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

Here’s a post I’ve written on the need for coalition building across a range of motivations and organisations if successful change is to happen in social care. This is part of the #socialcarefuture series that @mroutled has been bringing together, designed to create a space to get past just thinking about stabilising the current social care system which isn’t fit for the future. Here is the rest of the #socialcarefuture blog series.

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Much debate in public policy focuses on the “why” and the “what”. Why is this issue important? Why should it be prioritised over something else? What should be in place that isn’t? What needs to change for this to happen?

Comparatively little focus is placed on “how” – the practicalities of putting the why and what into action. The “how” follows once the “why” and the “what” have been largely agreed, and is important because it’s in this space that all of people’s experiences are generated. It’s also where good ideas can turn into bad delivery.

But below the “how” is a question even less attention is given to: “who?” Rarely is it considered: who is asking for this change? Who is the change being asked of? What are the motivations of these respective groups?

It is too easy to lament how poor commissioning and commissioners are; or how it would be so much better if only senior leaders recognised the radical difference that x or y would make. But this is to fall into the trap of “what’s the matter with these people?” rather than thinking, familiarly enough, “what matters to these people?”

This thought came home to me when, for around three years, I was simultaneously on both “sides” of a policy argument. For around half of my time I was working in a disabled people’s user-led organisation (DPULO), advocating for disabled people’s equality and rights, delivering user-led services and promoting choice and control through personalisation in social care. The other half of my time was in, of all places, the Office for Disability issues within the Department for Work and Pensions (DWP_.

What was fascinating about this was, even though I would say exactly the same things when wearing my DPULO or DWP hat, people would receive a message considerably differently depending on how they perceived me in that moment. Disability rights campaigners would broadly be ok with my thoughts when shared from a DPULO perspective. But the exact same thoughts wouldn’t be acceptable if I expressed them from a DWP platform.

In neither situation was the idea that disabled people’s equality and rights mattered to me. Nor was it recognised I was consciously choosing different means to others by which to achieve what was, in fact, a common goal.

This leads to two connected conclusions relevant for #socialcarefuture.

The first is to understand that what matters to people, matters. Motivations for engaging in an issue will differ. There will be a junior minister who wants to be promoted; there will be lifelong advocates who have dedicated themselves for 25 years to a certain change; there will be civil servants who want a pragmatic solution to a pressing problem they are facing. But all of these different motivations are as present as each other, and can be skilfully aligned to achieve a common change that works for all.

The second is to recognise that such a broad coalition of people with different motivations will be located across a wide range of organisations. Indeed, the coalition has to be widely distributed if it has any chance of succeeding: each participant will have access to something others don’t, and that is needed for the overall change. As a result, some coalition members will be “inside” the system. Some will be outside (possibly literally, chained to railings or waving placards). Some will be in the grey area that is neither inside nor outside (the voluntary sector is most often found in this space). Some may not even know they’re in the coalition.

What leads to change is consciously acknowledging and valuing the existence of such a broad coalition across motivations and organisations. Each participant – each “who”, with their all too human motivations and positions – makes a needed contribution, and it is only through this coalition that successful change will come about.

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(For those interested in the public policy theory that underpins such coalitions, this primer on Advocacy Coalition Frameworks https://paulcairney.wordpress.com/2013/10/30/policy-concepts-in-1000-words-the-advocacy-coalition-framework/ is excellent.)

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The Tory answer to the question “who pays for social care?”: You!

Image via WikiHow

Two excellent responses to the Conservatives’ social care manifesto proposal: Torsten Bell at the Resolution Foundation and, of course, The King’s Fund.

It took me quite a long time to figure out the main implications of the proposals (I’m not sure I understand them even now).

We can summarise them as:

• If you have assets under £100,000, you’re a winner
• If you have assets over £100,000, you’re not a winner

In essence, the Tory answer to the question “who pays for social care?” is “you, not us”.

Coupled with the proposal to scrap the universall Winter Fuel Allowance, one argument is that the Conseratives’ proposals are progressive, redistributive mechanisms that will benefit people from lower incomes, or working-age people who have been reliant on social care for their adult lives (and are less likely to have built up assets).

