Social value?

The Social Value Act (SVA) allows public bodies in England to score the creation of social value when they are putting public services out to tender. Bidding companies can score extra points for the way in which they will deliver the contract, where they can show they will have a positive impact on the environment or local communities. Employing local people from low-income communities can be scored, as can volunteering, or carbon reduction.

I’ve championed the Social Value Act for several years now, arguing in the Joint VCSE Review that its powers should be used by default, rather than as an exception. What’s not to like: the taxpayer gets extra value for money, and social purpose organisations are more likely to win public service contracts?

So I was concerned when I read in the excellent report on disability services commissioning from the Voluntary Organisations Disability Group (VODG) of one charity’s experiences of the SVA being used in such a rigid way it felt almost impossible for a small organisation to demonstrate the kinds of added value being asked for. I’ve subsequently talked with the charity and seen the part of the tender specification, which accounts for 20% of the tender score – an unusually high proportion. It’s a frustrating study in what results when you see a useful , creative concept through the lens of a bureaucratic world view. The form has been written with large private sector contractors in mind, and over 8 pages itemises a host of specific kinds of social value. Some makes sense: the number of employees, apprenticeships and work placements for people from specific local communities features. But there is also a long list of prescribed kinds of employee volunteering which bidders can commit to, with a strong preference for visiting schools and giving careers talks for some reason. Each kind of social value has a multiplier applied to it, which means that each ‘unit’ of social value may be worth £1, or nearly £30,000 for some of the employment related units. It looks like it’s been derived from the NHS Sustainable Development Unit’s helpfully-intended calculator.

You can see the rationale: if social value is to be scored, there has to be some rigour to it. How do you compare carbon reduction with creating volunteering opportunities? But the problems are also obvious: what would be the point of committing to any of the kinds of social value which attract 1:1 scores, if some attract 1:30,000 scores? And for an organisation with a small staff team and low margins, the ability to commit to large amounts of employee volunteering will be much more limited than for a large corporate. The charity I talked to creates huge social value: their whole approach creates community connections, draws on volunteers and social action as its core operating function, and no public money is siphoned away from the community to offshore tax havens. But it could easily be out-competed on social value in this format by a large corporate which is clever about the way it cites its employee volunteering programme in all of its tenders.

One of the problems here is that social value is being placed in a gap where commissioning for outcomes should be: if organisations were judged on the wellbeing outcomes they created, a good social purpose organisation would already have a built-in advantage. The commissioner in this instance sees social value as something created in addition to the main purpose of the contract, which doesn’t allow them to value organisations which build social value and community impact into the way they deliver their core work. Ironically, I can find little evidence of not-for-profits being involved in designing the tools and calculators developed to enact a change in the law which was intended by parliament to work in support of those organisations.

The other problem is the balance between the need for transparency and fairness in public service contracting, which is subject to legal challenge, and the desire to value something which is valuable precisely because of its subjective, locally-decided nature. If other areas emulate the approach I saw, social value will be killed off as a concept just as it is gaining momentum.  So it feels urgent that the sector, government and NHS promote good approaches such as Liverpool CCGs social value objectives (picture below)  and Greater Manchester’s framework which, crucially, includes the intention to develop the voluntary sector:

  • Promote employment and economic sustainability – tackle unemployment and facilitate the development of residents’ skills
  • Raise the living standards of local residents – working towards living wage, maximise employee access to entitlements such as childcare and encourage suppliers to source labour from within Greater Manchester
  • Promote participation and citizen engagement – encourage resident participation and promote active citizenship
  • Build the capacity and sustainability of the voluntary and community sector– practical support for local voluntary and community groups
  • Promote equity and fairness – target effort towards those in the greatest need or facing the greatest disadvantage and tackle deprivation across the borough
  • Promote environmental sustainability – reduce wastage, limit energy consumption and procure materials from sustainable sources
Liverpool CCG
Liverpool CCG

How would we know?

