#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.

 

Public services: only a means to living full and active lives

GYA

I’m involved with the Get Yourself Active campaign and recently wrote a blogpost for it, which is reproduced below. There’s also a fantastic post by Anne Beales of Together UK (on small steps and grand plans) and from Leanne Wightman (who is doing a great job of running the whole project) on the opportunity of Get Yourself Active. You can follow Get Yourself Active via @GetYrselfActive

There were some headlines recently about how people were using their Personal Health Budgets. Concerns were raised about whether items like games consoles, a summer house and satnavs were the best use of public money, with the inevitable calls for resources instead to be focused on traditional ways of doing things – beds, staff, medical equipment.

A positive aspect of the debate was it provided an opportunity for people who have Personal Health Budgets and the professionals who support them to explain why they’re so important in meeting their care and support needs. Kevin Shergold, for example, highlighted:

The PHB has given us freedom to live our lives as we choose – in a way that’s sensible and cost effective. Developing a severe disability might seem hopeless, but I want people to know that it’s possible to live a good, full, interesting life when you have the right support and choice.

This gets to what I think is a vital but often unasked question: what is the point of public services and so the money that funds them?

The vast majority of people with lived experience and who have used care and support services say that they want a life, not a service. Their focus isn’t on getting a few more hours of home care here or seeing an occupational therapist there; it’s about living as full and enriching a life as possible.

Norman Kirk – a New Zealand Prime Minister in the 1970s – described it this way:

People don’t want much. They just want someone to love, somewhere to live, somewhere to work and something to hope for.

He could well have added “something to do”, because wanting to be physically active or play sport is often reported by all people, including disabled people, as a key source of general wellbeing.

The point of public services and the money that funds them, therefore, covers being a means to support wellbeing and achieve what people want to do in their lives – including being active and playing sport. We have already heard from a number of people through the Get Yourself Active project that using their personal budget in this way has changed things for the better.

This means there are three main reasons why I feel Get Yourself Active is such an important contribution:

  1.  It helps to support people who use care and support services and the professionals who work in them to recognise the value of physical activity and sport
  2.  It provides a much-needed wider focus on how Personal Budgets can be used to directly support such activity, and not just focus on traditional ways of meeting people’s needs
  3. And, by the way, it helps councils and their partners meet the general wellbeing requirements of the Care Act.

If this leads to more stories about how Personal Budgets are being used to fund exercise classes, gym memberships or being involved sporting activity, I for one won’t be disappointed. It will mean that public services are doing their job well.

 

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.

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.

Following the money can support personalised payment mechanisms: exploring the health payment system

Alternative Guide to the NHS - from the King's Fund
Alternative Guide to the NHS – from The King’s Fund

Most discussion about health and social care is about how much money there is(n’t) in the system. Relatively little attention is given to how the money in health and social care flows through that system.

This post shares some extended thoughts on what we know about the payment system in health, how this has been applied to mental health and how, despite potential perils, we can use current and future payment system changes and extensions into social care to support personalisation.

It is a bit dense in places, but it hopefully gives a useful grounding in the payment system for those who’d like to know a bit more about it and the opportunities (and difficulties) it presents. The post is broken up into 3 parts: (1) How the health payment system works; (2) How the health payment system has been extended into mental health; and (3) The perils and opportunities of moving a health payment system into social care.

I. The health payment system

To understand how a system works a good rule of thumb is to follow the money. In large parts of the health service this is pretty easy to do because of the payment/tariff system (which used to be known as “Payment by Results”[1]).

The core building blocks of the payment system are currencies and tariffs. The currency defines the unit of healthcare for which a payment is made (i.e. the ‘what’, such as a hip replacement or cataract operation) and the tariff defines ‘how much’ for each currency (i.e. what will be paid).

Thus, for any person receiving any treatment in certain settings, the following basic process is followed:

  • Treatment occurs
  • Treatment is coded using separate classification systems for diagnoses and interventions
  • Grouping of treatment – a Healthcare Resource Grouping (HRG) is allocated based on clinical codes and other patient data
  • Tariff – The tariff price depends on HRG and type of admission, and there are a variety of tariff adjustments made
  • Payment – standard monthly payments are made in advance, based on activity plan. Actual activity transmitted from provider to commissioners adjusts these payments up or down

In its introduction to the payment system (from 2013) the Department of Health produced this useful diagram to explain the broad principles of how the payment system applied to Mrs Smith having twins, Mr Jones having an emergency hip replacement and how much their treatment costs.

