Co-producción en los Servicios Públicos. Un nuevo acuerdo con los ciudadanos

8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos

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This is a discussion paper. It is not a statement of government policy

Co-production in public services:a new partnership with citizens

Matthew Horne and Tom Shirley

March 2009

The Strategy Unit


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Contents

Executive Summary

Introduction

What does co-production mean?

How important is co-production and what are the potential gains? How could co-production in public services be accelerated?

Background Analysis

Annex A: Examples of programmes which foster co-production

Annex B: Individual Budgets and Budget Holding Lead Professionals

Annex C: Measuring the quality of relationships and encouraging peer support



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What does co-

production mean?

Co-production is a partnership between citizens and public servicesto achieve a valued outcome. Such partnerships empower citizens tocontribute more of their own resources (time, will power, expertiseand effort) and have greater control over service decisions and

resources

How important is co-

production and what

are the potential gains?

We argue that co-production should be central to the Governmentsagenda for improving public services because of emerging evidenceof its impact on outcomes and value of money, its potential economicand social value and its popularity

How could co-

production in public

services be

accelerated?

Rather than simply replicating specific co-production practices, such asapproaches to working with patients or learners, we argue thataccelerating co-production rests some more structural changes to:budgets, with more control passed down to individual users and front-lineprofessionals support for civic society and mutual help performanceregimes and professional training and culture.


Executive Summary

This paper provides an introduction to co-production in public services what itmeans, why it is important and how it can be accelerated


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Executive summary:

1. What does co-production mean?

This paper considers how individuals and communities should address a number of emergingchallenges, such as the rise of chronic health conditions and the need for supporting youngpeoples emotional development.

We argue that co-production - a partnership between citizens and public services to achieve avalued outcome is essential to meeting a number of these challenges, for neither government norcitizens have access to all the resources necessary to solve these problems on their own

This approach is distinct from other traditional responses:

Voluntarism

Managerialism Paternalism

Co-production

We propose that effective partnerships are based on four clear values: a) everyone has something tocontribute b) reciprocity is important c) social relationships matter d) social contributions (rather thanfinancial contributions) are encouraged

Such partnerships empower citizens to contribute their own resources (time, will power, expertise andeffort) and give them greater control over public resources to achieve outcomes.



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Executive Summary:

2. How important is co-production and what are the potential

gains?

There are already many examples of co-production in practice - including Nurse FamilyPartnerships, Family Intervention Projects, Family Learning, Restorative Justice, Time Banks andYouth Courts.

Compared to other European countries, UK citizens are also relatively involved in working withservices.

But the question remains as to whether such partnerships will characterise more mainstream publicservices in the future.

The evidence suggests that in many instances it should:

i. Co-production often improves outcomes evidence shows that interventions that adoptthis approach have a big impact on outcomes.

ii. The public frequently want to be more active partners the public want to be moreinvolved when public services relate directly to them and their family we usuallyunderestimate peoples willingness to help others.

iii. The value citizens can contribute is significant the scale and value of the resources thatthe public contribute is enormous families and communities generate a huge amount ofeconomic value that is unmeasured and unrecognised by public services.

iv. Co-production often improves value for money evidence also shows that the economicbenefits of co-production approaches outweigh the costs.

We also find that co-production is not appropriate in every public service. We suggest the greatestpotential benefits are in relational services such as early years, education long term healthconditions, adult social care and mental health, rather than transactional services.



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Executive summary:

3. How could co-production in public service be accelerated?

Choice and control- give citizens greater control

over resources

Peer Support- empower citizens tosupport one another

Consider extending individual budgets and budget holding leadprofessionals to more areas

Empower people to better support each other, with new rights forgroups of service users2

1

Incentivise partnerships- through performance

management

Give greater weight to the quality of partnerships between staff andservice users in performance management frameworks

3


Professional Culture- ensure professionals value

citizen contributions

Involve more service users in professional training, staffrecruitment, and inspection and support local leaders to driveculture change

4

We propose that the way to mainstream co-production is not primarily to spread specificprogrammes, but to change the nature of budgeting, relationships with civil society, performancemanagement and professional cultures. We suggest some specific measures.

These recommendations would need to be part of wider reforms to empower citizens, foster a newprofessionalism and provide more strategic role for government, particularly giving citizens betterinformation, involving citizens more directly in policy making and commissioning for long term outcomes.


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Contents

Executive Summary

Introduction



Background Analysis






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There are a number of complex social problems facing individuals and

communities

Chronic disease affecting17.5m people, 80% of all GPvisits3

Child wellbeing

obesity almost doubledin 10 years, affecting children1

Anti-social behaviour cost 3.9bn pa2

Choice and control>1m users of social care

(1) Health Survey for England 2004. Updating of trend tables to include childhood obesity data, DH, 2006 (2) The one day count of anti-social behaviour, Home Office, 2003 (3) Boyle D,et al, Life begins at 60: What kind of NHS after 2008? The Young Foundation, 2008


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It is both undesirable and too costly forgovernment to substitute the resources that

really only citizens can contribute such asbringing up children

Our hypothesis is that neither government nor citizens have

access to all the necessary resources to tackle these problems on

their own

Citizens own resources Knowledge, skill and understanding

Energy, time and effort

Will power and personal agency

Motivations and aspirations

Social relationships within families and

communities

Governments resources Money

Rules and regulation

Expert knowledge and skills

Energy, time and labour of public servicesprofessionals

Leadership, expectations and aspirations

Solutions to these

problems require a newrelationship between

citizens and government

that mobilises more of the

resources necessary to

achieving better

outcomes

The resourcesneeded to tackle

these problems aredistributed between

government andcitizens

Currently, citizens have

little control over theresources that

government provides,and are rarelyencouraged to

contribute their ownresources



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Bringing these resources together in a partnership - co-production

- represents a distinct approach from traditional responses to

social problems: voluntarism, paternalism or managerialism

Voluntarism achieved by rolling back thestate reducing entitlements, cutting publicprovision and encouraging families,communities and the third sector to fill thevacuum

Managerialism achieved using a carrot andstick approach to incentives for both providersand citizens: discouraging and rewardingdifferent behaviours e.g. paying citizens to livehealthily, or targets for providers to involve

service users

Paternalism achieved through theprofessional gift model of services. Doctors,nurses, teachers, social workers etc. treatingcitizens as recipients of services by handingdown knowledge and expertise in a top-down

way, rather than by building partnerships

Co-production establishing a partnershipbetween citizens and government to tackle asocial problem. Citizens contribute moreresources to achieving an outcome, sharemore responsibility and manage more risk inreturn for much greater control over resourcesand decisions

This paper investigates co-production what it means, why it is important and howit can be accelerated through public services



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Contents

Executive Summary

Introduction



Background Analysis






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Co-production is a partnership between citizens and public

services to achieve a valued outcome.1 The most effective

partnership are based on four clear values2

1. Everyone has something to contribute

Everyone has something to contribute, even thoughsome have more resources than others

2. Reciprocity is important

Two way mutual relationships where responsibility,risk and power is shared and decisions are negotiated

3. Social relationships matter

Social networks, especially families and communities,are vital for achieving some types of change

4. Social contributions are encouraged

Recognise the unpriced and often unvalued work offamilies and communities, not just people's financial

contributions

e.g. Parents and grandparentshave resources which the statecannot substitute. These

contributions are recognised andfostered

e.g. Home School Agreementsset out the rights and

responsibilities of both familiesand schools

e.g. Taking-a-Stand recognisesthe commitment and energy of

people who improve theircommunities

e.g. Peer support networksencourage support and sharing of

expertise for example:Netmums.com and Expert Patient

Programmes

(1) Here we define a partnership as a relationship characterised by mutual co-operation and sh ared responsibility for the achievement of a valued goal (2) This values model is based on theanalysis set out in Cahn, E. No More throw away people, 2000


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Surveys suggest that co-production is moderately higher in the UK

than other countries and that many people believe their contribution

can make a difference

How much do people believe they can make a

difference in improving community safety, the

local environment and health?