If an area becomes ‘asset-based’ in everything it does, how would you know? You would expect to see everyone – public services and charities; citizens and people with power – thinking, speaking and behaving differently. This is the second of three blogs written with the Chair of Think Local, Act Personal, Clenton Farquharson MBE, and available in full here. Last time, we revisited the Asset-Based Area (ABA) model which tried to distil down how an area can become asset-based in everything it does from strategy down to the grassroots, into ten actions, starting with mapping your local assets, and including sharing power with people who are usually excluded, and building a diverse range of community approaches which are now gathered in an online catalogue. Three years after the original thinking, we are developing the ABA model in more detail through the Social Care Innovation network.

In this blog, we want to think about how we would know that an area had become asset-based. What would we measure and how?

Greater Manchester has adopted use of system activity measures collected every quarter, combined with a range of personal outcome measures collected locally across the city region. These include measures already well-established across public services, such as health outcomes, measures of demand and cost, and wellbeing outcomes: recognising that wellbeing – living a good life in a good home and a welcoming community – is intertwined with more clinical outcomes.

Key Human Indicators

Many areas and organisations have Key Performance Indicators (KPIs). Perhaps every area needs Key Human Indicators. Are people achieving wellbeing? That usually means that people who need support are able to experience the right balance of independence and connection for them, which will change at different times in their lives. For workers and systems, KHIs will include warmth, kindness (as set out in Julia Unwin’s brilliant report) and dignity. Networks can be more important than bureaucratic service structures. In Shared Lives, friendships are seen as key indicators of wellbeing, so Shared Lives Plus’ national outcomes measuring tool asks participants how many friends they have and whether Shared Lives support is helping them make and sustain those connections, or getting in the way.

Read the rest of this blog on the Social Care Institute for Excellence website, in the Social Care Innovation Network’s minisite.

The idea of the Asset-Based Area

The Social Care Innovation Network is helping 15 local areas and a similar number of innovative organisations take innovative approaches to social care and support. We aim to provide answers to the challenge of scaling up primarily small, community-focused examples of innovation. It’s led by The Social Care Institute for Excellence; Think Local, Action Personal, and Shared Lives Plus. We are keen to encourage as many people as possible to contribute, share and benefit.

I’ve co-written three blogs with Clenton Farquharson who chairs TLAP (among other things) on the thinking behind the Innovation Network and the workstrand that Clenton and I are leading on, which is on The Asset-Based Area. This is our first blog (the full article is here):

The idea of the Asset-Based Area (ABA) started life as a blog and was co-produced 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. So many areas are doing some community building or transformational stuff, but so few are trying to turn their community initiatives into core business. There is not enough ambition, partly because it’s hard to get past the apparent paradox that the good stuff often feels small and personal, whilst the challenges faced by public services feel huge.

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 have attempted, with local priorities defined and put into a community plan which is built on local knowledge. So we tried to distil down how an area can become asset-based in everything it does from strategy down to the grassroots, into ten actions, starting with mapping your local assets, and including sharing power with people who are usually excluded, and building a diverse range of community approaches which are now gathered in an online catalogue.

Three years after the original thinking, we are developing the ABA model in more detail through the Social Care Innovation network, and revisiting this as a work in progress as we do. We’ve grouped the ten actions into three:

  • Co-production, partnership and power sharing: building & valuing community capacity and community organisations, tackling inequalities
  • A strategic approach: a clear story translated into shared outcomes, asset-based commissioning, grant-giving, and provider market development
  • Diversifying workforces & building local enterprise: investing in volunteers & social entrepreneurs, valuing lived experience, growing mutuals & co-ops

We are also taking this opportunity to look at where the model needs improving – and as ever we want this to be a joint effort so your views are very welcome.

One key area that the model does not say enough about is self-directed support. (Read the rest here).

 

Hero, villain, angel, machine

The other week I broke a bicep tendon, which I wouldn’t recommend. I posted this twitter thread with some reflections about using the NHS.

I had quite a few responses, so I’m reposting it as a blog here:

As an NHS Assembly member I thought I should road-test the NHS. So last weekend I snapped my bicep tendon while rock climbing training. Ouch. Here are some reflections.

Firstly, this was a self-inflicted sports injury, but can only be fixed by surgery. That the risks we choose to take (exercise, lack of it, etc) are covered, free-at-point-of-use seems miraculous at times like this.

A&E on a Sunday at Leeds LGI hospital. A wait of course, but in under 4 hours, I was assessed, x-rayed, seen by a specialist, booked me in for next week, by busy, effective, kind people.

