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What is the problem? Some people face severe difficulties in leading a socially and economically functional life. These are usually people who have been let down and badly harmed from a very early age. They have learnt not to trust other people, and they struggle to cope with mental scars from early trauma. We don’t know the scale of the problem, but we can guess at it through the numbers of people who are long term homeless, who are in and out of prison regularly, who sell sex, abuse hard drugs, and who are exposed to serial violence. All of these symptoms are strongly associated with very problematic developmental experiences that leave people at odds with the world around them in ways that can be very hard to address. But on the whole, these people are not viewed as social victims because their own behaviour can be highly anti-social. They can cause others harm and may not appear ready to take much responsibility. What complicates this picture is that not all of this behaviour is psychologically driven. Notoriously, the systems that we have developed to respond to acute social need can only cope with one symptom at a time. Those people who have more than one need, which tends to be those described here, are placed at a considerable disadvantage as they are shunted from pillar to post. The systems generate perverse situations where some of those in greatest need receive the least help – characterised as the inverse care law.
The early experience of being let down is re-enforced again and again, triggering entirely natural feelings of frustration and despair. Behaviours that were already liable to be problematic are amplified and added to by the experience of exclusion. The consequence of which is that we need yet more systems to manage those behaviours, systems that are considerably more costly than the original systems that failed to meet the need. These are even less likely to lead to effective resolutions because they are caught between at least two primary tasks: to transform the individual and to deliver punishment and disapprobation. In attempting to deal with this problem, one obvious question arises: what causes support systems to focus so exclusively on single needs when enlightened self-interest ought to drive them to deal more effectively and economically with people? There are a number of possible causes: 1. Several of these issues command public attention and politicians tend to create systems that respond directly and singly to the concerns of the general public. 2. We tend to deliver public services through command and control systems that are vertical not horizontal. 3. Our systems focus on the breadth rather than depth of need, and there are larger numbers of people with single issues. 4. Systems inevitably focus where the results are most easily obtained. 5. There is an inherent human need to compartmentalise and reduce complexity to manageable chunks. The main paradigm in which we have tended to think of ‘wicked’ or intractable problems such as this is known as ‘what works’. ‘What works’ suggests that our main task is to identify a better intervention with an evidence base and then roll it out to all those who need it. In this case, a better intervention is most obviously one that is holistic and capable of working across siloes.
We have seen several examples of this in recent years. National strategies to deliver evidence-based interventions at scale, often involving new centrally mandated delivery structures accompanied by new money cascaded from national to local level. The problem with this paradigm is that, in the majority of cases, the new intervention only lasted as long as the central mandate and funding. It failed to become hard wired into the delivery of local public services, let alone their culture and ethos. Also, central Government almost never has sufficient funding to secure national coverage. Now that the economic chips are down, we can no longer afford this kind of additionality. But where are the solutions likely to come from when the tools in the box have been designed for a very different time? Systems change One of the problems with our enthusiasm for evidence-based interventions is that they don’t tend to replace siloed systems, they usually augment or mitigate those systems. So in good economic times, we accrete all sorts of pockets of interventions for all sorts of groups and needs. These in turn create an increasingly complex maze of services each negotiating interfaces with each other. One solution that we like to generate is case coordination, where people are employed to help vulnerable individuals navigate the maze. This can reach surreal levels of inefficiency when each part of the system invents its own locus of coordination, so you can end up with a room full of case coordinators all negotiating with each other over the same person. Our focus on interventions and coordination has provided a welcome distraction from the much harder work of fundamental system reform. The result is that you often get islands of excellent practice in a relative desert of poor systems. The systems themselves aren’t required to change, they are just subject to the brokerage, advocacy and special pleading of professionals