The counter argument – including when comparing the proposals against the Dilnot Commission’s proposals – is that these proposals create a further breakdown in the inherent universalism and sharing of risk that only government can provide (see also: the NHS).

These proposals may provide a financial solution to the social care crisis*, but they certainly don’t shore up the idea that “we’re all in this together”.

*Though deferred payments from housing still requires large short- and medium-term injections of cash, and we don’t know how inheritance law and behaviour will respond to these announcements.

We can’t all be change agents

Around 16% of people in an organisation are change agents. About 50% of people are late adopters or laggards.

Image via Helen Bevan on Twitter

Similarly, around 13% of employees are engaged contributers in the workplace:

Image via School for Change Agents

All the rest are compliant – disconnected from the purpose of their organisation, controlled by performance management and procedures, largely resistant to change.

An idle thought: though we’d all dearly love to be change agents and contributors, by definition, we can’t all be change agents; we can’t all be contributors.

Half the battle – actually, over 80% of the battle – may be recognising our place in the organisational picture.

The opportunity for public services of truly engaged expert citizens

The World Wide Web was invented in 1989 and Google was incorporated as a company nearly a decade later, in 1998. AirBnB started in 2007 and Uber in 2009.

I wonder why there was such a big delay between the web and Google, and then Google and AirBnB, Uber etc., and then a subsequent delay in their reaching a tipping point in terms of awareness and use by the general public?

I ask this because there have been a very wide number of approaches and initiatives for improving public services, not least health and social care, through technology and particularly the web. For example, there have been care comparison sites a-plenty, much talk of open data and suggestions of location-based services to replace off- and online directories. And yet we see relatively little evidence of these approaching a tipping point, let alone being used regularly by local authorities, providers and the general public when it comes to health and social care.

The prompt for these thoughts is this excellent, detailed post at Policy Exchange about the rise of the citizen expert.

In it Beth Simone Noveck (former United States deputy chief technology officer and director of the White House Open Government Initiative) takes as a starting point another area of public policy – citizen engagement – and notes how the obvious opportunity to improve public services and local communities hasn’t been taken in the way it could have been.

Citizen engagement isn’t just the equivalent of technology: it’s clearly bigger than that. Beth makes clear this point by showing how better harnessing the interests and expertise of citizens can help both bridge the democratic divide and make the most of people in contributing to their local communities and society.

The internet is radically decreasing the costs of identifying diverse forms of expertise so that the person who has taken courses on an online learning platform can showcase those credentials with a searchable digital badge. The person who has answered thousands of questions on a question-and-answer website can demonstrate their practical ability and willingness to help. Ratings by other users further attest to the usefulness of their contributions. In short, it is becoming possible to discover what people know and can do in ever more finely tuned ways and match people to opportunities to participate that speak to their talents.

But she also notes the most significant barrier to this: the continued dominance / monopoly of policy- and service-elites in the work that they do:

[There is a] long-held belief, even among reformers, that only professional public servants or credentialed elites possess the requisite abilities to govern in a complex society.

Why? Because it is believed

Citizens are spectators who can express opinions but cognitive incapacity, laziness or simply the complexity of modern society limit participation to asking people what they feel by means of elections, opinion polls, or social media.

The shifting of the cause of the problem of a lack of engagement onto citizens themselves rather than the professionals asking the questions is a familiar refrain. We regularly hear laments about “the usual suspects”, limited response rates or adversarial consultation processes that create more problems than they solve.

But this characterisation of this situation only makes sense for one set of players: it suits both the technocratic elites who dominate public policy and services, and the other well-embedded elites with (vested) interests who can mobilise quickly to respond to consultation/engagement that affect their organisations.

It is, of course, a characterisation that doesn’t really stand up to scrutiny. For example, we know that (proper) co-production in health and social care has a solid evidence base in the difference it makes. But we also know it continues to be at best a nice-to-have rather than a must-have.

Thus we come back to the questions kicking about in my mind at the start of this post: if the ability to do this sort of thing exists (be it citizen engagement or technology), why hasn’t social care and the like made the most of this opportunity?