I was phoned on the Sun and Mon to book and confirm a Tuesday appointment. The surgeon and his team there were friendly & clear. Options & risks explained. Surgery booked for Sun.

One of the great things about our NHS is the sense of equality. The surgical ward’s patients were a cross-section of Leeds. An unconscious homeless man brought in by 2 police. An older lady keen to chat. A young man having to wait ‘too long’ left in a huff (or maybe in fear?)

An unconscious homeless man was brought in by two police officers. An older lady fretted about getting home. A young man left in a huff when told how long his surgery would be.

Being trolley-ed half-dressed to theatre, scalpels & general anaesthetic feels like being wheeled away from the land of the living. Porters have a degree in cheerfulness which helps a lot.

I met the surgeon just before being anaesthetised. Ideally, I’d have had some significant last minute risk info earlier. He did what seems to be a great job of the op.

Waking up. I burble at the endlessly patient nurse & spill my water. Back to the ward. More kindness + a chemically-enhanced sense of wellbeing. I love the NHS!

This album on my phone seems to have lasted a month.

All morning on the ward TV politicians shouted about Brexit, immigration & NHS crisis. While the multi-cultural, multi-national team were busy, effective, cheerful & kind to us all.

I hear a passionate discussion about an issue to do with unnecessary waiting, and what the team planned to do to fix it. A strong sense of us patients as people with lives outside of this ward.

I think about someone I know in a mental health crisis & my experience of those services: overwhelmed with demand. Long-term care lost behind waiting lists & ‘life-or-death’ criteria.

With my ‘self-inflicted’ injury fixed, I thought about my colleague Meg who talks about being treated for self-harm injuries with less compassion: results of a mental illness seen as ‘self-inflicted’

Is the balance right between the impressive resources here & those available to people with life-long conditions? This team is under pressure, but imagine social care resourced like this…

Later I read this harrowing BBC report into Mark Stuart’s death: autistic & fatally lost in a hospital’s care system. His parents said, “It was like he didn’t matter”.

The NHS is a miracle which has not yet reached all those who need long-term care. It is easy to simplify the NHS to hero, villain, angel, or machine, based on our latest experience.

The NHS needs us not to worship it, or despair at its faults, but to see it clearly, value it and question it. The staff here were at their best when they listened, explained, empathised.

In some places, that culture of kindness and professionalism will break if we take the NHS for granted. We need to invest in it. & we need to listen to those who don’t yet experience it.

The bill for all this was of course, nothing: just paying my taxes. I dread to think how much my care has cost the NHS, or how much private paying health care systems would charge.

Finally, huge thanks to everyone at the Leeds General Infirmary – you are doing an amazing job in tough circumstances and I couldn’t be more grateful.

Accelerating Ideas – shaping local systems

In two blogs, I and my colleague Anna McEwen will reflect on what we achieved, struggled with, and learned around two of the main objectives of our recently completed Accelerating Ideas UK development project, supported by Nesta and funded by the National Lottery Community Fund.

  • establishing a new strategic advice arm and supporting commissioners to start and expand Shared Lives and Homeshare services
  • establishing our work in all four UK nations, building on our success and government support in England and Wales

We wanted to develop a strategic advice business for two main reasons: to help local leaders to work with their  provider organisations to improve and grow Shared Lives, Homeshare and other personalised models, and to bring us a sustainable source of income so that we rely less on grant funding.

This work started to in earnest in 2017-18 and accelerated rapidly: nearly 70 contracts to date, including work with Australia’s changing disability support service and in British Columbia. A typical example is the Shared Lives service review for Bridgend Council which included an evaluation and analysis of Shared Lives in Bridgend, and a comprehensive business case and options appraisal looking at externalised and in-house delivery, working with other localities, and growing the scheme. A key aspect of our work is the work of the team of people with lived experience and their Shared Lives carers, who carry out peer-to-peer research, alongside colleagues who look at practice, use of resources and compliance, to produce a rounded picture of what a local service does, its outcomes, but also how it feels to the people who actually use and deliver it.

