Governance International Blog
What can co-production do for me? New opportunities for commissioners and providers to achieve better outcomes
This January we’ve already had lots of enquiries from local councils, social care and health partnerships and third sector organisations about our training and consultancy offer in user and community-led co-production.
So it’s becoming clear that more and more people now understand that it is no longer good enough just to talk about co-production – it’s time for public services to take action to strengthen co-production with specific service user groups and at neighbourhood level. This is the good news.
The bad news is that there are still many people working in local councils who believe that co-production has nothing to do with them. After all, service users will simply have to take what (reduced) services we decide to given them. And, obviously, “communities are an issue for the third sector”. Wrong on both counts!
However, this is symptomatic of how outcomes-based commissioning has often been diverted away from the big issues. In theory, it offers great opportunities for enabling communities to improve outcomes. However, many commissioners perceive it as a service planning concept, internal to their organisation. Furthermore, many commissioners and service managers are facing (continuous) restructuring, often involving major disruption, so they become absorbed with internal processes, while neglecting what their job should be all about: Better citizen outcomes.
This is not just a public sector issue – many third sector organisations working in health and social care still embrace a ‘clinical model’ of health, whereas co-production promotes a social model of health, with a focus on wellbeing rather than illness. Some third sector organisations have indeed embedded co-production principles in their work - the Mosaic Clubhouse in London and Community Catalysts are good examples. However, in an era of permanent austerity, third sector organisations need to be able to demonstrate the social value that has been added through co-production. The recent evaluation of the Balsall Health Neighbourhood Forum in Birmingham by Governance International demonstrated a positive cost-benefit ratio from investing in co-production in community safety and revealed new opportunities for making co-production even more effective.
So how can co-production champions in local councils, the NHS and third sector organisations motivate and incentivise colleagues, who are not directly involved with local communities or people accessing services, so that co-production becomes their business, too, not just the agenda of some ‘engagement bods’ and ‘community nerds’?
Here are some new arguments for key stakeholders to get buy-in (literally) for co-production:
- Heads of strategy and finance: Co-production can be used as a budget management strategy, using the right mix of substitutive and additive co-production to achieve short-term savings while also releasing public sector investment in communities so they can help to improve outcomes.
- Integration Leads working in health and social care: Co-production can be used as a driver to promote the integration of health and social care, as it focusses more on outcomes rather than services and brings in communities who tend to be ‘sector-blind’.
- Commissioners interested in behaviour change: While there is increasing interest in ‘design thinking’ and ‘nudges’ to trigger behaviour change of specific target groups, the Governance International Co-Production Star shows that co-design is only one element in pathways for better outcomes. Governance International case studies, such as the peer training of learner drivers by young offenders in Austria or the Community Health Trainer Scheme in Manchester, show the potential of peer support, peer learning and peer training for sustainable behaviour change.
- Open data officers: While there has been a lot of attention on how to open up governments so citizens can find out what they want to know, the big unresolved issue is what do (local) governments really know about local communities? Of course, there is a lot of talk about ‘big data’, usually as a top-down exercise, but this has so far not given governments that understanding of everyday behaviours of their citizens that many firms in the private sector have established, often with significant profit implications, through their monitoring of people’s purchasing patterns. There has also been some interest in asset-mapping, as evidenced by the group work in a recent West Midlands Co-Production event, but there are surprisingly few practical examples of asset-mapping leading to systematic mapping of community needs to community capabilities. So, it’s time for open data officers to engage with colleagues, especially those working in personal services, to drive the open data agenda from the bottom-up. We’d be very interested in working with commissioners and providers in further pilots of Governance International’s ‘See What You Can Do’ Toolkit to map individual capabilities, link them to the needs of service users and others in the community, and bring people together to improve personal outcomes.
So now over to you. In this blog, we have explored the potential benefits of co-production to four different stakeholder groups, who up to now have been talking about co-production but not grasping the nettle and making it central to their approach. We have also suggested ways of convincing each of these stakeholders that they need to take co-production more seriously. What about your organisation and your local area? Who are the sceptics whose hesitation is holding back co-production in your work? What arguments do you suggest might convince them? What evidence would be needed to give these arguments real force with those stakeholders?
