NHS that involves and listens to local people is in all our interests

Cllr Ketan Sheth

Readers may be aware that the way in which the local NHS is run is likely to see big changes in the months ahead. Part of the NHS Long Term Plan is for local NHS bodies in each area to work in partnership with local councils as part of an ‘Integrated Care System’ (ICS). In North West London, this will mean a huge partnership across eight boroughs, including Brent – my Local borough. It may also mean a merger of the eight clinical commissioning groups (CCGs) across these areas into a single CCG for North West London (subject to a vote of GPs in each borough).

NHS leaders assure us that this is not a change to services, but to how their staff are organised. They say that any changes that are proposed under the new working arrangements will be subject to the same – or more – consultation and scrutiny. We need to hold them to this promise. The biggest concern for me, as a Brent councillor, is that the voice of Brent residents is not lost in a new system covering a huge geographical area (the North West London ICS and the single CCG would be the biggest in the country).

At a recent Joint Overview and Scrutiny Committee, we had the chance to question managers and GPs about the single CCG merger. There were certainly encouraging words about their future approach to involving local people in shaping health services. They have put in place a new programme, rather grandly called ‘EPIC’ (Engage, Participate, Involve, Collaborate), which they say is a direct response to the challenge of maintaining the voices of local residents in a much bigger system.

Working with local patient groups and Healthwatch organisations, they are co-producing an ‘Involvement Charter’ setting out how the public can get involved and setting standards we can hold them to. They have expressed a commitment to strengthening the current approach and involving more people, reaching deeper into our communities than ever before. They have promised to work with councillors and others to reach the most vulnerable and isolated people, who the NHS does not have a good track record of engaging. And alongside this ‘qualitative’ engagement, they have set up a 4,000-strong Citizens’ Panel, representative of local communities, allowing them to test public opinion through surveys and focus groups on a range of issues.

The programme is ambitious and no one could argue with its stated objectives. But as ever, the proof of the pudding is in the eating. The NHS is facing big challenges right now, not least in getting services up and running again in the wake of Covid-19. Getting public engagement right is going to be more important than ever. If this programme really does see a step change in how the local NHS works with our residents – and most importantly, if it acts on what people tell them – it will have my support. My message to NHS colleagues is simple: the goals you have set out are welcome, but we will need swift and tangible evidence that things are really changing for the better. The National Health Service that involves and listens to local people is in all our interests.

 

ketan

Cllr Ketan Sheth

Chair, Brent Council Community and Wellbeing Scrutiny Committee

Local Government and the NHS Integrated Care System

Cllr Ketan Sheth

For those councillors in local government who scrutinise the NHS, it seems to have become an expectation that as one great change ends in our local health services, another begins.

A good few years ago in north-west London we saw the start of the Sustainability and Transformation Plans (later rebranded as Sustainability and Transformation Partnerships) or STPs as they were widely called. Now it seems another change is on the way. By April 2021 an Integrated Care System (ICS) will have been introduced, taking forward much of what was developed by the STPs. And, they are coming at a time of incredible change for the NHS and local government as a result of dealing with the Covid-19 pandemic.

I’m sure many of you are familiar with an ICS. If I had to summarise, I would say they are in essence bringing together health providers and commissioners, along with local government, to plan healthcare based on local population health needs in a defined geographical area. I’ve noticed the term ‘place’ features frequently in the NHS documentation and published reports. I should say as well, that the underpinning and thinking for them is all set out in the NHS Long Term Plan. In a few areas such as Greater Manchester, they started in 2018, and more have been set up to the point where around half of England’s population is now covered by an ICS.

As for my local proposed ICS, this will be cover around 2.3million residents across eight London boroughs in north-west London stretching from Westminster out to Hillingdon, with multiple providers, and community healthcare Trusts as well, and not to forget, the local authorities. At the moment, each borough has its own clinical commissioning group (CCG), but the plan is for one CCG to cover the whole area as well (but that development is best discussed at another time) across the eight boroughs.

