Public performance and delivery

Innovation in social care: it’s the how as much as the what

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Catherine Needham

People with personal budgets need to have something to buy. For some people the money will be spent on a personal assistant. But there will be lots of people who don’t have a big enough budget to employ someone, or don’t want to take on employer responsibilities. For them a more attractive option may be to buy some support from within the community. What budget-holders probably don’t have in mind is buying care slots from a big domiciliary care agency employing a high turnover workforce on zero hour contracts, replicating the local authority offer. The transformational stories that have spread about personal budgets have been based on people thinking much more creatively about the kinds of choices that budget-holders might want to make. Of course some people might want short visits from agency carers; plenty of self-funders already opt for that. But local commissioners of care services, particularly as they become market-shapers, need to ensure that 15 minute services aren’t simply chosen because there is nothing else to buy or nothing else that can be afforded.

One way to get more cost-effective and innovative services could be for commissioners to stimulate the growth of micro-providers: very small local care providers who keep costs low through minimal bureaucracy but who can find innovative ways to offer support. The Putting People First consortium has endorsed these micro-enterprises (employing 5 people or fewer) as a key element of the move to personalisation: ‘Micro social care and support enterprises established and managed by local people are in a good position to deliver individualised services and are vital elements of a diverse market’.

But is it true that very small organisations are more innovative and cost-effective than larger ones? The University of Birmingham is leading a project to evaluate the contribution that these micro enterprises make, testing if they outperform larger care providers in delivering services to users that are valued; innovative; personalised and cost-effective. We will be speaking to people who use services, and to carers, in micro, small, medium and large care providers, as well as to the providers themselves and the local authorities in which they are based.

The existing literature on scale and innovation is ambiguous: small organisations can be more versatile and lean, intimately knowing their customer-base and innovating quickly. On the other hand, large organisations have the inhouse expertise and the financial security to be experimental, utilising economies of scale. However existing studies have rarely looked at micro-providers (with 5 or fewer staff), as opposed to small organisations (classed as having 6-25 staff). Micro organisations may magnify the benefits of smallness, providing very personalised support to just a few people, and drawing on the ‘natural networks’ of the community to keep costs low. However micros may be more fragile than small providers, heavily dependent on one or two staff, and unable to participate in local tendering processes that are more accessible for small organisations.

A central issue for the research team is the extent to which micro-enterprises can become a new core offering for social care, or whether they offer creativity at the margins, for people who have the resources or imagination to step outside the domiciliary or residential mainstream. This links to the question of what kind of innovation is on offer from micro-providers: is it a what innovation, i.e. a new kind of support. Or is a how innovation: delivering ostensibly traditional services such as residential and domiciliary care in more personalised ways, being better attuned to what kind of support is being asked for, and developing more relational forms of support which utilise the assets of those being supported.

Some of the micro-enterprises supported by the national body Community Catalysts are very much offering what innovations. There is no obvious ‘old world’ equivalent of an animal-human therapy service or a bike-powered smoothie business, just two of the diverse services which Community Catalysts helped to get started. What innovations hit the headlines and help to generate excitement about how personalisation can break the mould of social care service-land. However it is the scope for process-based how innovations that constitute the most radical challenge to the mainstream of social care. People will continue to need help getting out of bed, getting washed and dressed; for some people residential care will continue to be the best place to get this support. If micro-enterprises are an affordable way to get the personalised, responsive, dignified,  domiciliary and residential support that we would all wish for our families, that will be a radical finding from the project.

For more details about the project please see the website or contact Catherine directly.

Catherine Needham is Reader in Public Policy and Public Management at the Health Services Management Centre, University of Birmingham, and is developing research around public service reform and policy innovation. Her recent work has focused on co-production and personalization, examining how those approaches are interpreted and applied in frontline practice. Her most recent book, published by the Policy Press in 2011, is entitled, Personalising Public Services: Understanding the Personalisation Narrative. Follow Catherine on Twitter: @DrCNeedham.

Could a lack of trust between professionals undermine health and social care integration?

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Catherine Mangan

The latest guidance on the health and social care integration transformation fund emphasises the need for ‘genuine commitment to partnership and recognition of the challenges’ to ensure success. We all know that successful integration will rely on genuine, positive relationships between health and social care professionals in the system. But are we taking these positive relationships for granted?