Index of belief in making a difference

64

70

71

77

79

0 100

Germany

Czech Republic

France

United Kingdom

Denmark

None Maximum

An EU survey shows people in the UK are more likely to believe that they can make adifference to public outcomes through doing more themselves.1 The same survey showsthat levels of involvement in public services is highest in the UK

Levels of citizen participation in

public services in EU countries

Index of co-production

48

51

52

53

56

0 100

Denmark

France

Czech Republic

Germany

United Kingdom

None Maximum(1) Loffer, et al., If you want to go fast, walk alone. If you want to go far walk together: citizens and the co-production of public services, October 2008

Equivalent to 56%

saying they oftenget involved



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There are also many innovative projects that exemplify more

intense forms of co-production in practice. However, they are

limited in scope and number

Family Nurse

Partnerships

Self directed support and

individual budgets

Family Intervention Projects

Support for young mothers duringpregnancy and until the child is 2 Continuity of relationship Builds on mothers strengths Shared goals and aspirations Clear focus on taking responsibility

Devolves power over decisions andresources to the citizen Person centred planning Shared goals and outcomes Accountability direct to the citizen

Sustained trusting relationship with persistentkey worker Explicit contract of rights and responsibilities Whole family approach Building capacity of family Strengths based approach



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Contents

Executive Summary

Introduction



Background Analysis






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We argue that co-production should be central to the Governments

agenda for improving public services

Our analysis has considered whether government should build on the moderatelyhigh rates of citizen involvement in services and innovative co-productive approaches(set out in the previous section) and make strengthening partnerships between servicesand users a more central part of public service reform strategies.

We suggest there are four reasons co-production should have a more significantrole in the delivery of mainstream public services:

a) Co-production often improves outcomes evidence shows thatinterventions that adopt this approach have a big impact on outcomes

b) The public frequently want to be partners the public want to be moreinvolved when public services relate directly to them and their family weusually underestimate peoples willingness to help others

c) The value citizens contribute is significant the scale and value of the

resources that the public contribute is enormous families and communitiesgenerate a huge amount of economic value that is currently unmeasured andunrecognised by public services

d) Co-production can improve value for money evidence also shows thatthe economic benefits of co-production approaches outweigh the costs



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Across a number of sectors there is relatively robust evidence that

enabling citizens to work in partnership with professionals and to

do more for themselves improves outcomes

Self-care by

patients

Peer and self

assessment

by learners

Support with

parenting

Involving

parents

in education

Students managing their own learning can improveexam results by the same amount as reducing class-sizes by one third2

Self care programmes for long term health conditionscan:1

Reduce visits to GPs by up to 69% Reduce hospital admissions by up to 50% More than pay for themselves through savings

Sustained interventions with parents can improve childand parent outcomes. Positive evaluations include: 48% reduction in abuse and neglect

59% reduction in arrests (61% for parents)

3

Every $1 spent saving $4.25 in lower crime alone4

High levels of parental involvement can produce a 24%increase in exam results5

(1) Self Care Support: The Evidence Pack, DH, 2007 (2) Does Assessment Hinder Learning? William, D., presentation to ETS 11 July 2006 (3) For further details of the three randomisedcontrol trials in the US visit http://www.nursefamilypartnership.org (4) Supporting Parents Why it matters, Home Office, 2007 (5) Desforges, C. The Impact of Parental Involvement,Parental Support and Family Education on Pupil Achievements and Adjustment: A Literature Review, DCSF, 2003

Training can reduce GP visits,while user groups can have apositive impact on individuals

sense of personal strength,improved inter-personalrelations and alleviating

depression

The OECD/CERI reports thisis a powerful means ofmeeting goals for high-

performance, high-equitystudent outcomes, and for

providing students withknowledge and skills for

lifelong learning

Successful co-productionprogrammes work through

partnerships betweenprofessionals and citizens

combined with clearexpectations and conditionality
http://www.nursefamilypartnership.org/


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Surveys indicate that a high proportion of patients and parents

want to be treated as partners and want to do more for themselves

90%+ patients interested inbeing more active self carers1

50% patients said not oftenencouraged by professionals to

do self care1

33% patients said they hadnever been encouraged byprofessionals to do self care1

43% said the NHS could domore to support self care1

65% of parents would like to bemore involved in their childsschool life3


-5

5

15

25

35

45

55

Primary Care

2006

Inpatient

2006

Mental

Health 2006

Stroke 2004 Emergency

2004

Outpatients

2004

CHD

People often find themselves less involved

in services than they would likeProportion of patients feeling uninvolved in decisions2 (%)

%

(1) Self Care Support: The Evidence Pack, DH, 2007 (2) Picker Institute (3) Parental Involvement in Childrens Education, DCSF, 2007

A t t i ifi t b f l


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A recent survey suggests a significant number of people are

willing to spend more time each week and month improving their

health, neighbourhood and environment

How much more time are citizens willing to spend in

different sectors?

About how much time are you willing to spend

to . . .

0 10 20 30 40 50 60 70 80 90 100

improve your local environment

make your neighborhood safer

improve your health/health care

Percent

Few hours a wee k Few hours a month Few hours a year No time at all

An EU survey shows that largenumbers of citizens are willing tospend more time trying improve theirhealth, neighbourhood andenvironment.1 Taking these threeareas together:

28% willing to spend a fewhours more per week

43% are prepared to spend afew more hours per month

only 29% indicate that theyare not willing to spend any

time at all

(1) Loffler et al., If you want to go fast, walk alone. If you want to go far walk together: citizens and the co-production of public services, October 2008


Thi l f d th t iti i th UK lik l t


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This survey also found that citizens in the UK are more likely to

participate in groups that improve their health, environment and

neighbourhood

Levels of regular participation in community

safety, local environmental and health

organisations/groups across countries

How often do you participate in a group or organisation that

works to improve ...

