Co-producción en los Servicios Públicos. Un nuevo acuerdo con los ciudadanos
-
Upload
diseno-de-servicios -
Category
Documents
-
view
222 -
download
0
Transcript of Co-producción en los Servicios Públicos. Un nuevo acuerdo con los ciudadanos
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
1/72
This is a discussion paper. It is not a statement of government policy
Co-production in public services:a new partnership with citizens
Matthew Horne and Tom Shirley
March 2009
The Strategy Unit
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
2/72
2
Contents
Executive Summary
Introduction
What does co-production mean?
How important is co-production and what are the potential gains? How could co-production in public services be accelerated?
Background Analysis
Annex A: Examples of programmes which foster co-production
Annex B: Individual Budgets and Budget Holding Lead Professionals
Annex C: Measuring the quality of relationships and encouraging peer support
This is a discussion paper. It is not a statement of government policy
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
3/72
3
What does co-
production mean?
Co-production is a partnership between citizens and public servicesto achieve a valued outcome. Such partnerships empower citizens tocontribute more of their own resources (time, will power, expertiseand effort) and have greater control over service decisions and
resources
How important is co-
production and what
are the potential gains?
We argue that co-production should be central to the Governmentsagenda for improving public services because of emerging evidenceof its impact on outcomes and value of money, its potential economicand social value and its popularity
How could co-
production in public
services be
accelerated?
Rather than simply replicating specific co-production practices, such asapproaches to working with patients or learners, we argue thataccelerating co-production rests some more structural changes to:budgets, with more control passed down to individual users and front-lineprofessionals support for civic society and mutual help performanceregimes and professional training and culture.
This is a discussion paper. It is not a statement of government policy
Executive Summary
This paper provides an introduction to co-production in public services what itmeans, why it is important and how it can be accelerated
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
4/724
Executive summary:
1. What does co-production mean?
This paper considers how individuals and communities should address a number of emergingchallenges, such as the rise of chronic health conditions and the need for supporting youngpeoples emotional development.
We argue that co-production - a partnership between citizens and public services to achieve avalued outcome is essential to meeting a number of these challenges, for neither government norcitizens have access to all the resources necessary to solve these problems on their own
This approach is distinct from other traditional responses:
Voluntarism
Managerialism Paternalism
Co-production
We propose that effective partnerships are based on four clear values: a) everyone has something tocontribute b) reciprocity is important c) social relationships matter d) social contributions (rather thanfinancial contributions) are encouraged
Such partnerships empower citizens to contribute their own resources (time, will power, expertise andeffort) and give them greater control over public resources to achieve outcomes.
This is a discussion paper. It is not a statement of government policy
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
5/725
Executive Summary:
2. How important is co-production and what are the potential
gains?
There are already many examples of co-production in practice - including Nurse FamilyPartnerships, Family Intervention Projects, Family Learning, Restorative Justice, Time Banks andYouth Courts.
Compared to other European countries, UK citizens are also relatively involved in working withservices.
But the question remains as to whether such partnerships will characterise more mainstream publicservices in the future.
The evidence suggests that in many instances it should:
i. Co-production often improves outcomes evidence shows that interventions that adoptthis approach have a big impact on outcomes.
ii. The public frequently want to be more active partners the public want to be moreinvolved when public services relate directly to them and their family we usuallyunderestimate peoples willingness to help others.
iii. The value citizens can contribute is significant the scale and value of the resources thatthe public contribute is enormous families and communities generate a huge amount ofeconomic value that is unmeasured and unrecognised by public services.
iv. Co-production often improves value for money evidence also shows that the economicbenefits of co-production approaches outweigh the costs.
We also find that co-production is not appropriate in every public service. We suggest the greatestpotential benefits are in relational services such as early years, education long term healthconditions, adult social care and mental health, rather than transactional services.
This is a discussion paper. It is not a statement of government policy
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
6/726
Executive summary:
3. How could co-production in public service be accelerated?
Choice and control- give citizens greater control
over resources
Peer Support- empower citizens tosupport one another
Consider extending individual budgets and budget holding leadprofessionals to more areas
Empower people to better support each other, with new rights forgroups of service users2
1
Incentivise partnerships- through performance
management
Give greater weight to the quality of partnerships between staff andservice users in performance management frameworks
3
This is a discussion paper. It is not a statement of government policy
Professional Culture- ensure professionals value
citizen contributions
Involve more service users in professional training, staffrecruitment, and inspection and support local leaders to driveculture change
4
We propose that the way to mainstream co-production is not primarily to spread specificprogrammes, but to change the nature of budgeting, relationships with civil society, performancemanagement and professional cultures. We suggest some specific measures.
These recommendations would need to be part of wider reforms to empower citizens, foster a newprofessionalism and provide more strategic role for government, particularly giving citizens betterinformation, involving citizens more directly in policy making and commissioning for long term outcomes.
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
7/72
7
Contents
Executive Summary
Introduction
What does co-production mean?