The early findings from iMPOWER’s Home Truths programme suggests that we are, and that we face some fundamental challenges around levels of understanding, and, ultimately, levels of trust between professionals in the health and social care sectors.

The original Home Truths report was published in September 2012 and suggested that GPs were inflating demand for residential care because they didn’t understand the alternatives and that by failing to address this issue, local authorities were failing to manage demand for residential care. Since then, six geographical areas have been working with iMPOWER to explore these issues further, with the University of Birmingham acting as a critical friend.  The sites have conducted surveys of GPs and older people, interviews and data analysis; culminating in an action plan. This week sees the launch of the interim evaluation report on the work of the six sites. The initial findings make for interesting, albeit uncomfortable reading:

  • Over half of GPs rated their relationship with adult social care as poor or unsatisfactory. 41% of GPs felt they could make a better assessment than social workers about a patient’s need for residential care.
  • On a more positive note, 92% of GPs wanted closer links with Adult Social Care staff to better understand local service offers and 76% of GPs said they could be helped to do more to intervene earlier to delay or avoid the need for residential care admissions.  A third of GPs felt that at least some of their patients who had gone into residential care had been admitted before they needed to be.
  • GPs lack knowledge and understanding about social care and prevention type services. Half of GPs who took part in the surveys knew nothing about telecare services (even though they were available in their area), whilst a third knew nothing about the available exercise classes or social support networks. Even where GPs do know about social care services there is a strong perception that these services are not good quality.

Sites also discovered that GPs have a significant influence on older people’s decision-making about care options, with the survey of older people showing that after family, most older people would turn to their GP for advice.  This is perhaps made even more significant by the finding that older people don’t pre- plan their entry into residential care, so may be turning to GPs in a moment of crisis.

For the sites these findings made difficult reading, but most of those involved admitted they had a ‘gut feeling’ about the problems. They have started to address the issues by developing a variety of approaches which aim to:

  • Improve communication about social care referrals
  • Improve access to information about social care services
  • Train GPs and consultants about social care services and processes
  • Embed joint working between social workers and GPs
  • Influence the influencers of older people’s decisions about care

For the sites involved, the Home Truths programme has acted a useful catalyst and provided a focus around which health and social care professionals can begin to converge. The work has acted as a first step in understanding and addressing the relational challenges of integration that lie ahead.

We suggest that all Health and Well Being Boards would benefit from thinking about how these issues might apply within their health and social care systems and ensure that alongside structural plans for integration, fundamental issues around trust and understanding are recognised and addressed.

The Home Truths evaluation report will be launched today at the NCAS conference #ncas and will be available at www.impower.co.uk.

Portrait of OPM staff member

Catherine Mangan is a Senior Fellow at INLOGOV.  Her interests include public sector re-design, outcomes based commissioning and behaviour change.  Prior to joining INLOGOV she managed the organisational development and change work for a not-for-profit consultancy, specialising in supporting local government; and has also worked for the Local Government Association, and as Deputy Director of the County Councils Network.  She specialises in adult social care, children’s services and partnerships.

Caught in the crossfire: local authority outsourcing and the murky world of employment law

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Ian Briggs

Given the extent of legislation affecting officers and members in local government, it can be rather misleading to see the influence of Westminster solely through the lens of direct local government legislation. Wider legislation on employment has arguably had as big an impact on the way that local government and local government services are delivered.

For councils the reshaping of delivery means, in the majority of cases, seeking partnerships with external providers. Where services are outsourced or delivered through contract, the costs associated with redundancy and passing over employment duties to others is an issue that perpetually causes debate and discussion.

The application of the Transfer of Undertakings (Protection of Employment) Regulations 2006 (TUPE) to transfers from the public sector, commonly known as ‘TUPE plus’, has been regarded as being more onerous on public sector employers than others. The Coalition Government has since 2010 gradually watered down these legal obligations but they are still regarded as problematic.

It is generally accepted that employment legislation is a problem area for local government and for many there is a desire to see a more flexible approach to employment. By implication, employment law is a matter that perhaps needs some review.

