How does a health and social care organisation become a big player in employment? The power of stepping back from a diagnosis.

How does a health and social care organisation become a big player in employment? The power of stepping back from a diagnosis.

Clare Hammond looks at why health, social care and employment are so important to each other

18 months ago, we were working with a Scottish Health and Social Care Partnership (HSCP) and were struck by what we found. This HSCP was spending the equivalent of 50% of the value of the new national programme for those further from work, on helping their service users into employment. How does a HSCP end up being such a big player in employment?

More and more, services are stepping back from a diagnosis, or presenting issue, and looking at the whole person. A perfect illustration of buzz words such as ‘person centred’ and ‘holistic’. In health and social care, this is driven by a growing understanding that medical conditions are often driven by, and in turn drive, other issues such as trauma, poverty, social inclusion, and worklessness.

These intersections are what has driven the growth in health and social care integration, information and support services, complementary therapies, and social prescribing, and where prevention has found a practical expression.

Subsequently, services have needed to work across their typical service boundaries. These partnerships find two main forms (1) strategic and structural partnerships, and (2) practical and operational partnerships at the coal face.

Much of the focus on health and social care integration in both England and Scotland has focused on structural integration. However, we have found numerous examples of long standing, pragmatic and effective operational partnerships as front-line staff recognise the need to engage with other services to get the best outcome for their clients.

So, while strategic partnerships often feel that they a have responsibility to support partnership working across every level, there is a lot that strategic partners can learn from front line delivery staff for whom partnership working has long been part of their everyday approach to support provision.

Coming back to the HSCP mentioned at the beginning of this blog, how did they end up here? This HSCP had 16 employability related projects covering a variety of health and social care services. Despite operating independently over a period of more than 5 years, front-line staff working across all projects had identified the important role that employment (or the prospect of employment) could play in managing an individual’s health and wellbeing and maintaining their progression. As such, working towards employment became part of a recovery journey in mental health, addictions and criminal justice, and a way of improving health and care outcomes for those with disabilities, or young people raised in care.

From an employability perspective, these service users were effectively pre-stage 1 in the Strategic Skills Pipeline. By encouraging participants to lift their aspirations of future employment and begin setting goals. these HSCP services effectively prepare them for mainstream employment services.

This approach is echoed by new national employability programmes (Work and Health Programme and Fair Start Scotland) being developed across the UK which have a particular focus on supporting those with multiple barriers to employment. The only way these programmes are going to be successful is if they link in with projects like those being delivered through the HSCP and encourage people to think about employment as part of their recovery journey. Doing so should improve the level of engagement when they enter the first stage of the employability pipeline and the outcomes achieved.

To reach this point, health and social care services can learn from this HSCP, step back from the diagnosis and consider how they can help service users make the next steps on their longer term pathway to employment.

Clare Hammond is an Associate Director at Rocket Science specialising in health and social care including evaluation, strategy and organisational development, cost modelling and cost benefit analysis. You can check out her profile here.

This blog is part of a wider series on Health and Social Care Integration. Other blogs in this series can be found here

Health and Social Care – What’s the point?

Health and Social Care – What’s the point?

Health and Social Care Integration – What’s the point? Clare Hammond explores the early evidence on the impact of health and social integration

Health and Social Care integration has been in the spotlight in both England and Scotland with promises of large financial savings coming from both countries. But can integration really be the silver bullet for these financially stretched services?

The Scottish Government estimated a potential annual savings of between £138 million to £157 million from the integration of Health and Social Care. This represents less than 2% of the more than £8 billion of spend integrated bodies are responsible for. When compared with the expected increase in demand of between 18 and 29% between 2010 and 2030 it is hard to see integration as the saviour of financial woes.

A core element of integration in England is the Better Care Fund which was estimated to save £511 million in its first year, a little under 10% of the pooled budget of £5.3 billion. Interestingly, the NHS Sustainability and Transformation Fund for 2016/17 had £1.8 billion of its £2.1 billion rediverted from integration to fund NHS deficits, indicating the scale of the financial situation.

So, it seems unrealistic to expect health and social care to plug the growing gap between demand and public budgets. But how is integration going in achieving the savings that are expected?

The primary assumption for integration related savings is that a more preventative and social care focused approach can steer people away from the more expensive emergency hospital-based care.

The National Audit Office (NAO) concluded that integration in England has “yet to show that integration leads to better outcomes for patients”. NHS England had hoped to reduce hospital activity growth from 2.9% to 1.3% (by 2020/2021), however both the number of admissions and delayed discharge days increased in 2015/16 at a total extra cost of £457 million. Audit Scotland are due to report on the progress in Scotland in November of this year.

