Carl Binns

Continuing our celebration of National Apprenticeship Week, this dissertation explores systems change in violence reduction. The introduction of Violence Reduction Units (VRUs) from 2019 represented a paradigm shift in the strategic leadership and policy development relating to serious violence in the UK. Multi-disciplinary VRUs can co-commission services across sectors and engage with a multitude of partner to tackle the root causes of violence.

This research draws on the experiences and insights from a range of systems leaders working in and around the case study VRU. The study found that principles underpinning the public health approach to violence can be implemented and connected to a wide range of partners via effective systems leadership. However, systems leadership as a specific skillset is often under-recognised in the professional development of public leaders working to reduce and prevent violence.

Key findings:

• VRUs differ widely across the country in their composition and focus, but their introduction represents a paradigm shift towards focused and intensive multi-agency working.
• The public health approach can shift the focus from reacting to violence (the symptom) to a focus on changing the social determinants that cause violence, which can be systemic as well as linked to individual life experiences and capacities.
• VRU staff need to step away from the operational realities that can often blinker professionals, to enable a more encompassing view of those factors that influence susceptibility to violence.
• VRUs can provide space for innovation to develop in the form of strategies and conditions to develop interrelationships and effective ways of working in collaboration and partnership. Key to this is developing trust, between professionals and with communities. 
• VRUs have the opportunity to engage in ‘active listening’ with the community as a whole and with specific sub-groups such as victims of violence or potential perpetrators and victims.
• When practically applied, concepts of systems leadership can help system leaders to ‘become comfortable with chaos’ and enable them to extend public health principles across a system with otherwise diverging priorities and policy drivers. 

Background

Violence Reduction Units were established in 18 policy forces in 2019 as new multi-agency units responsible for tackling and preventing violence.  They represent an important step forward in regards local leadership around complex social issues.  This research investigated the extent to which VRUs can implement a ‘whole-systems’ policy response to serious violence using a case study of a large urban Violence Reduction Unit.  In seeking to tackle violence, this VRU has adopted a public health approach which brings with it a tradition of ‘integrative leadership’.

Fieldwork interviews in the dissertation identified VRUs as an important opportunity to do things differently and enhance strategic coordination at a regional level.  They can facilitate violence prevention activity by making information, advice and guidance more accessible and taking central responsibility for convening key partners. 

What we knew already

The UK government’s adoption of VRUs was inspired by experiences in Glasgow from 2005, which concluded: ‘Violence is preventable, not inevitable’.  The Glasgow partnership, formed of police and other local community partners, worked in an intensive and focussed way to provide to opportunities in employment, activities and education for those involved in violence. Accompanying this was a strong enforcement arm which ensured those who did not engage faced tough penal sentences.

VRUs differ widely across the country in their composition and focus, with two main operational models: a centralised multi-disciplinary unit and a hub and spoke structure. Central to both models is a tripartite structure which includes a governance board, a dedicated team of staff from a range of professional backgrounds and an additional localised resourcing to deliver focussed activity on the ground. The emerging literature on VRUs presents their introduction as a paradigm shift towards focused and intensive multi-agency working.

The public health approach can be seen as a shift in cultural thinking from a limiting focus on reacting to violence (the symptom) to a focus on changing the social determinants that cause violence. Where historical policy responses were often characterised by fragmented interventions spearheaded by the criminal justice sector, the public health approach prioritises principles of connectivity and collaboration and the inclusion of community voice and agency. This transition clearly requires a different set of skills for public sector leaders, with boundary crossing activity as ‘the new normal’ for effective service delivery.

Practical steps for implementing whole-systems approaches include the identification of ‘ways of working’ and specific activities such as enabling distributed leadership, being flexible and adaptive, and communicating effectively with partners via systemic data sharing across systems.  Systems leadership can be viewed as an interactive process of continual negotiation between many interacting actors; a marked change from the ‘bureaucratic ideal type’ mode of governance.  Leading in such a complex environment is often disconcerting, intellectually demanding and emotionally draining, often described as ‘emotional labour’.

The causes of violence are complex

VRUs need to develop a common understanding of the causes of violence in their locality.  Some responses focus on systemic issues prevalent within society, such as poverty and deprivation, a lack of opportunity and meaningful employment.  Others focus more on the pervasive impact of personal relationships and community contexts, drawing out trauma and negative life experiences in early childhood as central to a propensity towards violence.  A third perspective considers individual risk factors and protective factors, drawing out concepts of gender, psychology and individual capacity to resolve conflict.

