Heading Upstream: Deinstitutionalisation & Public Service Reform
Author: Simon Duffy
The harm caused by Austerity is enormous and unjustifiable. In most cases it seems that public services have responded as one might expect, cutting support and increasing eligibility thresholds. Increased death rates for older people are just one symptom of this dreadful policy.
It does not justify Austerity however to note that some organisations and individuals have acted differently and have tried to identify solutions to the crisis that are progressive. For instance, a few leaders have recognised that in order to respond to this crisis they must engage citizens and communities in the effort to ensure social justice and well-being.
There is a compelling case for rethinking the relationship between the welfare state and its citizens. In fact even to make this point in that way is to make the point in the wrong way. The welfare state should not be distinct from us - it should be ours - our legacy to build on and to advance, requiring both our protection and our ongoing commitment (Duffy, 2016).
The vital role of public services
Nor must we be compelled to move from questioning the role that public services play to rejecting those services. Public services will continue to play a vitally important role in our society, both in providing vital support, often support that individuals and families can never provide for themselves, and also in providing leadership for the whole community to develop strategies for wider social change. It is important not to lose sight of the essential role of public services nor to minimise their importance in the search to engage citizen and community capacity.
What is really required is a new kind of partnership, public services will continue to play the lead role in:
- Providing crisis provision where no other alternative is possible (e.g. A&E, safeguarding)
- Ensuring access to high quality care as efficiently as possible (e.g. elective surgery)
- Ensuring people get a fair entitlement to manage long-term care (e.g. personal health budgets)
- Ensuring people get access to specialist advice and assistance to increase skills or reduce need
- Creating an infrastructure to make care easier and more efficient (e.g. tele-care, information services)
- Encouraging different lifestyles, choices and tackling wider public health problems
- Protection for the environment and good regulation
However this still requires innovation in public services. In particular two kinds of innovation are necessary:
- Practice innovation - Models of practice can become established, or even reinforced by policy, and yet on examination they may be inefficient and can be significantly improved. For example, there is significant evidence that peer support is critical in promoting better mental health, yet peer support is still very under-developed in mental health services (Duffy, 2012).
- Strategic innovation - There is a tendency for resources to move to the immediate crisis: e.g. accident and emergency services, institutional placements, prisons. It is hard to focus on the underlying problems that cause these crises: e.g. income inequality, social isolation or domestic violence (Broad, 2012).
The institutional challenge
Unfortunately resources and practices tend to become institutionalised. Often the system’s centre of gravity lies in those responses which are often far from ideal or which are even damaging. For example, people can end up in prisons, institutional care units, care homes or acute hospitals, even though we know that there are significant risks associated with all of these kinds of services. However it becomes very difficult to move responses upstream, to promote the necessary innovations that prevent need or which allow people to meet their needs more effectively and more efficiently.
The solutions we find upstream are various and will develop in the light of the local context, but as Figure 1 suggests, they are all capable of reducing the demand for more expensive and less efficient solutions downstream:
- Nature - The natural world is our home and the source by which we meet all our needs. It must be safeguarded in order that it can provide physical and spiritual resources for all of us in the years ahead.
- Society - There is strong evidence to suggest more income equality will promote wellbeing (Wilkinson and Pickett, 2010). Working to create a fair society is likely to create a society which is better for everyone.
- Community - Relationships, stronger and more inclusive communities, lives of meaning and purpose also have benefits for our health and wellbeing (Halpern, 2005). Creating richer communities which open up multiple opportunities for contribution and commitment is critical.
- Family - Families are the key to personal development, good mental health and the good upbringing of children. Families provide most of the care and support people receive. Supporting families to stay strong, tackling abuse and domestic violence and valuing the role of the family is important.
- Citizen - People can do more for themselves and personal control often correlates powerfully with better physical and mental health (Alakeson, 2014). More broadly a sense of personal responsibility, capacity and freedom strengthens family and community structures.
- Professional - Expertise and professional development is vitally important. However some countries are finding that the most efficient use of the professional is as a teacher and educator - supporting upstream change, not just responding to downstream problems (Crisp, 2010).
- Services - Services continue to play a vital role in keeping people safe, providing a guarantee of support in all circumstances and creating an infrastructure around which individual and collective decisions can be made. The challenge is for services not to take on such a prominent role that they reduce the space for community action in all its forms. At its worst this leads to the bureaucratisation of everyday life.
Unless there is the right investment of time, money, creativity or self-discipline in these upstream responses then the result will be expensive, and often risky or violent, institutional responses. And once resources are locked into those institutional arrangements then they are very hard to shift again.
Once resources have been locked into hospitals, institutions, respite centres, prisons or care homes then there is a tendency for the system to meet needs by using those resources. The per capita cost may be high, but for the professional making the referral or placement the cost has already been met by a prior funding decision or by the fact that it is ‘someone else’ who meets the cost and manages any future risk. For instance, social workers often observe that the pressure to place someone in an appropriate service and so reduce any immediate risk they face can reduce their ability to work with citizens, families and communities to design better solutions (Rhodes, 2010).
There is also strong evidence that support can be offered to families so that women and children do not need to go to prison and that the cost of sending someone to prison is much higher than the cost of providing appropriate support. But the prison system is funded from Whitehall, so there is a weaker incentive for local areas to invest in these preventive measures (Hyde, 2011).
