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

mirror mazeHere’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.


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.

(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.)

Advertisements

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.)

 

Commissioning

IPCMy current work is on the Integrated Personal Commissioning (IPC) programme, working for Think Local Act Personal and closely with NHS England.

A natural question to ask is “What’s that?”, and it’s a very good question.

Before answering that, though, I think there are questions we should ask before, such as:

  • “What do we mean by ‘integrated’, ‘personal’ and ‘commissioning’?”
  • “What difference do each make?”

This is the third of three posts looking at each topic individually (see the introduction to this short series and the posts on ‘integrated’ and ‘personal’). It’s a very quick way into the issue of commissioning, sharing information that I’ve found useful in my own learning. It’s not intended in any way to be comprehensive! Thus, if there are things you think should be added feel free to do so in the comments or on Twitter. I’ll update the posts accordingly.

What do we mean by ‘commissioning’?

Put bluntly, the core role of commissioners has been to buy services for their populations, although it has always been more than this.

This is from Health Select Committee’s report on Commissioning in the NHS (pdf) – a report which notes (rightly) that the vast majority of the public don’t know what commissioning is despite its central importance to the running of health and social care.
Commissioning models in the NHSThere are endless reports, chapters and even books on the topic of commissioning. Below, therefore, is a very brief summary of some of the key developments in commissioning relevant to health and social care.

Commissioning in the NHS began in earnest with the ‘purchaser-provider’ split of 1991 and has
been maintained since then (though in various guises – see Box 1 to the right). The “more” than buying services for populations that commissioning is has best been captured by the commissioning cycle. There are hundreds of versions of the commissioning cycle, but each is essentially a variation of the following:

IPC_commissioning_cycleAs with integration, commissioning can happen at a variety of different levels. This is most obvious in health:

Commissioning levelsCommissioning in social care also emerged at the same time as the purchaser-provider split in the NHS. It took a slightly different form, however, with more emphasis put on the role of care management – where social workers were central to assessing need, arranging packages of care and managing and negotiating resources. This new approach was reflected in the Caring for People White Paper (1989).

Commissioning has come a long way since then, at least in the number of commissioners. The Barker Commission highlighted particular the problem of increasing fragmentation of commissioning responsibilities between different organisations within the NHS and local government – estimating there to be over 400 organisations with responsibility for commissioning. The main response to this has been “joint” or “integrated” commissioning across health and social care.

The development of personalisation in adult social care was a focus of attention in commissioning, especially focusing on the role of market shaping, market facilitation and market development. This was a new role for local government, best captured in the work of the National Market Development Forum (pdf).

Finally, an alternative to top-down commissioning is bottom-up commissioning, or more nicely what we might call people- or community-led commissioning. At the individual level this is essentially what Direct Payments are (and what we are seeing in the extension to Personal Health Budgets; see the post on Personal for more information on what this is and its effects). At a collective level it is best represented by the idea of co-production in commissioning or people-powered health.

(It’s worth noting that relatively little attention has been paid to decommissioning. Two honourable exceptions are this paper from IPC (pdf) and this decommissioning toolkit from the National Audit Office.)

Here is a selection of what I’ve found to be the most useful documents on commissioning:

What difference does commissioning make?

[It is] clear that there are few examples of robust evaluations of commissioning in the academic literature. Moreover, the grey and practitioner literature tends to focus on commissioning in single government departments, local initiatives or single services/client groups. It has been noted that the efficiency, effectiveness and efficacy of commissioning and strategic commissioning is typically taken for granted rather than demonstrated… The evidence base on the outcomes of commissioning remains under-developed and such evidence as exists is equivocal – Williams et al. (pdf)

Asking whether commissioning makes a difference is a very interesting question. One of the issues with it is knowing exactly whether what is happening in practice is actually good commissioning. Mark Britnell, who led the development of World Class Commissioning within the NHS, commented:

It might strike you as slightly odd—it did me coming into the department—that no-one had defined what good commissioning was in 20 or 30 years. (para 137) (pdf)

Having thus defined what good commissioning looked like, an assurance framework to quantify how good commissioners were showed that most commissioning wasn’t very good: in only one of ten competencies did people achieve better than half marks in their ranking:

Source: King's Fund
Source: King’s Fund (pdf)

If knowing what was happening in practice was actually commissioning was one problem, the other major issue was in understanding the difference commissioning makes is. The main issue here was the lack of a counterfactual: if commissioning is the only option, there’s nothing to compare it against.