How important is co-production and what are the potential gains? How could co-production in public services be accelerated?
Background Analysis
Annex A: Examples of programmes which foster co-production
Annex B: Individual Budgets and Budget Holding Lead Professionals
Annex C: Measuring the quality of relationships and encouraging peer support
This is a discussion paper. It is not a statement of government policy
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
8/72
8
There are a number of complex social problems facing individuals and
communities
Chronic disease affecting17.5m people, 80% of all GPvisits3
Child wellbeing
obesity almost doubledin 10 years, affecting children1
Anti-social behaviour cost 3.9bn pa2
Choice and control>1m users of social care
(1) Health Survey for England 2004. Updating of trend tables to include childhood obesity data, DH, 2006 (2) The one day count of anti-social behaviour, Home Office, 2003 (3) Boyle D,et al, Life begins at 60: What kind of NHS after 2008? The Young Foundation, 2008
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
9/72
9
It is both undesirable and too costly forgovernment to substitute the resources that
really only citizens can contribute such asbringing up children
Our hypothesis is that neither government nor citizens have
access to all the necessary resources to tackle these problems on
their own
Citizens own resources Knowledge, skill and understanding
Energy, time and effort
Will power and personal agency
Motivations and aspirations
Social relationships within families and
communities
Governments resources Money
Rules and regulation
Expert knowledge and skills
Energy, time and labour of public servicesprofessionals
Leadership, expectations and aspirations
Solutions to these
problems require a newrelationship between
citizens and government
that mobilises more of the
resources necessary to
achieving better
outcomes
The resourcesneeded to tackle
these problems aredistributed between
government andcitizens
Currently, citizens have
little control over theresources that
government provides,and are rarelyencouraged to
contribute their ownresources
This is a discussion paper. It is not a statement of government policy
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
10/72
10
Bringing these resources together in a partnership - co-production
- represents a distinct approach from traditional responses to
social problems: voluntarism, paternalism or managerialism
Voluntarism achieved by rolling back thestate reducing entitlements, cutting publicprovision and encouraging families,communities and the third sector to fill thevacuum
Managerialism achieved using a carrot andstick approach to incentives for both providersand citizens: discouraging and rewardingdifferent behaviours e.g. paying citizens to livehealthily, or targets for providers to involve
service users
Paternalism achieved through theprofessional gift model of services. Doctors,nurses, teachers, social workers etc. treatingcitizens as recipients of services by handingdown knowledge and expertise in a top-down
way, rather than by building partnerships
Co-production establishing a partnershipbetween citizens and government to tackle asocial problem. Citizens contribute moreresources to achieving an outcome, sharemore responsibility and manage more risk inreturn for much greater control over resourcesand decisions
This paper investigates co-production what it means, why it is important and howit can be accelerated through public services
This is a discussion paper. It is not a statement of government policy
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
11/72
11
Contents
Executive Summary
Introduction
What does co-production mean?
How important is co-production and what are the potential gains? How could co-production in public services be accelerated?
Background Analysis
Annex A: Examples of programmes which foster co-production
Annex B: Individual Budgets and Budget Holding Lead Professionals
Annex C: Measuring the quality of relationships and encouraging peer support
This is a discussion paper. It is not a statement of government policy
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
12/72
12
Co-production is a partnership between citizens and public
services to achieve a valued outcome.1 The most effective
partnership are based on four clear values2
1. Everyone has something to contribute
Everyone has something to contribute, even thoughsome have more resources than others
2. Reciprocity is important
Two way mutual relationships where responsibility,risk and power is shared and decisions are negotiated
3. Social relationships matter
Social networks, especially families and communities,are vital for achieving some types of change
4. Social contributions are encouraged
Recognise the unpriced and often unvalued work offamilies and communities, not just people's financial
contributions
e.g. Parents and grandparentshave resources which the statecannot substitute. These
contributions are recognised andfostered
e.g. Home School Agreementsset out the rights and
responsibilities of both familiesand schools
e.g. Taking-a-Stand recognisesthe commitment and energy of
people who improve theircommunities
e.g. Peer support networksencourage support and sharing of
expertise for example:Netmums.com and Expert Patient
Programmes
(1) Here we define a partnership as a relationship characterised by mutual co-operation and sh ared responsibility for the achievement of a valued goal (2) This values model is based on theanalysis set out in Cahn, E. No More throw away people, 2000
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
13/72
13
Surveys suggest that co-production is moderately higher in the UK
than other countries and that many people believe their contribution
can make a difference
How much do people believe they can make a
difference in improving community safety, the
local environment and health?