So, is this an issue that is shared in other places? The approach to employment practices that is enshrined in law across Europe raises some interesting issues. The media has made much of the economic problems in Greece, citing the high levels of protection afforded to civil servants and public employees there. The European Working Time directive is taken very seriously there; when the hours are worked the person stops and goes home! A similar situation exists in France and Italy, where anecdotal evidence suggests that even police officers, when they are part way through an arrest, have clocked off and gone home as their hours are worked.

The obligations of local authorities in a TUPE transfer are not entirely clear; TUPE plus has been significantly eroded but not removed altogether. In any future outsourcing situation, a local authority risks being caught in the crossfire between prospective contractors and trade unions. On the one hand, prospective contractors are likely to be reluctant to incur costs, offering generous employment benefits which go beyond the normal requirements of TUPE. On the other hand, the trade unions are likely to push for full-scale TUPE plus protection, or as close to this as they can realistically achieve. Any such situation is likely to need careful handling to minimise any potential exposure and legal advice should be taken wherever necessary.

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Ian Briggs is a Senior Fellow at the Institute of Local Government Studies. He has research interests in the development and assessment of leadership, performance coaching, organisational development and change, and the establishment of shared service provision.

A new response to the ‘jaws of doom’

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Catherine Staite responds to Local Government Chronicle’s anonymous ‘Insider’ columnist about the ‘jaws of doom’ and INLOGOV’s New Model of Public Services.

Dear Secret Chief Executive

I’m so sorry to hear you are having such a miserable time.  Leading in difficult times really does take it out of you. However, this isn’t like you – so buck up.  If you give way to despair, how will your staff cope?

You describe an impossible conundrum.  You have rising demands and falling resources – otherwise known as the ‘jaws of doom’.  You know that the solutions of the past aren’t going to solve the problems of the present or the future.  You need some new thinking.  The good news is that there is a lot of it available and much of it is pretty much free.

At INLOGOV, we’ve developed a model that you can use to re-think the way you meet your challenges. We’ve tested the model with many of your chief executive colleagues who’ve shared their time, insights and inspiration with us so we can offer something useful to you.  Our book ‘Making sense of the future: do we need a new model of public services?’ is available to download on our website. There are chapters on building better relationships, behaviour change and demand management, co-production and risk and resilience.  Chapters on collaboration and integration and on income generation will be added shortly.  The book is a gift from us to you.

In brief – here’s some of our thinking. You operate in a whole system. Changing the way you think and operate in one part of the system will have impacts elsewhere.  The old thinking – a focus on the deficits of individuals and communities, which placed councils and their partners in relationships of power over communities – doesn’t work anymore.  There isn’t enough money to be all things to all people  and perhaps it isn’t good to try to be.

staite 1

Here are some questions you might ask yourself:

  • Are we clear what the Council is for?  Do we know what we must do, what only we can do and what could be done as well or better by others?
  • Is political and officer leadership aligned and focused on shared ambitions? Can anyone I meet in the corridor tell me what those ambitions are? Now ask a few people in the street what matters to them and see if there is a strong match.
  • Do we have strong relationships with our communities? If not – what can be done to foster better relationships?
  • Are our services building confidence, capacity and resilience – or perpetuating  dependency?
  • Do we encourage and support co-production? Could our residents do more for themselves and others? Do we make the best use of volunteering to enhance lives and maintain services e.g. libraries, in our communities?
  • How do we recognise and build capacity in individuals and communities?
  • Do we understand the pattern of demand? Have we managed out waste and the demand  which is driven by service and communication failure, not need?
  • Do we invest in early intervention and prevention?
  • Do we understand how we need to change perceptions and influence behaviour to improve lives and deliver better outcomes?
  • Are we maximising income and using prudential borrowing as leverage for income generation and growth?

You might  think about creating a virtuous circle like this:

staite 2

If you can sew braid onto your daughter’s skirt, then the people you serve can also make a contribution to their own welfare and that of others.  Give them access to braid and sewing lessons and then let them adapt their own metaphorical skirts. If you can do it – so can they.

Catherine Staite

Catherine Staite is the Director of INLOGOV. She provides consultancy and facilitation to local authorities and their partners, on a wide range of issues including on improving outcomes, efficiency, partnership working, strategic planning and organisational development, including integration of services and functions.

This post was originally featured in Local Government Chronicle, September 2013.