Against this backdrop, we therefore shouldn’t be surprised to read that nearly all flavours of commissioning attempted in the NHS have not had much impact against a variety of themes, including efficiency, equity, changing patterns of service delivery, quality and partnership working.

The best of what we do have is therefore as follows:

Overall the research suggests that examples of fully integrated commissioning are limited, and that this approach is typically confined to a small number of service areas. It follows that research into the nature and, in particular, the effectiveness of joint commissioning is also relatively limited… The evidence that is available suggests that the nature and success of integrated commissioning arrangements varies significantly between local areas and between services.

Commissioning evidence of impact

In social care there is a similar issue. Only recently has the University of Birmingham attempted to create a comprehensive framework of what good commissioning in social care is. Even then, there is no requirement to use this framework or measure commissioner performance against it. Much of what we know about the effectiveness of commissioning in social care comes from the literature mentioned above.

People-led commissioning is an emerging area; as such, the literature is nowhere as well developed. There are some bits of evidence, however, most notably the findings of the People-Powered Health initiative (pdf). Other evidence is available from particular sites, such as work in the Isle of Wight done by the Health Foundation.

Personal

IPC

My current work is on the Integrated Personal Commissioning (IPC) programme, working for Think Local Act Personal and closely with NHS England.

A natural question to ask is “What’s that?”, and it’s a very good question.

Before answering that, though, I think there are questions we should ask before, such as:

  • “What do we mean by ‘integrated’, ‘personal’ and ‘commissioning’?”
  • “What difference do each make?”

This is the second of three posts looking at each topic individually (see the introduction to this short series). It’s a very quick way into the issue of what we might mean by ‘personal’, sharing information that I’ve found useful in my own learning. It’s not intended in any way to be comprehensive! Thus, if there are things you think should be added feel free to do so in the comments or on Twitter. I’ll update the posts accordingly.

What do we mean by ‘personal’?

The last 15 years have seen a shift towards more responsive, personal public services. Adult social care has been at the forefront of this shift, with policy areas such as health acknowledging and adopting the difference that social care has seen as a result.

I’d suggest a ‘personal’ approach to health and social care broadly encompasses two interconnected, perhaps even indistinguishable areas: personalisation and person-centred approaches.

Peronalisation quadrantsThe landmark policy statement for personalisation was the Putting People First Concordat of 2007 (pdf). In this we see the key principles of a personalised approach: “Replacing paternalistic, reactive care of variable quality with [a] focus on prevention, early intervention, and high quality personally tailored services… [where] people have maximum choice, control and power… People who use social care services and their families will increasingly shape and commission their own services” (p.2). The Care Act (2014) has since embedded many of these principles in legislation (see also the “policy and legislation” box here (pdf) (p.4)).

The second chapter of the Five Year Forward View is explicit about preventative, person-centred, empowering approaches in health. This itself builds on Domain 2 of the NHS Outcomes Framework which focuses on enhancing the quality of life for people with long-term health conditions through personalised care and support planning. Bothe the 5YFV and Domain 2 of the NHS Outcomes Framework are why we see such a focus on person-centred approaches in the Vanguards/New Models of Care support offer, whose Chapter 4 shares what that key programme will do to empower people and communities through, for example, person-centred care and support, and services created in partnership with people and communities (pp.18-19) (pdf).

Because personalisation and person-centred approaches have been around and developed over the last 15 years in particular there is no shortage of information about them. There are, I think, four sources that provide the best introduction to personalisation and person-centred approaches:

  1. Getting Serious About Personalisation in the NHS (pdf) – written for those who are working in health and care organisations that will need to change systems and practices to deliver personalised, integrated care and support
  2. Think Local Act Personal’s personalised care and support planning tool – This includes a section that usefully defines what personalised care and support planning is, its origins, its values and principles, related behaviours and beliefs of professionals and what personalised care and support planning looks like in health and care settings
  3. The Collaboration for Coordinated Care (C4CC) provides useful links to some of the best person-centred resources around
  4. The Health Foundation has a subsite focused on person-centred care, with a wide range of resources exploring this vast topic. This incorporates the link to key areas of person-centred approaches such as shared decision making and self-management

What difference does ‘personal’ make?