Index of belief in making a difference
64
70
71
77
79
0 100
Germany
Czech Republic
France
United Kingdom
Denmark
None Maximum
An EU survey shows people in the UK are more likely to believe that they can make adifference to public outcomes through doing more themselves.1 The same survey showsthat levels of involvement in public services is highest in the UK
Levels of citizen participation in
public services in EU countries
Index of co-production
48
51
52
53
56
0 100
Denmark
France
Czech Republic
Germany
United Kingdom
None Maximum(1) Loffer, et al., If you want to go fast, walk alone. If you want to go far walk together: citizens and the co-production of public services, October 2008
Equivalent to 56%
saying they oftenget involved
This is a discussion paper. It is not a statement of government policy
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
14/72
14
There are also many innovative projects that exemplify more
intense forms of co-production in practice. However, they are
limited in scope and number
Family Nurse
Partnerships
Self directed support and
individual budgets
Family Intervention Projects
Support for young mothers duringpregnancy and until the child is 2 Continuity of relationship Builds on mothers strengths Shared goals and aspirations Clear focus on taking responsibility
Devolves power over decisions andresources to the citizen Person centred planning Shared goals and outcomes Accountability direct to the citizen
Sustained trusting relationship with persistentkey worker Explicit contract of rights and responsibilities Whole family approach Building capacity of family Strengths based approach
This is a discussion paper. It is not a statement of government policy
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
15/72
15
Contents
Executive Summary
Introduction
What does co-production mean?
How important is co-production and what are the potential gains? How could co-production in public services be accelerated?
Background Analysis
Annex A: Examples of programmes which foster co-production
Annex B: Individual Budgets and Budget Holding Lead Professionals
Annex C: Measuring the quality of relationships and encouraging peer support
This is a discussion paper. It is not a statement of government policy
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
16/72
16
We argue that co-production should be central to the Governments
agenda for improving public services
Our analysis has considered whether government should build on the moderatelyhigh rates of citizen involvement in services and innovative co-productive approaches(set out in the previous section) and make strengthening partnerships between servicesand users a more central part of public service reform strategies.
We suggest there are four reasons co-production should have a more significantrole in the delivery of mainstream public services:
a) Co-production often improves outcomes evidence shows thatinterventions that adopt this approach have a big impact on outcomes
b) The public frequently want to be partners the public want to be moreinvolved when public services relate directly to them and their family weusually underestimate peoples willingness to help others
c) The value citizens contribute is significant the scale and value of the
resources that the public contribute is enormous families and communitiesgenerate a huge amount of economic value that is currently unmeasured andunrecognised by public services
d) Co-production can improve value for money evidence also shows thatthe economic benefits of co-production approaches outweigh the costs
This is a discussion paper. It is not a statement of government policy
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
17/72
17
Across a number of sectors there is relatively robust evidence that
enabling citizens to work in partnership with professionals and to
do more for themselves improves outcomes
Self-care by
patients
Peer and self
assessment
by learners
Support with
parenting
Involving
parents
in education
Students managing their own learning can improveexam results by the same amount as reducing class-sizes by one third2
Self care programmes for long term health conditionscan:1
Reduce visits to GPs by up to 69% Reduce hospital admissions by up to 50% More than pay for themselves through savings
Sustained interventions with parents can improve childand parent outcomes. Positive evaluations include: 48% reduction in abuse and neglect
59% reduction in arrests (61% for parents)
3
Every $1 spent saving $4.25 in lower crime alone4
High levels of parental involvement can produce a 24%increase in exam results5
(1) Self Care Support: The Evidence Pack, DH, 2007 (2) Does Assessment Hinder Learning? William, D., presentation to ETS 11 July 2006 (3) For further details of the three randomisedcontrol trials in the US visit http://www.nursefamilypartnership.org (4) Supporting Parents Why it matters, Home Office, 2007 (5) Desforges, C. The Impact of Parental Involvement,Parental Support and Family Education on Pupil Achievements and Adjustment: A Literature Review, DCSF, 2003
Training can reduce GP visits,while user groups can have apositive impact on individuals
sense of personal strength,improved inter-personalrelations and alleviating
depression
The OECD/CERI reports thisis a powerful means ofmeeting goals for high-
performance, high-equitystudent outcomes, and for
providing students withknowledge and skills for
lifelong learning
Successful co-productionprogrammes work through
partnerships betweenprofessionals and citizens
combined with clearexpectations and conditionality
http://www.nursefamilypartnership.org/ -
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
18/72
18
Surveys indicate that a high proportion of patients and parents
want to be treated as partners and want to do more for themselves
90%+ patients interested inbeing more active self carers1
50% patients said not oftenencouraged by professionals to
do self care1
33% patients said they hadnever been encouraged byprofessionals to do self care1
43% said the NHS could domore to support self care1
65% of parents would like to bemore involved in their childsschool life3
This is a discussion paper. It is not a statement of government policy
-5
5
15
25
35
45
55
Primary Care
2006
Inpatient
2006
Mental
Health 2006
Stroke 2004 Emergency
2004
Outpatients
2004
CHD
People often find themselves less involved
in services than they would likeProportion of patients feeling uninvolved in decisions2 (%)
%
(1) Self Care Support: The Evidence Pack, DH, 2007 (2) Picker Institute (3) Parental Involvement in Childrens Education, DCSF, 2007
A t t i ifi t b f l
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
19/72
19
A recent survey suggests a significant number of people are
willing to spend more time each week and month improving their
health, neighbourhood and environment
How much more time are citizens willing to spend in
different sectors?
