Your Place or Mine? – Why asking the question “Are Personalised Health Budgets a Good Idea?” cannot be answered by Health Care staff alone.

I was at the Kings Fund Annual Conference the other week and I was struck by how seriously most health contributors were taking patient involvement, patient feedback and the quality of the patient experience. There were plenty of examples – including those proposed by the Health Minister – that would strengthen the role and voice of the patient in the diagnosis, commissioning and delivery of health care. All of this felt to be appropriate and encouraging albeit a little familiar and repetitious. We have after all been saying this kind of thing for years.

However, as the conference went on the more I became uneasy about the nature of what was being proposed and the tone of the policy debate surrounding the issues. Despite the helpful and clear contributions from the Patients Association and the nascent HealthWatch the debate was essentially an internal one. How can we (Health Service Managers, Clinicians and Policy makers) design and provide structures and processes that engage the patient and public into what we do?

I came to realise that the debate was symptomatic of the gift relationship that exists between us professionals and the undifferentiated mass of others who are the (mostly) grateful recipients.

In other words “how can we help people share in the delivery of health services productively?” is the wrong question and one that is likely to be ultimately incapable of providing a sustainable or convincing answer.

The real question we need to ask is “How do citizens with health care needs want the NHS to involve itself supportively and helpfully in their ordinary lives?”

So, with this in mind can we answer to the question “Are Personalised Health Budgets a Good Idea?” I think there are three reasons for thinking that they are.

Firstly the research thus far says so unequivocally:

“… the majority of budget‐holders and carers reported positive impacts of the personal health budget – on their health and well‐being, health care and other support arrangements and for other family members. Effect on their use of health services or changes in relationships with health professionals were less likely to be reported. Most interviewees appreciated the increased choice, control and flexibility of the personal health budget.”

(http://www.thinklocalactpersonal.org.uk/News/PersonalisationNewsItem/?cid=9406)

Secondly the experience in Social Care where personal budgets are well established and growing strongly is that they change the relationships between people who need support and service providers in really fundamental ways. Rather than being a gift from the powerful to the powerless, services can be shaped and delivered in ways that support people to live ordinary lives. Personal budget holders have developed a strong, clear and challenging voice and the means to empower themselves. This has pushed professionals and services to engage in a different way and on different terms.

Thirdly and perhaps most importantly  they change the terms of the user involvement debate onto ground where what patients and citizens think and need are the determining factors.

Therefore it is not essentially a question about efficacy and efficiency but one of rights and citizenship. It cannot be answered by staying within the comforting embrace of the NHS but needs us to travel onto patients and carers territory to see what the question looks like from the other side. To answer such a question will need a much more equal dialogue between professionals and the people they serve and a broader understanding about who actually owns the NHS budget in the first place.

 

 

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What are they on about? Common language and misunderstandings in the business of health and well-being

It’s a well-worn quotation from George Bernard Shaw that Britain and America are countries divided by a common language. But is it also true that the language of health and of social care betrays a chasm of understanding and intention between leaders and practitioners in the respective systems? Can a linguistic divide also be a barrier to our efforts to bring together health and social care for the benefit of patients and users?

Recently I have been involved in supporting some of the local developments to bring together social care and CCGs around the shadow Health and Well-being boards based within local authorities. In this context it might be anticipated that professional and organisational language might be a barrier to partnership, but confusion isn’t confined to the technical or specialised lexicons in play.  Its ordinary words that also get in the way.

Listening to the discussions between the representatives of clinicians, local authority managers, elected members and representatives of users and patients it is striking how people use common terms very differently. It reveals a wide range of understanding and intention that could hamper the development of positive Health and Wellbeing integration.

The use of one simple word – quality – struck me as a particularly revealing illustration of the differences in conception and meaning that can abound between key actors in a system.

To many clinical leaders quality means the deployment of best treatments and procedures in an appropriate and effective way. Described by NICE and developed by trials and expert networks, researched and evidenced at a high level, quality in these terms means the best possible outcomes for a given input. In this case quality is more concerned with production – with the quality measures familiar to manufacturing and physical industries. In business terms this may lean towards EFQM, Six Sigma and the rest. It is absolute, definite and time-bounded.

In contrast local authority and social care leaders might have a more process orientated understanding of what quality means.  Quality in their terms might cover the process and experience of service delivery and might be much more about the level of overall engagement and satisfaction as well as sustained relationships and co-production. In Business speak this may lean more towards the notions of loyalty and relationship management found in service industries. For these participants quality is more conditional, emergent and ephemeral.

Just as the English language stands between Britain and the US, so too does the common language of health, social care and local government. It’s a bit like the Rosetta Stone in reverse – instead of finding a tool that can make two separate languages transparent these common words can actually obscure the meanings that players assume and understand.