So, what I want to address here is this – how does an elected member sitting on an overview and scrutiny start to grips with effectively reviewing and holding to account the development of a ‘system’ of such complexity, and in the constraints of the time and resources we all know elected members face? What should our starting principles be? It’s not easy to answer, but I have a few suggestions.

As an elected member, I don’t necessarily need to worry about being a ‘systems thinker’ but I do like to test the local ICS thinking constructively. I would perhaps ask this – thinking about the ordinary residents in my ward what will it deliver for them? What will an ICS do to make them and their families and children healthier, and be able to live longer and with a better quality of life? Ultimately, for me that’s what organisational systems in our public services should be about. Simply, a means to an end of delivering something better for ordinary people and our communities.

Also, while we talk about ‘systems’ in health services, let’s not forget that when we refer to hospitals in particular we are talking often about important local institutions which command a lot of local pride and attachment; not just because of the services they provide, but because of the outstanding research they do. Also, in my home borough of Brent, they are important local employers. I think this way of looking at the world from the grassroots should not be lost in these changes.

So that’s a few ways we can start to get to grips with such a big change, and complexity. Then it might be time to prepare for the next one, whatever that may be.

 

ketan

Cllr Ketan Sheth

Chair, Brent Council Community and Wellbeing Scrutiny Committee

Central Government, Evidence and Short-Term Strategies in the Support to Businesses and Local Economic Recovery in the Age of Covid

Tom Collinson

If there has been one mantra by which government policy has claimed to have lived by during the COVID-19 crisis, it is that it has been led by, guided by or that it is following the science. Intended to strike a reassuring tone, the claim to evidence was routinely emphasised by the government as either the Prime Minister or a deputy was flanked by a member of SAGE. When questioned on his previous disavowal of experts by Sky News at the beginning of the crisis, the Chancellor of the Duchy of Lancaster, Michael Gove, noted that these were economists he had referenced in the past, it was not established medical facts; suggesting that this time was different and that this science was different.

One article by the New York-based magazine The Atlantic even went so far as to claim that ‘Britain Just Got Pulled Back from the Edge’ as ‘the institutions and positions of state were…clicking into gear.’ While it appeared to be a rosy picture at the start, with the government publishing the scientific advice online, with a gesture that it would continue to do so, this tone quickly unravelled as the Guardian reported that non-scientists seemed to be advising government; there was no list of who exactly was in the SAGE group and why there were no (publicly available) minutes of the meetings and government advice was no longer transparent. Some of this has now changed.

All this has provoked an interesting question of the relationship between science, evidence and data-analysis with policy-making in the UK. How does one affect the other? Is it possible for one to distinguish between various forms of evidence in the policy-making process and make a judgement on which is the most appropriate? To distinguish between mathematical modelling, so-called evidence-based policy-making (that which traditionally elevates the role of Randomised Controlled Trials) and place-and-people contextualised policy? Is it possible to have what Kant called a constitutive judgement in public-policy? (I.e. a judgement which is not based on any further assumptions, hypothetical conditions or suppositions, such as values, narratives and aesthetics). For the past decade or so, there has been a growing literature on all of these questions and the urgency of the current pandemic has enlivened them.

These questions are of increasing interest to academics, journalists and opposition parties in the Anglosphere. With regards to the United Kingdom, the establishment of an ‘Independent SAGE group’ has been indicative of some dissent from the government’s claim to scientific unity.

For local government, these issues have taken on another interesting dimension, one that examines the relationship between governance and the collection and application of evidence in policy responses. In a report on the global picture of city-governments, the OECD has distinguished between two types of evidence-led responses. The first discusses local governments as instruments or ‘implementation vehicles of national measures such as confinement’. The second acknowledges the experimentation of ‘more bottom – up, innovative responses while… building on their unique proximity to citizens.’

Building on this insight, we can begin to describe a temporal framework, which provides further detail to the OECD’s report on the times when local government have been able to articulate their own evidence-based response and when the information and decision-making lies more in the hands of central government.