We’ll publish the best arguments, with your name (if you agree) and the chance for others to comment and build imaginatively on them.
In this way, we want to turn this blog into a ‘What Can Co-production Do For You’ Resource – a stakeholder-specific list of co-production benefits.
We look forward to hearing from you.
In our next blog, we will look at how some of these benefits might be tested in high-quality research, building on what has already been done. And, of course, we’ll be asking for you help on this, too!
From NEET to PETE: Join our #govint fishbowl on outcome-based commissioning for young people
Outcome-based commissioning is high on the agenda of many local public services. Yet it is still not well understood nor systematically managed. The #govint #fishbowl invites you to discuss with national champions and experts in young people services how to make outcomes-based commissioning work in this field. So join the debate on Friday 21 November at 12.00 and share your experiences, achievements, questions and proposals!
So what’s a fishbowl? Like Twitter it is a facilitation method for discussing topics within large groups. Typically, four to five invited speakers form an ‘inner circle’, with a chair left empty for other participants to come forward and join in the discussion – but every time a new participant comes forward, someone has to leave the fishbowl voluntarily to free up a new seat. In our virtual fishbowl, of course, it’s even easier - all Tweeps can join in the discussion simultaneously, without pressuring anybody to leave their chair or interrupting anyone!
So who’ll be sitting inside the fishbowl to discuss with you? We’re very pleased that Garath Symonds and Chris Tisdall of Young People Services in Surrey County Council, Andy Moreman, CEO of the Young Lambeth Coop, Diane Evans of the National Youth Agency and Suzanne Thompson, CEO of the Restore Trust, an inspirational multi-award winning organisation delivering skills & employment rehabilitation services, have agreed to share their experiences and views.
And our topic? The motto of our twitter debate “From NEET to PETE” is the brand of the recent transformation project which has achieved remarkable outcome improvements for Young People’s Services in Surrey County Council, providing many learning points for local councils and other organisations both in the UK and internationally.
The extraordinary results from this transformation have been highlighted in the external evaluation of the recommissioning of Services for Young People by @inlogov at Birmingham University and @govint Governance International, as well as in the case study produced by Chris Tisdall for the Governance International Good Practice Hub.
Another highly innovative and unique commissioning model for Young People’s Services in the UK is the Young Lambeth Coop (YLC), which is a membership organisation for residents in Lambeth to decide how services for children and young people are run in Lambeth. Anyone over 11 years old who lives, works or studies in Lambeth can become a member, as long as they have a genuine interest in what happens to youth and play services and believe in its core values. YLC has two types of membership - community members and youth members.
We’re also looking forward to hearing the views of the National Youth Agency, Restore Trust and other experts in young people’s services, and of, course, the views of young people in the UK and internationally – but especially we want to hear from YOU!
We suggest the following questions for kicking off the debate:
- Does focusing on outcomes make a big difference? Why?
- How can we design an outcomes framework with young people? How do we make sure we identify the 'right' outcomes?
- Whose outcomes? What if different groups of stakeholders prioritise different outcomes?
- How can we help young people to co-produce the outcomes for themselves and others that they most care about?
- How to build outcomes into commissioning, procurement, contracting?
- Barriers to outcomes-based commissioning?
- What works in outcomes-based commissioning – success factors?
The Governance International team is very excited about our first #fishbowl debate. Thanks to all #bigfish for making it happen!
From repression to co-production with citizens: Why we need behaviour change in healthcare
What’s the mission of health care?
I’ve been working as a physician and gastroenterologist both in Denmark and Sweden for more than 30 years. Over time, I’ve become more and more puzzled about our healthcare system and how otherwise responsible human beings can tolerate the way that common behaviourial rules are suspended when you access healthcare.