0

2

4

6

8

10

12

14

16

Total France Ge rmany UK Cze ch Denmark

Percen

t"Often

"

Safety

Environment

Health

An EU survey shows that citizenparticipation in groups andorganisations that encourage apartnership between citizens andpublic services is highest in the

UK1

Particularly encouraging are thehigher than average participation inhealth focused civic groups suchas exercise groups, weightwatchers, alcoholics anonymous

and community safety groups suchas residents associations, tenantsgroups and neighbourhood watch

(1) Loffler et al., If you want to go fast, walk alone. If you want to go far walk together: citizens and the co-production of public services, October 2008


Citizens want increased choice control and involvement in public


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Citizens want increased choice, control and involvement in public

services, but often not a supermarket style experience. Rather, a

partnership with professionals appears much more important

Citizens want to be empowered they

value choice, control and involvement1But citizens want public services to be

different from normal retail/supermarket

experiences2

High quality relationships in public services are premised on everyone having something tocontribute and enhancing citizen choice and control. The aim is not to mimic a supermarket

style experience

I like to makechoices myself I like to have expertsmake choices for me

50% ofthe public

3% of thepublic

2% of thepublic

31% of thepublic

13% of thepublic

Which two of the following aspects of serviceare most important in each of the following

situations? Publicservices

Supermarket

Quality of advice/knowledge of

staff

Respect and professionalism

Speed of service

Friendliness of service

64% 34%

39% 13%

30% 60%

30% 60%

(1) Opinion poll data on choice see Real Trends- Living in Britain 2008, Ipsos MORI, 2008 (2) Real Trends- Living in Britain 2008, Ipsos MORI, 2008


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The value of peoples contributions suggests a potential for extensive

partnerships between professionals and citizens

17.5m patients withLTC1

High levels of selfcare and publicengagement in

health could saveNHS: 30bn pa2

1m+ use social care3

Proportion of people over 85expected to treble4

Informal care worth: 87bn5

7.5m families and

13m childrenChildcare providedby households worth:

220bn6

(1) Improving LTCs across NE London www.nelondon.nhs.uk (2) Wanless Review, HMT 2002 (3) Wanless Social Care Review, Kings Fund (2006) (4) ONS Pop. projections Govt.Actuary's Department (5) Valuing Carers calculating the value of unpaid care, Carers UK & Leeds University 2007 (6) http://www.statistics.gov.uk/hhsa/hhsa/Section225.html ONSestimate of unpaid work by households
http://www.statistics.gov.uk/hhsa/hhsa/Section225.htmlhttp://www.nelondon.nhs.uk/


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And evaluations indicate that a number of examples of co-

production can deliver better value for money

Early interventions for families and

young people at risk of social exclusion

reduce the cost of crime1

% reduction in crime rate for different programmes in US

0 5 10 15 20

Adolescent Diversion Project

Family Integrated Transitions

Functional Family Therapy

Multisystemic Therapy

Juvenile Education Programmes

Nurse Family Partnership

%

Self care programmes in health

produce benefits that outweigh the

costs2

(1) Washington State Institute for Public Policy, 2006 (2) Research Evidence on effectiveness of self care support, DH, 2007



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Contents

Executive Summary

Introduction



Background Analysis





Co-production is not appropriate in every public service We suggest


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Co-production is not appropriate in every public service. We suggest

the greatest potential benefits are in relational services where the

benefits outweigh the risks

Risksofco-production

Bene

fitsofco-p

roduction

Value of professional expertise

Transactional

Services the risks

and the benefits tendto be lower

RelationalServices the

benefits outweighthe risks

Acute Services the risks outweigh

the benefits

Examples include: early years,

education, long term health

conditions, adult social care,

mental health, and parenting


In relational services, co-production can deliver the largest benefits


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There is no single solution to theseproblems. The best approach willvary from person to person

In relational services, co production can deliver the largest benefits

where the social issues are chronic and complex, and the solutions are

contested

Chronic Complex

Contested

The resources that citizens contribute affect outcomescumulatively over longer time, not immediately leading many people to discount future benefits

They are caused by multiple-factors thatinteract in complex ways

1. Citizens control the necessary resources tosolve it they are abundant, but they cannot besubstituted. They are non-market goods

2. The benefits gained from citizens contributingresources outweighs any increased risk fromsharing responsibility

Co-production should only be applied to social problems when:

Social problems that meet these criteria tend to have the following characteristics:



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Creates higher

demand for

preventative

services

Even where co-production is appropriate, there remain some risks

and limitations

Providers have

less control

Citizens

contribute more

resources to

tackling a

problem

Citizens have

more control

Citizens and

public services

work bettertogether

Giving citizens more controlover resources reduces theeffectiveness of traditionalcost control. New ways ofenabling public to control

costs are needed

Reduces

demand for

curative services

Those with most

resources will be

able to give the

most

Hidden costs in

the system

become more

transparent

Waste and failure becomesmore transparent

encouraging more riskmanagement, more

responsiveness and fasterlearning and evaluation

Effective partnerships could mean

better progress towards long termoutcomes, and lower demand forcurative services: hospitals, care

homes, CJS etc

IB pilots in adult social care

indicates there are benefitsfrom giving greater control

to service users1

Partnership working createsbetter relationships and

better experiences for thepublic and for professionals2

Risksand

Limitations

Potential

be

nefits

Equity can be threatened where peoplehave unequal levels of resources to

contribute. Co-production is also limitedwhere citizens lack capacity e.g. dementia

or where there are large knowledgeasymmetries e.g. pharmacy

(1) IBSEN Evaluation of Individual Budgets in Social Care: Final Report, 2008 (2) Evidence indicates that the public want professionalism, respect and knowledgeable staff in public services(all of which can arise through partnership working), the public do not want a supermarket style experience. See Real Trends- Living in Britain 2008, Ipsos MORI, 2008

We have therefore looked at a number of examples of co-production


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e a e t e e o e oo ed at a u be o e a p es o co p oduct o

in practice that provide insight into how best it could be accelerated

further

1. Health

2. Social

Care

3. Education

4. Work

5. Crime

Personal Budgets and personalisationIndependent Living Strategy

Employment & Retention Advancement PilotsPathways to work

Anti-social behaviour strategyFamily Intervention Projects

Obesity pilots - incentivise healthy livingExpert Patient Programme - courses on self managementLong Term Conditions Whole System Demonstrator Pilots

Family Learning programmes, Nurse Family PartnershipsParental support advisors providing 1-2-1 help


The conclusion of our analysis of specific programmes is that effective


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y p p g

co-production requires some fundamental changes to relationships,

professional roles and the management of services

Nurse-Family Partnerships

Nurse-Family Partnerships involve trained nursesvisiting first-time young mothers throughoutpregnancy and the first two years of a childs life.

An important lesson from projects is that the asustained personal partnership is essential to

success, based on trust, a clear understanding ofrespective responsibilities and a key worker withability to co-ordinate the work of various services.

The Expert Patient Programme

The programme is six week course for people withchronic or long-term conditions, designed to help themself manage their health. The course is delivered bytrained and accredited tutors who are also living with along term health condition.

An important lesson from the programme is that peers,with similar conditions, can play a strong role inencouraging and supporting co-production.

Individual Budgets in Social Care

Users are given significant control over the use ofbudgets.