While it is still unclear where we are on the timescale of the virus or the response to it – which indeed make the articles in this post preliminary – this framework can be outlined on the basis of the short, medium and long term response to the epidemic. Such an approach is based on how councils themselves are articulating a response (using similar language such as the ‘rescue’, ‘recovery’, ‘rebuild’ or, ‘hammer’, ‘dance’ and ‘reconstruction’ as distinct phases in the plans).

Categorising policy responses in this way has a lot of precedent in the field of economics. With regards to the economics of a crisis, the same typology has been outlined by Professor Andy Pike, who’s presentation to the ‘Major Economic Shocks Workshop’ at the What Works Centre for Local Economic Growth addresses the types of policy responses available with regards to the local economy, businesses, supply chains and labour markets in the three different time periods. The important point here is that in the short-term responses are direct, and contingent on the problem, whereas long-term responses are open-ended and rely on change. Short-term employment issues for example are addressed through subsistence allowances, while (re)training and entrepreneurship should be leveraged in the long-term. The same applies to supply chains; the short-term goal is to secure capacity and jobs through say refinancing, while in the long-term diversification and innovation is required.

Focussing on short-term strategies during the current epidemic and lockdown, the measures taken have exhibited the direct qualities that Pike addresses. However, these have often been delivered by way of decisions and information collected in the devolved governments and Downing Street. While there have been ongoing efforts by local authorities to assess immediate likely impacts – as seen in Cardiff and the West Midlands – the role of councils has largely been to act as something of a lightning rod (or courier, depending on how you judge their efficiencies) for UK government policies. While there has been some contestation around these matters from local councils, for example in the early closure of parks, the wide picture has been one of convergence throughout the country in a number of areas of practice, including areas of communication and awareness rising, social distancing, confinement and taking targeted measures to help vulnerable groups. In many cases, this has been guided by national government regulations and the ‘dos and donts’ policy responses, financial backing of £3.2bn to be awarded to councils in England to ensure a continuation of services, as well as some financial restrictions or ring-fencing.

The reliance on central government publications and financial backing has characterised the issue of supporting businesses and economic recovery too, where councils are in the front line for conducting policies made primarily in London but also Cardiff, Edinburgh and Belfast. While there may be some differences between the England and the devolved assemblies – for example on the differences in the administration of business support in Wales and England, or the degree of discretion councils are exhibiting when it comes to business support, the general theme of subsistence pay to employees, business relief and grant funding through councils has taken the same shape throughout the country, as we can see from the following examples:

  • In England, the business relief announced by the Chancellor is being paid for by councils through the Small Business Grants Fund and the Retail, Hospitality and Leisure Grant Fund, and reimbursed to local authorities should the guidance published by the MHCLG be followed.
  • There is £6 billion in local authority payments of the Central Share of retained business rates that were due to be made over the next three months.
  • A £500 million Hardship Fund ‘of new grant funding to support economically vulnerable people and households in their local area’ administered through existing ‘local council tax support schemes’.
  • In Wales, the Welsh Government are offering a years relief on business rates to shops, leisure and hospitality businesses, and also offering small grants. Local councils are calculated to have distributed £508m to 41,000 businesses by the end of April.
  • In Scotland, Local Authorities are administering Small Business Support Grants as well as Retail, Hospitality, Leisure Support Grants of up to £10,000 and £25,000 respectively.
  • Similarly, in Northern Ireland a grant scheme of £25,000 for Retail, Hospitality, Tourism and Leisure has been offered, should the criteria outlined by the Northern Ireland Executive be followed.

In one of the foundational texts of modern political science, Alexis de Tocqueville describes the governance structure of the ancien regime, whereby all administrative corridors in French political life led back to the King. Intendants hired by a King to administer a province in-turn hired a sub-delegate to administer canons, where the happiness or misfortune of individuals depended entirely on ‘the whole operation of the central government’. The argument for arranging matters in this centralised manner was a financial one – to levy taxes in order to guarantee the State’s safety. But this ultimately led to the downfall of the regime itself. While I’m not comparing the UK Government to the House of Bourbon, modernity offers a number of examples where centralisation – justified because of finance and security – tends towards political and social disintegration. Further examination will do well to determine whether there is a different path forward in the long-run response to this crisis.