PbR worked examples
Click to enlarge

To get to this point the payment system in health has evolved a lot since it was first introduced in 2003/4. That year this type of payment system made up around £100m of health spending (some 0.2% of relevant commissioner allocations); by 2011/12 it made up £28.9bn of health spending (32.4% of relevant commissioner allocations).

II. Extending the health payment system into mental health

For things that are relatively well defined (such as giving birth or hip replacements), a currency/tariff system is relatively easy to define. This is partly to do with how well the evidence base is developed: in health, NICE pathways exist http://pathways.nice.org.uk/ which outline exactly what should be done and when. (Here’s the pathway for multiple pregnancies and here’s the one for hip fractures.)

What if, though, we apply similar principles to areas where definitions or boundaries aren’t so easy to come across: mental health and social care?

In mental health, a lot of effort has already been made in this direction. All of the various mental health problems that people can have are divided up into 21 ‘clusters’ – a way of grouping people with mental health problems according to their needs, based on descriptions of characteristics of people who are assumed to have similar mental health support needs, and the level of resource needed to meet these needs. In mental health, these ‘clusters’ are the currency (i.e. the ‘what’, or the equivalent of hip replacements etc.).

If this were to follow the twins / hip replacement example, we would then allocate an amount of money to the treatment of someone in a particular cluster and all would, we hope, be sorted. In mental health, though, there are a whole range of other factors that affect what is or isn’t included in someone’s treatment. These factors include (but are not limited to):

  • Mental health episodes are more difficult to define and diagnoses are less clear-cut
  • There is less clinical consensus on optimal care pathways, making cost variations more pronounced. Even if there was a consensus on pathways, mental health support is not consistently available across the country, including where some types of support simply aren’t available
  • Interrelationships with physical health are complex, with mental health problems having a substantial impact on health conditions
  • Mental health problems typically imposes costs and benefits in non-health sectors
  • There are shortcomings in both the availability and quality of activity data for mental health, which make very difficult the development of robust remuneration
  • The evidence base for mental health interventions is far less developed than for traditional health interventions
  • The money that meets different elements of the support comes from different sources, most notably health and social care pots of money.

What this list of factors means is that the pathway and the payment are much harder to determine in mental health.

Efforts have been underway since 2010/11 to both define the typical pathways associated with each cluster and the prices that might be attached to them. Progress is very mixed, though: clustering people with mental health problems is required by central government, but payment isn’t yet compulsory – local areas can develop their own ways of arranging payment. Furthermore, the extent to which the new payment system in mental health has changed the nature of activity and the differences it has made in people’s lives is a moot point. A recent survey by the Healthcare Financial Management Association (HFMA) (pdf) shared the views of health finance managers on progress regarding the mental health payment system. Findings included:

  • 84% reported commissioner understanding of the mental health payment system to be very poor, poor or fair
  • 60% reported cluster-based activity as having “no” financial impact
  • 70% reported that they still operated under a block contract with commissioners with a shadow tariff.

III. The opportunities and perils of moving a health payment system into social care

As it is in mental health, so the picture would be (even) more complicated in social care.

It isn’t yet the case that formal segmentation of the care population (to create ‘currencies’ and ‘clusters’), associated care pathways and prices have been developed. What we are starting to see, though, is a more concerted effort to define what we might typically expect from a social care pathway; this is mainly been driven through the NICE Collaborating Centre for Social Care (guidelines are being produced, for example, on the topics of home care and reablement). The drive to integration will also bring social care far more, perhaps fundamentally, under the aegis of agencies like Monitor and NHS England, who are jointly responsible for the payment system in health. CQC is, of course, already a joint regulatory body that operates across both health and social care.

In my personal view, and drawing on the experience in mental health, there are both perils and opportunities of bringing a health-type payment system into social care.

The biggest peril is that social care could be the less richer for such a payment system. This lost richness would be made up of a more medical focus in social care, painting a more black and white picture of people than the complexity and range of social care represents. Health is making attempts to shift away from this viewpoint (see, for example, the Coalition for Collaborative Care, Co4CC), but the experience in mental health suggests the practice of anything other than medical thinking related to payment systems is very hard to do.

There are, though, 4 positive opportunities we can take from any current or future attempts to develop currencies and payments in social care.