An important lesson is that devolving control overbudgets can be very empowering for users, lead toradical changes in the delivery of services andpromote culture change in service professions.

Home-school agreements and other

contracts

Home-school agreements and other, more tailored

contracts such as Acceptable Behaviour Contacts,have had some success.

An important lesson is the importance of clarifying theexpectations of service users and service providers.

Annex A sets out information on these and other programmes in more detail

Based on our analysis of these case studies and the research


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y

evidence on behaviour and culture change, we propose four ways of

accelerating co-production in public services1

(1) See Achieving Culture Change, Cabinet Office, 2008 (2) Co-production will not grow without large scale cultural change led by professionals. However, we make less detailedsuggestions in this area and do not provide an annex, reflecting our primary focus on citizen empowerment.


Choice and control- give citizens greater control

over resources

Peer Support- empower citizens tosupport one another

Consider extending individual budgets and budget holding leadprofessionals to more areas

Empower people to better support each other, with new rights forgroups of service users

2

1

Incentivise partnerships- through performance

management

Give greater weight to the quality of partnerships between staff andservice users in performance management frameworks

3

Professional Culture- ensure professionals value

citizen contributions

Involve more service users in professional training, staffrecruitment, and inspection and support local leaders to drive

culture change

4

These recommendations would need to be part of wider reforms to empower citizens, foster a newprofessionalism and provide more strategic role for government, particularly giving citizens betterinformation, involving citizens more directly in policy making and commissioning for long term outcomes.

Consider extending individual budgets to further specific funding1


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Community

g g g

streams and explore the development of budget holding lead

professionals

(1) See: Unlocking the Imagination, Duffy, S., 1996 and, Transformational Care in Oldham, Maybury, B. and Rolfe, A., 2008 and The Keys to Citizenship, Duffy, S., 2005

Citizen

Professional GovernmentContributionvia taxation

Entitlementto funding

Negotiationof service

Individual Budgets change the oldprofessional gift model of services, whereprofessionals assess citizens needs,determine eligibility, ration resources andcontrol services. They create instead a newcitizenship model1 for commissioning serviceswith public money.

This is a discussion document. Not a statement of Government policy

Budget Holding Lead Professionals have been pilotedin childrens services. Lead professionals are given a

budget to commission services and procure goodsdirectly from providers, to build a service package for

core groups of children and families

Budget Holding Lead Professionals can successfullycommission a range of services from providers in a joined

up way, so as to best meet an individuals needs

Evidence from practice in childrens services, suggests that the leadprofessional role is a key element of effective frontline delivery ofintegrated services. It ensures that professional involvement isrationalised, coordinated and communicated effectively1

Budget holding lead professionals can enable a speedier, morepersonalised and more effective response to meeting an individualsadditional needs2

Overall, Budget Holding Lead Professional models can yield manyof the benefits of Individual Budgets:

1. Increasing opportunities for preventative spending byimproving coordination of services to secure the best long termoutcomes2. Strengthening relationships between professionals and usersto provide opportunities for service users to contribute their ownknowledge and understanding of what will work

Analysis

Analysis

Consider extending individual budgets to further specific funding1


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RecommendationsConsider extending individual budgets to further

specific funding streams

For example, consider integrating NHS funding forcontinuing care, social care, and mental health care

Explore the development of budget holding lead

professionals, particularly where individual budgetsare not possible

For example, explore integrating offendermanagement, employment services, education,

housing support, and drug and alcohol servicesthrough a budget holding lead professional model

(See Annex A for more details)

Enhance user controland sense ofresponsibility

g g p g


professionals

Improve

coordination ofservices

Improve serviceresponsiveness

Users do nothave the capacityto make decisions

Professional attitudeshinder improvement

A viable supply sidedoes not develop

Increased expenditureduring transition period

Loss of financialcontrol or predictability

Drive professionalculture change

Increase opportunitiesfor preventative

spending

Analysis

It is essential to weigh the benefits and risks ofdevolving more control over resources

To minimise the risks, individual budgets should be piloted

through identification of appropriate funding streams (orelements of funding streams)Careful consideration of the different needs of distinctgroups of users (e.g. older people) will be required1

Individual budgets are a valuable way of giving users ofpublic services more choice and control over their everydaylives2

(1) IBSEN Evaluation of Individual Budget Pilots in Social Care: Final Report , 2008 (2) Bartlett, J., Leadbeater, C., Gallagher, N., Making it Personal, Demos, 2008

1


Empower people to better support each other with new rights for2


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Analysis

What is peer support? Peer support groups of patients, parents, carers, andvictims empower citizens to participate more fully inpublic services. Evidence shows increases inconfidence, self efficacy, and wellbeing and that groupsare cost effective1

Peer support provides the practical advice andemotional support that only peers can provide. Peer

support also provides social capital to isolated orvulnerable groups

Peer support is provided by a range of voluntary andcommunity organisations from national charities likeAlzheimer's Society and small community groups, user-controlled organsiations and user networks

Empower people to better support each other, with new rights for

groups of service users

(1) See National Evaluation of the pilot phase of the Expert Patient Programme, DH, 2006

Former Patients(experience and

knowledge)

Family carers(Emotional supportand practical help)

Friends andneighbours

(practical help)

Volunteers(practical help and

education)

Patient and Carers group(Social support, advice and

recommendations)

Online network of patients

(encouragement andknowledge)

Patient receiving care from GP, communitynurse and social care team

Increasingly, health and social care staff work with a

network of support and care from family, friends, peers

and the community

2


Empower people to better support each other with new rights for

2


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Empower people to better support each other, with new rights for

groups of service users

Online peer support groups are often unable tocapitalise on the volume of traffic to central andlocal government websites

Local grant funding is low, insecure and lackstransparency2

Frontline workers are well placed to set up peersupport networks for service users but they are notempowered or incentivised to do so1

Public service providers do not always encouragecitizens to participate in service user organisations1

No easy or reliable access to facilities for meetings,admin etc.

The extent to which local authorities recognise andengage with peer support organisations variesgreatly

Key problems for peer support groups

(1) Finding of workshops with parents, carers, and users of social care (2) Denmark provides an alternative approach to grant funding for User Associations.

Recommendations

Empower people to better support each

other, with new rights for groups of

service users including the right to:

use commissioners and providers rooms and

facilities for meetings (or cash for private hire) apply for local grant funding based on simplecriteria and number of members

publicity by local services and on governmentwebsites

auto-enrolment or auto referral for patients,carers and service users (with an opt out)

request a budget for staff in public serviceswho set up and run peer support groups flexible working for staff who volunteer to run

peer support groups official recognition by commissioners

(See Annex B for more details)

2

2


Give greater weight to the quality of partnerships between staff and3


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g g q y p p

service users in performance management frameworks

RecommendationGive greater weight to the quality of

partnerships between staff and service

users in performance management

frameworks

adopt a principles-based approach toregulating the quality of relationships between

staff and citizens (rather than a compliancemodel). This would involve service providersreporting against high-level principles relatingto the quality of these relationships, such astrust, dignity and respect, rather than justshallow indicators of customer satisfaction

benchmark perception data relating to citizens

real, local and recent experiences to driveimproved performance

develop self-evaluation tools to measure thequality of relationships between front line staffand service users(See Annex B for more details)

This is a discussion paper not a statement of Government policy

High Quality Partnerships

NegotiatedMutual

recognition of whatboth sides have to offer, and

joint negotiation of goalsand plans

Trust-basedTrust is both a product ofhigh quality relationships

and essential for their maintenance.