 

Tom is a postgraduate researcher with an MA in Political Thought and a BSc in Economics and Politics from the University of Exeter. His main research interests are in modern political thought, with particular expertise in the political philosophy of Hannah Arendt and Karl Jaspers, on whom he wrote his thesis, rethinking the concept of political participation and civic action in modernity. Tom is now researching the role of local and central government responses to the Covid-19 pandemic, inspecting how they complement and contrast one another. He tweets at @tzcll.

The success of Police and Crime Commissioners in drug harm reduction in the West Midlands

Megan Jones

Police and Crime Commissioners (PCCs) were introduced in 2012, (2011 Police Reform and Social Responsibility Act), representing one of the most radical changes to governance structures in England and Wales. PCCs are directly elected by the public and their statutory functions require them to (1) hold their own police force to account on behalf of the public, (2) set the policing priorities for the area through a police and crime plan and (3) appoint a Chief Constable.

They replace the former Police Authority committee style structure, which was criticised for their lack of visibility and accountability to the public and communities they were designed to serve. The emergence of PCCs was therefore a result of the failings of the previous governance mechanism and a political shift of focus from national to local governance.

In my research, I look at the impact that PCC governance has on drug policy, using the West Midlands police force area as a case study. Drugs policy, and specifically a harm reduction approach*, is just one area of policing and priorities that was used to explore the statutory role of PCC and more broadly, how the role can be interpreted or used wider than its statutory framework.

In August 2019, the latest drug-related death figures were announced by the ONS. They are now the highest on record, with 4,359 deaths in England and Wales recorded in 2018 (ONS, 2019). In the West Midlands, there is a drug-related death every 3 days (West Midlands PCC 2017a). Over 50% of serious and acquisitive crime is to fund an addiction and the cost to society is over £1.4 billion each year (West Midlands PCC 2017a). This topic often divides opinion and can be politicised. However, these debates rarely prevent the considerable damage caused by drugs to often very vulnerable people and wider society. The official national response is focused on enforcement of the law, criminalising individuals for drug possession.

By interviewing a number of key actors within the drug policy arena and as leaders in policing both within forces and PCC’s offices, I looked at how the PCC structure can enable a change in policy. This was combined with desk-based document study of public available document into the drugs policy approach taken in the West Midlands. Four key themes were explored: the statutory role of the PCC; the individual PCC; governance and public opinion; and the approach taken.

My results showed that the PCC role and this new form of civic leadership benefitted from: convening power and their ability to draw upon key partners from across the public sector, lived experience, and third sector. This is an informal mechanism of governance strengthened by public mandate. PCCs have the ability to prioritise by setting their strategic priorities in the police and crime plan. For example, in the West Midlands, the approach to drug policy has been narrowed to focus on high harm drugs (heroin and crack cocaine), thus ensuring ‘deliverability’. This means that limited resources available are more narrowly focused and can have a greater impact. The statutory role of a PCC allows work at pace and decisions to be made quickly, which means that trial and pilot new approaches and innovations.

Of course, there are limitations. PCCs vary across the country and often do not speak with one voice, particularly on drug policy. There are also huge advantages of a good working relationship between Chief Constable and PCC, demonstrated through the joint approach in the West Midlands.

Figure 1: Drivers to drug policy, derived from the findings

My research allowed me to concluded that three key drivers are optimum for delivery of a PCC-led harm reduction approach: using the levers at their disposal, such as the statutory functions, and informal governance mechanisms, such as convening power, which are able to provide the strategic and political coverage required to deliver at pace.

PCCs are unique in the landscape of UK governance and whilst weaknesses in mechanisms designed to reign in their power could be viewed as worrying, in the drug policy space this has allowed for the development of a new approach in the West Midlands, one that is evidence-based and has the ability to save lives, reduce costs and reduce crime.

