December 4, 2013
Finally, a bit of the how
Not since the Christie Commission reported, and certainly not since the economic crisis blew such a gaping hole in the public finances, has anyone tried to argue against the need to change the way in which public services are delivered. Lots of talk about the need to find ‘new ways of working’ and ‘doing things differently’ but precious little detail on the vital question of ‘how’. Which is why there’s more than a little excitement about what been happening in Stoke recently.
Reshaping Public Services – a radical approach to reforming public services
PURPOSE OF THIS PAPER
• To share learning from a recent conference about a radical “whole systems” approach to public service reform that has been piloted in Stoke-on-Trent.
• To invite us to consider whether we should incorporate any of this learning into our current thinking.
• To make colleagues aware that the Chief Executive championing this has offered to visit Scotland with his senior management team to share with us what they have learned.
Bromsgrove & Redditch Councils and Stoke City Council have piloted a new way of working with partners that appears to go beyond co-location, co-production or shared services. Two pilots brought together partners including Housing, Health, Fire, Police and others to apply a whole systems approach to problem solving.
Their starting point was to understand the person/ family and target help to meet their needs, rather than each agency providing isolated services to address single issues. In the councils’ own words: “the results are profound. Citizens previously labelled as ‘lost’ are living good lives, demand on services is going down and the size of opportunity to reduce cost is staggering”.
As a result of evidence gained from the pilots, money is already being transferred from other partners’ budgets (such as Health) to redesign front line council services. The emerging evidence is being used to commission new services not previously provided, and the Third Sector is playing an integral role in delivering those services.
Another significant outcome appears to be the effect of this new way of working on staff morale, engagement and empowerment. Judging by what I heard at the conference, and the people I spoke to, this seems to be profound. One front line worker, with many years local authority experience said from the floor “this has given me boundless energy and set me free to make a difference”.
As a result of the success of these pilots, the Council Chief Executive said that: “ the Council is now at the beginning of a total system redesign based around locality”.
This paper will set out just a brief summary of the pilots, taken from my conference notes. I’m happy to provide more information if required
Background – preparatory work
• The Council chief executive hosted a 6 day facilitated event with all partners (health, police, fire, social services etc) – to assess demand on all services and their capacity to respond in light of budget cuts.
• They found that between 36% and 53% of demand for all services was “failure demand” (waste) – this is demand caused because of a fault in the system (a basic example of this would be someone calling to ask why an earlier request had not been dealt with).
• The partners spent a lot of time examining what was causing the failure. They mapped complex cross cutting individual cases back to when they first presented problems (in some cases over 10 years). For example Case A – disabled woman, multiple problems, 11 year history of interactions with public bodies. Tracked every interaction over last 11 years. First presented in 2002 as a problem due to anti-social behaviour of child– what she said she needed was help with the housework and she wanted to be able to access the upstairs of her home (this would have cost £20,000). What she got was anger management classes for the child, a place on a parenting programme and help to clean 1 bedroom. Since then there have been over 100 interactions (social work, police, housing, health etc) – total cost so far £107,000 (and this doesn’t include the cost of the child being taken into care).
• The team mapped all local service providers for both professionals and users (over 300). They identified “superusers” (high consumers of services) and examined case studies back to when they first presented and examined referral routes and interactions. Found lots of examples of people being told “go away until you get worse” and no one person or agency ever had “ownership” of the case. Total cumulative costs (per individual case) were often over £1 million
• Lessons learned – we record when people are not coping but we don’t do anything about it. Red flags are not seen or heard. We do only what we have to. we protect our budgets, we refer problems to others, there are barriers to sharing data (we don’t trust each other), we focus on our targets. In most cases, the underlying problems had never been fixed. People have different needs. No one agency could meet those needs. We each believe that what we are doing is working (and it isn’t)
All partners agreed to pilot a preventative, whole system approach in local areas. The partners agreed there would be no targets, no top down management structure, they would share information and share funding
Pilot 1 – The locality approach (housing)
Pilot 2 – the “rebalance me” approach (whole system support to help people “live their lives well”)
• Both pilots staffed by multi – disciplinary locality teams – based in the community – no procedures, no targets, no timescales – one person had ownership of the case and acted as single point of contact (with autonomy to decide what was needed and authority to pull in expertise and services as required). The “rebalance me” team also included secondees from fire, police and third sector)
• the teams worked to purpose and principles.
• Purpose: “1. You understand what I need 2. You help me resolve my problems”
• Principles “you fully understand me and the real problems to solve – you will help me to identify solutions to my problems – you will help me to help myself – you will pull on expertise as needed”
• “I am the owner of this case – how can I get you the help you need”
• Case officers did not work to procedures and had autonomy to “bypass the system”, but worked under agreed controls – their action had to be: Proportionate, Legal, Auditable, Necessary and Safe.
