Heading Upstream: Deinstitutionalisation & Public Service Reform

The solutions we find upstream are various and will develop in the light of the local context, but as Figure 1 suggests, they are all capable of reducing the demand for more expensive and less efficient solutions downstream:

1. Nature - The natural world is our home and the source by which we meet all our needs. It must be safeguarded in order that it can provide physical and spiritual resources for all of us in the years ahead.
2. Society - There is strong evidence to suggest more income equality will promote wellbeing (Wilkinson and Pickett, 2010). Working to create a fair society is likely to create a society which is better for everyone.
3. Community - Relationships, stronger and more inclusive communities, lives of meaning and purpose also have benefits for our health and wellbeing (Halpern, 2005). Creating richer communities which open up multiple opportunities for contribution and commitment is critical.
4. Family - Families are the key to personal development, good mental health and the good upbringing of children. Families provide most of the care and support people receive. Supporting families to stay strong, tackling abuse and domestic violence and valuing the role of the family is important.
5. Citizen - People can do more for themselves and personal control often correlates powerfully with better physical and mental health (Alakeson, 2014). More broadly a sense of personal responsibility, capacity and freedom strengthens family and community structures.
6. Professional - Expertise and professional development is vitally important. However some countries are finding that the most efficient use of the professional is as a teacher and educator - supporting upstream change, not just responding to downstream problems (Crisp, 2010).
7. Services - Services continue to play a vital role in keeping people safe, providing a guarantee of support in all circumstances and creating an infrastructure around which individual and collective decisions can be made. The challenge is for services not to take on such a prominent role that they reduce the space for community action in all its forms. At its worst this leads to the bureaucratisation of everyday life.

Unless there is the right investment of time, money, creativity or self-discipline in these upstream responses then the result will be expensive, and often risky or violent, institutional responses. And once resources are locked into those institutional arrangements then they are very hard to shift again.

Once resources have been locked into hospitals, institutions, respite centres, prisons or care homes then there is a tendency for the system to meet needs by using those resources. The per capita cost may be high, but for the professional making the referral or placement the cost has already been met by a prior funding decision or by the fact that it is ‘someone else’ who meets the cost and manages any future risk. For instance, social workers often observe that the pressure to place someone in an appropriate service and so reduce any immediate risk they face can reduce their ability to work with citizens, families and communities to design better solutions (Rhodes, 2010).

There is also strong evidence that support can be offered to families so that women and children do not need to go to prison and that the cost of sending someone to prison is much higher than the cost of providing appropriate support. But the prison system is funded from Whitehall, so there is a weaker incentive for local areas to invest in these preventive measures (Hyde, 2011).

Figure 1. Moving investment upstream

Moving resources upstream will require a new kind of deinstitutionalisation. What, in Barnsley, is called inverting the triangle. Inverting the triangle means shifting the focus away from long-term and institutional provision and towards enabling people to stay healthy and well in their communities. The Barnsley model distinguishes:

• Tier 1 - Information and advice
• Tier 2 - Assistance to support self-care
• Tier 3 - Helping people regain skills
• Tier 4 - Supporting people with long-term conditions

Inverting the triangle does not just mean shifting resources and attention upstream away from institutional services, it means changing the whole philosophy of care. Everyone is assumed to be capable of managing their own care and support - but some people will need significantly more assistance or resources. Supporting autonomy and citizenship becomes a core value at every point in the system.

Responding to the challenge

But the size of this challenge cannot be underestimated. Most expenditure for health and wellbeing is NHS expenditure (over 76%), and most of this expenditure is committed to acute services, with hospital and mental health services using nearly 50% of the total budget. Even community services and primarily health care services are primarily focused on employing professional staff. Very few resources are spent upstream or in engaging citizen and community capacity.

We get some sense of this by looking at the data for Barnsley as set out in Table 1 and Figure 2.