Of course, you can’t know what would have occurred without a counterfactual. The NAO themselves acknowledge that there is a lack of comparable data across different care settings to place evaluation findings into context.  So, what does the evidence have to say about integration’s ability to reduce hospital admissions?

A University of Oxford study published in 2017 concluded that, while the policy discourse around Health and Social Care has pushed the approach as a solution for reducing emergency admissions, the evidence available tells a very different story. According to them, there is a mixed view on the success of a number of integrated care programmes that have been evaluated so far. Of 13 reviews conducted, only three had a significant impact on the number of hospitalisations that occurred. This review included studies on Case Management systems (a common component of health and social care integrated models) found that this approach did not have an impact on hospital admissions.

 

The Kings Fund has reported on a range of examples of integration at the coal face – where integration of services occurs rather than the integration of the institutions that sit behind them. One example described is in east Kent where professionals are working together across five community hubs coordinating the care individuals identified as high risk of hospitalisation. These community hubs include teams of “GPs, community nurses, social care workers, mental health professionals, pharmacists, health and social care co-ordinators and others”. They conclude that early findings suggest “that these changes have led to year-on-year reductions in emergency admissions to hospitals”.

So why is the evidence available so mixed? Well, perhaps it is as the Barker Commission concluded in 2014 of integration in England. “Moving to a single budget with a single commissioner is not a sufficient condition to tackle the myriad problems of integration that face health and social care. But we believe it is a necessary one.” Or as Scottish Government said “[s]tructural integration brings few benefits unless accompanied by many other changes”.

There may also be a problem with the focus on structural change rather than on the behavioural and relationships changes that are needed to drive real transformation.  Research by the King’s Fund identified that there was “a strong recognition that the relational and behavioural aspects of transformation deserve as much, if not more, attention than technical and structural aspects.” So integration bodies may be looking in the wrong place and not paying enough attention to how staff behave and work together on the ground

Is it too soon to tell? While Health and Social Care Integration has been discussed for more than a decade, large scale action is still relatively new. In addition, integration is occurring in already financially strained and very complex environments. It is hard to isolate the various strands in this complexity to understand what has worked, what hasn’t, and why.

Indeed, a frequently quoted example of ‘best practice’ is Greater Manchester who are operating multi-disciplinary neighbourhood teams, intensive support targeted at those considered high risk, and driving the use of community and primary health care settings to reduce hospital use. But when you explore what makes Manchester work so well it appears to boil down to two factors:

  • Their long established public-sector partnership that crosses typical service boundaries.
  • Their ability to access additional funding for integration activities from the Sustainability and Transformation Plans Fund that reduces the choice between either funding rising financial pressures or integration initiatives.

 

Clare Hammond is an Associate Director at Rocket Science specialising in health and social care including evaluation, strategy and organisational development, cost modelling and cost benefit analysis.You can check out her profile here.

This blog is part of a wider series on Health and Social Care Integration. Other blogs in this series can be found here

.

The integration barometer – the state of play of health and social care integration

The integration barometer – the state of play of health and social care integration

The integration barometer – Clare Hammond looks at the state of play of health and social care integration

The integration of health and social care. Currently held as the holy grail of getting public services right. Both England and Scotland have been attempting to integrate these services in various ways for a while now. So, where are we? What have we achieved? This blog looks at what each country is doing and what where they have got to.

So, what’s happening in Scotland?

In Scotland, the Public Bodies (Joint Working) (Scotland) Act 2014 requires NHS and Local Authorities to integrate social care and a proportion of NHS activities. This move is driven by the Scottish Government’s 2020 Vision where everyone in Scotland can ‘live longer, healthier lives at home, or in a homely setting”.

The integrated activity equates to around £8 billion of the nearly £15 billion spent on health and social care across Scotland and covers adult social care services, adult primary care and community health services and a portion of hospital services. The integration of services such as criminal justice social work and children’s services are at the discretion of each area.

The legislation dictates that this integration must cover governance, planning, and resourcing recognition of Joint Bodies as legally separate entities. Since then, 31 Joint Bodies have developed across all 32 Local Authority areas in Scotland (with a slightly different model operating in the Highlands.

A 2016 report by Audit Scotland provided an update on the progress of integration. It acknowledged that new approaches to making health and social care integration really work are springing up across Scotland. However, they also conclude that this integration isn’t occurring fast enough to keep up with the growing service demand resulting from an ageing population and the increasing complexity of need. Audit Scotland are due to report again on the progress of Health and Social Care integration in November 2018.