employed to champion the most disadvantaged. In other words, we employ one set of workers to try and persuade another set of workers to do the right thing. Where new interventions do offer actual help, closer inspection often reveals that this help is what most of us would reasonably assume was being provided by the rest of the system in the first place. Indeed, it sometimes turns out to be a piecemeal reinvention of what the system did provide 20 years ago. In other words, many of the interventions generated by the ‘what works’ paradigm were put in place to address or soak up social needs created by poor systems that don’t work. This is a phenomenon that the systems thinker John Seddon calls failure demand. Huge proportions of public money are spent mitigating the failure of public services elsewhere in the system. So if you look at any system that is set up for highly excluded people, such as many homelessness services, the criminal justice system, mental health hospitals, and arguably a large proportion of advice and legal services, most of these are dealing with the fall out of failures elsewhere, and arguably these are failures that could have been better handled elsewhere. Evidently we can no longer afford massive failure demand, but there is looming risk that we will need to pay for more and more of it as mainstream systems gatekeep their services ever more tightly. This is rapidly becoming a burning platform. What we have to avoid is a worse funded version of the system we have now. So rather than top-slicing, we need to be in the business of reconfiguring major chunks of public service, as only by doing this will we be able to release sufficient cashable savings. The most obvious starting point is an urgent examination of those parts of the system that are soaking up failure demand, and our task in doing so has to be to understand and prevent what is driving that demand. We need to examine rigorously the journeys that people take to those services and identify where
the missed opportunities occur. In other words, we need to develop strategies that can stem the leakage of failure into the crisis end of the system. Prisons and homelessness services provide a great vantage point on wider systemic failure. If you trace back people’s journeys into these services what you tend to find is a striking commonality of experience: people subject to multiple episodes of risk assessment, case review and inter-agency referral that have resulted in very little actual help being offered. Because the consequences of this failure to help are absorbed elsewhere, the imperative to change these systems is rarely felt. Our prison and homelessness systems are a standing critique of mainstream failure, and yet we treat the problems they inherit as if they had fallen out of the sky. Transforming this situation implies data-driven whole system change, with a view to putting some parts of the system out of business, in the most positive sense of that phrase, so that spend can either be shifted to preventative approaches or stopped altogether. In driving this systems change, there is a very good argument for focusing on people who face severe and multiple disadvantage. They are effectively where all of the faultlines in existing systems converge. By paying close attention to their experiences, listening carefully to their stories, they can reveal a whole host of systemic problems that actually affect a much broader group of people. There is a false dichotomy emerging between helping the poor and the really poor. Arguably this has been allowed happen partly because the services we have created for the most disadvantaged are separate and additional to mainstream services. Perhaps what we need to ask now is how we can create systems that work for everyone. Hence the experiences of people facing severe and multiple disadvantage become not a separate case but a litmus test for the effectiveness of services used by a much wider group of people. Power shift
The experiences of the most disadvantaged are not just sources of important data. There is also something here about power that needs to be addressed if we are serious about change. Elsewhere, we reform public services by increasing public choice and consumer power. We create localised governance structures designed to ensure that services don’t retreat into fiefdoms captured by providers. However, this kind of philosophy seems to run out of road when it reaches the margins of society. The most disadvantaged people are treated as if they don’t deserve choice, even when this is patently self-defeating in the battle to improve outcomes. But now that we can no longer afford ineffective services that do things to people, we have little choice but to put people into the thick of service design to make sure the services are what they actually want. There is a great deal of evidence to suggest that an effective service is one that is personalised, co-produced and integrated around the needs of the individual. If the last 15 to 20 years have taught us anything, it is that services are least effective when they lose touch with the lived reality of the people they are meant to serve. And yet we continue to locate the specification of ‘needs’ and accountability for meeting those needs remotely. Hence providers are continually looking up to commissioners to determine their priorities. Of course, somebody has to hold services to account and specify what they should be providing. But is it such a leap of faith to suggest that the people to whom they should be accountable are the people who use them? Commissioners are not sighted on what is actually going on in the lives of the most disadvantaged. They are not an all-seeing-eye. Yet our current response seems to be to push the same solution harder. We are developing commissioning colleges, world class commissioning and payment by results as though it is the execution and not the model that might be flawed. If we are serious about putting people at the centre of services, then we need a radical shift in power that ensures services care a great deal more about their views and a great deal less about the views of officials. In other words we need horizontal rather than vertical accountability. All political parties are clear