In my role I am supposed to order people named ”patients” to behave the way that I or the ”science” believe is the right way to behave. At the same time, most medical practitioners know that their patients will not in fact behave the way recommended. Most studies on “compliance” with recommended treatment show that only 40-50% of patients actually follow therapy recommendations (WHO, 2003). This behaviour is most often a result of their conscious choice and does not arise from stupidity or ignorance. This mismatch is remarkable and the result is devastating to health as more than 50% of patients will be untreated for treatable or preventable diseases.
So, how did we get into this paradoxical situation?
To understand the modern healthcare system and its rules of behaviour, it is necessary to look back in time and try to understand how and why the system has developed. The healthcare system reflects society and is the result of the outlook and the values of citizens. From the beginning of the 16th century, the institutionalisation of health care started in monasteries. Naturally, the rules of behaviour (i.e. obedience and silence) were in accordance to monastic rules. The history of silence, and how we as humans can use the expectation of silence as a tool through which to rule over others, is fascinating. The monasteries aimed at helping people in need - but to get help you were expected to conform to the rules of the organisation.
In the early industrial period, and continuing into the post-world-war era, there was a widespread Western European political vision of the perfect society, in which blessed citizens would live happy and productive lives and where the state would look after all citizens. As a result of industrialization and urbanization, individuals who were not productive or who were a danger to public health (e.g. those suffering from tuberculosis or other infectious diseases or psychiatric conditions) were isolated in hospitals or sanatoria, which was a generally accepted approach. In Sweden this idealized state was named ”Folkhemmet” (”the people's home”) but the fundamental ideas and dreams were quite uniform throughout Western Europe. Moreover, there was a belief that the State would help vulnerable groups by creating special enclaves designed to meet their specific needs.
The organisational models of the healthcare systems evolved by inspiration from the most advanced industrial model of the between-the-wars era, namely the car industry in Detroit. Therefore, healthcare was organized in departments and special units in order to focus upon production outputs instead of supporting people. The idea that the employees of the healthcare system should and could dictate how “patients” should behave is probably a consequence of the roles and rules arising from history, reinforced by the influence of an industry handling production outputs and seeking very hard to standardize. The term “patient” is revealing, as a problematic and stigmatizing construction. It is not connected to “patience” (although often you do need to be patient to put up with the wait for healthcare). It actually comes from the Greek word ”pathos” - ”to suffer” – which marks the people concerned as different from “us”, making a repressive approach more possible.
This first post-war era ended when politicians such as the UK’s Prime Minister Margaret Thatcher recognized that this vision of an ”idealised” society went beyond the bounds of possibility and that, even if it could be achieved, this would only be at the price of an intolerable repressiveness towards individuals. What politicians like Thatcher realized (I believe) is that society actually is a conglomeration of individuals. This led inevitably to marketing the ideas of individualisation and personalisation.
However, this led to many health care workers getting stuck in an antiquated system with an extremely conservative structure. The reason why it has been so hard to change is difficult to understand. However, I think that one of the key reasons is that it is a very hierarchical system and that people at the top of the system are comfortable with it, so they do not have much motivation to change. Furthermore, it is becoming increasingly obvious that modern public management systems are focusing on processes instead of results, which preserves the current system.
How can we change healthcare towards a more human system?
We have to accept that the behavioural rules underlying the traditional system are unacceptable and out of line with citizens’ expectations in the 20th century. So we need to redesign the system. To do this we will have to change the way we think about healthcare. In particular, we need to develop an alternative approach, harnessing the skills and capabilities of human beings instead of continuing to use repressive approaches. We have to incorporate principles of co-design and co-production into how we think and interact – with staff, clients and their families, friends and networks.
This is how I started to transform my ward at in the Highland Hospital in Eksjö hospital in 2001 as described in the Governance International case study.
One important driver of co-productive forms of behavior in healthcare may be greater transparency. Since we have moved to giving patients a much greater understanding of their own conditions, and how to interpret all of the information which we have on how their condition is progressing, we have had great improvements in our results. New ways of reinforcing this are now becoming available. For example, in the US and Sweden the rules are now changing so that patients have internet access to their own health record in order to help patients make proper choices. In the future, patients may even have the opportunity to add their own notes to health records which will open new possibilities.
