In health, a little nugget to consider is that National Insurance raises roughly how much the health service costs. NI receipts in 2016/17 were £126bn and the NHS budget for 2016/17 was £120bn. But if you follow where those NI receipts go, I’d be surprised if they go directly to the NHS.
There’s a nice paper from the World Health Organisation (pdf) that I’d recommend reading on this thorny topic. I like it because it digs behind the economics of hypothecation and examines the reasons for and against it. The reasons given for hypothecation include:
You can therefore see why @NHSMillion would be keen on hypothecation – particularly looking at that last point: the lack of trust that appears to exist is exactly why people want to protect NHS resources.
This said, I’ve never been a fan of hypothecation. Whilst it would be foolish to argue against trust and transparency in particular, I’m not sure you need hypothecation to ensure trust and transparency. The other cons of hypothecation also point to my reluctance to embrace it. They include:
Exemption from review
Inappropriate funding levels
Tying the hands of government.
It’s coincidence that funding levels and NI receipts are roughly similar in health. But controlling for this, my worry with hypothecation is that we quickly undermine solidarity for tax revenues and public services. Hypothecation opens the possibility of people saying “yes, I’ll pay tax for x” and so potentially “no, I won’t pay tax for y.” I fear it would exacerbate what we already see in areas like welfare support and social care.
Whilst hypothecation isn’t an answer, I think it at least helps us pose the right sorts of questions: how do we ensure transparency in how public money is spent, how do we debate the right balance between different types of services, and how do we build trust between those who make these decisions on a day-to-day basis on behalf of the electorate.
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.
Immediate (or relatively immediate), permanent accommodation is provided to service users directly from the streets, without the requirement of assessed housing readiness
No preconditions of treatment access or engagement are made (housing first, not treatment first)
Comprehensive support services are offered and brought to the service user
A harm-reduction approach is taken to dependency issues and abstinence is not required. However, the support agency must be prepared to support residents’ commitments to recovery
Support can ‘float away’ or return as needs arise and the housing is maintained even if the resident leaves the programme, for example through imprisonment or hospital admission.
In the US, a four-year study found that the Housing First approach led to 88% housing retention rate, compared to a 47% retention rate for treatment first models. A shorter UK study of nine housing services (pdf) has found a range of excellent outcomes, too, including housing retention, improved mental and physical health, some reductions in drug and alcohol use, some positive evidence of social integration, and some reductions in anti-social behaviour.
It’s interesting to me the parallels between the housing first model (get people a house, then support them) and the Individual Placement & Support employment model for people with mental health problems (get people a job, then support them).
This is intriguing stuff, and I’ll be keeping a lookout for more on this.