Figure 1. Moving investment upstream
Moving resources upstream will require a new kind of deinstitutionalisation. What, in Barnsley, is called inverting the triangle. Inverting the triangle means shifting the focus away from long-term and institutional provision and towards enabling people to stay healthy and well in their communities. The Barnsley model distinguishes:
- Tier 1 - Information and advice
- Tier 2 - Assistance to support self-care
- Tier 3 - Helping people regain skills
- Tier 4 - Supporting people with long-term conditions
Inverting the triangle does not just mean shifting resources and attention upstream away from institutional services, it means changing the whole philosophy of care. Everyone is assumed to be capable of managing their own care and support - but some people will need significantly more assistance or resources. Supporting autonomy and citizenship becomes a core value at every point in the system.
Responding to the challenge
But the size of this challenge cannot be underestimated. Most expenditure for health and wellbeing is NHS expenditure (over 76%), and most of this expenditure is committed to acute services, with hospital and mental health services using nearly 50% of the total budget. Even community services and primarily health care services are primarily focused on employing professional staff. Very few resources are spent upstream or in engaging citizen and community capacity.
We get some sense of this by looking at the data for Barnsley as set out in Table 1 and Figure 2.
|Public service type:||Spend (£ millions):||Distribution:|
|Acute healthcare (NHS)||181.33||40%|
|Primary care services (NHS)||47.81||10%|
|Long Term Care (MBC)||41.44||9%|
|Mental Health Services (NHS)||37.24||8%|
|Community Health Services (NHS)||32.57||7%|
|NHS Management & Reserves||25.22||6%|
|Continuing Healthcare (NHS)||16.15||4%|
|Public Health (MBC)||13.57||3%|
|Children in Care (MBC)||10.28||2%|
|Family Social Work (includes disability) (MBC)||7.20||2%|
|Substance Misuse (MBC & NHS)||5.75||1%|
|Community Support (MBC)||5.55||1%|
|Adult Social Work (MBC)||4.44||1%|
|Libraries and information (MBC)||4.21||1%|
|NHS Children Services (NHS)||4.33||1%|
|Long Term Care mental health (MBC)||3.26||1%|
|Intermediate Care (MBC & NHS)||3.19||1%|
|Crisis Response (MBC & NHS)||2.31||1%|
|Local Area Council (MBC)||1.99||0%|
|Mental Health Care Management (MBC & NHS)||1.4||0%|
|Advocacy and Carer Support (MBC)||0.77||0%|
|Prevention and Early intervention (MBC & NHS)||0.45||0%|
Table 1. Health and Well-being Expenditure in Barnsley 2013-14
Figure 2. Health and Well-being Expenditure in Barnsley 2013-14
It is also very challenging to make this shift when resources are tight - yet this is also when it is most important to make the change.
So it may be helpful to identify some key principles going forward:
- Invite sustainable innovations - If leaders make it clear that they will work hard to support innovations which reduce downstream demand then innovators can focus on solutions that will be sustainable for the long-run. Innovators exist both within and without the public service system, but there are rarely opportunities for these leaders to emerge, test ideas and develop new forms of practice. It is also important not to exclude those services which are further downstream from moving upstream themselves. In the past deinstutionalisation has - sometimes - been led by leaders from within those institutions themselves.
- Transparent information - The resources spent on public services belong to citizens. It may be helpful to build on the early integration work to help all citizens understand how those resources are used and how the demand on services arise. Citizens are quite capable of acting responsibly and of helping to solve social problems if they have the opportunity to do so (Titmuss, 1970).
- Focus conversations locally - It is only within local communities that it becomes possible to see the real opportunities for innovation and synergy. Meeting a family’s need for support with a disabled children can also be an opportunity for employment, peer support, education - as well as helping to reduce demands on statutory services. However this is only visible at the micro level. Local communities must be encouraged to see how they can strengthen themselves, both by solving their problems locally and by pulling in funding that would otherwise have been spent outside the community.
One of the most interesting approaches for promoting innovation at the local level is the Local Area Coordination concept - first developed in Western Australia - but now being used in Scotland, England and Wales (Broad, 2012). This model involves embedding workers within small local communities - where they work with people who would be at high risk of needing costly or institutional services. Instead the Local Area Coordinator encourages people to connect and to solve problems by building on local resources.
This is not the only strategy for better prevention, early intervention, information and sign-posting. However it is a commitment to strategies such as these that will be vital. This is less about ‘commissioning innovation’ and much more about helping people craft local innovations - which make sense in their communities.
The critical question will remain:
Do we have the capacity to move resources towards better solutions upstream?
There will be no extra funding for innovation or change. Positive change will need to be transformative - it will need to make better use of existing funding. However this means changing how resources are used - this doesn’t just mean money - more fundamentally it is about people - the professionals currently working in the existing system. They must be engaged as part of the solution, they must themselves start to work upstream, and train others to do so. Otherwise the system will be locked into its current pattern.
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The publisher is the Centre for Welfare Reform.
Heading Upstream: Deinstitutionalisation & Public Service Reform © Simon Duffy 2016.
All Rights Reserved. No part of this paper may be reproduced in any form without permission from the publisher except for the quotation of brief passages in reviews.