Fundamentally this is a political issue, the basic question is how to let individuals take control of their own lives in a way that is in accordance with the 20th century.
Jörgen Tholstrup is the Chief Medical Officer at the Highland District County Hospital in Eksjö, Sweden. Until December 2013 he was the head of the gastroenterology unit in that hospital.
Transformational change in the city of Mannheim
The City of Mannheim (about 329,000 inhabitants) in South-West Germany is one of the most ambitious local authorities in Europe when it comes to transforming public services. The transformation programme Change Squared www.change2.de (which alludes both to the scale of the transformation programme but also to the famous baroque grid-like layout of the inner city, the “City of Squares”) is widely admired in German local government for its comprehensive portfolio, based on all public services being provided in-house. What makes Mannheim’s transformation strategy so interesting for the UK and other countries is its strong commitment to implementation based on a carefully designed top-down and bottom-up strategy. Mannheim doesn’t just have great ideas – it is great at implementing them.
So what is the Mannheim transformation programme about and what are the results after the first phase of delivery (2008 to 2013)?
1. Rationale of Mannheim’s transformation
When the directly elected mayor Dr. Peter Kurz took office in 2007, Mannheim council was characterised by a number of shortcomings, which are common to most other local authorities in Germany:
- A strong focus on inputs (budget and staff) but little awareness of outcomes to be achieved.
- Fragmented public services, with departments operating as ‘silos’.
- A strong service orientation but neglect of governance issues, such as citizen participation.
For Dr. Kurz it was obvious that a new direction of travel for Mannheim entailed changing behaviours and perceptions inside and outside the local council. Mannheim had lost most of its industrial base in the previous 25 years (having been the city where Daimler invented the world-famous Mercedes brand) and was in the process of shaping its new identity as ‘the inclusive city’. This new identity focused on the diversity of local people (representing more than 170 nations) as a central asset. Furthermore, Dr. Kurz introduced the idea of the political citizen, who has both rights and responsibilities, and who is not just a passive “consumer” of public services.
2. Design of the transformation strategy
In order to make this new vision real, an overarching strategy was needed. It has focused on seven strategic goals:
- Strengthening urbanity
- Promoting talent
- Winning business
- Living in tolerance
- Raising educational equality
- Strengthening creativity
- Supporting involvement
For each of these strategic goals, strategic performance indicators were defined to measure outcomes. Besides conventional indicators like the number of recorded criminal offences or the unemployment rate, data from the Urban Audit perception surveys are used to measure the satisfaction with such things as the cultural facilities and cleanliness of the city. Since 2009 the number of registered associations, used as an indicator of Mannheim‘s inhabitants involvement in its civic society, rose from 2,384 to 2,576 in 2013.
All stakeholders participating in the delivery of the strategy took up the new city motto “Together We Have More Impact” (Gemeinsam mehr bewirken).
3. The Masterplan with 36 projects
A new unit to reshape the organizational architecture (Fachgruppe Verwaltungsarchitektur 2013) was set up, reporting directly to Dr. Kurz. It co-ordinated 36 projects to deliver the seven new strategic goals. These projects ranged from macro-concepts such as preparing an application for Mannheim to become the European Capital of Culture in 2020, all the way through to strengthening localism through neighbourhood management. A key project focused on increasing the level of volunteering and participation in decision-making processes in the conversion of a former military base.
Another project involved the participation of the managers of all local services in ‘strategy workshops’ to define outcomes and performance measure to assess progress towards agreed targets. An important project was the development of new guidelines for “leadership, communication and collaboration” in Mannheim Council, co-designed with senior managers. In 2010 a Competence Centre was set up to help the local council to recruit new staff and train existing staff. A steering committee representing council members, heads of services and the staff council (a distinctive feature of German organisations) monitored the transformation process.
