Mystery and Bureaucracy

A twitter exchange between Rob Mitchell and Prof Chris Hatton put me in mind of the famous quote from L’Arche founder, Vanier: “Some people say that communities start in mystery and end in bureaucracy”.

Chris, a skilled combiner of academic rigour and humanity, said, ‘Bureaucracy is a vampire. It feeds on people’. Lots of people reading this blog will relate to that, perhaps because they will have felt their own lives drained by working within, or even living within, a public service bureaucracy. What is bureaucracy though?

We all come across bureaucracies. They feel inhuman: some are machine-like; some fanged as Chris says; some have tentacles which we feel reaching around us into our lives.

But a bureaucracy is always a group of people, choosing to behave in a certain way. People will dispute that word “choosing”. The nature of bureaucracies is that, whilst someone at some point wrote their rules, and other people added to them, they feel like they have come to life, operating beyond the control even of those who profess to lead to them.

But whilst Vanier’s quote is often read to mean that every community – a group of people who share some beliefs and ways of behaving – already has some bureaucracy in it, it also suggests that every bureaucracy is also a community.  He could equally have said that every community starts in mystery, and ends in mystery: the mystery of how a group of humans created something which feels so utterly unlike themselves.  The bigger the bureaucracy, the deeper its mystery: the gap between the values of the people within it and the way we feel instructed to behave. This is why I think the challenge facing public service leaders is no longer how to scale up (the business growth model of marketised public services) but how to scale down.

But even in a vast bureaucratic community, no rule is unchangeable, or incapable of more than one interpretation. The choice to be human can feel difficult, or downright dangerous, when we work within a bureaucracy, but nevertheless we make choices. Ultimately, then, the nature of a bureaucracy, lies in the choices the people within it make every day.

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The need for a Slow Policy movement

(I was not aware when writing this blog of this 2005 paper by Peter Bate which has a similar theme and which draws on In Praise of Slow by Carl Honore, also new to me. Some ideas percolate, well, slowly.)

There is a slow food movement, which began in Italy, based on the belief that fast food lacks real nourishment and flavour and that its intensive production methods and short cuts are unsustainable for the environment within which it is grown and produced. Slow food is produced with time, care and the understanding of local culture, farming and ecology which can only be developed over years, or even generations. It tends to value small-scale production for its sustainability and for being rooted in community and place.

At present, government and the NHS express the importance of a policy change through the urgency of the deadlines they set themselves and their partners and the amount of money they can ‘find’ in an emergency to fund the change. NHS Sustainability and Transformation Plans (STPs), in which every area was required to set out how its health system would transform itself to survive the current resource crisis and become sustainable, were clearly important, and therefore urgent. So, most were drafted by small groups of very senior people, who regretted they had not the time nor resources to engage widely, particularly with charities, grassroots groups and people with lived experience who are the most complex and time-consuming to find and talk to. It is no surprise that STPs, despite many containing necessary and pragmatic ideas, have been widely reported by the media as ‘secret NHS cuts plans’.

This cycle of crisis, frenzied activity and shallow changes is endlessly repeated. The urgency turns out to be illusory every time: whilst a report will be rushed out in months, underlying causes of problems will remain unaddressed for years. STPs are morphing into the next set of initials whilst the NHS and social care continue to go bust.

We need a slow policy movement in our public services: a new norm for how to create change. No more flurries of reports and plans from the same group of highly paid people, who remain embedded in group-think. No more heroic leaders on a mission to fix things.

Instead, the slow policy approach would be to cultivate different people and networks which are more deeply-rooted in the lives and service cultures of those affected: people with lived experience, their families and front line workers, who all need training, preparation and a slower pace in order to contribute meaningfully. A change programme would examine the problem or challenge from the point of view of people use services, families, front line workers and people who do not or cannot currently access the service. The conversations with them will start with “What does a good life look like?” not “How can we improve, cut or close replace our service?” The questions will include, “What are you willing to contribute to achieving the goal we all agree is important?” (which is a different question to “Will you pay for our service?”, or “Will you volunteer for us?”)