  1. Such a payment system begins to bridge the gaps (professional, language etc.) people from different professional backgrounds bring. Health and social care professionals start from very different technical positions, though aren’t different in what they seek to do for and with the people they support. Thinking about pathways and payments and trying to put them in place enables people across the piece to come together for a common goal, starting from where they currently respectively are
  2. Building standard national mechanisms won’t, I think, work. But providing a strong requirement to develop a local model, backed up by excellent guidance, support, encouragement and sharing of learning can help areas to create strong local health and social care economies through their common work to develop (if not produce) pathways and payments
  3. Attempts to build the picture will show where evidence is most needed in social care (and health). I am by no means advocating the unrealistic position that we should only spend money on models/interventions/supports backed up by ‘gold-standard’ evidence; but I am saying that knowing where more appropriate evidence is needed will help us to ensure more of what is available through social care is as effective as it can be in supporting people
  4. Perhaps the most exciting opportunity is that developing payments systems like this does much of the heavy lifting in identifying how much money is associated with the care and support of an individual. Even more exciting is the idea that such information would incorporate both health and social care provision. Once the amount is known it is then easier for an individual to take that resource as a Personal Budget / Personal Health Budget, with all the benefits we know are associated with this. After such work, the natural foundations for things like Integrated Personal Commissioning are then in place.

These are 4 reasons I could get behind.

Reforms in health and social care aren’t always renowned for their subtlety. What I’ve therefore endeavoured to do in this post is show how there are always opportunities in reforms – in this case, the payment system, with its currencies and tariffs  – that can be used to support a whole range of ends. Here, following the money provides a chance to bring health and social care people together and do much of the heavy lifting that personalisation through, for example personalised payment mechanisms, requires. Though this isn’t without its perils, as the experience in mental health shows, the opportunities aren’t too bad either.

Notes:

[1] – Back in 2013 I wrote an introductory guide to what was then Payment by Results in mental health. Though some of the technical information has been superseded by development since then (and on which a publication is forthcoming) most of the information in the guide remains useful. You can find it here.

Self-Directed Support in mental health: what can you do differently?

Permission to DreamBelow is a post written for Outside the Box in Scotland, ahead of their Permission to Dream event next month on how people across Scotland have been getting on over the first year of Self-Directed Support.

Last year, Outside the Box ran a series of great events on what the new Self-Directed Support Act (2014) might mean for mental health in Scotland. The events brought together a range of people from across the mental health system: people who use services, families, carers and representative organisations; social workers; team managers; commissioners and providers. As a result, the conversations were rich and engaging.

One thing that struck me during people’s discussions was that very few people thought the health and social care system was working for people with mental health problems as it was. This feeling wasn’t limited to just social care outcomes and people’s mental health themselves: it included what opportunities people with mental health problems had in areas of life like housing, employment and fairly accessing welfare support.

The question before everyone was clear: how do we make things better? The Self-Directed Support Act 2014 is a major part of the answer. The Act aims to empower people to have control and responsibility over how their care and support is arranged, including offering people different choices for organising their care. (You can find out more information about the Act on the Getting There website.)

Henry Ford famously said: “If you always do what you’ve always done, you’ll always get what you’ve always got.” The Act is therefore a really good chance to do something differently. A really interesting question for everyone with an interest in the mental health system to ask themselves is: what can they do differently as a result of the new SDS Act?

Here are a few suggestions (you can find more in this practice paper on the Getting There website):

  • For people who use services, this could mean finding out more about the Self-Directed Support Act so you know what your rights are and how to access the support available to live the life you want.
  • For a frontline practitioner, this could mean working in partnership with a person rather than thinking of them as someone to assess and put in place a package for. This could include thinking together beyond the usual menu of ‘traditional’ services people might access.
  • For team managers, it could mean creating regular opportunities for their team members to talk about the good things they’ve done as a result of self-directed support, or to talk about the challenges this new way of working brings and enabling people to support each other to address those challenges.
  • For people who commission services, it could mean knowing how much money was spent on what types of mental health support and then explicitly aiming to change this over the next 3 years, responding to the different choices that people make.

The pressure and constraints that currently exist in the mental health system sometimes lead people to think they can’t do anything themselves to make things better – it’s “beyond their control”. The places that make the most progress are those where as many people as possible take the opportunity to do something different in their part of the system and give it a go – no matter how small a change they personally make. Let’s all of us use the opportunity of the Self-Directed Support Act to help improve the lives of people with mental health problems.