• Measures were used to understand whether what they were doing was working (but crucially, no targets were set – this gave freedom to tailor individual solutions and do what was needed, and only what was needed.)
Pilot 1 Early results – the locality approach
• Before the pilot started, the team assessed everyone according to need (5% needed specialist long term professional help to live their life well – 31% had multiple problems and “could go either way” – 64% had housing problems but were living their life well.
• After 6 months, the respective figures for the three categories were: 5% (no change), 15% (down from 31%) and 80% (up from 64%). So half of the people with multiple problems who had been classed as “could go either way” were now classed as “living their life well”.
• Staff report dramatically increased job satisfaction and engagement. Quotes included “we know we are doing the right thing – we know how our customers feel – we work as a team (no silos) – Agencies work alongside each other”
• For Case A (the complex case referred to earlier) the total cumulative projected costs until 2022 are £782,000. Had the person been given what she had asked for when she first presented, then received ongoing support under the pilot method, the figure would be £61,000.
COSTS AND SAVINGS
The council collated the costs of all activity carried out per person for the 2 years prior to the pilot (across all agencies and partners). They then collated the cost of all activity since the pilot started. This allows then to map future projections for both methods and compare the two. They also identified 35 key measures to assess progress. They also measured progress against the city as a whole and similar “control” wards in the city (to prove that any change was as a result of the pilot)
The team also captured costs per agency both before and after the pilot, so they could compare.
Early findings (caution – this is based on a small sample of cases and data points)
• Rent arrears down by 14% ( against a 5% reduction across the city)
• Notices of eviction down 1.5% (compared to a 6% increase city wide)
• Anti social behaviour down 5.2% (compared to 21% increase)
• Under the pilot, costs to NHS (for the people in the pilot) down 80%, police costs down 95%
• But – Local authority costs increased by 10%, and the cost of services commissioned by the local authority increased by 150% [in most of the examples given these services were commissioned from third sector providers]
• (so costs shifts from health, police etc to local authority commissioned services – many of which are provided by the third sector)
• Ratio of demand on each service (from the people on the pilot) – before the pilot was Police 40%, council 40%, NHS 18%. After the pilot the figures were council 84%, Fire 11%, NHS 7%, Police 4%
• Whole system costs under the pilot (compared to pre pilot): Justice (-99.9%), fire (-71%), NHS (-69%), Police (-95%), council direct provided services (-42%), but council commissioned services (+150%)
PROJECTED SAVINGS – NEXT TWO YEARS
• For the 7 cases that it has been possible to fully cost, the cumulative projected savings over the next two years are £104,000. (Under the old method, the 7 cases would be projected to cost £337,000 – under the pilot the figure is £233,000)
• If this was applied to every similar case in the city, the potential saving to the public purse would be £81.5 million over 2 years.
OTHER SYSTEMS THINKING BASED INTERVENTIONS
The council has also used a whole systems approach to redesign how it delivers council house repairs (results – average days to repair down to 3.2 (from 20), average visits per day cancelled down to 4% (from 11%), calls where problem not fixed first time down to 25% (from 42%) – customer satisfaction rating 96%).
The council has also applied a similar approach to equipment for independent living, pothole repairs, benefits advice and development planning, with similarly impressive results.
KEY LEARNING POINTS SO FAR
(From the keynote conference address by Tony Oakman, Stoke Council’s Executive Director of People):
• We need to “let go” – and be less solution orientated
• Need greater appetite for risk
• Need to ask more questions
• Can’t be top down
• We must suspend the rules (in part)
• There is no “manual” for this
• Need to persevere and hold nerve
• “integration” and “shared services” do not resolve the problems – the issue is not how efficiently we do things. The issue is whether we are doing the right things – are we making a difference? (Peter Drucker quote: “there is nothing so useless as doing efficiently what should not be done at all”)
• Need to move away from the “computer says no” model (where, perversely, we tell people that they need to get worse and meet the threshold before we can help them) – to a model that instead switches off the demand.
Reshaping Public Services Academy
The councils have also established the “Reshaping Public Services Academy”. This claims to be unique in that its approach to change is based on systems thinking principles and method.
Kevin Dicks, CEO of Bromsgrove and Redditch Councils and Tony Oakman, Executive Director of People with Stoke City Council have volunteered to bring their team to Scotland to share their experience with SG and any other interested partners. Equally, they would be happy for us to visit them for a study visit. Their experience of this pilot has clearly enthused them and their colleagues, and they are keen to share the potential of this as widely as possible.
I’m happy to offer to facilitate any visit.
Scottish Government Local Government and Communities Directorate, Third Sector Unit
October 21, 2013
0131 244 1593 or 07584 481452