In place of short term pilots generating tentative findings, new models should be implemented on a small scale but with a plan to scale them up incrementally if they appear to be working, until they replace the current system. As my colleagues in Local Area Coordination say, ‘move slowly, to move fast’. With people who use services genuinely involved in their design and delivery, we would finally have the confidence to remove resources from models which do not work, rather than continuing to resource the status quo, regardless of how much more effective new models proved.

High Performance Failure

Every public service organisation has the potential to forget its purpose – working for the people who use its services – and instead being run for the benefit of those who work for or lead it. This happens in poor services through incompetence or laziness, but it also happens in high performing services, which get seduced by their own reflection.

The recent scandal of St Olave’s school, found to be unlawfully expelling sixth formers whose first year results looked like they might bring down the school’s A level results and threaten its league table position, is an example of this phenomenon. This was a state school, spending public money, which was lauded as one of the best, but which was in fact becoming in some ways one of the worst: wilfully failing and damaging young people at a crucial time in their education. This now appears to have been the practice of a number of ‘top-performing’ schools, who presumably shared the view that their league table success, and accolades for their leaders, outweighed the importance of harming those pupils seen as inconvenient. Arguably, this ‘wheat from chaff’ view of children is just a reflection of a wider crisis of values within the education system, with its lingering fondness for selective schools.

The school system has some features of which make this ‘high-performance failure’ more likely. The head teacher and the education system places huge value on the ‘heroic leader’, with ‘super heads’ wielding unchecked power. 2016 Harvard Business Review research looking at hundreds of heads showed that the most lauded head teachers, who made dramatic short term gains in academic performance, often through excluding more pupils, left no lasting legacy of success, but probably a trail of destruction as they removed ‘problem’ pupils and staff who disagreed).

Governing boards can lack real power, with parental voice limited or non-existent. Despite talk of empowering pupils, the focus of most school policies is on their compliance to rules set by others. An extreme example of this was circulating the internet today: the behaviour policy of an academy school, which, whilst clearly starting with the laudable aim to raise young people’s level of ambition (speaking clearly and confidently in full sentences, for instance) had strayed into an Orwellian nightmare: shy pupils could expect to be punished for speaking too quietly (city hypothetical future job interviews, this would make them appear ‘not that bright’) or even failing to smile enough, which was ‘ungrateful’ and ‘negative’. Despite glib slogans about how successful this would make children (“We’re Charter. We’re smarter”), it’s hard to see what leadership or creativity skills could be learned from being subject to such a monoculture.

This is partly a product of the gap between simplistic notions of success and quality in the education system, and what makes a diverse group of children not just as academically successful as they can be, but also as happy, kind and resilient – which are outcomes either unmeasured or which take second place to results. We also see this gap in adults’ services which are ‘high-quality’ but fail to help people achieve wellbeing or build resilience. Continue reading

The Asset Based Area 2017

This new Think Local, Act Personal resource started as a blog post here. Thanks to the TLAP team and its Building Community Capacity network, along with inspiration from local areas such as Wigan (see the Wigan Deal link below), it has now become a how-to guide giving ten pointers towards becoming an Asset-Based Area. Here is my blog for the Dept Health social care blog on the paper:

A GP noticed that one of his older patient’s appointments were increasing, and felt that this was not for medical reasons, but due to her isolation which had worsened following a bus service closure. He linked the lady to her Local Area Coordinator (LAC).

The coordinator helped her to build more links and activities in the community to reduce her isolation and to approach a community organisation which ran a community bus service. Her increased support networks meant she felt less reliant on her GP.

They were also felt to be key to her quick return home from hospital after a heart attack.

The LAC helped link the community organisation to colleagues who gave support for a successful bid for a new community bus service.