The role of social value outcomes in commissioning services

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William Jabang

A contract culture has become widespread in public services, but the question often asked is: is ‘price’ alone a satisfactory mechanism for deciding what is done and by whom? The very meaning of ‘value’ has been dominated by the notion of price. In many organisational settings, price is seen as the most obvious way of gauging contract performance, as well as the means by which to judge efficiency.

However, many have questioned this approach and successive governments have sought to widen the debate by bringing forward policies that go beyond price as a mechanism for deciding what has to be done and how. This could be best illustrated by the ‘Best Value’ regime that emerged in the latter part of the twentieth century and still places a duty upon public services to seek best value – where price alone is seen as restrictive in ensuring that services match with what the public actually wants and needs.

This has brought with it certain difficulties and challenges that many public sector managers and elected members have experienced. However, the search goes on for policies and legislative instruments that help bring the public’s needs and requirements closer to an institutional decision-making mechanism that looks beyond price to ensure that what the public value is in line with what they get. Few citizens take the time to investigate the actual cost (in price terms alone) of contracts that are led by public bodies. Eric Pickles took the lead in expressing his desire to have an ‘army of armchair auditors’ scrutinising the books of public bodies after the 2010 General Election, though little evidence beyond the activity of the Tax Payers’ Alliance exists to support this desire.

Many public service managers will have been exposed to the debate introduced by Mark Moore some years ago on the concept of ‘Public Value’ – an interesting line of thinking that has occupied academics for some years now. The next step in this journey has now been taken. On 31st January 2013, the Public Services (Social Value) Act came into force in Engaldn and Wales (although its application to Wales is limited). The Act provides a new statutory requirement for public authorities to consider the economic, social and environmental wellbeing of the local area when commissioning or procuring services.

Consideration of social value is generally not promoted in the existing design, process and delivery of procurement. A recent survey carried out by Guardian Professional indicates that many procurement and commissioning staff feel they don’t even have the skills and training needed to carry out social value commissioning and procurement effectively.

Given the relatively short time for which the Act has been in place, it could be argued that it is too early to assess its full impact on procurement design, process and delivery. However, an appraisal of the level of awareness and degree of implementation of the Act by the public and voluntary/community sector could be important, providing a useful pointer to the potential effectiveness of the Act and the outcomes it could deliver.

In view of this, INLOGOV is working together with the Society of Procurement Officers (SOPO), the National Association for Voluntary and Community Action (NAVCA) and the Association of Chief Executives of Voluntary Organisations (ACEVO) to carry out a survey. The survey aims to:

  1. Examine the awareness and perception of the Public Services (Social Value) Act 2012
  2. Identify changes (if any) which organisations are making as a result of the Act
  3. Establish whether or not the Act has opened up (or is likely to open up) more contract opportunities for voluntary, community and social enterprise organisations (VCSEs)
  4. Establish whether cost is a deterrent to pursuing social value outcomes.

We would appreciate it if you could provide us with your views by completing one of our survey questionnaires. The survey findings will be published jointly by the four organisations named above. It is the aim of the researching organisations that the information from this survey will help to improve existing practice and will enhance the sharing of knowledge between organisations.

The survey is likely to take approximately 15-20 minutes and all information provided will be held in strict confidence – and will be recorded and stored in accordance with the Data Protection Act 1998.

Please click to complete either the Voluntary, Community and Social Enterprise organisations questionnaire; or the Public Sector/NHS organisations questionnaire.

Thank you for taking part.

William Jabang is a Doctoral Researcher at INLOGOV. His PhD research is focused on commissioning and procuring social value.

Fracking: the latest challenge in the Tory heartlands

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Martin  Stott

The hot days of July finally saw the debates around the implications of ‘fracking’ of unconventional hydro-carbons in the UK reach out and grab the attention of the national media. As Tory grandee Lord Howell called for the process to be focussed on the ‘desolate North’ (he corrected the initial impression that he was referring to the North East by saying that he really meant the North West) and  Energy Minister Michael Fallon was reported in the Mail on Sunday as warning that fracking was likely to face fierce resistance from the middle classes in Conservative heartlands, as if to prove his point dozens of protesters were arrested at an exploratory drilling site near the village of Balcombe in West Sussex.