ReciprocalGive and

take on both sides, aa sense of mutuality

and we are in thistogether

Citizen Professional

Partnerships

Partnerships between service users and professionals ensure thatproviders are more accountable to citizens andincrease the

commitment of citizens own resources to achieving outcomes

3

Involve citizens in professional training staff recruitment and4


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Involve citizens in professional training, staff recruitment, and

inspection and support local leaders to drive culture change

AnalysisCo-production requires a culture change whereby

professionals consistently encourage citizen

empowerment and seek partnerships with service

users that share responsibility

Citizen empowerment has big implications for professionals.It fundamentally changes the power dynamic between the

public and professionals that may have been in place forgenerations

Culture change within the professions requires visionaryleadership and changes to professional training, recruitment,and performance management. Innovative practice in health,education and social care suggests that higher levels ofservice user involvement in these area makes a difference1.There is an opportunity to empower citizens to help define the

new professionalism set out in Excellence and Fairness

Partnerships between the public and professionals placegreater value on new skills: advice, brokerage and support.Self-Directed Support advisors in social care or ParentSupport workers in schools provide personalised support andwork in partnership with service users and their families

Recommendation

Involve citizens in professional training, staff

recruitment, and inspection and support local

leaders to drive culture change

4

Involving service users in training the workforce shouldbe encouraged further. In social care, progress in this

area could be accelerated by focusing on improving thequality of provision Service users should be involved systematically in staff

recruitment, performance management, and inspection.For example Experts by Experience could be extendedinto new areas

New professional roles that provide highly skilledadvice, brokerage and key worker support to citizensshould be supported and encouraged e.g. Learning

Mentors, Self-directed support advisors and a range ofPersonal Advisors in different sectors In education, Parents Councils and Students Councils

could be more systematically involved in feedback tostaff, research, school self-evaluation, budgeting anddeveloping a vision for the organisation

(1) See Experts by Experience www.csci.org.uk, and Involving Services Users in Social Work Training on the Reality of Family Poverty in Social Work Education,Volume 27, Issue 5 August 2008 , pages 459 - 473

Our recommendations would need to be part of wider reforms on

citizen empowerment professionalism and a more strategic role for
http://www.informaworld.com/smpp/title~content=t713447070~db=all~tab=issueslist~branches=27http://www.informaworld.com/smpp/title~content=t713447070~db=allhttp://www.csci.org.uk/


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citizen empowerment, professionalism and a more strategic role for

government set out in Excellence and fairness and Working Together1

Supporting citizen decision making with betterinformation

Empowering citizens requires not only greateraccess to information but the power to use it andre-use in ways that professionals do not control,and officials could not imagine.

Commissioning long term outcomes Public

service commissioning that is able to trulycommission long term outcomes rather than shortterm outputs or service activity is much more likelyto create the incentivise professionals to work inpartnership with users and co-produce betteroutcomes to chronic, complex and contestedissues

A strategy for incubating local innovationWorking in partnership with citizens andempowering them to contribute more of their ownresources is often incompatible with a top downapproach to reforming public services. Localinnovation that involves citizens in the wayservices are designed and delivered is much morelikely to generate co-production in practice

Involving citizens in policy makingThe leading examples of co-production in practice (e.g. theexpert patient programme, direct payments, time banks,participative budgeting) did not originate from policy makers,think tanks or governments but were first set up by citizenswho then campaigned (for many years) for government toadopt their ideas. Systematically involving the citizens in thepolicy making process from defining the problem, generatingideas and implementing solutions - is likely to lead to muchgreater co-production in public services

(1) Excellence and fairness: achieving world class public services, Cabinet Office, 2008 Working together- Public services on your side, Cabinet Office 2009This is a discussion paper. It is not a statement of government policy

Contents


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Contents

Executive Summary

Introduction


How important is co-production and what are the potential gains?

How could co-production in public services be accelerated?

Background Analysis





Annex A: Examples of programmes which foster co production


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Nurse-Family Partnerships a strengths based approach, with a


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sustained partnership between nurse and young mother at its heart

Description: Nurse-Family Partnerships involve trained nurses visiting first-time young mothers throughout pregnancy and thefirst two years of a childs life. They usually offer a combination of health advice and support (e.g. around breastfeeding, childhoodillnesses), practical support and coaching (e.g. life skills) and addressing psychological issues (e.g. motivational interviewing)

Key characteristics of the

partnership Intimacy and continuity building trust Aligning the goals and aspirations of thenurse and family Building on the persons strengths andprevious successes towards improved selfefficacy Establishing a sense of responsibility in theindividual Clear structure and understanding of whatthe programme entails Having highly skilled professional nurseshave skills for the nurse and individual todeal with anxiety and stress

Target Group:Currently offered to first time mothers who are under 20. Current Scope:Over 1000 clients are currentlyenrolled on the programme in ten sites, with plans to expand this to 20 sites by 2009 (as set out in the Youth Crime Action Plan,2008). Expansion after 2009 will depend on successful implementation in the first 30 sites

Evidence The model was developed in the US where it has been rigorously testedover the course of 27 years Three random controlled trials have been conducted in the US. Theprogram had positive impacts on pre-natal behaviours improvedpregnancy and birth outcomes led to more sensitive and competent careof child reduced child abuse and mortality improved outcomes for theparent and, importantly, benefits were still evident when the child was 15

The nurse-family partnership is offered in 20 American states, and itserves more than 20,000 families annually. The programme costs about$8,000 per family for two and a half years support. However, economic

evaluation by the Rand Corp. shows a payback to the public purse of fourtimes its cost.

The partnership topped WAVEs evaluation system and wasrecommended by the Sure Start review, the Blueprint programme, Supportfrom the Start and Communities that Care

Moving Forward:If the programme is shown to be successful it is hoped that 50% of PCTs/LAs will operate the programme by2011. A key challenge will be mainstreaming and sustaining the nurse-family partnership if the pilot proves successful

Sources: www.nursefamilypartnership.org Billingham, K.. The Family Nurse Partnership Programme, Cabinet Office Seminar, 2007


The Expert Patient Programme peer support that enables patients to
http://www.nursefamilypartnership.org/


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contribute their expertise to one another

Description:A six week course for people with chronic or long-term conditions. The course is delivered by trained and

accredited tutors who are also living with a long term health condition. It aims to give people the confidence to take moreresponsibility and self-manage their health, while encouraging them to work collaboratively with health and social careprofessionals. Course topics include healthy eating, dealing with pain and extreme tiredness, relaxation techniques and copingwith feelings of depression

