Last week we discussed how today, and increasingly every day, we hear more stories about a failing Health and now Social Care system. We start from an assumption that there is enough public money in the system to support those who are most vulnerable and the creative thinking about how to use this money better is effectively being masked by the Mexican standoff between the NHS and Treasury over additional funding. That is not to say however, that there does need to be a substantial cash injection into Health and Social Care if this proverbial oil tanker is to change course.
We’ve outlined the five areas that we believe need to be addressed together in order to start to make in roads into these problems. These are:
- Budgetary and structural divides
- No Real Evidence
- Supporting Social Workers
- Identifying real risk and mitigating it
In this update, we will discuss the second and third of these areas – namely, no real evidence and commissioning.
No Real Evidence
There is a mass of anecdotal evidence outlining the benefits of more independent living and how this can help reduce the pressures in health and social care. This is backed up by a number of qualitative studies, most recently ‘Social Care for Older People: Home Truths’ by Richard Humphries et al, which reinforce that message and the Government’s objective to support people living at home. It is not the lack of evidence but confidence in decision making that prevents the focus on those activities which create more independent living.
Rather than focussing solely on ‘high-quality’ interventions for a few, there needs to be a focus on getting as many people as possible doing the right things for themselves. Looking at prevention programmes from a cost per head perspective puts this point into sharp relief. The challenge is what can system leaders do to use all of the assets in the system, not just in their organisations. There has been significant investment in infrastructure and intellectual capital in the last 10 years in public services – so there are assets that can be used.
Payment by results programmes, where providers are paid for delivering outcomes, exist across the public and private sectors. The inherent difficulty in any of these programmes, be that smoking cessation or welfare to work, is that the outcome is driven by an individual amending their behaviour.
To try and understand which activities and their associated costs lead to a particular outcome is virtually impossible and certainly extremely costly, as the programme cannot begin to see all the factors that may lead to the individual continuing with their old habits. It is part of the reason why evidence does not exist. The other reason is that measures that link to outcomes are not fully understood, specificed and the meachanisms of measurement are not set up propely at the beginning of many of these pogrammes.
As described in our first article, we have developed programmes that create frameworks that allow the controlled and managed testing of new approaches and concepts. Setting these up correctly – with agreed and commonly understood aims and measures – is critical. The framework allows system leaders to make decisions based on good information when it presents and invest at the appropriate levels.
The frameworks are made of broad parameters held together by design principles that align to the health and social care system’s objectives and have a golden thread of measures, based on a reasonable set of starting assumptions that are refined as more data is gathered. Key to it is understanding which activites lead to which outcomes or indeed produce no significant outcome.
The concept of commissioning does not sit well alongside the creation of independence. It is by its very nature patriarchal. Contractual arrangements and the processes they drive can and do disempower individuals. In addition, Government and the welfare state have created a ‘do to’ culture, where government knows best.
Most service delivery in health and social care does not recognise the concept of the expert patient where the service user or patient knows more about their condition and how they live with it that the professional that supports them. As a result a formulaic, one size fits all approach to commissioning is adopted. This approach ends up stifling innovation, silences the patient voice and changes the care landscape into one where the focus is on meeting contractual commitments and the endless search for funding.
We have seen many fantastic third sector organisations that previously provided high impact interventions and support being turned into businesses. We are now reaping this reward. There is a desperate need for new approaches that link the development of markets to support care at a local level.
Local Authorities must urgently find new models, using tools such as the Social Value Act and the work done around Asset Based Community Development to create more supportive communities based on asset exchange and facilitation rather than just contracts. Again there are studies and anecdotal evidence to support this drive and technology has eventually caught up so that it is now possible to facilitate this at a system level.
This radical concept requires organisations to let go. This is something that government bodies are not used to doing. To make this more comfortable and to manage risk, the framework approach, referred to above, should be adopted.
Of course there is a strong need for proper controls, as there are real risks and these organisations do have statutory responsibilities. In our view, these risks and their mitigations should be thoroughly reviewed and analysed to ensure that the activities that are being carried out do actually mitigate the risk. For example, there are still far too many stories about frail and elderly people not wearing their alarms when they have taken a fall.
Next week, we will discuss the final pieces of the jigsaw: ‘Supporting Social Workers’ and ‘Identifying real risk and mitigating it’. Taken together, these five action areas will put both sectors in a much stronger position to be able to design and implement solutions that have a much more realistic chance of delivering better outcomes for society.