Recognising the complexity of the system

VRU staff need to step away from the operational realities that can often blinker professionals, to enable a more encompassing view of those factors that influence susceptibility to violence.  Complex adaptive systems have a large number of agents that interact, adapt and learn together. They are particularly difficult to navigate through in that they are emergent in nature and cannot be perceived of or predicted by standard linear deduction.  System mapping can help actors build a visual picture of interdependencies and key players within a system, highlighting a key role for VRUs in coordinating local violence reduction activity. Framing a view of the system around the needs of individuals of specific cohorts can help.  Each agency within the system also needs to recognise the importance of violence as a societal issue.  VRUs must work within a context where national policy is not ‘joined up’ in addressing issues of violence.

Thinking in systems and leading across sectors

VRUs can provide space for innovation to develop in the form of strategies and conditions to develop interrelationships and effective ways of working in collaboration and partnership. Key to this is developing trust, between professionals and with communities.  Building effective partnerships with schools may be particularly important. As well as this facilitation role, VRUs at times need to take more of an active role in directing and shaping action to effect change. 

VRUs have the opportunity to engage in ‘active listening’ with the community as a whole and with specific sub-groups such as victims of violence or potential perpetrators and victims. Community involvement is often momentary, an afterthought or tick-box exercise without the true ambition of incorporating their views into the policy process. Active listening must build from the concept of transparency; providing communities with an understanding of how they can target their issues at specific parts of the system, then truly listening to what they have to say and acting on it.

VRUs have important roles in creating a shared and compelling narrative which mobilises, convenes and stimulates system actors by making sense of complexity and bringing together different strategies and visions to form a common purpose. Developing such a narrative requires the sharing and collective use of data and evidence, and developing a unified understanding of the problem and subsequent appropriate action to take. This takes time to develop.

VRUs can also empower others to view violence as their business by creating a shared sense of responsibility around violence prevention and reduction activity, in spite of the system’s current fragmentation.  A whole system response necessitates a cultural shift within society, so that all people understand the part they play within a violence prevention system.

The pandemic and recovery

The pandemic created unprecedented challenge for those working to reduce and prevent violence; impeding service delivery, increasing risk factors relating to violence and vulnerability and restricting the ability of VRUs to access partners or carry out face-to-face engagement with communities and stakeholders, and exacerbating the disconnect which can exist between different elements of the public services.  But the pandemic has also provided new opportunities such as the advances made in virtual connectivity via digital innovation, a new sense of unity, and a recognition that agencies and communities can work effectively together to tackle difficult issues.  

Conclusions

The introduction of VRUs is a paradigm shift towards greater local autonomy around violence prevention activity, and marks the beginning of a journey towards enhanced sector collaboration where risks are identified earlier, and vulnerable people are better supported by end-to-end services.  When practically applied, concepts of systems leadership can help system leaders to ‘become comfortable with chaos’ and enable them to extend public health principles across a system with otherwise diverging priorities and policy drivers. 

VRUs should lean into the diversity of opinion and expertise that exists across the system and find ways of connecting this up. Through analysis and insight generated via data, and the effective sharing of resources and knowledge with different sectors, VRUs have begun to foster a collective sense of both the challenge that faces their area, and the solutions to be acted upon. The direct mandate from the Home Office, coupled with flexible funding places them in an ideal position to corral partners around tangible change programmes. This serves a double purpose in that this as well as delivering activity for those in need, it also initiates engagement, and provides VRUs with an opportunity to influence and shape ways of thinking. VRUs can embody the principles of a public health approach to violence, and can make these tangible through carefully exercised systems leadership.

_________________________________________________________________________________

About the project

This research was a Master’s dissertation as part of the MSc in Public Management and Leadership, completed by Carl Binns, now a Senior Policy Advisor at the UK Home Office, and supervised by Dr Stephen Jeffares.

Further information on Inlogov’s research, teaching and consultancy is available from the institute’s director, Jason Lowther, at [email protected]    

Courtney Brightwell

Even before the rapid increases in fuel prices in 2021, schools across England faced a challenge to buy goods and services that represent value for money in terms of the price paid, quality of the product and its ease of access. The best deals, for example for energy, will often be beyond the reach of schools without significant procurement capability. 

This project explored how schools could save on their energy bills, which total over £600m per year in England.  This challenge is set to increase further as energy prices have risen to record levels in 2022, due to low levels of gas storage in Europe and lower pipeline imports from Russia, and the importance of gas-fired power stations. 

