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1. July 2014

Better Outcomes

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:

  1. A strong focus on inputs (budget and staff) but little awareness of outcomes to be achieved.
  2. Fragmented public services, with departments operating as ‘silos’.
  3. 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:

  1. Strengthening urbanity
  2. Promoting talent
  3. Winning business
  4. Living in tolerance
  5. Raising educational equality
  6. Strengthening creativity
  7. 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”.

 

The authors:

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.

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Better outcomes

Not just good value: A Social Return On Investment (SROI) Study of Hertfordshire Community Meals

Making the business case

Hertfordshire Community Meals (HCM) is not just a provider of meals. Our recent ‘Social Return On Investment’ (SROI) study revealed that HCM has a hugely positive indirect impact on a wide range of stakeholders. Perhaps most importantly, this impact translates into tangible savings for public sector organisations. Indeed, the SROI study argued that from a total investment of around £2.3m (in 2011/2012), HCM generated approximately £12.3m in wider social value. 

The study was carried out by an SROI practitioner in collaboration with Anglia Ruskin University and was subsequently approved by the assurance process of the SROI Network. After going through a detailed process of analysis the study found that, on average, for every £1 invested in HCM’s core meals service, £5.28 of value was created for stakeholders (44% of the value for clients, 36% for public organisations such as the local authority, and 20% for carers and/or family members).

Methodology of the SROI Study

Broadly speaking there are seven stages to carrying out an SROI study: (1) establish scope; (2) identify stakeholders; (3) map outcomes; (4) evidence outcomes; (5) give outcomes a value; (6) establish impact and (7) calculate SROI. These stages, and examples from HCM’s study, are described in greater detail below:

  1. The scope of HCM’s SROI study was to demonstrate the social value generated by community meals services for the purpose of commissioning, funding applications, and internal strategic business planning. The study focused on HCM’s core business activities; namely delivering meals, carrying out basic welfare checks during delivery, ‘Operation Sponge Pudding’ (a joint HCM-Hertfordshire Constabulary-Hertfordshire Fire and Rescue community safety project), and volunteering opportunities associated with the delivery of MoWs. 
  2. Stakeholders were identified as clients themselves (a total population of 1500), carers and/or family members of clients (1200), volunteers, Local Authorities, and the NHS.
  3. Consultation with stakeholder groups was key to the mapping of outcomes. For example, interviews with clients and their carers revealed that as a result of receiving HCM’s MoWs service, some clients feel happier, healthier, safer, more secure, and have greater independence.
  4. In evidencing its outcomes HCM had to go through a process of developing appropriate methods of data collection. Generally speaking, this meant interviewing stakeholders, carrying out focus groups, and then developing relevant questionnaires for those groups on a larger scale before analysing the results.
  5. In giving outcomes a value it was necessary to attach appropriate ‘financial proxies’ to a range of different outcomes reported. For example, a significant proportion of clients reported that if they did not receive HCM’s MoWs service it is likely that they would be placed into residential care. The SROI Practitioner asserted that the average cost of residential care in the UK is £987 per week, or £51,278 per year, and according to the Wanless Social Care Review around 38% of social care expenditure was funded by social service departments, or £19,483.
  6. In establishing impact the study goes through a sensitivity analysis and thus the processes of ‘attribution’ and ‘deadweight’ to ensure HCM’s impact is neither underestimated nor overestimated respectively. This is key to ensure both the credibility and objectivity of the study.

The social value provided by Hertsfordshire Community Meals

The statistical evidence suggests that HCM generates considerable value for its stakeholders. Yet in addition to quantitative evidence, HCM gathered a significant quantity of qualitative evidence, particularly from clients and their carers, which indicates the value that the service provides. For example, a large number of clients reported that because of the service provided to them by HCM, they are happier, healthier, and have greater peace of mind. Clients and their carers also told HCM that they felt more independent, their lives are easier, and that they are now able to work full-time as a result of not having to take time off from work to feed their relatives.

Sam Tappenden

Business Development Manager, Hertfordshire Community Meals
Email: 
sam.tappenden@hertscommunitymeals.co.uk

 

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Health and Wellbeing

Co-producing healthier outcomes

Learning from a bike crash in Belgium

I recently travelled to Belgium for a cycling weekend.  I was showing off by riding over some cobbles when I crashed.  Luckily, one of my friends was carrying a portable medical kit, and promptly put on some latex gloves, cleansed my wounds, and administered industrial quantities of pain killers.

I was promptly re-installed on my bicycle, until I decided to call it a day and managed to find a local train station.  Just as I was about to board the train to Brussels a local handyman offered me a lift to the local Accident and Emergency Department. I was pleasantly surprised to be seen after a few minutes.