that this has to be the engine of change elsewhere in public services, and we need the same conviction here. Otherwise we reproduce exactly the dynamics of social exclusion that we claim we are trying to address. This has further important implications for the culture and ethos of public service. A fairly toxic polarisation has emerged in the way the statutory and voluntary sectors are viewed, between oppressor and martyr, gatekeeper and advocate, bureaucrat and innovator. The voluntary sector is felt by many to be closer to the end user, and therefore to be more values driven, more ethical. If we accept, however, that behaviours exhibited by different workers are not necessarily inherent but perhaps determined by wider systems that have a dynamic and logic of their own, then this polarisation starts to look like a red herring. Rather than privileging (or indeed purchasing) the values and ethics of one sector over another, our energies may be better spent focusing on the values and ethics of the determining systems themselves. If these systems were radically shaped by accountability to the people who use them, rather than by command and control, would they not foster and inspire a different set of values and ethics in the professionals working in those systems, regardless of which sector they happened to belong to? Conclusion Tools such as commissioning, and more recently social investment, are important but if they become our jumping off point, which arguably they have become in many cases, then we risk getting results already defined by their limitations. These tools have to be put at the service of a bigger vision and of the fundamental reform that we urgently need. To conclude with one specific example. A key challenge that needs to be addressed by any new vision of public services is how we support socially excluded people while also building bridging social capital. Commissioning has arguably not helped here. The competitive model has required organisations to act as rivals and to spread business risk rather than deepen social value, so they often bid for contracts in communities with which they have no relationship. One consequence is that services for the most disadvantaged can
be delivered despite, rather than because of, the local community. In other words, the commissioning model risks sealing out the relational side of public service and, worse still, driving a wedge between vulnerable groups and their communities. Community-led organisations, with an open door and a genuine knowledge of, and commitment to, their local populations can be one of the best ways of people getting the support they need in a preventative and non-stigmatising way. These multi-purpose organisations are low threshold but can be highly skilled, providing a continuum from community café through to debt counselling through to mental health services. They can be ideally placed therefore to provide the holistic response that eludes specialist services. In difficult times, we need such organisations more than ever. Organisations that are rooted, resilient and responsive; a valued and trusted resource to communities not just another commissionable provider. And yet the finances and structures of community-led organisations are often a ‘house of cards’ determined by multiple masters and funding streams. What would allow such organisations genuinely to exist for and be led by their communities? Above all it would require a shift in accountability towards those communities, but this would only work if there was a similar shift in resources, allowing those organisations to operate, to some extent, outwith the day to day demands of the state. Does it really serve us that communityled organisations are forced endlessly to chase short term contracts and second-guess commissioners? An ambitious programme to shift power and assets to such organisations, so that they become independently endowed and therefore capable of long term action, could create a lasting and transformative legacy. But it requires a very different mindset to prevail about who and what public services are for. In difficult and highly constrained times, we need to make leaps of faith towards ideas that appear unorthodox and counter-intuitive. There will be inevitable risks in doing so, but these risks need to be balanced against the known costs of current system failure that are set to escalate rapidly beyond our capacity to afford them.
Julian Corner is Chief Executive of the LankellyChase Foundation, which is an independent charity focused on severe and multiple disadvantage. The paper is based on a think piece presented to a roundtable of North East leaders in Newcastle on 23 May 2013, hosted by Tyneside Cyreneans. It is not intended to define the position of LankellyChase Foundation. Political notes are published by One Nation Register. They are a monthly contribution to the debates shaping Labour’s political renewal. The articles published do not represent Labour’s policy positions. To contact political notes, email email@example.com
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