Institutionally speaking, these organisations are in their infancy. This shift is considered the largest change in services since the creation of the NHS. The integration of two very different organisations, service structures, budget priorities and cultures is going to take a while. And it is probably going to be longer than 4 years for the benefits of integrated governance and decision making to bear substantial and financial fruits. Even one of the most advanced examples of health and social care integration, in Canterbury New Zealand, has failed to achieve a financial saving to their District Health Board despite achieving a large impact against a range of the typical indicators of success (average bed days per admission etc).

And, what about England?

In England, the picture is somewhat more complicated than Scotland. Here, Health and Social Care integration requires coordinated efforts from NHS England, the Department of Health (DoH), the Ministry of Housing, Communities and Local Government (MHCLG), and Local Authorities across England.

Numerous commitments to integration have been made by these organisations over the years. In 1999, the Health Act allowed Local Authorities and the NHS to pool budgets and merge services where appropriate. Very little action occurred in response to the 1999 Act, much of which is put down to Clinical Commissioning Groups and the Health and Social Care Act 2012 complicating integration.

 

English health and social care bodies have made more recent recommitments to integration. In 2013, the Department of Health committed to making health and social care integration ‘the norm’ by 2018. In 2014, NHS England made a commitment to integrate health and social care by 2020.

Various integration approaches have been used. There was the rise (and current slow death) of Health and Wellbeing Boards around 5 years ago. The latest are Sustainability and Transformation Partnerships (STPs) between the NHS and Local Authorities. There are currently 44 of these across England. A national performance system for STPs has been established with a dashboard of measures that STPs will be measured against annually. July 2017 saw the release of the ‘baseline’ performance of STPs.

Some of these STPs have ‘upgraded’ to Integrated Care Systems (ICS) which indicate an even closer integration between health and social care than the STPs. In 2017 there were seven ICS with a limited range of accountabilities around operational and financial performance. In 2018, ICS are expected to gain greater flexibility in financial management.

How integration occurs in England is less specified than in Scotland with local areas able to choose what integration looks like for them with no requirement for that integration to be the creation of a joint institution. For example, integration could include joint commissioning, or joint patient assessments.

Also unlike Scotland, English integration recognised that to reduce the pressures on hospitals means that social care will need to pick up the slack. At a cost. The 2010 Spending Review transferred £2.7 billion from NHS to Local Authorities for the following four years.

Despite the commitments, development of STPs, ICS and a number of integration initiatives, the National Audit Office (NAO) released a fairly scathing report in February 2017. Most of their recommendations were for NHS England, DoH and MHCLG and related to providing national standards, guidance and oversight on progress. However, there were two conclusions that are particularly pertinent in terms of encouraging integration in the future.

As in Scotland, there was recognition that a number of examples of good integration are occurring across England. However, these were yet to be tested at scale, not where they proven to have a sustainable impact on service budgets and outcomes. As with Scotland, comprehensive proof that integration can reduce budgets and improve patient outcomes is yet to be provided.

NAO concluded that attempts at integration are still ‘siloed’, with each ‘side’ having their own mechanisms to encourage integration. The Better Care Fund is seen by most as helping Local Authorities, while the Sustainability and Transformation Planning Process is viewed as an NHS initiative, despite both initiatives’ focus on integration. This siloed view of programmes as either NHS or Local Authority, combined with concern that much of the funding available for integration is being diverted to plug funding gaps in an already struggling NHS, leads the NAO to conclude that much needs to be done for services to see themselves as part of the same team.

 

Clare Hammond is an Associate Director at Rocket Science specialising in health and social care including evaluation, strategy and organisational development, cost modelling and cost benefit analysis.You can check out her profile here.

This blog is part of a wider series on Health and Social Care Integration. Other blogs in this series can be found here

 

The changing face of health and social care

The changing face of health and social care

Health and social care services are changing, and so is the help we provide our clients. Clare explores some of the changing nature of what clients want.

Across the UK health and social care staff are exploring how to work in a more integrated way for the benefit of their clients and patients – who are often those ‘further from work’ and clients of a wide range of services. There is still a need for independent evaluations, but our experience is that clients are seeking help in three other areas.

Supporting service improvement

After almost a decade of budget reductions, services are feeling it. This is not a new story, but the easy efficiency wins have often gone. For services where demand is still increasing (for example those supporting older people), this poses a particular issue: resources are already stretched, and services need to make  more sophisticated, creative and cultural changes if they are to continue to meet demand while managing their budgets.

What has proved helpful here is acting as expert advisor, critical friend, and independent facilitator.