Key points

• The costs of energy are beginning to dominate school budgets and the lack of transparency and unpredictable nature of the size and frequency of bills prevents good financial planning. 
• The energy market is complex involving major energy suppliers on one side, and schools with limited market knowledge and experience on the other.
• Energy costs vary markedly between schools.  Median costs per pupils are highest amongst secondary schools, particularly in London (over £100 per pupil).  Primary schools pay much less (around £50 per pupil) and special schools much more (over £250 per pupil). 
• Schools often use energy brokers or their local authority, as they lack specialist understanding of the energy market.  Many are concerned whether these third parties are truly focussed on getting the school the best energy deal.
• Schools can save energy and reduce costs by improving the energy efficiency of their infrastructure and influencing the behaviours of staff and pupils.  This commonly includes the use of LED lighting, solar panels, and replacement boilers.  
• More can be done to help schools be intelligent buyers and users of energy.   Government could make it easier for schools to switch supplier and ensure more transparent pricing information. 
• There may be potential to develop a national aggregated energy deal for schools.

Background

Many school staff are concerned regarding how the costs of energy are beginning to dominate school budgets and that the lack of transparency and the unpredictable nature of the size and frequency of bills prevents good financial planning.  This research addresses the questions: “What problems do schools experience when buying energy?” and “Why do they experience these problems?”. 

The energy market is complex and includes many major suppliers who are large private companies, so the market quite starkly poses schools, often with limited market knowledge and experience, against large often multi-national companies.  It raised the question whether public funding to schools is being swallowed up in part by the exploitation of schools’ weak buying position.

Following a detailed literature review, interviews were completed with 11 School Business Professional staff from a variety of school types (e.g. local authority, academy, special and private) and education phase (primary and secondary).  In addition, national data on expenditure in over 20,000 schools was analysed.

What we knew already

The UK (along with the USA and Canada) has increasingly decentralised decision making in education from local authority to school level.  Interestingly the opposite trend can be observed in Southern and North West Europe and parts of Asia.

The existing literature shows that energy consumers are most likely to switch supplier for an improved deal in countries with more established liberalised energy markets, and where tariff calculators and customer ratings of suppliers are available.  The availability of the consumer having time available to search for savings is an important factor.  Barriers to switching include the complexity of energy tariffs, low attention to the issue of energy prices, expected costs of switching and lack of switching experience.  Many of the key challenges consumers face in securing a good deal are magnified in the school setting, since the business energy market does not offer fixed unit costs for energy, nor access to handy price-comparison tools.

Variations in energy costs

Analysis of the national dataset demonstrated that energy costs per pupils are highest amongst secondary schools, particularly in London (over £100 per pupil).  Primary schools pay much less (around £50 per pupil) and special schools much more (over £250 per pupil).  Regions such as London, the Northeast and Yorkshire & Humber pay more than some other regions.  Generally, there is little consistent difference between the spend of academies and LA maintained schools, nor between rural and urban schools.

Diagram 1:  Median per pupil energy spend in Secondary Schools – broken down by region and school type (2017-18)

How schools buy energy

Schools often look to outsource procurement expertise on energy through a broker or reverting to an external process which they regard as being robust.  Even Multi-Academy Trusts (MATs), more likely to have their own procurement capacity and capability, were not found to be running their own energy procurement processes. This may be because the school needs not just a procurement expert, but one who fully understand the energy market, which is too specialist a role to fit in within schools’ typical staffing structures.

The most common routes to market were through a private broker, a local authority or a LA established company; some schools instead use a Public Sector Buying Organisation.  Schools generally reported finding buying energy relatively easy, particularly when using a broker or local authority route, although many were not sure they had a good deal there were concerns that the incentives of brokers or LAs may not always match those of the schools (what academics call principal-agent differences). 

Energy companies can try to pressurise schools into signing contracts quickly, as this quotation from an interviewee in a MAT demonstrates:

it’s a very high-pressure environment for a business manager.  So, for example Gazprom with my 6th form college is just rolling over at the moment there’s no particular agreement in place. They e mailed me just the other day saying oh we’d be interested in chatting, so I just e-mailed back saying yeah that’s great – end of Covid we will start to look at this as I want to ensure I’m getting the best deal … we’ll be in contact. The next thing you know I’ve got a flurry of e mails from Gazprom saying that’s great, what we’ll do is get the deal together, we need it signed by the end of the day because we’re live pricing, so you need to sign the same day. I get a follow up the same day saying have I thought about it, are you ready to sign?… That is what business managers are dealing with from these energy companies.

(Participant 5 – Multi Academy Trust).

Reducing energy use

The relatively high variation in energy costs per pupil between schools is partly due to tariff differences and partly due to differing levels of energy use.  High costs could be due to the age of the building, its state of repair, the energy efficiency of its infrastructure, or the behaviours of staff and pupils. There are a range of measures a school could put in place to reduce its energy costs.

All schools in the project had undertaken some kind of activity in recent years and the most common were the use of LED lighting, solar panels, and replacement boilers.  

What can be done?