At a time when primary care services are feeling under huge pressure, it can be hard to argue for new approaches and creative thinking. But this story shows that, with the right help and a positive mindset, someone possibly viewed as a ‘problem’ can not only find ways to help themselves, but their new connections can also lead to benefits for the whole community.

LAC is an example of an asset-based approach, which, like all similar approaches, starts with questions like, “What does a good life look like to you?” and “What can we do together to pursue it?” Coordinators have the time and remit to get to know people: not just what they need, but also the goals and capabilities they and those around them can bring.

Sometimes this means that someone accessing a service will need less formal support.  However, asset-based thinking shouldn’t be limited to ‘informal’ or voluntary organisations. Nor should it be seen as only relevant to preventative services. It needs to be embedded across the whole system, including in approaches to supporting people with significant health, care or other needs.

Shared Lives carers, having been through rigorous approval processes to join local CQC-regulated schemes, are matched with adults needing support, such as people with learning disabilities, mental ill health or dementia.

This is not a referral process: matching means both parties getting to know each other and making a positive choice to share their lives. The adult either moves in with their Shared Lives carer or visits them regularly for short breaks or day support.

James has significant learning disabilities and mental ill health. He has spent significant periods in institutional care and still needs some hospital stays, but his life with his Shared Lives carer Phil revolves not around the times when he is most unwell, but around the day-to-day things he and Phil both enjoy doing such as fishing and going to the greyhound races.

The Asset-Based Area was coproduced with input from many people and organisations working in asset-based ways, from the Think Local Act Personal national network for practitioners and commissioners who share an interested in Building Community Capacity.

We wrote it because we cannot successfully or affordably add in asset based approaches around the margins, whilst ‘core business’ remains unchanged. We need whole areas to take up the challenge of becoming asset-based, resetting their relationships with local citizens, as Wigan council and a few others attempted. It is time for steady, incremental, whole-place change: it’s all or nothing.

Flipping the narrative

My essay for NPC’s series on the future of not for profits is here:  http://www.thinknpc.org/publications/flipping-the-narrative

It starts like this:

For years, charities and social enterprises that deliver support services have been told to emulate the private sector: to become more efficient and bigger through growth and mergers. We increasingly use the language of customer service, despite the fact that our ‘customers’ often have not chosen to come to us and are not spending their money. Our branding and marketing is getting slicker, even as the budgets for our front-line services are being cut like never before. We talk about quality, excellence and the need to ‘professionalise’, whilst many charities have to employ people on minimum wage to make ends meet while some senior salaries continue to rise.

Some not-for-profits have been so successful in competing with the private sector on that sector’s own terms that it is getting hard to distinguish them from their profit-making counterparts. Others have found themselves, like some private sector organisations, at loggerheads with their own workers, local branches or ‘beneficiaries’.

There are always gains to be made from becoming more efficient, but the challenges facing providers of public services that are genuinely values-led are now far beyond solving through leaner processes or smaller back offices. They are existential. It is time to consider not how charities can emulate the public or private sectors, but what makes our sector uniquely valuable to people who need support, and how we can work with those people to ensure that our public service system values that contribution. Read more.

Let’s get started

The government’s care inspectors, the Care Quality Commission, have just published their three year report on social care, having now inspected all care services in England under their new regime. They found that whilst three quarters of care services are good or outstanding, a fifth of all services need to improve and that rises to a third of nursing homes, which care for people who have the most complex needs. There has been a lot of focus on the role that funding cuts play in this, which is undoubtedly significant: commissioners in some areas are trying to pay so little to their care providers that it is hard to see how those providers could even meet their legal duties such as minimum wage. There needs to be more money put back into the system to avoid catastrophe and the government needs to stop diverting any new social care money into a focus on saving acute hospitals, as has just happened with the Better Care Fund.

But there are other lessons to learn. In this report as in all recent ones, CQC has found that smaller services are more likely to be good than bigger ones. People want to live in somewhere that feels like home, but huge care homes are still being built and registered for older people, and ‘units’ of ten or more beds are still be developed for younger disabled adults.