Service change like this requires buy in and change from within. So, we facilitate workshops, oversee the progress of workstreams, and provide a steering hand based on our experience of what works (and what doesn’t) in service delivery and managing change. For a recent client, we have been helping delivery staff to think strategically about their service. This is really about helping the service to find the breathing room to explore the evidence about current delivery in a carefully structured way and develop the solutions themselves.

Reviewing service need and delivery

Health and social care needs are becoming more complex. Policy makers are also shifting their focus on the interaction between health, social care and other outcomes such as housing, education and employment. 

Service providers are responding to this by undertaking reviews of their range of services to answer the questions, “What are the needs of my target group, and is what I am delivering – and the way I’m delivering it – addressing these needs?”

Our work with one Health and Social Care Partnership in Scotland has been typical of this.

Having explored with them the range of employability services they funded, and how they could enhance their impact by connecting these around specific client routes and journeys, they asked us to review their tailored health services for young people.

These are delivered through different models that have grown organically in response to local needs and available resources. These services were one part of a range of services provided by an array of partners. We identified the needs of young people in the area and recommended a service delivery model that would best meet these needs while fitting in with, taking advantage of, and influencing other services. This can feel a bit like three-dimensional chess at times!

Understanding costs and benefits

As Clara and I wrote some months ago, in an environment where every pound comes under the microscope, common sense is not enough to drive decision making. Commissioners are asking themselves, “How do use my resources in a way that supports service users, while generating savings elsewhere”. Clients want to understand how spending can relieve the financial pressures and free up resources to be reinvested elsewhere.

One example is the help we are providing to a Clinical Commissioning Group in England to understand the likely financial return to commissioners from changes to clinical follow up procedures. We are also evidencing and measuring how non-clinical support for patients can lead to tangible savings to clinical services (and therefore commissioners), while improving the service users experience. Another example has been helping The Yard Scotland to articulate how much its service reduces the demand for Local Authority funded respite care for young people with disabilities.

You will gather from this that client support needs in the area of health and social care are fluid and shifting. They need to maintain progress and make significant changes while ensuring that their clients and patients receive high-quality care and support.  Our experience is that there are still improvements to be made against a background of tightening budgets and increasing demands. But it needs evidence, leadership, sustained investment in staff and their development – and great collaboration across the front line.

 

Clare is a Principal Consultant in our Edinburgh Office. She works on health and social care projects across the UK and is trained and experienced in economics and public policy. You can check out her profile here.
Social Inclusion through sport

Social Inclusion through sport

Can sport really support social inclusion?  Helen Fagan reflects on our experience of managing funding into sports activities and her own passion for six sports.

London 2017 kicked off with the World Para Athletics Championships on July 14th, once again bringing some of the world’s most inspiring athletes to one of London’s most iconic venues for sport. A few weeks later on August 4th the IAAF World Athletics Championships will also begin, marking the last competitive races of some of the athletics’ world’s biggest stars including Mo Farah and Usain Bolt.

But why are these major sporting events important to Londoners? Why is the Mayor of London so keen to have London as the ‘home of World-class sport’? And what does this have to do with social inclusion?

It is true that not many of those watching will make it to compete at such events. However, seeing athletes on the world stage can inspire people to get involved in sports they wouldn’t otherwise consider. Increases in participation of over 17% were seen in athletics disciplines following the successes at London 2012. And this increase in participation is a key outcome. There is an obvious correlation between involvement in sport and its participants being more physically fit and healthy.  A lot of evidence also exists for the transferable skills and mental focus that sport can teach. But there is growing evidence of its link to improving social inclusion as a result of involvement as well.

Ask many people involved in sport what their favourite element is and answers often mention the others involved. Whether this be teammates, competitors or training buddies, this social interaction is key. The social gatherings following, often centred around food and/or drink help too! I regularly take part in six different sports myself and can definitely relate to this.  Indeed, most of the friends I have gained since moving to London have been either via sport, or we do something sport related when we meet up. Even if we have nothing else in common, we share an enjoyment of the activity and that is enough to build a friendship on.

But it goes beyond simply reducing isolation. The UN recognises that sport ‘…can be a successful tool for tackling inequality in hard-to-reach areas and for empowering individuals and communities…[eliminating] obstacles and barriers.’[1]We at Rocket Science saw this was indeed the case through our management of the Freesport programme.

 

 

35,000 Londoners got involved in the free sport activities organised by the community groups and sports clubs funded by this programme 2014-2016. It was particularly successful in reaching groups which tend to be less likely to engage in sport – females, black and minority ethnic groups and vulnerable people. Individuals could come together in public spaces to interact in a different and often new way. Particularly as over 50% of the participants categorised themselves as previously inactive.