It’s largely because elites aren’t yet comfortable with distributing leadership and expertise.

One of the ways to overcome this discomfort, then, is to make it valuable and rational for the existing elites to engage in effective citizen engagement by ensuring a ‘good’ group of people are engaged and involved in public service reform in the first place.

Noveck rightly says:

To make all forms of engagement more effective, we need to increase the likelihood that the opportunity to participate will be known to those who need to participate. If a city really wants to improve the chances of crafting a workable plan for bike lanes, it should be able to reach out to urban planners, transportation engineers, cyclists, and cab drivers and offer them ways to participate meaningfully. When a public organisation needs hands on help from techies to build better websites or data crunching from data scientists, it needs to be able to connect.

To do this:

[I]nstitutions [must] begin to leverage such platforms to match the need for expertise to the demand for it and, in the process, increase engagement becoming more effective and more legitimate.

This is appealing. Citizen engagement may not be valued by elites because there hasn’t been adequate effort or ability to engage sufficient citizens to make it worthwhile enough.

As Noveck concludes:

This is about chances for civic participation; to be a member of a local community and to make a contribution based on this… It has everything to do with what it means to be a citizen in a contemporary democracy.

This is why I particularly like this: this isn’t just about technical changes around the edges of public service economies, but the broad meaningful difference it could make.

 

Culture change is change if we understand culture properly

I enjoyed Alex’s post on why “culture change is no change”, though this is a rare occasion on which I don’t wholeheartedly agree with him.

He notes:

Most [of] the profound and important changes we need to see in public services, we describe as ‘culture changes’… What do we mean by ‘culture change’? Generally, it’s code for a change we don’t think will happen and that we don’t think is our fault when it doesn’t.

Though I can see the point, I don’t think it is right.

Before looking at Alex’s central points and so exploring why I don’t think the above is  right, let’s briefly try to answer the following: “What is culture?”

There are many ways or frameworks for defining or understanding culture. McKinsey & Co famously defined it as

How we do things around here.

Schein expands (summarised in The Art of Change Making (pdf), p.131):

Culture is the way that an organisation survives. It is a way of being, believing and feeling that gives consistency and stability. It gives a way of surviving internal and external threat and disruption. It is how a place makes sense of the world. It is how it does things and how it chooses to be seen.

What this gives rise to are three levels of culture: tacit (what is assumed), espoused (what is spoken of) and observable (what is done in practice):

Schein’s three types of culture

How then, does culture – the way an organisation or system does things, survives and makes sense of the world – manifest itself? One of the more common ways of seeing this is through the Cultural Web (see pp.134-137 of The Art of Change Making). This sees culture as the result of the wonderfully Kafkaesque

Paradigm.

The paradigm is

the core beliefs of [an] organisation about themselves. The paradigm and the organisation’s behaviours, actions and thoughts are interlinked, they are a complex web and are inseparable. Every thought, behaviour and action feeds into the paradigm and the paradigm in turn influences every thought and action.

There are then thought to be six cultural influences that inform this paradigm and which are themselves informed by the paradigm (all of which exist at each of the three levels noted by Schein: tacit, espoused, observable).

The Cultural Web

With these common definitions of culture (and so culture change) in place, we can therefore explore the two central points of Alex’s post.

Just so you can see where I’m going with this, I’ll say now: we’ll see that culture change is precisely the sort of change Alex is rightly looking for.

The first main point in Alex’s post is this:

[I]n reality culture is always, always trumped by the hard levers and incentives in any system.

I think there is a grain of truth in this, but I think it underplays two issues.

The first is that hard levers and incentives themselves are part of the culture. In the Cultural Web they are examples of “Control Systems”, which

are the ways that an organisation controls how things are done, from things such as quality control and financial control, through to reward and punishment… People will behave in ways that they think will please the control system.

That is, what the organisation or system values is what leads to the creation of hard levers or incentives in the first place.

