The G8 Dementia Summit in London in December 2013 has raised awareness of the dementia challenge and the need to take action. In fact, East Dunbartonshire (with about 100,000 inhabitants) to the north of Glasgow had already started to deal with the dementia challenge in 2010.

East Dunbartonshire is the Scottish local authority with the highest proportion of older people. Some 21% of the local population are over 60 years old, and this is rising sharply; moreover, the population aged over 75 years is set to increase by 71% by 2024. There are currently an estimated 2,020 people living with dementia in East Dunbartonshire. 

Faced with two huge costs - the human cost and the budget costs - we all must find better solutions to the dementia challenge.

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.

Co-production of public services is firmly on the agenda of government at state and national level in Australia. As in other countries, this has partly been a matter of imitating developments elsewhere. But the distinctive characteristics of Australian society and geography have also shaped the nature and extent of co-production, prompting original initiatives in many cases, while limiting the possibilities in others.

First, its relatively small population spread over a very large area – 6^th in land area, but only 52^nd in population – combined with its remoteness from other developed countries, mean the ‘tyranny of distance’ looms large.

Secondly, its relatively small population is concentrated mainly in capital cities (64%), with 89% of its total population living in urban areas. Drought plays a large part in the lives of many rural Australians, as roughly 75% of the country is classified as arid or semi-arid. Much of Australia’s Indigenous population also inhabits remote or very remote areas, meaning some of its most socioeconomically disadvantaged people live the furthest from public service hubs.

These characteristics call for innovative policies, to address not only the problems of high-density urban living, but also the difficulties of delivering effective services to the relative minority living in remote and very remote areas. Community organisations play a particularly important role in remote Australia.

Co-production by another name?

The factors above have historically prompted major developments which can clearly be seen as co-production, but have not been labelled explicitly as such. A classic example is the Victorian Country Fire Authority, where a corps of ~58,000 volunteers, of whom 35,000 are trained as fire-fighters, works with a small core group of paid 1,400 paid fire service employees. This is the only practical way to economically provide fire services to Victoria’s vast outback. Similar arrangements exist in the other states, and there are many examples in other services, such as hospital services, court administration, or aged care.

Growing interest in co-production

Now, co-production is more explicitly on the Australian political agenda. Citizen engagement, consultation, co-design and co-delivery are terms to be found in many high-level strategy documents, and are championed by senior public servants such as two (former) Secretaries of the Department of Prime Minister and Cabinet – Terry Moran and Peter Shergold – and head of the NSW Department of Premier and Cabinet Chris Eccles.

The 2007 Australian Public Service Blueprint, championed by Moran, recommended “enable[ing] citizens to collaborate with government in policy and service design”. There was a much publicised 2020 Summit in 2008 to draw citizens into a consultative and advisory process to assist the government to identify priorities and shape policies. Then in 2010 the Australian Government made a Declaration of Open Government, stating that “Citizen collaboration in policy and service delivery design will enhance the processes of government and improve the outcomes sought. Collaboration with citizens is to be enabled and encouraged”.

However, rhetoric is not always reality, and some commentators have noted a cultural adherence to the notion of the state as provider; the instrumentalism of government providing services to grateful citizens. Shergold notes that the NGO sector is “a raucous cacophony of organisational innovation”, and while community organisations are more crucial than ever to the delivery of human services for governments, the relationship between the public and community sectors is “mired” in the rhetoric of outsourcing.

Co-design and co-delivery in Australia

Other Australian agencies also have long-standing traditions of engaging their clients to carry out parts of their production processes – for example, the Australian Taxation Office introduced client self-assessment in the early 1990s, freeing up a large part of its resources for auditing and assistance purposes. Around the same time, many agencies began revising their service processes to make it easier for their clients to contribute information or effort to delivering the service, for example, by pre-printing renewal forms for vehicle registration.

More recently, there has been increased emphasis on co-design and consultation. The Family by Family program in South Australia is a strong example of both co-design and co-delivery. Developed by The Australian Centre for Social Innovation in conjunction with the SA Government, it is a mentoring program in which a network of families helps other families to grow and change together. It began as a collaborative project, asking the question “how can we enable more families to thrive, and fewer families to come into contact with crisis services?”

The shape of the program was strongly influenced by the consulted families, who gravitated toward the idea that struggling families would benefit immensely from support and mentoring from other families. The team realised that some families could be described as ‘positive deviants’ – they thrive despite socio-economic and other disadvantages. These ‘sharing families’ are trained and supported to link up with families who want things to improve (‘seeking families’), and through behavioural modelling, seeking families can make fundamental changes in the way they ‘do family’.

Everyone thinks innovation is great, everyone thinks working with the public is great. But how do you actually get this to happen? My colleague Tom Hoy has shown how it’s possible. Check out the next Made in Lambeth weekend make-a-thon to see how he’s helping create an alliance against violence, stopping pay day loans, and creating a brand identity for a local Brixton paper. Made in Lambeth now gets people from across the local community contributing and doing stuff. Most of the work is done in an amazing 48 hours.

But what about creating change within the council? Recent research in the sector has shown that the majority of council officers think innovation is one of the answers, but feel pace is far too slow.

So what can you do? Do you need to spend millions on branding, fancy buildings, and lots of experts? Do you need to launch more initiatives? I’m sure that could help. However, in Lambeth, we’ve gone back to basics. We’ve shared our ideas about what really seems to create a buzz on the ground. We’ve look at what captures our imaginations. Some of it is rational, some of it unexpected.

My colleagues Giles Gibson and Sue Sheehan have been baking delicious cakes. Sue is famous for her lemon drizzle, and Giles for his chocolate brownies. I have been pouring the tea. We find that it’s enough to get people talking and coming up with ideas and plans. We’ve also found that many of our colleagues love baking, and we have been able to capitalise on this tradition of sharing.

We decided the most important thing was talking to people, listening to their ideas, and giving them practical support. Money was rarely a barrier to coming up with ideas. Instead of using external designers, we found an artist amongst our council colleagues, and we designed our own promotional materials and worksheets. We produced all of these within seven days, from start to finish. Get in touch if you want to see what we came up with.

We have a letter from our Chief Executive Derrick Anderson, supporting each team to see what they can do over 30 days over the month of October. The idea is to help people try something new. We know that there is too little risk taking, too little experimentation and sometimes people need explicit support to try something new. We now have a dozen teams, with ideas ranging from re-launching an unused kitchen in the town hall, to involving residents in carrying out environmental inspections in their neighbourhoods, to growing and sharing vegetables in GP surgeries. We are supporting them in overcoming any barriers they encounter. At the same time, we are developing an in-house school of innovation, based on creating networks within the organisation, and working with local residents.

But we are not spending money on new buildings, or fancy prizes. We are working on the basis that people enjoy collaborating to solve challenges, and make life better. We find a little piece of cake and a cup of tea can go a long way.

This blog has been written by Governance International Associate Ajay Khandelwal, email: Ajay.Khandelwal@govint.org

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.