About how much time are you willing to spend
to . . .
0 10 20 30 40 50 60 70 80 90 100
improve your local environment
make your neighborhood safer
improve your health/health care
Percent
Few hours a wee k Few hours a month Few hours a year No time at all
An EU survey shows that largenumbers of citizens are willing tospend more time trying improve theirhealth, neighbourhood andenvironment.1 Taking these threeareas together:
28% willing to spend a fewhours more per week
43% are prepared to spend afew more hours per month
only 29% indicate that theyare not willing to spend any
time at all
(1) Loffler et al., If you want to go fast, walk alone. If you want to go far walk together: citizens and the co-production of public services, October 2008
This is a discussion paper. It is not a statement of government policy
Thi l f d th t iti i th UK lik l t
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
20/72
20
This survey also found that citizens in the UK are more likely to
participate in groups that improve their health, environment and
neighbourhood
Levels of regular participation in community
safety, local environmental and health
organisations/groups across countries
How often do you participate in a group or organisation that
works to improve ...
0
2
4
6
8
10
12
14
16
Total France Ge rmany UK Cze ch Denmark
Percen
t"Often
"
Safety
Environment
Health
An EU survey shows that citizenparticipation in groups andorganisations that encourage apartnership between citizens andpublic services is highest in the
UK1
Particularly encouraging are thehigher than average participation inhealth focused civic groups suchas exercise groups, weightwatchers, alcoholics anonymous
and community safety groups suchas residents associations, tenantsgroups and neighbourhood watch
(1) Loffler et al., If you want to go fast, walk alone. If you want to go far walk together: citizens and the co-production of public services, October 2008
This is a discussion paper. It is not a statement of government policy
Citizens want increased choice control and involvement in public
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
21/72
21
Citizens want increased choice, control and involvement in public
services, but often not a supermarket style experience. Rather, a
partnership with professionals appears much more important
Citizens want to be empowered they
value choice, control and involvement1But citizens want public services to be
different from normal retail/supermarket
experiences2
High quality relationships in public services are premised on everyone having something tocontribute and enhancing citizen choice and control. The aim is not to mimic a supermarket
style experience
I like to makechoices myself I like to have expertsmake choices for me
50% ofthe public
3% of thepublic
2% of thepublic
31% of thepublic
13% of thepublic
Which two of the following aspects of serviceare most important in each of the following
situations? Publicservices
Supermarket
Quality of advice/knowledge of
staff
Respect and professionalism
Speed of service
Friendliness of service
64% 34%
39% 13%
30% 60%
30% 60%
(1) Opinion poll data on choice see Real Trends- Living in Britain 2008, Ipsos MORI, 2008 (2) Real Trends- Living in Britain 2008, Ipsos MORI, 2008
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
22/72
22
The value of peoples contributions suggests a potential for extensive
partnerships between professionals and citizens
17.5m patients withLTC1
High levels of selfcare and publicengagement in
health could saveNHS: 30bn pa2
1m+ use social care3
Proportion of people over 85expected to treble4
Informal care worth: 87bn5
7.5m families and
13m childrenChildcare providedby households worth:
220bn6
(1) Improving LTCs across NE London www.nelondon.nhs.uk (2) Wanless Review, HMT 2002 (3) Wanless Social Care Review, Kings Fund (2006) (4) ONS Pop. projections Govt.Actuary's Department (5) Valuing Carers calculating the value of unpaid care, Carers UK & Leeds University 2007 (6) http://www.statistics.gov.uk/hhsa/hhsa/Section225.html ONSestimate of unpaid work by households
http://www.statistics.gov.uk/hhsa/hhsa/Section225.htmlhttp://www.nelondon.nhs.uk/ -
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
23/72
23
And evaluations indicate that a number of examples of co-
production can deliver better value for money
Early interventions for families and
young people at risk of social exclusion
reduce the cost of crime1
% reduction in crime rate for different programmes in US
0 5 10 15 20
Adolescent Diversion Project
Family Integrated Transitions
Functional Family Therapy
Multisystemic Therapy
Juvenile Education Programmes
Nurse Family Partnership
%
Self care programmes in health
produce benefits that outweigh the
costs2
(1) Washington State Institute for Public Policy, 2006 (2) Research Evidence on effectiveness of self care support, DH, 2007
This is a discussion paper. It is not a statement of government policy
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
24/72
24
Contents
Executive Summary
Introduction
What does co-production mean?
How important is co-production and what are the potential gains? How could co-production in public services be accelerated?