The second issue is that in any complex system the “hard” and the “soft” interact with each other in complex and possibly unknowable ways. (This is true even if you don’t think hard levers and incentives are part of the culture.) What this means is that for successful change to happen we should have both changes to the law, policy and financial flows that govern how systems are structured (the “hard”) and to the culture that governs how/why they work (“soft”).

The second main point in Alex’s post is about power:

Power on the other hand, is not elusive, and rarely dispersed… So next time someone in power suggests a culture change is needed, perhaps the appropriate question is, “[H]ow are you going to give your power to someone else, to start that happening?”

This point and related question about power are exactly right. From the definition of culture, though, we can see that power and power structures are part of the culture of an organisation or system. Or put another way: for power to be moved from one person to another is exactly to require a culture change.

It’s rare for me to disagree with Alex but I hope this post has explained why, on this occasion, I do. To summarise: if people use the phrase “culture change” as code for things they don’t think will happen, I’d suggest they probably don’t understand definitions of culture (at either a system or organisation level), how it manifests itself, and so what culture change might actually entail.

Scooby Doo and the human reasons reform doesn’t happen

Image via Variety.com

Francis Fukuyuma noted 4 reasons why political reform happens:

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

Humans are a significant (actually, the only) reason these reforms don’t happen – we can see this in, for example, the lack of speed with which any public service reform happens.

Why are we like this? Fukuyama notes:

Human nature has provided us with a suite of emotions that encourage rule or norm following that is independent of the norm’s rationality. Sometimes… we follow rules simply because they are old and traditional. We are instinctively conformist and look around at our fellows for guidelines to our own behaviour.

Instead of reason, human behaviour is grounded in emotion and resulting biases (pace Kahnemann) like pride or shame.

Such human behaviour aggregates to institutions, and there are two main reasons institutions don’t adapt either.

The first is because they’re made up of humans, who follow rules for reasons that aren’t rational – see above!

The second is that institutions contain groups who have a vested interest in keeping things as they are:

Political institutions develop as new social groups emerge and challenge the existing equilibrium. If successful institutional development occurs, the rules of the system change and the former outsiders become insiders.

This is encouraging for those who seek and are successful in change.

As the institutions update themselves, though, so we have to be wary about the new elites within them:

But then the insiders acquire a stake in the new system and henceforth act to defend the new status quo. Because they are insiders, they can use their superior access to information and resources to manipulate the rules in their favour.

As each baddie in Scooby Doo notes they’d have gotten away with it if it weren’t for those pesky kids, so we’d achieve every public policy aim we could ever wish for if it weren’t for those pesky humans.

Four lessons for political reform

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

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

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

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

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

Wicked issues and constructive conversations in health and social care

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.

Commissioning

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 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.
There 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:

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

Commissioning 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:

• A history of commissioning in the NHS (pdf) (pp.8-18), Health Select Committee
• A wonderful timeline on the history of commissioning in both health and social care. The section specifically on the advent and realisation of the purchaser-provider split between 1989-1995 is especially relevant
• 10 years of joint commissioning across health and social care
• Options for integrated commissioning – a very useful document that looks at what existing joint/integrated arrangements currently exist (Section 75 arrangements etc.) and what options we have for the future (King’s Fund)
• Outcomes-based commissioning – the newest game in town. The Institute for Public Care has published an excellent discussion paper on this looking specifically at outcomes-based commissioning in social care
• The implications of personalisation for commissioning
• People-led commissioning – both through co-production in commissioning and people-powered commissioning (Note: we don’t here include information approaches to building community capacity or community empowerment, although these are arguably varieties of commissioning.)
• In case that isn’t enough and you are this way inclined, here’s an overview of commissioning and how it relates to different areas of public policy (pdf) (including health, social care, working with the third sector, children’s services, welfare etc.)

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 (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:

• Significant early findings about the impact of commissioning are here (pdf)
• A considerably detailed review of joint commissioning is here
• On integrated commissioning, there is even less information. As concluded here:

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.

• A summary of all findings on integrated commissioning is here; a more comprehensive (though accessible) treatment is here (pdf), summarised in the Table below:

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

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.

The 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)
• The 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.