4. Communication and staff participation as key success factors
The change management process introduced new forms of communication across services. A roadshow, based around the concept of a “mobile bar” (called “veränderBAR” in German, which is clever word play, which we might translate as The ChangeAble Bar) invited managers and staff to engage in dialogue. Dr. Kurz invited a randomly selected group of staff to have a conversation with him on a regular basis. A new staff journal reported regularly on the new projects. Furthermore, several staff and customer surveys were conducted to assess levels of satisfaction. As one district manager said:
“Previously, I used to send masses of e-mails and thought that was sufficient. Now I take time for discussions with individual staff members more often.”
The recently published report on phase 1 of the transformation process also points to the importance of:
- Strong leadership of the corporate management team, with the directly elected mayor as the central driver of the transformation process
- Clearly defined objectives and strategies
- New organisational structures
- Culture change
- Public participation and local democracy
Professor Gerhard Banner, a senior local government expert in Germany and former Director of Governance International, states: “Never was comprehensive reform in a local authority implemented as quickly as in Mannheim. The objective, stated in public in 2008 by the Dr. Kurz, to make Mannheim one of the most modern cities in Germany, can already be said to be achieved”.
Prof. Dr. Jürgen Kegelmann, Pro-Rector of the University of Public Administration in Kehl (www.hs-kehl.de). He is an international expert in public governance and change management in local government. Before he joined the university, he was a senior advisor in an international consulting company, finance director of cbm (an international non-governmental organization) and a change manager in the City of Friedrichshafen.
Oliver Makowsky is a member of the staff unit “Strategic Governance” and responsible for strategic performance management.
How we grew timebanking in rural Scotland: The Argyll and Bute Timebanks
One day in 2005 a woman called Verity walked into the Volunteer Centre in Argyll and Bute where I was employed as a development worker at the time. She was new to the area, keen to make new friends and join in with community activity. She wanted to know if we had a Timebank. Having never heard of this concept, my colleagues and I looked into it. We learnt that “Timebanking is a means of exchange, where time is the principal currency.” The basic principle is “an hour for an hour.” We also found out about Timebanking UK which provides a lot of resources and support to people who want to set up a Timebank. We decided to give it a go, as it seemed to add something extra to the traditional volunteering opportunities already available in the area and nationally. It gave people a way to join in who may feel excluded from volunteering – an easy way to get involved, whether busy with work, a single parent, or just out of prison. It also has increased flexibility – so organisations can have one-off help at events, or a small group can get professional help such as designing a leaflet. It also has more flexibility for individuals – they are under no pressure to do something if they’re busy with visitors or heading off on holiday.
We did get some start-up funding from Big Lottery and other funders, which was used to pay for development staff across our large geographical area. We also had help from established Timebanks in the country with paperwork, and training from TBUK on how to use the Timebank system. Timebanks also need some finances for covering internet and phone usage and volunteer expenses. In the day-to-day running of the Timebank itself, though, no money changes hands, except to make sure that fellow Timebankers are not out of pocket, for example a member will cover another member’s bus fare if they are travelling to come and help them in the garden. Some Timebanks have insurance to cover exchanges, but not all. The Volunteer Centre is now Argyll Voluntary Action which is part of the Third Sector Interface, but the Timebank continues.
We have worked in a variety of ways – finding that what works best is a team of volunteers in each neighbourhood, rather than a member of staff covering the whole area. Argyll and Bute is a large geographical area, with 80,000 residents located in small towns, remote rural areas and twenty-five inhabited islands. We have set up seven Timebanks across the area, each operating differently, as works best for them, but each linked together in one system. So an exchange can happen locally, or with another Timebank in the area, if need be. Currently in Cowal, we have five volunteers working as time brokers, supported by various members of staff, who all work on different projects, including Reshaping Care for Older People which is a Scottish Government initiative aimed at improving services for older people by shifting care towards anticipatory care and prevention.