Like integration there is no shortage of evidence regarding personalisation and person-centred approaches. Here’s the evidence that I’ve personally found most useful.

  • The Individual Budgets evaluation – the first significant, robust study on the difference that personalisation makes – especially through the mechanism of Direct Payments / Personal Budgets (SPRU, 2008)
  • A partnership of In Control and Lancaster University has published three Personalisation Outcomes Evaluation Tool (POET) survey findings. These surveys explore the difference Personal Budgets have made to people with them and their carers, as well as their experience of the process. Findings are available for 2011 (pdf), 2013 (pdf) and 2014 (pdf)
  • HSCIC’s annual adult social care survey includes comparisons of the experiences of people on Direct Payments or Personal Budgets compared to other forms of social care support. The latest data available is for 2013/14 (pdf) (and see, for example, Figure 2.8 on page 53 – reproduced below)
  • ASC satisfactionThe Social Care Elf and Mental Elf have usefully summarised some key studies on the effects of personalisation and Personal Budgets for key user groups: for older people, for people with mental health problems, and for carers
  • A significant formal evaluation of Personal Health Budgets (pdf) was published by PSSRU in 2012
  • Building on their surveys for adult social care, In Control and Lancaster University have also produced three POET surveys capturing the difference Personal Health Budget have made to their holders and their carers, as well as their experience of the process: 2013 (pdf), 2014 (pdf), 2015 (pdf)

There is equally significant evidence on the topic of self-management and shared decision making (often called “patient activiation”). National Voices has produced a summary of systematic reviews on the topics of self-management (pdf) and shared decision-making (pdf). Similarly, the Health Foundation has pulled out its take on the best reviews of existing evidence. Finally, NIHR has a synthesis on the evidence available on interventions that support self-management of long-term conditions.

Integrated

IPCMy current work is on the Integrated Personal Commissioning (IPC) programme, working for Think Local Act Personal and closely with NHS England.

A natural question to ask is “What’s that?”, and it’s a very good question.

Before answering that, though, I think there are questions we should ask before, such as:

  • “What do we mean by ‘integrated’, ‘personal’ and ‘commissioning’?”
  • “What difference do each make?”

This is the first of three posts looking at each topic individually (see the introduction to this short series). It’s a very quick way into the issue of integration, sharing information that I’ve found useful in my own learning. It’s not intended in any way to be comprehensive! Thus, if there are things you think should be added feel free to do so in the comments or on Twitter. I’ll update the posts accordingly.

What do we mean by ‘integration’?

It’s perhaps easier to ask the question: “Integration between what?” because there is no one type of integration. Integration could mean:

  • Across sectors (e.g. health and social care; health, care and education; health, care and housing etc.)
  • Within one sector (e.g. between mental health and physical health)
  • Across different levels (e.g. prevention, early intervention, primary, community, secondary and tertiary health services)
  • Across providers
  • At parts of a process (e.g. single assessment or review).

There is also a question of the extent to which integration happens. So, for example, it’s possible to link things together, co-ordinate things or fully integrate them (see page 15 here (pdf)). Finally, there’s the option of whether integration is “real” (i.e. mergers between organisations or physical assets, such as teams) or “virtual” (i.e. partnerships, alliances or other relationships between organisations).

Since integration can mean a whole host of things in practice, there are various “typologies of integration” that try and capture these. See, for example, Fulop’s typologies of integrated care (p.4) or a discussion of macro, meso and micro levels of integration (pdf). Thus, locating yourself in what type of ‘integration’ is being done is important in the first place.

Useful overviews of what integration is:

We most typically associate integration in the current context within integration across health and social care. A 2011 discussion paper from the King’s Fund that covers this topic quite comprehensively is here (pdf). A 2015 article on the same from Richard Humphries is here.

What difference does integration make?

You can fall into this rabbit hole and never emerge, so significant is the literature on the difference (or otherwise) that integration makes. It literally has its own journals (note: plural).