The answer to unravelling this linguistic muddle aren’t easily prescribed. More time together is undoubtedly part of the answer, as is finding ways to do more things together – to merging the routine processes of health, social care and local governance so that a material reality begins to provide an underpinning to shared understanding. But time is the one resource that is in shortest supply and when people are busy finding the space for developing understanding generally gets little priority.

Stopping to ask the awkward question, maintaining a drive for understanding and adopting behaviour of active listening are ways that we can make the most of the time available to us.

And therein lays hope – for asking questions, challenging assumptions and being persistently curious are things that exceptional leaders display across the divide.

Why Culture Comes First Not Last – Banking Reform and the NHS

Banking reform is at the centre of political debate currently. It strikes me that there are key issues thrown up by the debates about what should happen with the banks that can cast a useful light on what we should be thinking about – urgently – in the creation of the new commissioning arrangements for health care. As we move rapidly onwards with creating the commissioning and delivery structures for CCGs here are some thoughts stimulated by the discussion about what we need from banking reform.

There has been a lot of discussion about the reform of banking and what should be the way forward. Repeatedly statements from Government suggest a three-phased approach, tackling reforms to regulation, structure and finally, culture. Different politicians and experts play different tunes on this troika of instruments but the basic mantra is much the same across policy makers and the commentariat. Solid things first – structures and rules, less tangible things such as culture can follow later.

However, anyone with the slightest understanding of leadership, organisational development and human behaviour will know at once that there is something wrong with this formulation. It’s simply the wrong way round. Whilst it is perhaps natural to place culture, the soft stuff, at the end of the reform process this is a profound mistake. It is the exact opposite of what is needed.

We know that organisational culture (or more simply what people do and believe they are doing) emerges from the interaction of structures, purpose, rewards, sanctions and rules with the sense making activities of people in the system – bankers, managers and customers (or clinicians, staff and patients).  It is the material environment that shapes culture and its people that derive meaning from their activities. Culture grows out of the practical and physical realties of work and the routines of work organisations but it is nurtured and shaped by the actions of individuals, teams and senior leaders.

But, somewhat paradoxically, whilst culture is emergent, it doesn’t mean that it can be left to chance or to the eventual distillation of quixotic actions and behaviours of actors into something meaningful. It follows that the way we build our institutions and processes will have a profound influence on how staff and professionals behave and what they think. So, if the objective is to create a precise culture – particularly one that serves the bank’s customers (or in the NHS’ case, the patient and citizens) better, the way that regulation, structures, governance, rewards and processes are designed has to be congruent with the cultural objective.  Trying to create a positive culture in a negative system is bound to be an uphill struggle. Key actors will face failure or, perhaps even worse, absorption and complicity within an irretrievably flawed system. Leaders will find themselves continually battling with people and organisations that never seem to improve.

At the sharp end, from a bank customers point of view, it’s the culture of the organisation or the team that matters most since it is this that they experience first and most intimately. The hidden machinery of regulation, process and delivery is of little interest to the customer as it is can only be experienced by its outward manifestation  – often the attitude, values and behaviour of staff.

Leadership can go a long way to shaping culture and we know that excellent leadership can give meaning, purpose and clarity to the way an organisation functions. However, the underlying structural and productive reality of organisations cannot be negated no matter how brilliant the ability and vision of leaders.

To give an obvious example an aggressive bank bonus scheme based on competition in the market with no voice for customers or wider interests is unlikely to be ameliorated by attempts to create a different culture no matter how altruistic and collaborative the leadership style. In fact it is absurd to even consider that leaders in such an environment would consider the creation of such a culture would be desirable or possible. The leadership culture is more likely to follow the material and process underpinnings of the industry itself.

So what can we say about culture in the reformed NHS. Should we, like politicians want to do with the banks, get on with the important business of reform and structural improvement and leave the cultural issues for later when the smoke has cleared and we know what we are doing?

For my part I think there is a fleeting opportunity before us to consider the kind of culture we wish to create in our new commissioning systems, structures and on our emerging boards. We need to consider what kind of impact we intend across the delivery of services locally. It is difficult to think about such soft issues when there are so many uncertainties and pressing organisational issues to resolve in order that the system is capable of functioning at all.  However we should resist the temptation of sorting out the practical and immediate at the expense of the long term and fundamental.  A system that places professionals at the heart of its rationing and prioritisation will struggle to ensure that its emergent culture is truly patient or citizen led unless this is built into practice and structures from the start.