In order to gain Timebank members we held large events, but found that word of mouth works best – as soon as someone finds out that they could get their ironing done they will want to join! Our Timebank has grown from its humble start in 2005 to currently 1406 members across Argyll, across seven Timebanks all linked together. We have 235 in our small town. We have a wide range of people – employed, unemployed, various ethnic groups; the youngest member is nine, and many are aged over ninety (we don’t always get people’s actual age!). The highest proportion of people is aged between fifty and sixty, although all age groups are fairly evenly represented.
A Timebank works like a bank – people can spend their hours as fast as they earn them, save them for a rainy day, or donate them. One member recently donated hours to a friend as a birthday gift, and another donates regularly to local groups. It is rare to encounter issues. Some people slip into ‘overdraft’ but most people like to earn their hours before spending them - the bigger ‘problem’ is encouraging people who want to earn and not spend to ask for help so the system doesn’t grind to a halt. We also say to members to think how good they would be making someone else feel if they get to help!
We have many exchanges, including grass-cutting, picking up shopping or doing an internet search. Some activities are more creative – guitar lessons, advice on pruning apple trees or publishing a book. This month we have organised Polish/English translation, shortening trousers, cleaning kitchen cupboards, hoovering and changing bedding, amongst other things. The bedding is a regular exchange that two teenage girls take turns to do for an eighty year old lady who would like to stay independent, but struggles with some housework. She earns hours by making shortbread for local events, and writing certificates for a youth organisation (she has beautiful hand-writing) and for giving cookery advice. The teenagers have received help with school projects and homework. The Timebank also works well for people busy with work, volunteering, caring or parenting – they can earn credits when they can – for example, through their voluntary work, by picking up shopping while out doing their own, or by doing internet searches during leisure hours. In exchange they may get their garden tended to, child-care, or someone to wait at the house for a parcel delivery.
Are you already thinking of how a local Timebank might help you? So, while you imagine getting a huge pile of ironing done, I will answer some typical questions.
Are you already busy and can’t imagine fitting it in? Our Timebrokers will discuss with you what you can contribute to the Timebank and when and how often to do it. You can opt in and out of the system, so it can be arranged that you only get asked for week-end matches, or during your annual leave. You will be one of many people who are offering the same thing, so if a Timebroker calls and you can’t do it, they will just move on to the next person on the list. No pressure.
What about letting someone into my home that I don’t know? We can arrange to send two people, maybe one of them being someone you have already met. We also arrange regular drop-ins and get-togethers so that Timebank members can get to know one another. We get to know time bank members ourselves, and use our judgment about whether people will get on, or arrange for exchanges to happen outside the home if possible.
How do I know if someone is reliable? We collect references that ask about someone’s honesty, team-working, punctuality and their ability to get on with others. It gives us a good starting point. We never turn anyone away, but we won’t match someone to get you to a hospital appointment if they don’t seem too reliable. In some cases, we do require a PVG check, but can only do these in respect of regular matches such as a person offering tutoring to a school child. As with all volunteering opportunities, it is free to get the check done.
Will it cost me anything? If you want your kitchen painted, you will buy all the materials needed, but we can share tools and equipment between us all. If travel is necessary, we arrange a set amount before the exchange happens to cover costs. All members sign an agreement - not to ask for or accept any gifts or money, not to use someone’s phone without agreement, and to treat one another with respect.
The best part about Timebanks is their equality – everyone can both give and receive help, and everyone’s time is worth the same, whether they plumbing or picking up a prescription. For some people being asked to help, when they have traditionally just been receiving services is transformational. For example, one of our Timebank members has learning disabilities, earns credits by photocopying, and gets help with ordering online, and doing searches about holiday destinations.
A lot of what I have mentioned has been about individuals but our Timebank also includes local voluntary groups, and businesses. As I type we are just heading off to one of our local cafes, which accepts Time Credits for teas and coffees, and then spends them on getting their windows cleaned and help with publicity…
You can find out more in our Co-Production Case Study published by the Joint Improvement Team. If you need further information simply get in touch with Timebanks UK - through them you can also get expert help in setting up a Timebank in your area. Or contact me at email@example.com or on 01369 700100. Get Timebanking!