There are several ways schools could be supported to lower energy costs.  The National School Buying Service could provide support walking a school through the energy procurement process and advise them throughout the journey.   Schools who represent an outlier on energy spend could be supported to understand and take action on the underlying reasons for their high costs in terms of the efficiency of their energy infrastructure, their current energy deal or behaviours in school. Since the dissertation was written this service has started helping schools with energy procurements.

Government could consider intervening in the energy market with regulation to require energy providers to provide more transparent pricing to schools so that they are clear on what their future liabilities will be, or to make it very simple for schools to switch supplier quickly if they are not convinced they are accessing value.

There may be potential to develop a national aggregated energy deal if it delivers return on investment after factors such as support with meters and bill validation is factored in and if assurance can be gathered that the new deal would involve less cost to schools than the least costly energy deals currently in place.

Conclusions

There is potential to help schools save money by improving market regulation and procurement support, and individual schools can take steps to reduce significantly their energy use.

_________________________________________________________________________________

About the project

This research was a Master’s dissertation as part of the MSc in Public Management and Leadership, completed by Courtney Brightwell in 2020, supervised by Dr Peter Watts. 

Cllr Ketan Sheth

Stories of long waits for NHS treatment are rarely out of the news. I am only too mindful that behind those headlines are real people and families who rely on planned care, emergency treatment, and a complex mix of outpatient and specialist services.

In Brent and across north-west London, the number of people waiting for an orthopaedic operation, according to the NHS, has increased by around 30% since April 2022. Whilst procedures like hip or knee replacements are not usually considered to be time critical, waiting for treatment can severely affect a person’s quality of life. Many conditions can, indeed, worsen over time, making treatment and recovery that much harder.

There is, however, some good news for people living in north-west London who find themselves on the waiting list for orthopaedic operation.

In December, an Elective Orthopaedic Centre, a new purpose-designed centre of excellence for orthopaedic surgery, was opened at Brent’s Central Middlesex Hospital (CMH). Since CMH does not provide emergency care, any planned operation is far less likely to be postponed due to emergency pressures. 

The new centre is managed by London North West University Healthcare NHS Trust (LNWUH), in partnership with three other hospital trusts in north-west London. Between them, they manage 12 hospitals in north-west London, serving a very diverse population of 2.2 million across eight London boroughs.

The model of care that the new centre works to, is simple, but effective — wherever a patient lives in north-west London, their operation will now take place at the new centre. Care is overseen by the consultant from their local hospital, who are already well practised and expert in what they do, joins them at the new centre to do the operation on the day. The rest of their care — before and after operation — takes place at their local hospital, in their community, or online at home. 

But since CMH does not provide emergency care, might that be a concern for a patient if there are complications during an operation? Well, the evidence from, for example, the orthopaedic centre at Epsom Hospital, which has been running for the past decade and performs one of the largest numbers of hip and knee replacements operations, suggests that complications requiring emergency care are exceptionally rare. 

However, for many patients, CMH may not be the easiest place to get to and so free transport is provided for those who need it. Also, for these who prefers not to travel to CMH for their operation, some procedures will continue to be provided in their local hospitals, though the new centre will treat them quicker.

The new centre is, therefore, a fast-track surgical hub, dedicated to routine orthopaedic operations. As for patients with more complex needs, the NHS anticipates that they will also benefit from shorter waiting times as the new centre will free up capacity in other north-west London hospitals. With this model of care, it is expected that many more patients will be treated much quickly, have shorter hospital stays, a better experience and follow-up care.

As Chair of the North West London Joint Health Scrutiny Committee, I have seen an enormous amount of work that went into making the new £9 million centre a reality. Clinicians and other NHS staff from across the four trusts worked with GPs, residents, and other stakeholders to develop a detailed plan, including the funding model, affordability, capacity, faster and fairer accessibility, and length of stay. The plan was then subjected to rigorous scrutiny at my committee. Additionally, a further 2,000 individuals and organisations contributed to a public consultation.

Indeed, the four trusts worked in partnership with my committee. This ensured that organisational and geographical boundaries did not get in the way of our shared commitment to delivering equitable services and continuous improvements at scale for our residents across north-west London.

They could, of course, have looked at a hybrid model combining NHS and private care and it is arguable this would have more capacity. But the priority was clearly to get the new centre up and running quickly and negotiating a model like that would have taken time. I know many will welcome the model as it is, and it is clearly likely to make a difference for our residents. All this shows what can be achieved when different parts of the NHS, local government and residents come together, dare to challenge, and think differently. Addressing orthopaedic waiting lists will significantly improve many people’s quality of life. As we start 2024, that’s certainly some good news for people in living across north-west London.

Cllr Ketan Sheth chairs the North West London Join Health Scrutiny Committee