One of our largest projects has been with Greater Manchester Health and Social Care Partnership (GMHSCP) to develop and implement an ambitious five year plan for an additional 600 people using Shared Lives, across Greater Manchester. Jo Chilton, Programme Director, Adult Social Care Transformation Programme said, “Greater Manchester has high ambitions for scaling up Shared Lives but we want to ensure that people currently involved in Shared Lives and those who may wish to be supported in Shared Lives in future, help assess how ready we are to do more, and what would need to happen to make our ambition a reality. Our partnership with Shared Lives Plus is vital to getting this right from the start.” This included a detailed evaluation of five of the ten Shared Lives schemes using a combination of scheme health checks and data analysis. The city region is investing and working towards the UK’s most ambitious goal to date, of  15% of people who have a learning disability and use social care to be using Shared Lives.

Our main challenge has not been winning work, it has been expanding our delivery capacity to keep pace with demand. We use a small number of associates for specialist tasks, but a lot of the delivery has been in-house, and the expansion of our capacity off the back of demand for support, rather than through grant-funded expansion, is one of a number of culture changes for our team: we have needed to be willing to take some different kinds of risk to expand. We tailor our work to the local places we are working in, rather than around a bid submitted to a grant maker.  In changing our model, we were focused on remaining true to our values and serving our members, who are 6,000 Shared Lives carers and 170 local organisations. The key to this has been to develop an offer which is shaped by our values and coproduction approach, and marketing this and our unique place as the only national Shared Lives and Homeshare organisation, not as extra cost or time, but as the best reason to work with us: after all, what would be the purpose in expanding the most personalised support approaches, if you didn’t pursue that expansion in a personalised way?

Some of the impacts of this are more expected than others. We have long understood the need to get local areas to invest in development work, if they are to value it, so we hoped to see the buy-in we have achieved through contracted work, but one risk we identified was that it might make our campaigning work harder, around issues like Shared Lives carer pay, for instance. In fact, embedding the practice of coproduction with Shared Lives carers, and developing closer relationships with local leaders, has in some areas made it easier to raise issues around valuing supporting – and paying – Shared Lives carers, rather than harder.

It’s not all been plain sailing, of course. All the advisors who helped us develop this business talked about the risks of under-valuing and under-pricing our work, over-promising, and under-estimating the time needed for work. We thought we’d understood that advice, but we did all of those things and had to learn the hard way. This has increased pressure on our team at times. We’ve coped with those challenges though and this new way of working has not only given us a more sustainable future as a charity, it’s brought a level of learning and insight which we could not have achieved in any other way.

Could self-management work in care homes?

This blog is co-authored by Helen Sanderson, founder of Wellbeing Teams and Alex Fox, CEO of Shared Lives Plus.

Social care’s inspectors, CQC, consistently find that smaller care homes are, on average, better than big care homes. John Kennedy’s JRF research into older people living in care homes found, unsurprisingly, that relationships are key: people want where they live to feel like a real home.

The number of small care homes is reducing, however, because the economics of running a small care home are increasingly difficult. Care home businesses are consolidating as the pressure increases. This shouldn’t inevitably mean that each individual service gets larger, but care homes for older people with 100 beds are commonplace. This may create economies of scale for those businesses, but it may equally create dis-economies of scale, as the markers of great value in care can become harder to achieve in services which reach institutional scale: feeling connected and human both inside the service and with the wider community. Where those businesses are hierarchical, it can also be harder to foster the trust in workers, personal sense of responsibility and autonomy that create transformational support relationships in social care. Some of the largest businesses have financing and ownership models which feel a long way from the idea of ‘community’ or ‘social’ care, and appear to have been used partly as vehicles for risky property speculation. We have seen some huge care provider bankruptcies affecting thousands of older people and there may be more on the way.

So, given that half a million people live in care homes is there a way to create the high value and quality of small care homes, with the economies of scale on things like training and registration which larger businesses can enjoy, but without the added costs of large management infrastructures and profit-hungry big business models?

One approach is the household model, where a care home is divided into small, self-contained households with a focus on creating a family like atmosphere. Dementia Care Matters supports care homes to use this approach and become Butterfly Care Homes. One Butterfly Care Home in Nottinghamshire reports a 43% reduced incidence of falls and 1.7% reduction in staff sickness.