Key characteristics Peer support provided by patients ishighly valued

Tutors need to be trained andaccredited to provide patient education

Encouraging personal responsibilityand self efficacy

Reinforces current good self

management

Target Group:17.5 m people living with long term health challenges including 8.5 m with Arthritis 3.4m with asthma, 1.5mdoctor-diagnosed cases of diabetes in the UK, 80-90k people with Multiple Sclerosis (MS)

EvidenceCourse questionnaires showed Outpatient visits decreased by 10%, A&Eattendances decreased by 16%, Pharmacy visits increased by 18%

However, the external evaluation found no reduction in use of primary orcommunity care. This RCT found that course participants have:

Gains in patient self-efficacy and energy

Improved quality of life and psychological wellbeing for patients, high levels ofsatisfaction, improved partnerships with doctors, reduced isolation and

increased confidence to manage their condition Reduced inpatient/day case hospital costs making EPP cost effective

Moving Forward:Delivered to 30,000 people already with plans to grow from 12k pa to 100k pa by 2012. New course forcarers and specific conditions. Current group of patients tend to be white middle class and well educated who volunteer to

attend, want to learn and are motivated to help others.

Sources: National Evaluation of the pilot phase of the Expert Patient Programme, DH, 2006


Budget holding lead professionals- integrates resources, enables


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greater personalisation, involves people in commissioning decisions

Description:Similar to personal budgets, budget holding lead professionals allow money, and decisions over how money is

spent, to be devolved to the lowest level possible. Budget holding lead professionals are used where professional intervention isrequired to effectively deploy resources

Key characteristics The role can be taken on by a wide range ofpractitioners, as the skills, competence and knowledgerequired to carry out the role are similar regardless ofprofessional background The amounts of money allocated by the leadprofessional varies. The amount spent is determined onbasis of need e.g. from small sums, for example, 1.50for a bus ticket, to 1,000 for a package of counsellingsessions The lead professional liaises very closely with serviceuser, the family and professionals to allocate resourceseffectively

Target Group:Service users who cannot be granted their own personal budget (e.g. because of age/vulnerability) can havea lead professional coordinate resources and services on their behalf

Current Scope: There have been 16 local authority pilots of budget-holding lead professionals in childrens services.Emerging reports are very positive (full evaluation due in Autumn 2008)

Evidence

Evidence from practice in childrens services, suggests thatthe lead professional role is a key element of effectivefrontline delivery of integrated services.

It ensures that professional involvement is rationalised,coordinated and communicated effectively

Budget holding lead professionals can enable a speedier,

more personalised and more effective response to meeting anindividuals additional needs

Moving Forward: There are proposals to use budget-holding lead professionals in drug treatment services. Their use inchildrens services could be accelerated. There is also potential for their use in resettlement and rehabilitation services

Sources: What is a Lead Professional? DCSF, 2005 Realising the potential efficiency gains from budget holding lead professionals, OPM, 2007


Family Intervention Projects- a whole family approach, driven by a

partnership with a strong persistent and assertive key worker


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partnership with a strong, persistent and assertive key worker,

backed up by an explicit contract of mutual responsibilities

Description:FIPs is an intensive whole family approach to reducing ASB. It provides an out reach service,accommodation in the community and 24-hour monitored residential accommodation for chaotic families. At the heart of it isa relationship between the whole family and a key worker backed up by a contract with sanctions.

Key characteristics Key worker with persistence and assertiveness A contract with the family establishing areciprocal relationship not letting down my keyworker Clear sanctions linked to tenancy Practical learning about routine and structuresof daily living Whole family approach

Encouraging authoritative parenting Establishing trust and listenin Needs highly skilled, highly motivated staff

Target Group:targeted at families exhibiting anti-social behaviour, focused on those who are at risk of loosing theirhousing tenancy or children being taken into care

Evidence

Evidence comes from the evaluation of Dundee FIPs and aSheffield Hallam evaluation of six projects in the North West. Theyfound that 85% of existing participants had reduced or ceased theirASB and the risk of homelessness and family breakdown haddeclined1

Projects cost 8k - 15k per family. Estimates of cost savings

suggested that FIPs saved money by replacing demand for otherservices, although the evidence on cost/benefits and long-term impactis not as robust

Moving Forward:There are currently 53 FIPS that have helped around 500 families. Further money has been earmarkedfor expansion and we aim to support around 1,500 families a year

Sources: Impact Assessment of the Youth Crime Action Plan, Home Office/Department for Children, Schools and Families, Ministry of Justice, 2008


Contracts of rights and responsibilities establishes reciprocity,

i h l ib d i


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recognises what people can contribute and sets expectations

Description:Voluntary mutual agreements are already in use. They set out behaviour expectations and can be used to tackle

crime/anti-social behaviour e.g. Acceptable Behaviour Contracts and Parenting Contracts. But, they can also be used to outlinerights and responsibilities in mainstream services such as health, education and social care

Key characteristics of

mutual agreements

Explicit: Clear aims andexpectations on both sides

Shared understandings:Making the agreement leads toshared understandings of roles

and solutions

Social pressure: The partiesshould have a good relationship

with one another so there issocial pressure to meet theagreed expectations (avoid

losing face)

Sanctions: They cansometimes be effectively

backed up by harder sanctions

Target Groups: Wherever more than one person needs to contribute something to achieving an agreed aim. They are mostpowerful where they are made on a 1-2-1 basis with regular contact between the parties e.g. in social care

Evidence

ABCs and Parenting Orders affect individualsbehaviour. 65% do not engage in further anti-

social behaviour after an ABC intervention

Home-school agreements can contribute toschool effectiveness by enhancing relationshipsbetween parents and teachers

Research evidence points to the value ofparenting contracts and orders. It will benecessary to support parents through access toadditional services, such as mental healthservices

The Royal College of General Practitionersargues that general practice achieves the bestpossible outcomes for each particular individualby negotiating an individual care plan with thepatient that makes sense to them, their socialcircumstances and enables them to share theresponsibility for treatment

ABCs are written, voluntaryagreements between a young

person, housing services/school andthe police. The young person agrees

not to carry agreed anti socialbehaviours

Home-school agreements foster apartnership between parents andschools. The agreement clarifies

what the school is trying toachieve and sets out the role ofthe school, parents and pupils

Parenting contracts are negotiatedbetween a YOT worker and theparents of a child involved in

criminal or anti-social behaviour.Parents either work voluntarily withthe YOT or a parenting order can

be put in place. Both parentingcontracts and orders have a

statutory basis

Sources: Think Family literature, Cabinet Office Impact Assessment of the Youth Crime Action Plan, Home Office, Department for Children, Schools and Families, Ministry of Justice,2008 http://www.standards.dfes.gov.uk/parentalinvolvement/hsa/


Individual Budgets in social care control over resources and

decisions empowers disabled people, and leads to greater


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decisions empowers disabled people, and leads to greater

personalisation

Description:Personal budgets are one vehicle for devolving money and decisions over how money is spent to citizens. Other,

closely related, models for devolving more money/power to citizens include budget-holding lead professionals andcollective/community budgets (e.g. Youth Opportunity Fund)