Hydraulic fracturing or fracking – the process of drilling and then injecting fluid into the ground at high pressure to  fracture shale rocks to release natural gas, has caused a revolution in energy policy in the USA where gas prices have dropped dramatically as gas from fracking particularly in North Dakota, and more controversially Pennsylvania, has come on stream. Coal has suddenly seemed a dirty and expensive option and as a consequence carbon emissions from the world’s biggest economy have dropped significantly.

Can the trick be repeated in the UK? The Coalition Government is betting the farm –  quite a  few farms actually – that it can. Chancellor George Osborne announced in this year’s Budget that fracking companies would receive tax allowances for developing gas fields and would be able to offset expenditure on exploration against tax for ten years.The next tax avoidance scandal perhaps. Best known and a pioneer in the field is Cuadrilla (referred to by some opponents as ‘Godzilla’) whose explorations in Lancashire have amongst other things led to a couple of minor earthquakes near Blackpool in April and May 2011. But there are quite a few other companies across the country as the official estimate for UK reserves is 37 trillion cubic metres of shale gas in the north of England and geologists have yet to quantify reserves in the south.

But it is Balcombe in rural West Sussex which is becoming the test bed for what this means for energy experts, planners, campaigners and politicians. Campaign group Don’t Frack with the Fylde certainly raised the issues and those earthquakes, 1.5 and 2.3 in magnitude respectively, shook confidence in the safety of the technology (let’s face it: who notices in North Dakota where the  nearest house is 60 miles away?) but the opposition in southern England is having a greater impact on politicians and opinion formers. The Mail on Sunday’s  report of Sevenoaks MP Michael Fallon’s private briefing on fracking reported him as saying of potential well-heeled protesters ‘We are going to see how thick their rectory walls are, whether they like the flaring at the end of the drive.’ He admitted that exploratory drilling was likely to spread the length and breadth of southern England saying ‘The second area [after the North West] being studied is the Weald. It’s from Dorset all the way along through Hampshire, Sussex… all the way a bit into Surrey and even into my own county of Kent.’

This focus on the lusher parts of the South East which has started at Balcombe is going to be a real concern for Conservative strategists. The ‘Noting Hill set’ has repeatedly been accused of ignoring its rural base as proposals ranging from the sell-off of forests, to wind farm policies, changes in planning laws, opposition to which has been championed by the Daily Telegraph, and the HS2 rail route through the Chilterns have all been seen as a slap in the face for this rural base, many of whom have gravitated towards UKIP. But the Greens too have a presence in the South East, with their charismatic MP Caroline Lucas representing a Sussex seat, an MEP for the region and their only council, Brighton and Hove, only a few miles away.

Meanwhile up in Whitehall, the Department for Communities and Local Government has been ruminating on what to do about the planning and land use implications of promoting the fracking revolution and on 19 July it spoke,  issuing guidance  to local planning authorities. The guidance stresses that fracking could be a vital source of energy, saying ‘Mineral extraction is essential to local and national economies… minerals planning authorities should give great weight to the benefits of minerals extraction including to the economy when determining planning applications.’ It goes on to explicitly exclude any attempts by planning authorities to trade off fracking with renewable developments saying, ‘Mineral planning authorities should not consider  demand for or consider alternatives to oil and gas resources when  determining planning applications.’ Because of the scale and strategic nature of minerals planning applications these have remained a planning function of county councils, still Tory controlled in southern England.

It  remains to be seen if DCLG will allow a level of discretion in determining these applications by county planning authorities which could well limit or even stop fracking in its tracks in the south, or whether  as would be possible using potential secondary legislation  under the Growth and Infrastructure Act, it could take applications for  fracking for shale gas  out of the hands of county councils and instead have them decided by the Secretary of State as  part of the regime for nationally significant infrastructure projects. On the one hand it could bow to Tory pressure in the shires and allow all the developments to happen ‘up north’ by default as counties refuse most if not all applications. On the other, it may decide to take the risk, strip counties of their power and pull shale gas development permissions back into Whitehall. Only time, and a bit of local politics in the home counties, will tell.

stott

Martin Stott joined INLOGOV as an Associate in 2012 after a 25 year career in local government. He is National Policy Adviser on minerals planning for the Royal Town Planning Institute.