Personalisation, S117 aftercare, out-of-area placements and George Clooney

Image via Cascade Fellows
Image via Cascade Fellows

A significant component of the personalisation agenda fundamentally challenges and changes where money goes as a result of the different choices people make about achieving what they want. This is rightly so, for “if you always do what you’ve always done, you’ll always get what you’ve always got.”

We know some pretty good numbers about how much money is spent in the social care system through Direct Payments. They show that the scale of spend through Direct Payments against all social care expenditure is growing, but small[1].

Does this mean that personalisation has failed? No. But what does it mean?

There have undoubtedly been compromises and manifestations of what was originally intended, meaning personalisation hasn’t always translated into what it was hoped and intended it would. For example, resource allocation systems and panel processes have become unwelcome norms. (We should remember that money was only ever one aspect of personalisation.)

Status Quo
Image via EIL

But in any change that fundamentally disrupts, or has the potential to disrupt the status quo, other forces – invisible or not – will always play their role. These include organisations who benefit most from the status quo and have literally vested interests in maintaining it. This is, I think, one of the more powerful reasons why personalisation in mental health is still taking hold rather than taken hold, as seen through the Direct Payment numbers.

In mental health the status quo is a particular challenge because the overwhelming destination of money is in the health system. For health organisations dealing with mental health it tends to be more a question of how much money they’ll get rather than whether they’ll get it[2].

Organisations generally exist in order to protect what they are currently doing. The personalisation agenda in mental health is thus a fundamental challenge to health organisations and the status quo. How do we therefore bridge the chasm of effecting the change personalisation seeks to achieve by working with and through health organisations?

Rather than just mechanisms and processes, we need to think explicitly and tactically. We need to speak in a language that others will understand, and recognise their existing, actual starting point and create a path from that point to where we want things to be in the future.

Start where you are. Use what you have. Do what you can – Arthur Ashe (via @areynolds67)

To change the status quo you need a variety of approaches. Policy and legislation through government have their role. So does compulsion through regulation. Peer or public pressure is another, as is the drive to maintain existing levels of business.

A useful tactical way to change the status quo is to align agendas.

I’ve often talked about the public policy idea of the Advocacy Coalition Framework[3]. Here, people with often very different perspectives share a common goal and form a coalition through which they advocate for particular outcomes. They align their agendas. Changes in the treatment of domestic violence are a good example of a successful Advocacy Coalition approach, bringing together feminists and the police as unlikely allies.

Another way of thinking of this is by imagining being George Clooney’s character in Up In The Air. He specialises in making people redundant, but how he frames it is not as an opportunity to carry on doing what’s always been done, but to take the opportunity to do something different. Despite it being painful, and a process that doesn’t always work for everyone, what Clooney’s character does is align one set of objectives – the company’s, wishing to make people redundant – with another – the person’s, wanting to make a different future[4].

What if we apply this to personalisation in, say, the area of mental health? I think it can be strongly argued that personalisation is a solution to two existing problems that health organisations (and others) are grappling with: Section 117 aftercare and out-of-area placements.

Without going into the details here, key elements of the personalisation agenda, if done properly, would directly address causes or effects of problems related to S117 aftercare or out-of-area placements. Personalised funding, integrated at the level of the individual, with a clear plan that matches assessed need with outcomes and choice over how best to achieve those outcomes, helps to address a myriad of S117 aftercare problems. Good market development in an area, that enables supporting people at the right level at the right time, with good information and a focus on maintaining meaningful networks important to the person, directly addresses many of the problems of out-of-area placements.

By tactically aligning agendas through choosing to address issues around S117 aftercare and out-of-area placements using personalisation, there is an opportunity to normalise personalisation. This approach takes account of where health organisations currently are, but gives them a different set of tools for addressing the problems they face which has the added benefit of showing them personalisation works. It is undoubtedly tactical, and may well involve an element of compromise, but I’d strongly suggest it would help with where we want to get when it comes to personalisation.

Notes:

[1] – See Figure 3.2 in HSCIC’s 2013/14 Personal Social Services Expenditure and Unit costs release (pdf)

[2] – Remember when NHS England imposed a 1.8% deflator on non-acute health services, including mental health, compared to a 1.5% deflator for acute services? The equivalent cut to local authority social care services – also covering mental health – has been 26% to date since 2010/11. For more details see LGA’s Adult social care funding: 2014 state of the nation report

[3] – I can’t recommend highly enough Paul Cairney’s 1,000-word summary of the Advocacy Coalition Framework

[4] – (Spoiler) We should note that Clooney’s character is a bit of a schmuck for most of the film, but he comes good in the end.