The potential of PCCs is arguably still being explored, but their ability to test new approaches and work effectively with partners will be essential in other areas of policy, such as the response to serious violence and the potential for an increasing role across the criminal justice system.

PCCs have a number of levers at their disposal, and are able to use informal and formal governance mechanisms to foster real change at the local level and drive forward evidence-based policy.

Megan Jones is the Head of Policy for the West Midlands Police and Crime Commissioner and is a former INLOGOV student, studying on the MSc Public Management programme. She tweets at @MegJ4289.

 

What Do We Miss out on When Policy Evaluation Ignores Broader Social Problems?

Daniel Silver and Stephen Crossley

With local government funding being stretched to breaking point over the last decade, it is more important than ever to know whether investment into policy programmes is making a difference.

Evaluation draws on different social research methods to systematically investigate the design, implementation, and effectiveness of an intervention. Evaluation can produce evidence that can be used to improve accountability and learning within policy-making processes to inform future decision making.

But is the full potential of evaluation being realised?

We recently published an article in Critical Social Policy that demonstrated how the Troubled Families programme evaluation remained within narrow boundaries that limited what could be learnt. The evaluation followed conventional procedures by investigating exclusively whether the intervention has achieved what it set out to do. But this ‘establishment oriented’ approach assumes the policy has been designed perfectly. Many of us recognise that the Troubled Families programme was far from perfect (despite what initial assessments and central government announcements claimed).

The Troubled Families programme set out to ‘turn around’ the lives of the 120,000 most ‘troubled families’ (characterised by crime, anti-social behaviour, truancy or school exclusion and ‘worklessness’) through a ‘family intervention’ approach which advocates a ‘persistent, assertive and challenging’ way of working with family members to change their behaviours but, crucially, not their material circumstances.

Austerity, mentioned in just two of the first phase evaluation reports, was not considered as an issue that might have had an impact on families. Discussions of poor and precarious labour market conditions, cuts to local authority services for children, young people and families, and inadequate housing provision are almost completely neglected in the reports. Individualised criteria such as ‘worklessness’, school exclusion and crime or anti-social behaviour were considered but structural factors such as class, gender, and racial inequalities were not; nor were other issues such as labour market conditions, housing quality and supply, household income or welfare reforms.

The first phase outcome of ‘moving off out-of-work benefits and into continuous employment’ did not take into account the type of work that was secured, or the possible impact that low-paid, poor quality or insecure work may have on family life. Similarly, the desire by the government to see school attendance improve did not necessarily seek to improve the school experience for the child, and there is no evidence of concern for any learning that did or did not take place once attendance had been registered. Such issues were outside of the frames in which the policy had been constructed and so were considered to be outside of the boundaries of investigation for the evaluation. The scope for learning was therefore restricted to within the frames that had been set by national government when the programme had been designed.

So what can be done?

While large-scale evaluations of national programmes will still take place, local councils can add to these with independent, small-scale evaluations. These can adopt a more open approach that examined what happened locally and contextualise the programme within the particular social problems that residents experience.

A more contextualised form of evaluation can broaden the scope of learning beyond the original framing of a policy intervention. Collaboration between councils and participants who have experienced an intervention through locally situated programme evaluations can explore people’s everyday problems and the tangible improvements that have been delivered by an intervention (and what caused these outcomes to happen). Such an approach with ‘troubled families’ would recognise the knowledge, expertise and capabilities of many families in dealing with the vicissitudes of everyday life, including those caused by the government claiming to be helping them via the Troubled Families programme. Analysis of the data can be used to identify shared everyday problems and narratives of impact that show improvements to people’s everyday lives. By building up a picture about what approaches have been successful, an incremental approach to improving policy and culture within local institutions can be developed – based on the ethos of learning by doing.

In addition to learning about what works, we can also develop our knowledge of what problems have been left unresolved. Of course, no single policy intervention can possibly solve every dimension of our complex social problems. This does not necessarily mean a failure of the intervention, but rather that there are broader issues that need to be addressed. Knowing about these issues can produce useful evidence to find out about social needs in the local community that are not being met, and which the Council might be able to address or use the new knowledge to inform future strategies.