Table 1. Health and Well-being Expenditure in Barnsley 2013-14

Figure 2. Health and Well-being Expenditure in Barnsley 2013-14

It is also very challenging to make this shift when resources are tight - yet this is also when it is most important to make the change.

So it may be helpful to identify some key principles going forward:

1. Invite sustainable innovations - If leaders make it clear that they will work hard to support innovations which reduce downstream demand then innovators can focus on solutions that will be sustainable for the long-run. Innovators exist both within and without the public service system, but there are rarely opportunities for these leaders to emerge, test ideas and develop new forms of practice. It is also important not to exclude those services which are further downstream from moving upstream themselves. In the past deinstutionalisation has - sometimes - been led by leaders from within those institutions themselves.
2. Transparent information - The resources spent on public services belong to citizens. It may be helpful to build on the early integration work to help all citizens understand how those resources are used and how the demand on services arise. Citizens are quite capable of acting responsibly and of helping to solve social problems if they have the opportunity to do so (Titmuss, 1970).
3. Focus conversations locally - It is only within local communities that it becomes possible to see the real opportunities for innovation and synergy. Meeting a family’s need for support with a disabled children can also be an opportunity for employment, peer support, education - as well as helping to reduce demands on statutory services. However this is only visible at the micro level. Local communities must be encouraged to see how they can strengthen themselves, both by solving their problems locally and by pulling in funding that would otherwise have been spent outside the community.

One of the most interesting approaches for promoting innovation at the local level is the Local Area Coordination concept - first developed in Western Australia - but now being used in Scotland, England and Wales (Broad, 2012). This model involves embedding workers within small local communities - where they work with people who would be at high risk of needing costly or institutional services. Instead the Local Area Coordinator encourages people to connect and to solve problems by building on local resources.

This is not the only strategy for better prevention, early intervention, information and sign-posting. However it is a commitment to strategies such as these that will be vital. This is less about ‘commissioning innovation’ and much more about helping people craft local innovations - which make sense in their communities.

The critical question will remain:

Do we have the capacity to move resources towards better solutions upstream?

There will be no extra funding for innovation or change. Positive change will need to be transformative - it will need to make better use of existing funding. However this means changing how resources are used - this doesn’t just mean money - more fundamentally it is about people - the professionals currently working in the existing system. They must be engaged as part of the solution, they must themselves start to work upstream, and train others to do so. Otherwise the system will be locked into its current pattern.

References

Alakeson V (2014) Delivering Personal Health Budgets. Bristol, Policy Press.

Broad R (2012) Local Area Coordination. Sheffield, Centre for Welfare Reform.

Crisp N (2010) Turning the World Upside Down. London, RSMP.

Duffy S (2012) Peer Power. Sheffield, Centre for Welfare Reform.

Duffy S (2016) Citizenship and the Welfare State. Sheffield, Centre for Welfare Reform.

Halpern D (2005) Social Capital. Cambridge: Policy Press.

Health & Wellbeing Board (2013) Summary Financial Information. 

Health & Wellbeing Board (2013) Joint Financial Planning and the Better Care Fund.

Health & Wellbeing Board (2013) Pioneers in Integrated Care and Support - Expression of Interest.

Hyde C (2011) Local Justice. Sheffield, The Centre for Welfare Reform.

Rhodes B (2010) Much More To Life Than Services. Peterborough, Fastprint Publishing.

Titmuss R M (1970) The Gift Relationship. London, George Allen & Unwin.

University of Leeds (2013) Stronger Barnsley Together - Proposal for Strategic Evaluation.

Wilkinson R and Pickett K (2010) The Spirit Level Why Equality is Better for Everyone. London, Penguin.

The publisher is the Centre for Welfare Reform.

Heading Upstream: Deinstitutionalisation & Public Service Reform © Simon Duffy 2016.

All Rights Reserved. No part of this paper may be reproduced in any form without permission from the publisher except for the quotation of brief passages in reviews.