Background Analysis
Annex A: Examples of programmes which foster co-production
Annex B: Individual Budgets and Budget Holding Lead Professionals
Annex C: Measuring the quality of relationships and encouraging peer support
This is a discussion paper. It is not a statement of government policy
Co-production is not appropriate in every public service We suggest
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
25/72
25
Co-production is not appropriate in every public service. We suggest
the greatest potential benefits are in relational services where the
benefits outweigh the risks
Risksofco-production
Bene
fitsofco-p
roduction
Value of professional expertise
Transactional
Services the risks
and the benefits tendto be lower
RelationalServices the
benefits outweighthe risks
Acute Services the risks outweigh
the benefits
Examples include: early years,
education, long term health
conditions, adult social care,
mental health, and parenting
This is a discussion paper. It is not a statement of government policy
In relational services, co-production can deliver the largest benefits
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
26/72
26
There is no single solution to theseproblems. The best approach willvary from person to person
In relational services, co production can deliver the largest benefits
where the social issues are chronic and complex, and the solutions are
contested
Chronic Complex
Contested
The resources that citizens contribute affect outcomescumulatively over longer time, not immediately leading many people to discount future benefits
They are caused by multiple-factors thatinteract in complex ways
1. Citizens control the necessary resources tosolve it they are abundant, but they cannot besubstituted. They are non-market goods
2. The benefits gained from citizens contributingresources outweighs any increased risk fromsharing responsibility
Co-production should only be applied to social problems when:
Social problems that meet these criteria tend to have the following characteristics:
This is a discussion paper. It is not a statement of government policy
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
27/72
27
Creates higher
demand for
preventative
services
Even where co-production is appropriate, there remain some risks
and limitations
Providers have
less control
Citizens
contribute more
resources to
tackling a
problem
Citizens have
more control
Citizens and
public services
work bettertogether
Giving citizens more controlover resources reduces theeffectiveness of traditionalcost control. New ways ofenabling public to control
costs are needed
Reduces
demand for
curative services
Those with most
resources will be
able to give the
most
Hidden costs in
the system
become more
transparent
Waste and failure becomesmore transparent
encouraging more riskmanagement, more
responsiveness and fasterlearning and evaluation
Effective partnerships could mean
better progress towards long termoutcomes, and lower demand forcurative services: hospitals, care
homes, CJS etc
IB pilots in adult social care
indicates there are benefitsfrom giving greater control
to service users1
Partnership working createsbetter relationships and
better experiences for thepublic and for professionals2
Risksand
Limitations
Potential
be
nefits
Equity can be threatened where peoplehave unequal levels of resources to
contribute. Co-production is also limitedwhere citizens lack capacity e.g. dementia
or where there are large knowledgeasymmetries e.g. pharmacy
(1) IBSEN Evaluation of Individual Budgets in Social Care: Final Report, 2008 (2) Evidence indicates that the public want professionalism, respect and knowledgeable staff in public services(all of which can arise through partnership working), the public do not want a supermarket style experience. See Real Trends- Living in Britain 2008, Ipsos MORI, 2008
We have therefore looked at a number of examples of co-production
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
28/72
28
e a e t e e o e oo ed at a u be o e a p es o co p oduct o
in practice that provide insight into how best it could be accelerated
further
1. Health
2. Social
Care
3. Education
4. Work
5. Crime
Personal Budgets and personalisationIndependent Living Strategy
Employment & Retention Advancement PilotsPathways to work
Anti-social behaviour strategyFamily Intervention Projects
Obesity pilots - incentivise healthy livingExpert Patient Programme - courses on self managementLong Term Conditions Whole System Demonstrator Pilots
Family Learning programmes, Nurse Family PartnershipsParental support advisors providing 1-2-1 help
This is a discussion paper. It is not a statement of government policy
The conclusion of our analysis of specific programmes is that effective
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
29/72
29
y p p g
co-production requires some fundamental changes to relationships,
professional roles and the management of services
Nurse-Family Partnerships
Nurse-Family Partnerships involve trained nursesvisiting first-time young mothers throughoutpregnancy and the first two years of a childs life.
An important lesson from projects is that the asustained personal partnership is essential to
success, based on trust, a clear understanding ofrespective responsibilities and a key worker withability to co-ordinate the work of various services.
The Expert Patient Programme
The programme is six week course for people withchronic or long-term conditions, designed to help themself manage their health. The course is delivered bytrained and accredited tutors who are also living with along term health condition.
An important lesson from the programme is that peers,with similar conditions, can play a strong role inencouraging and supporting co-production.
Individual Budgets in Social Care
Users are given significant control over the use ofbudgets.
An important lesson is that devolving control overbudgets can be very empowering for users, lead toradical changes in the delivery of services andpromote culture change in service professions.
Home-school agreements and other
contracts
Home-school agreements and other, more tailored
contracts such as Acceptable Behaviour Contacts,have had some success.
An important lesson is the importance of clarifying theexpectations of service users and service providers.
Annex A sets out information on these and other programmes in more detail
Based on our analysis of these case studies and the research
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
30/72
30
y
evidence on behaviour and culture change, we propose four ways of
accelerating co-production in public services1
(1) See Achieving Culture Change, Cabinet Office, 2008 (2) Co-production will not grow without large scale cultural change led by professionals. However, we make less detailedsuggestions in this area and do not provide an annex, reflecting our primary focus on citizen empowerment.