Staff turnover in social care is over a quarter a year and rising. The model of recruit quickly and cheaply hides huge re-recruitment costs and must contribute to the failings that the inspectors find.

Shared Lives is an approach in which Shared Lives carers are recruited slowly: a three to six month approval process. Shared Lives feels small and homely because it only takes place in the Shared Lives carer’s family home, and the surrounding community. So it perhaps shouldn’t be surprising that CQC once again find that Shared Lives outperforms all other forms of care. Shared Lives carers are trained and paid, and the scheme which recruits, matches and supports them also costs money, but this model is not more expensive: it is consistently significantly lower cost.

Shared Lives is not perfect everywhere. It is coming under increasing pressure from commissioners desperate for even greater savings, who don’t understand that the time and care taken in setting up and supporting Shared Lives is crucial to its safety and success, and also the reason it costs less overall. Some Shared Lives carers are being put at risk of burn out as they are expected to care 24/7, again with risks to people’s wellbeing and ultimately much higher costs. But the lessons from this model are clear: invest time and money in the conditions for success, not managing failure. Focus first and foremost on a good life if you want good services. Ensure rules and regulations are there, but in the background when they’re needed, not the whole focus of everyone’s time and energy. Think small and personal, not big and cheap. 

The government is about to consult on social care. This cannot just be a discussion about what social care costs and how to pay for it. It has to be a discussion with what that money is spent on, starting with the ambition to offer Shared Lives to everyone who want it. Almost every area now has a local Shared Lives organisation to build on. Let’s get started.

What could be

Finally, social care is being recognised by our political leaders as vital to our nation’s health and wellbeing. All parties now recognise that ordinary people can be called upon to pay vast amounts towards their care, in contrast to our free-at-the-point-of-need NHS. There is public recognition of what social care is, for the first time. But now we need to visualise what it could be.

Our annual State of Shared Lives Sector reports give a glimpse of a possible future. They have consistently shown that Shared Lives is growing in England, and now we have evidence of new growth in all four home nations. They have also highlighted the difference Shared Lives makes to people’s lives. Many people who might otherwise have lived on their own or in a care home are finding a settled home with their chosen Shared Lives household. Meanwhile, a new group of older people and others who live with their families, but need regular overnight or daytime breaks, get those breaks from visiting their chosen Shared Lives carer, often matched with them because they both enjoy the same activities, rather than struggling with the stress and disruption which more institutionalised breaks services can bring. People live well and sometimes achieve the impossible.

This year our annual report for England (as reported in Community Care) paints both an encouraging and concerning picture. In previous years, Shared Lives has grown strongly, despite the cuts which are shrinking all other forms of social care. The net growth has been about 1000 additional people per year. This year, the number of people using Shared Lives in England has grown by around 580, to just under 12,000 people, around half of whom are living with their Shared Lives carer, and the other half are split between short breaks and daytime support. Look at the numbers of people using Shared Lives by region, however, and it is clear that there is a widening gap between those regions which are accelerating and those which have in previous years been stalled, and are now starting to slip back. So the regions which are growing, have added over 1,100 additional people. Half of this growth comes from the North West, with London and the South West splitting most of the rest. There are signs of growth in the North East, which has been one of the smallest regions and where we are working with directors’ association ADASS and the region’s Shared Lives schemes and partners to create a regional hub. The South East and Yorkshire have seen significant reductions, however, after having previously been regions which were using and developing Shared Lives strongly. The East and West Midlands remain essentially unchanged and the East of England, which has been the smallest region for some time, is now falling. Meanwhile, the model is growing in Scotland, Wales and Northern Ireland and we have embarked upon ambitious new programmes in each nation, with strong support from the Wales Government in particular.

With so much news about cuts and the crisis in the NHS, it is easy to believe that the future of public services will just be less of what we have now. But we believe Continue reading