The Mayor of London, in recognising the impact of sport as a tool for social improvement launched the Community Athletics Fund earlier this year. 54 projects have been funded across London, and will bring individuals from different social groups together to take part in athletics activities. Approximately half of the funding is committed to projects providing activities for disabled participants, and all projects will look to bring non-disabled and disabled participants together.

It is exciting to think, as we see some of the greatest para athletics and athletics stars make their final competitive appearance, that around the same time, in another part of London the athletics stars of the future are trying the sport for the first time. London 2017 is using the hashtag #Bethenext for those inspired by watching their role models at the championships to dream of competing on that World stage in the future. And for those who don’t have such aspirations, funded projects will still provide a brilliant taster experience and allow them to interact with those from their local community they might never otherwise meet. We expect this will all result in a further increase in participation in athletics and the social benefits this can bring.

Sport can often divide us into opposing teams but, now, more than ever before with the divisions that exist in our society, we need something to help us realise that there is more that unites us than that which divides us. Sport is one such way to bring people from many different backgrounds together.

So now is the time to get involved!

[1] https://www.un.org/sport/content/why-sport/sport-and-sustainable-development-goals (Accessed 17/07/17)

Helen is the Grants Manager at Rocket Science based in our London office.  You can check out her profile here.

When common sense is not enough

When common sense is not enough

Clare Hammond and Clara Mascaro on using Cost Benefit Analysis to justify investing in prevention

The saying goes: “It’s better to build a fence at the top of a cliff than to park an ambulance at the bottom.” And this common-sense notion that it is better to prevent than to cure has in the last decade also become an accepted principle in public policy. This has been helped by the influential work of the Early Action Taskforce and other bodies such as NESTA.

But putting common sense into practice is often easier said than done. Designing a preventative intervention involves important decisions such as when to intervene, and whether the intervention should be universal or targeted at a specific group of people. In particular, making a solid financial case for investing in preventative strategies is proving to be the ‘do or die’ of whether these are implemented at all. This is where cost-benefit analyses (CBAs) have a crucial role to play.

…the costs and benefits of prevention are spread over time…

A major difficulty for financing such interventions is that service providers bear the costs now, for a service that may create benefits in the future – often 5, 10 or 20+ years in the future. Well beyond any service budget or political term. Convincing service providers to divert already limited money from those who need it now, to benefits in the future is a tough one. Particularly with all the uncertainty that goes with things not in the here and now.

… the costs are usually borne by one service and the benefits received by another…

The agency bearing the costs is not always the agency reaping the benefits. For example, a local authority may invest in a programme to facilitate youth transitions from school, but the savings from reduced youth unemployment will accrue to DWP as a result of having fewer out-of-work benefit claimants. In a world of siloed budgets and service pressures and demands for results, moving money across organisations, even within the public sector, is complex.

…the solution is trust and coordination between agencies – and a lot of hard evidence…

To support investment in preventative strategies, co-operation is needed. This could be facilitated by pooling and integrating budgets. For example, this is what happens with Health and Social Care Partnerships, which bring together local authorities and NHS Boards across agencies and institutions.

 

However, when such integration is not an option, strong partnership working, coordination and trust is needed to encourage investment. This can be helped by cost-benefit analyses showing who will benefit from an intervention, by how much and when. On this basis, agreements can be made between agencies to share the costs and benefits of a preventative intervention.

…Cost Benefit Analysis is critical to underpin conversations and agreements between agencies that build this coordination and trust…

CBAs can be used to make a case for investment now for future savings. By clearly showing the expected costs, savings, those who pay, those who benefit and when, decisions about prevention become more tangible. We have been working with a number of Local Authorities and service providers to create CBAs that help them to better understand and articulate the costs and benefits of a range of preventative investments.

A few of these include:

·        Helping the Dundee Partnership to estimate the likely savings to a range of agencies from reducing the incidence and duration of long term unemployment. Our work also identified who to invest in, when, and how to successfully prevent long term unemployment

·        The London Borough of Havering where we created a CBA to estimate the savings to the Local Authority from our recommended interventions to reduce unemployment. These savings were as a result of less demand for council services such as social work, care and housing

·        For a charity called The Yard Scotland, we estimated the savings to the Local Authority of their service through reducing the demand for council funded respite care for children and young people with disabilities by preventing issues from escalating.

In a context of tight budgets, a complicated landscape of provision, and a short-term bias, CBAs can provide the supporting weight to tip the scales in favour of early action. We may all agree that ‘it is better to prevent than to cure’ but, in this case, common sense alone won’t make prevention happen.

 

Clare is a Principal Consultant at Rocket Science based in our Edinburgh office.  You can check out her profile here.