific conditions needed to be in place: (1) People were aware they could request changes; (2) People had information and advice to make confident choices; (3) People had meaningful choices. The first two are extensions of my first point. The third – meaningful choice – is facilitated by two vital, complementary process: (1) coordinated care and support planning, and (2) market development. I’ll deal with coordinated care and support planning in a separate post. On market development, the most important lesson from the Right to Control is that market development didn’t start soon enough. It takes time to start, (re)negotiate or end contracts and agreements with providers of all sizes, to inform and work with them of the types of changes anticipated, to keep people and staff up-to-date on changes to the local ‘market’, and all the other similar activities that make for successful market development. Start early on market development, and be proactive about it.

3. The third lesson is no surprise at all: change on this scale takes time. By “change” I mean both practical and cultural change. Practically, for example, it took around twelve months in most of the Right to Control pilot sites just to get the right people around the table and to start having the right kinds of conversations. Where most good progress was made was for people with mental health problems accessing employment support. The reason for this was because the then Community Mental Health Teams became the most common entry points into the Right to Control because of greater partnership working that had existing from before the Right to Control pilot started. Of course, change taking time is no great lesson, but it is one that bears repetition, especially when the current demands on public services in health and social care are so pronounced, and when numbers are seemingly the only way we can convince people of progress.

4. One of the biggest cultural barriers in the Right to Control is represented by the question: “Whose money is it anyway?” Reasonably often, local managers referred to budgets as “their money”, resulting in difficulties in pooling budgets or integrating them around individuals. It’s actually a very good question, and surfacing these types of questions and discussing them was seen to help progress towards the Right to Control’s aims.

5. User responses to the question of “whose money is it anyway?” are probably best captured by this paraphrase:

We don’t give a toss where the money comes from – we just want a life.

What enabled this voice to be heard was co-production of the Right to Control. Co-production itself was therefore a major driver in changing attitudes, which helped to create confidence, support and a shift in relationships and mindsets between “professionals” and “people”. (It’s worth noting the formal evaluation concluded co-production would last well beyond the life of the Right to Control pilots themselves – a point proven so far, writing from the distance of 18 months since the programme finished.)

The last three lessons from the Right to Control are strategic ones that should be cause for reflection at higher levels in local government, health bodies and central government.

6. The first is to recognise that funding streams need to be integrated locally because they are separated centrally, i.e. government is asking local areas to merge budgets that they themselves had split up in the first place. As a participant in the evaluation ruefully notes:

What we need to do is look at pooling budgets at a much higher strategic level. It’s very difficult to align funding streams once the money is allocated, if not impossible, so hence the focus on pooling budgets at a much higher level, to have the one-pot approach.

Anything that central agencies can do to integrate funding as soon as possible should be done is the lesson to take from this.

7. The second is to be consistent in the intentions and outcomes of the programme. The Right to Control started as a new legal right to support disabled people to have better lives; it ended (via the evaluation) with a decision that questioned its economic efficiency and impact on primarily social care measurements. What if the evaluation had captured stories from two sites about people with learning disabilities signing housing tenancies for the first time, or fifty people gaining employment because of direct control over funding they never knew was previously spent on them?

8. This links to the final lesson: the Right to Control didn’t connect politically at either a local or national level. The Right to Control squarely support two significant agendas that have existed since 2008 – prevailing attitudes to public services (the idea of empowered consumers) and the zeitgeist of austerity (more for less) – and yet remained unloved, to the point where it was ended and largely forgotten. Reflecting on why it didn’t connect and the roles that different people/organisations could have played in addressing is useful for any current or future change programme.

There are many other areas of learning that can be drawn from what the Right to Control did and didn’t achieve during its time. In the ones above I’ve drawn out the ones that seem most relevant to me for current and future public service reforms, not least of which is Integrated Personal Commissioning and what it seeks to achieve.

*I should note that I was involved in the Essex Right to Control Trailblazer.