Key characteristics of personal budgets

Devolution to individuals of power over how to putresources to use

Mechanism for promoting professional culture change indirection of making services person-centred

Alternative to a market-based model (e.g. a vouchersystem) which constructs individuals as consumers andwhich are not necessarily person-centred (e.g. servicesseek profitable outcomes/respond to aggregate demand)

Numerous potential benefits include:

increased personalisation of services increased user control better coordination of services improved services for vulnerable groups improved value for money

Target Group:Analyses indicates that personal budgets are useful where citizens have the capacity to make decisions abouthow to allocate resources when their needs can be objectively assessed and where there are a range of available options as tohow a budget may be spent. Even if these three criteria are met it will be necessary to apply broader public resource criteriawhich specify that personal budgets must not undermine equity, efficiency, or the public goods of servicesCurrent Scope:Personal budgets have been piloted in social care services

Emerging Evidence

Evidence collected across 17 local authorities shows that 72% ofbudget holders say they have more choice and control over theirlives than previously, and that 63% say they take part in andcontribute to their communities more when on self-directed support

Early results from a small pilot run by In Control involving 6 localauthorities demonstrate cost savings of between 12% and 67%

Mental health patients in Florida, using personal budgets,reported significant rises in their sense of being respected by those

around them. Budget holders were able to combine traditionalclinical care with non-clinical services such as educational courses,so as to address all facets of their mental health. Moreover, thepercentage of users who felt able to participate in the communityrose from around 30% to nearly 80%

Moving Forward: There are ongoing discussions about where to extend personal budgets. Initial analysis suggests potentialareas for their use include NHS services such as maternity, mental health and LTC services, specialist education services, and

independent living for disabled people

Sources: IBSEN Evaluation of Individual Budget Pilots in Social Care: Final Report Florida Peer Network Bartlett, Leadbeater and Gallagher (2008) Making it Personal, Demos


Annex B: Individual Budgets and Budget Holding Lead

P f i l


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Professionals


The Government has already made relevant announcements and

undertaken pilots of individual budgets across a wide variety of


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undertaken pilots of individual budgets across a wide variety of

policy areas

NHS

Programmes

Services for

disabled

children

DrugTreatment

Recent commitment in NHS Next

Stage Review to explore and pilotuse of personal budgets in the NHS

A public consultation has beenfollowed by DCSF

commissioning a scoping studyfor the development of pilots

The 2008 Drug Strategy refers tothe piloting and more effective useof new approaches such as IBs

Social CarePilots have been followed by acommitment to the rolling out

of personal budgets

Users want to and are able to commission theirown care package according to their own needs,

within the constraints of the individual budget

There could be varying rationalesdepending on the service. Example services:

LTC management, Continuing Careand mental health services

If professionals hold a (notional) budget then therewill be better coordination of services/personalinterventions and prevention will be incentivised

Families with disabled children want toand are able to have choice and control

over the funding and services they receive

Education

and

Skills

DISU/Learning and Skills Councilsare piloting Adult Learner Accounts

Adults want and need to be able to select theeducation and skills services relevant to them. To

avoid misuse an accreditation system will be used

Stage of DevelopmentPolicy Area Rationale

This is not intended to bean exhaustive list


Individual budgets are embedded in a new citizenship model of

public services through which citizens are empowered as members


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Community

p g p

of the community1

It is useful to distinguish between the professional gift model and the citizenship

model of public services1

Services arenegotiated

between the

professionaland thecitizen

Citizens who are entitled tofunding are recognised as

members of the community notjust recipients of public services


The old professional gift model1

Community

Government

Professional

Person inNeed

Contribution

via taxation

Funding forservices

Assessmentand support

Citizen


Entitlementto funding

Negotiationof service

The new citizenship model1 for

individual budget funding systems


A key characteristic of both individual budgets and budget holding

lead professionals is the devolution of control to the lowest possible


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level

Services users are consumers in the marketplace they do not commission services

Service users and/or professionalshave commissioning role

Budget/fundsman

agedby

State/professional

Budget

/fundin

gmanaged

byserviceuser

Per capita

fundinge.g. of

hospitals/schools

Budget

holding lead

professionals

Individual

budgetse.g. in specialist

services

Mass

voucher

systems

e.g. for masseducation

Key Characteristics of individual budgetsand budget holding lead professionals

Per capita funding and mass voucher systemsaim to give service users more choice bymaking them consumers in a marketplace

Individual budgets and budget holding leadprofessionals mechanisms empower front line

professionals and service users by giving thema commissioning role, not just through moreconsumer choice

Budget holding lead professionals hold andmanage an allocated budget (this gives thefreedom and flexibility to front line professionalto coordinate services around the service user)

where the service user is unable to do so

Both individual budgets and budget holdinglead professionals achieve high levels ofpersonalisation Budget holding lead professionals control

and manage a budget where individual

service users are unable to do so


Areas where the benefits of individual budgets are likely to be

strong can be identified using three basic criteria


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strong can be identified using three basic criteria

Where these are in place there is good reason to consider whether

individual budgets or budget holding lead professionals should be introduced

Individuals have unique and valuable resources (e.g. knowledge of theirhealth condition and their needs and individual motivation) that are noteasily substituted by professionals/the state

Citizens have

valuable

resources

Alternative

provision is

possible

There are genuine alternatives as to how an individuals needs are met

which give rise to a set of ongoing decisions that have to be made

Private Goods

and PublicGoods are

aligned

There is a significant degree of compatibility between the private good

outcomes of the service and the public good (i.e. the public goods of theservice and the public good in general) e.g. adult social care, aspects ofhealth care, crime prevention/offender management


There are clear benefits that can be derived from the introduction of

individual budgets


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Increase user

control and

sense of

responsibility

individual budgets

Improve service

responsiveness

Increase

opportunities for

preventative

spending

Improve

coordination of

services

Citizens

involved in

policy

development

A study of self-directed care reports

that personal budgetscan help people meet

their distinctive andpersonal needs3

Evidence collected across 17 localauthorities indicated 72% of budgetholders said they had more choice

and control over their lives3. Theevaluation of IB pilots also found that

all user groups reported increasedlevels of control1

Services centred

on good

outcomes for

users

Drive

professional

culture change

Secure good

outcomes for

individuals with

complex needs

Budget holding lead professionals cancoordinate services around an individualsneeds and build a strong relationship with

service users and their families. Evidence fromwork with children and families4 indicates thiswill help secure good outcomes, especially for

individuals with complex needs

Mental health service in Florida used their IBto access services not traditionally provided inclinical care models, with good outcomes. The

number of patients who participated in theircommunity rose from around 30% to nearly

80%2

The IB pilots in adult social care involved

identifying funding streams for integration.Initial findings indicate some LocalAuthorities are keen to integrate fundingmore quickly than national government1

Communities of service

users contribute to thedevelopment of InControlinitiatives and the pilot

schemes

(1) IBSEN Evaluation of Individual Budget Pilots in Social Care: Final Report (2) Florida Peer Network (3) Bartlett, Leadbeater and Gallagher (2008) Making it Personal, Demos (4)For example, pilots of budget holding lead professionals in childrens services family intervention projects and family-nurse partnerships