Evaluation is often seen as a bolt-on to the policy-making process. But re-purposing evaluation to learn more about social problems and the effectiveness of tailored local solutions can create evidence and ideas that can be used to improve future social policy.

 

Daniel Silver is an ESRC Postdoctoral Fellow in the Institute of Local Government Studies (INLOGOV) at the University of Birmingham. He previously taught politics and research methods at the University of Manchester. His research focuses on evaluation, social policy, research methods, and radical politics.

Stephen Crossley is a Senior Lecturer in Social Policy at Northumbria University. He com- pleted his PhD from Durham University examining the UK government’s Troubled Families Programme in August 2017. His most recent publications are Troublemakers: the construction of ‘troubled families’ as a social problem (Policy Press, 2018) and ‘The UK Government’s Troubled Families Programme: Delivering Social Justice?’, which appeared in the journal Social Inclusion.

Troubled Families: How Experimenting Could Teach Us “What Works?”. Part 2.

Jason Lowther

In my last blog I looked at how designing a more experimental approach into this and future programmes could yield lots of insight into what works where. This week I would like to extend this thinking to look at how “theory-based” approaches could provide further intelligence, and then draw some overall conclusions from this series.

As well as rigorous analysis of quantitative impacts, theory-based approaches to evaluation can help to test ideas of how innovative interventions work in practice – the “how?” question as well as the “what works?” question[1].

For example the Troubled Families practitioners might have developed theories such as:

  • Having consistent engagement with a key worker, and working through a clear action plan, will increase families’ perception of their own agency and progress.
  • Having regular and close engagement with a key worker will enable informal supervision of parenting and reduce risk around child safeguarding concerns.
  • Having support from a key worker and, where needed, specialist health and employment support, will increase entry to employment for people currently on incapacity benefit.

Interestingly each of these appears to be supported by the evaluation evidence, which showed much higher levels of families feeling in control; lower levels of children in need or care; and reduced benefits and employment (compared to controls).

  • Having consistent engagement with a key worker, and working through a clear action plan, will increase families’ perception of their own agency and progress. The evaluation showed almost 70% of TFP families said they felt “in control” and their worst problems were behind them, much higher than in the “control” group of families.
  • Having regular and close engagement with a key worker will enable informal supervision of parenting and reduce risk around child safeguarding concerns. The TFP “final synthesis report”[2] shows the number of children taken into care was a third lower for the TFP families than for the “control” group (p.64).
  • Having support from a key worker and, where needed, specialist health and employment support, will increase entry to employment for people currently on incapacity benefit. Again, the final synthesis report suggest that the weeks on incapacity benefit for TFP families was 8% lower than the controls, and the entry into employment 7% higher (pp.56-57).

 

The TFP evaluation probably rightly writes off these last few examples of apparent positive impacts because there is no consistent pattern of positive results across all those tested. Given that the evaluation didn’t attempt to test particular theoretical hypotheses like this, it is possible that they have occurred through natural random variation. But if a much more targeted search for evidence built on theory delivered these results consistently, that would be worth celebrating.

Next week I will conclude the series by reflecting on the four key lessons we can learn from the TFP evaluation experience.

[1] See Sanderson, I. (2002) ‘Evaluation, policy learning and evidence‐based policy making’, Public administration, 80(1), pp. 1-22. And White, M. (1999) ‘Evaluating the effectiveness of welfare-to-work: learning from cross-national evidence’, Evaluating Welfare to Work. Report, 67.

[2] https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/560499/Troubled_Families_Evaluation_Synthesis_Report.pdf

 

lowther-jason

 

Jason Lowther is a senior fellow at INLOGOV. His research focuses on public service reform and the use of “evidence” by public agencies.  Previously he led Birmingham City Council’s corporate strategy function, worked for the Audit Commission as national value for money lead, for HSBC in credit and risk management, and for the Metropolitan Police as an internal management consultant. He tweets as @jasonlowther