Belong villages have a similar household model. Each Belong household is grouped into an ‘extended family’ sized community for around 12 people, with bedrooms that lead into an open-plan shared communal space, and a kitchen.

In both Butterfly Care Homes and Belong Villages team members often have greater autonomy than traditional care homes. Could self-management take this further?

One of the most promising and widely-talked about ways of organising care and support teams is the Buurtzorg community care model from the Netherlands: recruiting people who are able to work as part of small self-managing teams, supported by coaches rather than a traditional line management structure, with use of tech and data to track activity, payments and outcomes. This model can create better-paid, more fulfilling and autonomous roles, in which people have the time to build consistent relationships, and get better outcomes, at lower overall cost where people can move to independence, because of the better outcomes and vastly reduced need for management infrastructure.

A new briefing paper from the RSA boldly suggests that self-management could save social care. The paper describes five case studies from the UK. One of these case studies is Cornerstone in Scotland, who have drawn inspiration from it to completely reimagine what a large support business looks like around a self-managing rather than hierarchical management structure. The Wellbeing Teams model, which provides integrated, holistic community care on Buurtzorg-like principles, has already been awarded ‘outstanding’ by inspectors, CQC, as has a Buurtzorg UK team. Building-based care services have been slower to experiment with the self-managing model, perhaps because people who are attracted to a devolved, relationship-based way of working have tended to have more affinity for community-based care, but the model’s benefits are arguably most needed in the part of our sector which is most at risk of institutionalisation.

A fully scalable self-managing approach to care homes would perhaps look something like this:

  • Small, ‘home-sized’ care homes or using a household model, with teams recruited who had the skills and aptitude to self-manage, sharing responsibility rather than leaning on a traditional management structure.
  • Those small, largely autonomous businesses networked within a franchise-like structure, with a centrally-developed IT and finance system to track activity, outcomes and payments.
  • Coaches supporting each team and communities of practice for teams to share their challenges, innovations and learning.

Self-management wouldn’t be a panacea for the care home industry: self-managing teams in care homes would also need to adopt the most personalised and empowering cultures and approaches. The best care homes have strong links with their local communities. Few people want to volunteer for a large, faceless company, but where a care home feels genuinely like part of the community, there is huge scope for added value through volunteering, forming Community Circles and the invaluable benefits to health and wellbeing of feeling part of a community, not removed from it. This would fit particularly well with a mutual model of ownership, in which residents, families and perhaps even the wider community had a stake, as well as workers.

Often when we talk about reforming and personalising social care, we focus on models which are the most community-embedded, or, like Shared Lives, seen as the most innovative. But we need to gains of personalisation to reach the whole of social care: they can’t be reserved for the lucky few. There may be models of self-management in the care homes industry which we haven’t included here, so we would be grateful to hear of any examples we have missed. And if you are in the industry and just hearing about or starting to consider this radical transformation, we would love to hear from you. We will be happy to add links to this blog, but most of all we would love to start a new conversation.

Inequality creates ineffectiveness

Youth Justice Officer and author Andi Brierley (@andibrierley) may regret posting such an interesting comment on my blog entry about coproduction – because of course I asked him to turn it into a guest blog. I’m glad I did anyway: this is such a powerful personal piece on why we need many more people with lived experience working in – and leading – our public services. It follows Rachel and Tim’s guest blog yesterday about more meaningful relationships in social work, both of these pointing to the fascinating conversations which are taking place across the adult and children’s services divide about the relationships we have – and those we need – between people offering and seeking support. Andi writes:

I was born to a mother living in a children’s home aged just 16. I spent time in care as a result of mum’s capacity issues leaving me and my siblings abused and neglected. I was excluded from school aged 15, addicted to heroin aged 16 and then exploited into selling drugs by older men. When I was eventually caught, I was sent to a Young Offenders Institution for 18 months. This sentence did little to address my life challenges and upon release, I served a further 3 sentences for offences that all related to drug and alcohol related offences.

I eventually started volunteering for the Youth Justice service in 2007, only two years after release from my last prison sentence. Having been granted an opportunity, I grabbed it with both hands and have worked in youth justice ever since, qualifying in 2013. I have also written a book ‘Your Honour Can I Tell You My Story’ about my experiences, in which I draw on my unique combination of 11 years as a service user and 13 as a youth justice worker, to argue that our institutional responses to disadvantaged communities, children and families do not – and cannot – work.