There are plenty of great patient led examples of service design and function which can used as a way of thinking through how to approach the issues locally or can be used as a way of developing local initiatives. (See for instance http://www.richmondgroupofcharities.org.uk/RichmondGroup2010.pdf)

So, better to be clear about the vision and culture that we wish to create and design structures, processes, regulation and rewards to fit – from the very beginning. If patients and communities are to get a better deal from the new system we need a vision of how the culture of the new world will be shaped and replicated. Patient’s perspective and voice should be at the heart of this evolution even when we are apparently shaping the most internal, mundane and byzantine details of the new world. For it is in these seemingly unimportant corners of the new machine that culture will be formed.

Lord’s Reform

Two events – the death of Jack Ashley, (Lord Ashley of Stoke) and the joint committee report  on Lords Reform (published on 23rd April) highlight for me the contribution that people with specialist knowledge have made to the development of policy and law and how appointments to the Lords have helped. Jack Ashleys vision and reforming courage both as an MP and a member of the Lords and the joint committee report raise some important issues about representation that any reform proposals will need to consider.

Social care as an industry very often sees itself as the poor relation in public services and its representatives often express the view that care issues are poorly represented nationally. However, Lords with significant experience of the social care system have brought detailed understanding and expertise to the legislature that can be lacking in the selection and election of candidates through the routine functioning of political party machines. Their Lordships Warner and Abebowale and Baronesses Pitkeathley and Butler-Sloss are such examples.

Additionally the particular contribution of people with disabilities like Jack Ashley and Baroness Jane Campbell, who also have extensive understanding of health and social care, have been significant in the creation and amendment of legislation. These peers have brought challenge and real quality to the debates and process of law making and brought a voice into Parliament on behalf of people who are often excluded.

It is not my intention to enter into the policy and political debate about Lords Reform but it is important to consider how any new system will be strengthened by the contribution of people who have significant knowledge about key issues – particularly those that are not fashionable or don’t attach high kudos and riches. Social care, mental health or the rights of people with disabilities are areas where under-representation is an issue now and possibly will become more of an issue under any reform.

The voices of people who bring direct personal experience or expert knowledge are essential to the processes and integrity of government.  Recent changes to appointments to the Lords have given people the platform to make critical contributions to debates and have strengthened the perspectives of care and health as a result.

Whether or not we are about to see progress with Lords Reform we should consider how our representation and legislative processes can widen the range of voices that are heard. It would be good to think that the next round of reform will take the contribution of experts by experience to a new level of influence in shaping all our futures.

All Together Now? – health and social care integration

The publication of the latest report on the state of collaboration, partnership and integration across health and social care by the Audit Commission tells a familiar and depressing story (Joining Up Health and Social Care, improving value for money across the interface; Audit Commission, Dec 2011). The report describes the possible financial benefits of better integration across the health and social care interface with a potential saving to PCTs of £132m annually if all adopted the practice of the national average on  a limited number of adult care measures such terms of emergency admissions and so on. It describes progress towards effective integration as “patchy” despite many years of policy importance being given to this area. This is yet another salutary reminder of how far we have yet to go to develop smooth and efficient operational practice in the caring services.

Yet for me discussion about integration and partnership seem to always start in the wrong place – driven by considerations of policy and operational neatness, cost savings or pre-emptive organisational take-overs.  Despite the rhetoric of patient and user driven integration there are proportionally very few examples in practice – a finding endorsed by the Audit Commission.   As someone who has worked at the interface between health and social care for the past thirty years and like many others can see the benefits from better integration around the patient experience or pathway I find this is a considerable frustration – not to say source of anger.

However, to be cool and analytical about the context for integration it is easy to see why so much hot air and buster about joined up services has produced so little tangible evidence of progress.  There seem to me to be five factors that need alignment before integration can make headway:

1. Partnership and integration takes leadership, effort, goodwill, capacity and capability – all inputs that are likely to be in very short supply in the current environment of service cuts and retrenchment

2. Integration needs to be focussed, practical and achievable – vague aspirations for partnership are good contextual starting points but they will not deliver the hard outcomes that patients and users need

3. Integration and partnership are often focussed on commissioning and policy staff rather than practitioners – who in turn experience integration initiatives as another top down imperative to which they feel no ownership or obligation particularly if it seen to be another route to cutting services or disempowering practitioners. Without practitioner and clinical leadership integration is likely to fail

4. There is often good and bad reasons for clinicians and practitioners to resist integration and failing to distinguish the patient and centred concerns of staff who have to deal with real people from the natural anxiety and pessimism about change is a recipe for managerial and policy failure. Often staff are passionately against integration proposals not because they are being obstinate or failing to “get on board” the corporate band-wagon but because they know from experience that the proposals are dangerous and wrong

5. We to recognise that sometimes integration can make things worse; not all patient or client pathways benefit from integration and sometimes separate specialisms can lead to safer and more effective intervention.