This is a discussion paper. It is not a statement of government policy
Choice and control- give citizens greater control
over resources
Peer Support- empower citizens tosupport one another
Consider extending individual budgets and budget holding leadprofessionals to more areas
Empower people to better support each other, with new rights forgroups of service users
2
1
Incentivise partnerships- through performance
management
Give greater weight to the quality of partnerships between staff andservice users in performance management frameworks
3
Professional Culture- ensure professionals value
citizen contributions
Involve more service users in professional training, staffrecruitment, and inspection and support local leaders to drive
culture change
4
These recommendations would need to be part of wider reforms to empower citizens, foster a newprofessionalism and provide more strategic role for government, particularly giving citizens betterinformation, involving citizens more directly in policy making and commissioning for long term outcomes.
Consider extending individual budgets to further specific funding1
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
31/72
31
Community
g g g
streams and explore the development of budget holding lead
professionals
(1) See: Unlocking the Imagination, Duffy, S., 1996 and, Transformational Care in Oldham, Maybury, B. and Rolfe, A., 2008 and The Keys to Citizenship, Duffy, S., 2005
Citizen
Professional GovernmentContributionvia taxation
Entitlementto funding
Negotiationof service
Individual Budgets change the oldprofessional gift model of services, whereprofessionals assess citizens needs,determine eligibility, ration resources andcontrol services. They create instead a newcitizenship model1 for commissioning serviceswith public money.
This is a discussion document. Not a statement of Government policy
Budget Holding Lead Professionals have been pilotedin childrens services. Lead professionals are given a
budget to commission services and procure goodsdirectly from providers, to build a service package for
core groups of children and families
Budget Holding Lead Professionals can successfullycommission a range of services from providers in a joined
up way, so as to best meet an individuals needs
Evidence from practice in childrens services, suggests that the leadprofessional role is a key element of effective frontline delivery ofintegrated services. It ensures that professional involvement isrationalised, coordinated and communicated effectively1
Budget holding lead professionals can enable a speedier, morepersonalised and more effective response to meeting an individualsadditional needs2
Overall, Budget Holding Lead Professional models can yield manyof the benefits of Individual Budgets:
1. Increasing opportunities for preventative spending byimproving coordination of services to secure the best long termoutcomes2. Strengthening relationships between professionals and usersto provide opportunities for service users to contribute their ownknowledge and understanding of what will work
Analysis
Analysis
Consider extending individual budgets to further specific funding1
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
32/72
32
RecommendationsConsider extending individual budgets to further
specific funding streams
For example, consider integrating NHS funding forcontinuing care, social care, and mental health care
Explore the development of budget holding lead
professionals, particularly where individual budgetsare not possible
For example, explore integrating offendermanagement, employment services, education,
housing support, and drug and alcohol servicesthrough a budget holding lead professional model
(See Annex A for more details)
Enhance user controland sense ofresponsibility
g g p g
streams and explore the development of budget holding lead
professionals
Improve
coordination ofservices
Improve serviceresponsiveness
Users do nothave the capacityto make decisions
Professional attitudeshinder improvement
A viable supply sidedoes not develop
Increased expenditureduring transition period
Loss of financialcontrol or predictability
Drive professionalculture change
Increase opportunitiesfor preventative
spending
Analysis
It is essential to weigh the benefits and risks ofdevolving more control over resources
To minimise the risks, individual budgets should be piloted
through identification of appropriate funding streams (orelements of funding streams)Careful consideration of the different needs of distinctgroups of users (e.g. older people) will be required1
Individual budgets are a valuable way of giving users ofpublic services more choice and control over their everydaylives2
(1) IBSEN Evaluation of Individual Budget Pilots in Social Care: Final Report , 2008 (2) Bartlett, J., Leadbeater, C., Gallagher, N., Making it Personal, Demos, 2008
1
This is a discussion paper. It is not a statement of government policy
Empower people to better support each other with new rights for2
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
33/72
33
Analysis
What is peer support? Peer support groups of patients, parents, carers, andvictims empower citizens to participate more fully inpublic services. Evidence shows increases inconfidence, self efficacy, and wellbeing and that groupsare cost effective1
Peer support provides the practical advice andemotional support that only peers can provide. Peer
support also provides social capital to isolated orvulnerable groups
Peer support is provided by a range of voluntary andcommunity organisations from national charities likeAlzheimer's Society and small community groups, user-controlled organsiations and user networks
Empower people to better support each other, with new rights for
groups of service users
(1) See National Evaluation of the pilot phase of the Expert Patient Programme, DH, 2006
Former Patients(experience and
knowledge)
Family carers(Emotional supportand practical help)
Friends andneighbours
(practical help)
Volunteers(practical help and
education)
Patient and Carers group(Social support, advice and
recommendations)
Online network of patients
(encouragement andknowledge)
Patient receiving care from GP, communitynurse and social care team
Increasingly, health and social care staff work with a
network of support and care from family, friends, peers
and the community
2
This is a discussion paper. It is not a statement of government policy
Empower people to better support each other with new rights for
2
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
34/72
34
Empower people to better support each other, with new rights for
groups of service users
Online peer support groups are often unable tocapitalise on the volume of traffic to central andlocal government websites
Local grant funding is low, insecure and lackstransparency2
Frontline workers are well placed to set up peersupport networks for service users but they are notempowered or incentivised to do so1
Public service providers do not always encouragecitizens to participate in service user organisations1
No easy or reliable access to facilities for meetings,admin etc.