The decision on whether to develop individual budgets will involve

weighing up the benefits with a set of potential risks


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weighing up the benefits with a set of potential risks

Individuals do not

have the capacity

Professional

attitudes

or culture hinder

improvement

Needs assessment

is ineffective/

inefficient

A viable supply

side does

not develop

Increased

expenditure during

transition

period

Benefits of collective

consumption

are undermined

Funding is used

fraudulently

Loss of financial

control

or predictability

It may be very challenging

to objectively andtransparently assessindividuals needs making it difficult to

devise robust, transparentand joined-up resource

allocation systems

Variations in individual capacity could lead to

significant variations in quality of servicesindividuals receive with implications for equityof service provision. Importantly, individuals will

be able to top-up their service provisiondepending on their access to financial resources

Efficiencies that come fromeconomies of scale of

collective provision and thespin offs from collectiveconsumption could be

undermined

Alternatives will not berealisable unless a viablesupply side is established

within which users canmake decisions on whichservices to commission

Increased awareness of

entitlements and demand forfunding could necessitateincreased expenditure. In

addition, double running (overthe short or long term) would

lead to increased pressures onexpenditure

In some service areas

(e.g. mental health, andprovision of employmentservices for individuals

with learning disabilities)professional culture

change will be needed torealise benefits of IBs

Political risks

Shifting funding from provision ofcollective services to IBs is likely to

lead to changes in demand etc.,which will require the cessation ofsome services this is likely to beunpopular with some service users(e.g. closure of day care centres)

Service users

exposed to

increased risk


In reaching a decision on whether to move forward it will also be

important to consider the potential to mitigate some or all of the


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relevant risks (1)

Risk Risk mitigation strategies

1. Clear guidance for potential and actual suppliers2. Evolutionary development of regulation of supply side, with ongoing evaluations of itsdevelopment feeding into changes in regulation (e.g. lowering/raising barriers to entry)

A viable

supply side

does not develop

Loss of financial

control or

predictability

1. Sound financial management, including top-slicing global budgets for collective commissioningof preventative and social capital (e.g. peer support) services and for contingency funds

2. Careful piloting with ongoing process of learning the lessons of previous pilots3. Resource allocation systems may need to be redesigned comprehensively to integrate needsassessments and to better predict/control expenditure

Professional

attitudes orculture hinder

improvement

1. Professional training and support alongside introduction of these funding systems

2. Mechanisms to compensate for professional attitudes e.g. ring fencing specific funding streamsto ensure it is used to benefit the service user in the best way

Individuals do not

have the capacity

1. Establish systems of guidance, support and advice for budget holders, including professionaladvice, as well as peer support (e.g. building social capital)2. Carefully consider the different needs of distinct groups of users (e.g. older people)

1

3

4

5

Increased

expenditure

during transitionperiod

2


1. Shift funding away from provision of collective services to individual budgets on a fundingstream by funding stream basis (or at least elements of funding streams) to ensure there is not

inefficient double running (where collectively commissioned services run simultaneously withIBs)

In reaching a decision on whether to move forward it will also be

important to consider the potential to mitigate some or all of the

l t i k (2)


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relevant risks (2)

Benefits of

collective

consumption are

undermined

1. Top-slice budgets to continue to fund collective provision to maintain positive externalities2. Do not move to funding systems to individual budgets where loss of benefits of collectiveconsumption (including economies of scale) is likely to undermine quality or provision of services

Funding is used

fraudulently

1. Locate most likely source of fraud (e.g. providers/budget holders etc) and design preventionsystem (e.g. Learner Accounts pilots are using an accreditation model for providers)2. Carefully define what constitutes fraud so that the decisions ofcommissioners are assessed against standard and predictable criteria

Needs assessment

is ineffective/

inefficient

1. Sound advice on transparent and robust, but not overly rigorous, systems of needs assessment,accounting and audit will be required (e.g. Audit Commission is beginning to provide guidance onthis)

2. Professional training and culture change, so that users needs are assessed in a way thatrecognises the users own contribution

Political risks

Service users

exposed to

increased risk

1. Consultation with service users through which the likely consequences of a shift to individualbudgets are clearly presented and discussed2. Piloting of new systems in areas where there is political will and professional capacity to makethe systemic changes required

1. Development of good quality relationships between professionals and service users and soundprocedures to underpin that relationships, while simultaneously encouraging peer support2. Supply side systems (e.g. an accreditation system) to minimise risks

Risk Risk mitigation strategies


6

7

8

9

10

If the risks of service users holding an individual budget are

considered too great, then budget holding lead professionals should

b id d lt ti


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be considered as an alternative

Individuals do not

have the capacity

Funding is used

fraudulently

Loss of financial

control

or predictability

Service users

exposed to

increased risk

Budget holding lead professionals manage and control an individual budget drawn from

a variety of different funding streams. This mitigates some of the risks of service usersholding a budget themselves, but many benefits will still be reaped

Budget holding lead professionals mitigate some of the risks arising from individual budgets

Where individuals are unable orunwilling to manage and control abudget themselves budget holding

lead professionals can be used

Professionals will manage the individual budgetwithin professional and institutional governancestructures making loss of financial safeguards

and fraud far easier to prevent and to rectify

Professionals have farmore control and the final

say on commissioningdecisions

Budget holding lead professional models reap many of the benefits of individual budgets

Improve service

responsiveness1

Improve

coordination

of services2

Preventative

spending

Services

centred on

good outcomes

for users

Strengthen

relationships

between

professionals

and users

(1) Budget holding lead professionals can enable a speedier, more personalised and more effective response to meeting an individuals additional needs (Realising the potential efficiency

gains from budget holding lead professionals, OPM, 2007) (2) Evidence from practice in childrens services, suggests that the lead professional role is a key element of effective frontlinedelivery of integrated services. It ensures that professional involvement is rationalised, coordinated and communicated effectively (What is a Lead Professional? DCSF, 2005)

We have drawn up a long list of areas where individual budgets and

budget holding lead professionals could be introduced. This led us to

consider which services could become gateways


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consider which services could become gateways

Adultsocial care

Offendermanagement

Independentliving for

disabled people 16-18 educationand skills and

learner support

Housingservices

Employmentservices

Specialeducational

needs

Drug

treatment

Adult educationand skills

Maternityservices

Family andparenting

support

Mental healthservices

NHS continuingcare

Young peopleexcluded

from mainstreameducation

Public services often need to work together to meet an individuals distinct personal

needs. Bringing funding together within an individual budget (sometimes controlled by abudget holding lead professional) can improve joining up of these services

The links indicate where servicesshould ideally work together to

meet an individuals needs

Management ofLong term health

conditions

Blue circles represent potential gateways that is, services that should ideally work with

many other services

This is a discussion paper not a statement of Government policy

Consider extending individual budgets to further specific funding


professionals


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Community

professionals


Citizen


Documents

Co-producción en los Servicios Públicos. Un nuevo acuerdo con los ciudadanos