So what does this add up to?  Simply that service integration has a hugely valuable contribution to make to the future of care services but we need a more enlightened much more critical and expert engagement to make if effective. I refer back to the WHO report 2008 found that whilst the evidence base about integration is limited, a systematic review pointed to important lessons:

 

  • Supporting integrated services does not mean that everything has to be integrated into one package. In reality, there are many possible permutations
  • Integration isn’t a cure for inadequate resources
  • There are more examples of policies in favour of integrated services than examples of actual implementation. Managing change may require action at several levels and requires engagement of health workers and managers, plus a sustained commitment from senior management and policy-makers.

We might also insist on the involvement of users, pateints and citizens in this important dialogue.

In short, whilst cost saving may have a salience and drive at the moment they are unlikely on their own to be the most effective driver for delivering the integrated services users, patients and families demand.

Overseeing the Care Market – what can the state do?

In these troubled and uncertain times the relationship between the state and the market remains contested, uncertain and fluid.

For a micro study in the contradictions and complexities of the state’s relationship with the market I recommend a recent discussion paper produced by the Department of Health on the social care market following the high-profile collapse of Southern Cross.

Read with a critical eye it exposes the real political dilemma of those that see markets as the best way to stimulate innovation, create choice and drive up quality but who also seek to mitigate the negative consequences of market activity – overcapacity, imperfect consumer knowledge, unbalanced risk transfers and the high social costs of commercial failure.

The paper seeks contributions from experts and interested parties to a debate about how the market in care services can be maintained whilst protecting older people and adults with care needs. It makes clear that the Government does not want to impede the normal functioning of the market in this sector which sees services and homes opening and closing on a regular basis. It is not the Government’s intention to increase the regulatory burden or add unnecessary costs to providers.

Yet social care is a complex industry; diverse, jargon-filled and containing a fluid mix of not-for-profit, small owner-operated businesses and large multinationals. There is residual local authority provision but over recent years the private sector has come to dominate which a great deal of consolidation taking place particularly as the market tightens through tougher public expenditure.

However there are real issues of safety and exploitation that have to be managed in this sector. Choice needs high levels of information and ready access if it is to drive an open market but older people and their relatives and friends typically have little understanding or information about the way the care sector works. Deciding on care options and chosing a residential or nursing home are huge life-changing decisions which most of us might never face, and as past reports by regulators have shown, when faced with the need for care and support many make poor decisions about the style and cost of residential care.

For most people entering a nursing home it is a one-way journey. The state only provides a minimum of financial assistance, and none for people with assets above £23,000. With the costs of residential care typically ranging from around £600 per week to above £1000, people with assets will be forced to sell their homes in order to pay. The financial and social risks associated with these decisions are therefore monumental and quite unlike any other choice people make over their lifetime. Having chosen a residential or nursing home option residents are highly vulnerable to changes in business practices, ownership and business models made by their residential provider. Given the frailty of many residential home residents these changes can have irreversible consequences.

The paper floats a number of possible ways in which market failure might be avoided or managed better in the future. These range from activating the wider role for Monitor contained in current legislation, through to better market monitoring and financial oversight by local authorities. It highlights other industry examples that might be adopted by the sector including the regulation of the energy sector, risk pooling such as the ATOL scheme that operates in the travel industry and the recovery and resolution plans being made by the banking industry to avoid the “too big to fail” condition.

However, it is noteworthy that the paper suggests that this regulated market should only concern itself with the largest providers on the grounds that the collapse of major suppliers like Southern Cross provide the greatest distress to the largest number.  I would hope that this presumption is challenged by those that respond to the discussion paper. Unthought through it could create a framework that did the worst of things – protecting those that were too large to fail whilst condemning those that are too small to matter to an unscrutinised backwater.

At the same time, and interestingly, the paper confines itself to considering the ways in which the collapse of private sector providers might be mitigated. In this it rather makes the case for not-for-profit providers since it is implied that the charitable and co-operative parts of the sector are less prone to the dubious management practices and market volatility experienced by large private providers. This is largely a supportable contention. At the same time it proposes no change in the statutory responsibility of local authorities in overseeing the provision of care for the most vulnerable. Whilst no longer a direct provider of last resort the local state is still nevertheless the final guarantor of continuity of care for those at risk.

This paper provokes some really interesting questions and could stimulate a really fertile and challenging debate about the virtues and disadvantages of a managed market. It may have wider application than merely that which pertains to care. For my part I wonder if there are already some of the solutions before us. Models that are based on co-ownership, stake-holder capital and personal budgets may provide ways in which the huge expenditure on care by residents and the state buys more than a temporary presence in a transitory enterprise. Ways in which long-term rights and a genuine pooling of risk between citizens, providers and the state need to be created. This will provide the long term stability and quality that frail elderly deserve.