The extent to which local authorities recognise andengage with peer support organisations variesgreatly
Key problems for peer support groups
(1) Finding of workshops with parents, carers, and users of social care (2) Denmark provides an alternative approach to grant funding for User Associations.
Recommendations
Empower people to better support each
other, with new rights for groups of
service users including the right to:
use commissioners and providers rooms and
facilities for meetings (or cash for private hire) apply for local grant funding based on simplecriteria and number of members
publicity by local services and on governmentwebsites
auto-enrolment or auto referral for patients,carers and service users (with an opt out)
request a budget for staff in public serviceswho set up and run peer support groups flexible working for staff who volunteer to run
peer support groups official recognition by commissioners
(See Annex B for more details)
2
2
This is a discussion paper. It is not a statement of government policy
Give greater weight to the quality of partnerships between staff and3
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
35/72
35
g g q y p p
service users in performance management frameworks
RecommendationGive greater weight to the quality of
partnerships between staff and service
users in performance management
frameworks
adopt a principles-based approach toregulating the quality of relationships between
staff and citizens (rather than a compliancemodel). This would involve service providersreporting against high-level principles relatingto the quality of these relationships, such astrust, dignity and respect, rather than justshallow indicators of customer satisfaction
benchmark perception data relating to citizens
real, local and recent experiences to driveimproved performance
develop self-evaluation tools to measure thequality of relationships between front line staffand service users(See Annex B for more details)
This is a discussion paper not a statement of Government policy
High Quality Partnerships
NegotiatedMutual
recognition of whatboth sides have to offer, and
joint negotiation of goalsand plans
Trust-basedTrust is both a product ofhigh quality relationships
and essential for their maintenance.
ReciprocalGive and
take on both sides, aa sense of mutuality
and we are in thistogether
Citizen Professional
Partnerships
Partnerships between service users and professionals ensure thatproviders are more accountable to citizens andincrease the
commitment of citizens own resources to achieving outcomes
3
Involve citizens in professional training staff recruitment and4
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
36/72
36
Involve citizens in professional training, staff recruitment, and
inspection and support local leaders to drive culture change
AnalysisCo-production requires a culture change whereby
professionals consistently encourage citizen
empowerment and seek partnerships with service
users that share responsibility
Citizen empowerment has big implications for professionals.It fundamentally changes the power dynamic between the
public and professionals that may have been in place forgenerations
Culture change within the professions requires visionaryleadership and changes to professional training, recruitment,and performance management. Innovative practice in health,education and social care suggests that higher levels ofservice user involvement in these area makes a difference1.There is an opportunity to empower citizens to help define the
new professionalism set out in Excellence and Fairness
Partnerships between the public and professionals placegreater value on new skills: advice, brokerage and support.Self-Directed Support advisors in social care or ParentSupport workers in schools provide personalised support andwork in partnership with service users and their families
Recommendation
Involve citizens in professional training, staff
recruitment, and inspection and support local
leaders to drive culture change
4
Involving service users in training the workforce shouldbe encouraged further. In social care, progress in this
area could be accelerated by focusing on improving thequality of provision Service users should be involved systematically in staff
recruitment, performance management, and inspection.For example Experts by Experience could be extendedinto new areas
New professional roles that provide highly skilledadvice, brokerage and key worker support to citizensshould be supported and encouraged e.g. Learning
Mentors, Self-directed support advisors and a range ofPersonal Advisors in different sectors In education, Parents Councils and Students Councils
could be more systematically involved in feedback tostaff, research, school self-evaluation, budgeting anddeveloping a vision for the organisation
(1) See Experts by Experience www.csci.org.uk, and Involving Services Users in Social Work Training on the Reality of Family Poverty in Social Work Education,Volume 27, Issue 5 August 2008 , pages 459 - 473
Our recommendations would need to be part of wider reforms on
citizen empowerment professionalism and a more strategic role for
http://www.informaworld.com/smpp/title~content=t713447070~db=all~tab=issueslist~branches=27http://www.informaworld.com/smpp/title~content=t713447070~db=allhttp://www.csci.org.uk/ -
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
37/72
37
citizen empowerment, professionalism and a more strategic role for
government set out in Excellence and fairness and Working Together1
Supporting citizen decision making with betterinformation
Empowering citizens requires not only greateraccess to information but the power to use it andre-use in ways that professionals do not control,and officials could not imagine.