Let’s take the Criminal Justice System. The regulatory body of Probation and Youth Justice, Her Majesty’s Inspectorate of Probation (HMIP) is set up to regulate ‘risk management’ processes. Do these processes keep us safe?

According to a 2016 Ministry of Justice report, 25% of the adult prison population had experienced care and 42% had been excluded from school: they were known to services from a very early stage in their lives, and many excluded from school and criminalised in their care setting (see this 2018 DfE report). So risk management at that early stage was ineffective, and then, post-incarceration, the reoffending rate for children within 12 months of release is a high as 70%.

The most severe risk management tool is incarceration, which politicians want us to believe ‘rehabilitates’ offenders. However, rehabilitation implies that these individuals were once living a ‘normal life’, which the statistics above show was not the case, and the reoffending rate is currently 46% for all prisoners within 12 months of release. For prisoners serving short sentences, this rises to 60%.  I can’t find research on this, but from my lived experience, I think these will disproportionately be care-experienced prisoners: care experienced and traumatised individuals are more likely to be dysfunctional than organised armed robbers. The National Audit Office estimated in 2010 that this reoffending costs us as a tax payers, anywhere between 9.5 to 13 Billion.

So it seems hard to argue that the current Criminal Justice System is effective when dealing with children that have experienced childhood adversity. Research conducted by the US health maintenance organisation Kaiser Permanente and others found children that suffer abuse and neglect in the absence of an attachment to a positive adult show profound neurological damage. They found that that the more exposure to adversity, the more likely the individual is to experience teenage pregnancy, criminality, drug addiction, health problems and even early death. I can relate to this both personally, but also professionally. I am currently working with children that do not and cannot understand the impact of their environment on their own behaviour, yet we continually view them as a risk instead of doing more to change their environments. The criminal age of responsibility being 10 years old doesn’t take into account neurological impairments.

I believe that the root cause of this is the core belief of the criminal justice system that the children are making choices and therefore they can assist in helping them make better choices. This view is rooted in many professionals’ belief that they themselves would not commit crime, even faced with the environmental factors the children are facing. Let’s explore this even further. To become a professional in the care or criminal justice sector, you often require a degree, particularly if you want to rise to senior management level. Yes, there will be professionals that have faced adversity and even some that come from disadvantaged communities. However, they are extremely unlikely to have experienced the level of childhood adversity or transgenerational trauma the children in the criminal justice system have, particularly those that end up in custody. Currently, only 6% of Care Leavers obtain a degree between the ages of 18-21. The number of incarcerated children obtaining a degree will be considerably lower. This indicates criminal justice services, with some exceptions, are being shaped by a group which does not include people who know first-hand what it is like to be exposed to the environmental factors the children within it face.

HMIP recently inspected the service I work with and spent a week reading what we as professionals write on the recording system. They didn’t speak to the young people in reaching judgements about our practice. Now I see why, when I was a service user, I didn’t know the system was ‘managing’ my risk in this way. I was secondary: the institutional process was primary because that was what the regulators focussed on. But our failure to listen to or value service users goes a long way to explaining the ineffectiveness of the system in helping offenders desist from offending.

I am by no means the person with the answer, but I do have a unique perspective. I know for certain that professionals that haven’t experienced childhoods like ours should not take the view that they wouldn’t have been significantly challenged by such experiences. The Criminal Justice System needs to be built upon the findings of the Adverse Childhood Experiences research which can’t show the reason for a particular offence, which is a decision on an individual day, but does show clearly how a childhood like mine affects the individual’s life course and goes some way to explaining the root causes of the behaviour.

The system would become more effective if it was flexible enough to incorporate the views of people within the communities that the individuals come from. Lived experience is a skillset, so we must reduce barriers to work within the system itself, such as criminal record checks. Einstein said that the definition of insanity is continuing to do the same thing over and over,  expecting a different outcome. Co-production needs to be more than a buzz word. To create a more balanced, personalised and appropriate response to crime, which will keep us safe and cost less money, I have learned that we must fight the social inequalities and marginalisation faced by the vast majority of children who offend.