I was then bandaged up by nurse and doctor, and given a tetanus injection.  The only problem was that my cycling kit was splattered in blood and sweat, and I didn’t have any spare clothes with me.  It was a Sunday in rural Belgium and all the shops were shut.  I used my powers of persuasion and managed to leave wearing a crisp white nurse’s outfit.  Over the last few years I have spent a lot of time thinking about the role of patients in health care innovation, but this wasn’t exactly what I had in mind!

My recovery in the UK

In 2012, I had predicted that many of us would become much more active in our managing our own health care.  I argued that many people would seek out knowledge and expertise from their peers, and online, as well as consulting their doctor.  Well, this crash gave me the chance to put my ideas into practice. 

When I returned home, I sought advice from internet forums and my cycling friends about the best way to treat “road rash”, as we cyclists call abrasions caused by hitting the road.  But in the end, I decided I need help from the experts, and I went to a local “NHS walk-in centre.”  My walk-in centre in Peckham, South London was lot busier than rural Belgium. It would be more accurate to call it a “walk in and sit down for a while” centre, but once I was seen, the nurse who saw me gave me her full care and attention as she changed my dressing, and we shared some stories about our lives, in the fifteen minutes we spent together. 

The help of this nurse, who I saw every few days after this, was crucial in aiding my recovery.  This reminded me of how important it is that clinical staff and patients work together to achieve real outcomes together. There is a real risk that this human relationship, which requires compassion and genuine empathy, is often neglected in modern health systems and innovations. Indeed, Darian Leader has uncovered evidence that the majority patients visit their GP due to psychological distress, rather than for any medical reason.    

Need for a new form of collaboration between patients and clinicians

Nevertheless, the interaction of the patient and clinicians is an area that is ripe for change.  Genuine co-production between clinicians and patients can provide opportunities for better outcomes, experiences and improved efficiency.

 A number of organisations and individuals have been grappling with the question of how patients and clinicians need to work together.  The King’s Fund has argued that the UK needs to unleash a wave of innovation to find new ways to relate to patients in managing their health care conditions. The blogs from patients and experts on Time to Think Differently make the point that clinicians need to find out what patients want, and show why patients need to take more responsibility for their own care.

Often, this can be achieved through very small changes in conversational approach.  For instance, a London based GP reports that she is much more likely to start with “What are we working on today?” rather than “How are you today?”  Her experience was that the result of this shift is that patients are much more thoughtful about their own role in managing their long-term condition. The Health Foundation’s Co-creating Health Programme, has provided clinicians support to rethink about they work with patients with long-term conditions.  A key finding has been that patients respond constructively to jointly set agendas around how best to manage their care. 

Over the last few years I have been talking to clinicians, commissioners and patients around the country about how they can work together more closely as part of the NESTA People Powered Health Programme.  We set out with the idea that co-production was a marginal approach in health care, but we wanted to find out if it could produce real results if it was scaled up.

We need to test and try out creative new approaches

We worked with Professor Chris Drinkwater and GP Dr Guy Pilkington to support doctors to provide “social prescriptions” – linking patients to local activities to give them a sense of purpose and meaning.  We talked to commissioning manager Nick Dixon about how to help adults move out of inpatient psychiatric care and find support from peers who were in recovery themselves.  We worked with colleagues in Leeds to think about how to create multi-disciplinary teams that helped people with many long-term conditions.  We listened to clinicians and service users about how to use group consultations for individuals experiencing chronic pain.  We worked with a primary care centre in Earl’s Court to think about how to get patients to benefit from nurse coaches, and join a time bank to support other patients. My overall experience was that whilst there are many powerful political and professional barriers to giving patients a greater role, there are also interested clinicians and commissioners who are willing to try new ideas and develop new approaches. 

One such co-production champion is Paul Ballard, Deputy Director of Public Health of NHS Tayside. He has been heavily involved in the drive to embed co-production within all areas of work, including the design and implementation of a new Health Equity Strategy. This will imply a much stronger focus on asset-based approaches and behaviour change: As Paul states, “… during this process I have extensively used the Co-production Star which has proved to be an excellent resource to support our co-production work”.

Co-production offers a financial solution

Not only is there a moral case for co-production, there is also a financial case.  If we were to reshape the health service, so that it had a whole range of support for patient groups, peer to peer support, alternatives to medical care, new forms of medical consultation, and other co-produced forms of health and well-being, we could realise savings of at least £4.4 billion or 7% of the NHS budget.  This doesn’t always require the most expensive medicines, equipment or buildings. But it does require the public and professionals to show the will to re-think and re-imagine what the future of health care looks like. 

If you are interested in exploring how to think creatively about how to bring together clinicians and patients to co-produce healthier outcomes check out our co-production case studies and do get in touch.

 

 

Ajay Khandelwal, Associate, Governance International 
Email: Ajay.Khandelwal@govint.org

 

 

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