Even so, here are a few of what I’ve found to be the most useful bits of research on the difference integration makes:

Finally, from a policy point of view, it’s worth noting National Voices’ “Principles of Integrated Care” and the continuing Shared Commitment to Integrated Care.

Integrated. Personal. Commissioning.

IPCMy current work is on the Integrated Personal Commissioning (IPC) programme, working for Think Local Act Personal and very closely with NHS England.

A natural question to ask is “What’s that?”, and it’s a very good question.

Before answering that, though, I think there are questions we should ask before, such as:

  • “What do we mean by ‘integrated’, ‘personal’ and ‘commissioning’?”
  • “What difference do each make?”

Over the next couple of weeks I’m therefore going to write 3 posts on each of these topics, and for each I’m going to try and answer those questions.

Each post will be a very quick way into the issue, sharing information that I’ve found useful in my own learning. None will be in any way comprehensive! Thus, if there are things you’d like to add to each post or disagree with, feel free to do so in the comments or on Twitter. I’ll update the posts accordingly.

£1.25billion for children’s mental health: what’s it worth and what’s it for?

When large sums of money are announced in public services there are two questions to ask yourself: (1) What is the money worth in the context of the existing system?; and (2) What will it be spent on?

Over the weekend, the Lib Dems said there will be £1.25billion for “children’s mental health services”. This money is to be over 5 years, equating to £250million per year.

Piecing together various bits of news (BBC, Mind) it seems some of this funding will also go on supporting pregnant women and new mothers with their mental health (i.e. perinatal mental health services) and doubling funding for veterans’ mental health services[1].

Let’s answer our first self-posed question: what is this worth?

down graphSpending specifically on children’s mental health services has been cut by 6.4% since 2010. In 2009/10 some £766m was spent on children’s mental health, which by 2012/13 was £717m – a cut of £49m.

As NHS England and the Minister for Care Services, as source of these figures, make clear, this is only direct spend on children’s mental health services. The figures don’t include local authority spend on the same, where we know 60% of local councils have frozen or cut their children’s mental health spend since 2010/11. Nor do these figures include spending on adult mental health. We know this is relevant because (a) this is where perinatal and veterans mental health funding comes from, and (b) problems in children’s mental health mean that young people are often treated on adult mental health wards. Looking only at local authority mental health spending, this has been cut by £210m since 2009/10. (The question of levels of adult mental health spending in the NHS is questionable; at best, it has stayed static over the last year having been cut by 2.3% in real-terms between 2011-12 and 2013-14.)

In this context, £250m a year doesn’t seem so much, though any money is, of course, welcome[2].

What about our second question: what will this money be spent on?

Inevitably, given its provenance ahead of the Budget, details of how this money will be spent are unclear. The intention, though, seems to be for it to go on “early intervention schemes to stop children developing serious and potential fatal mental illnesses”. Such early intervention is to include therapy sessions, family support work, better training for clinicians and the development of help via websites and online apps.

This is better than I expected, though we should raise a word of warning: given the almost universal focus on children’s inpatient beds it will be hard for providers to not funnel this money into more inpatient beds. We should keep a close eye on where this money goes.

One suggestion I’d like to see is that at least some of the money should be ear-marked for use as Personal Health Budgets, including as part of the Integrated Personal Commissioning programme. Both the PHBs and IPC programmes have explicit focus on mental health and children and young people, and we know that this route leads to more control and more flexible solutions that can meet individual needs. We also know it can join up fragmented systems, and is likely to divert money away from institutionally biased provision.

Money is a blunt tool. Even if it’s questionable whether the amount of money being pledged to something is worth much, we should also ask how it will be spent and ensure it’s used not just to prop up more of what went before. The money to be pledged in the Budget on children’s mental health is a particularly acute case in point.

Notes:

[1] – The Lib Dem press release also says funding will go to “extend access to services for children under five and those with autism and learning disabilities”, which is strange to say the least.

[2] – I think it is worth noting just how difficult it is to get hold of spending figures on children’s mental health. The Health Select Committee’s recent report on children’s mental health services noted (paragraph 15 here http://www.publications.parliament.uk/pa/cm201415/cmselect/cmhealth/342/342.pdf (pdf)) there is a “lack of information about service provision, including demand,  access and expenditure” and that the best source of such information is currently voluntary. The spending figures found by Young Minds took an FOI request!