Commissioning long term outcomes Public
service commissioning that is able to trulycommission long term outcomes rather than shortterm outputs or service activity is much more likelyto create the incentivise professionals to work inpartnership with users and co-produce betteroutcomes to chronic, complex and contestedissues
A strategy for incubating local innovationWorking in partnership with citizens andempowering them to contribute more of their ownresources is often incompatible with a top downapproach to reforming public services. Localinnovation that involves citizens in the wayservices are designed and delivered is much morelikely to generate co-production in practice
Involving citizens in policy makingThe leading examples of co-production in practice (e.g. theexpert patient programme, direct payments, time banks,participative budgeting) did not originate from policy makers,think tanks or governments but were first set up by citizenswho then campaigned (for many years) for government toadopt their ideas. Systematically involving the citizens in thepolicy making process from defining the problem, generatingideas and implementing solutions - is likely to lead to muchgreater co-production in public services
(1) Excellence and fairness: achieving world class public services, Cabinet Office, 2008 Working together- Public services on your side, Cabinet Office 2009This is a discussion paper. It is not a statement of government policy
Contents
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
38/72
38
Contents
Executive Summary
Introduction
What does co-production mean?
How important is co-production and what are the potential gains?
How could co-production in public services be accelerated?
Background Analysis
Annex A: Examples of programmes which foster co-production
Annex B: Individual Budgets and Budget Holding Lead Professionals
Annex C: Measuring the quality of relationships and encouraging peer support
This is a discussion paper. It is not a statement of government policy
Annex A: Examples of programmes which foster co production
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
39/72
39
Annex A: Examples of programmes which foster co-production
Nurse-Family Partnerships a strengths based approach, with a
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
40/72
40
sustained partnership between nurse and young mother at its heart
Description: Nurse-Family Partnerships involve trained nurses visiting first-time young mothers throughout pregnancy and thefirst two years of a childs life. They usually offer a combination of health advice and support (e.g. around breastfeeding, childhoodillnesses), practical support and coaching (e.g. life skills) and addressing psychological issues (e.g. motivational interviewing)
Key characteristics of the
partnership Intimacy and continuity building trust Aligning the goals and aspirations of thenurse and family Building on the persons strengths andprevious successes towards improved selfefficacy Establishing a sense of responsibility in theindividual Clear structure and understanding of whatthe programme entails Having highly skilled professional nurseshave skills for the nurse and individual todeal with anxiety and stress
Target Group:Currently offered to first time mothers who are under 20. Current Scope:Over 1000 clients are currentlyenrolled on the programme in ten sites, with plans to expand this to 20 sites by 2009 (as set out in the Youth Crime Action Plan,2008). Expansion after 2009 will depend on successful implementation in the first 30 sites
Evidence The model was developed in the US where it has been rigorously testedover the course of 27 years Three random controlled trials have been conducted in the US. Theprogram had positive impacts on pre-natal behaviours improvedpregnancy and birth outcomes led to more sensitive and competent careof child reduced child abuse and mortality improved outcomes for theparent and, importantly, benefits were still evident when the child was 15
The nurse-family partnership is offered in 20 American states, and itserves more than 20,000 families annually. The programme costs about$8,000 per family for two and a half years support. However, economic
evaluation by the Rand Corp. shows a payback to the public purse of fourtimes its cost.
The partnership topped WAVEs evaluation system and wasrecommended by the Sure Start review, the Blueprint programme, Supportfrom the Start and Communities that Care
Moving Forward:If the programme is shown to be successful it is hoped that 50% of PCTs/LAs will operate the programme by2011. A key challenge will be mainstreaming and sustaining the nurse-family partnership if the pilot proves successful
Sources: www.nursefamilypartnership.org Billingham, K.. The Family Nurse Partnership Programme, Cabinet Office Seminar, 2007
This is a discussion paper. It is not a statement of government policy
The Expert Patient Programme peer support that enables patients to
http://www.nursefamilypartnership.org/ -
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
41/72
41
contribute their expertise to one another
Description:A six week course for people with chronic or long-term conditions. The course is delivered by trained and
accredited tutors who are also living with a long term health condition. It aims to give people the confidence to take moreresponsibility and self-manage their health, while encouraging them to work collaboratively with health and social careprofessionals. Course topics include healthy eating, dealing with pain and extreme tiredness, relaxation techniques and copingwith feelings of depression
Key characteristics Peer support provided by patients ishighly valued
Tutors need to be trained andaccredited to provide patient education
Encouraging personal responsibilityand self efficacy
Reinforces current good self
management
Target Group:17.5 m people living with long term health challenges including 8.5 m with Arthritis 3.4m with asthma, 1.5mdoctor-diagnosed cases of diabetes in the UK, 80-90k people with Multiple Sclerosis (MS)
EvidenceCourse questionnaires showed Outpatient visits decreased by 10%, A&Eattendances decreased by 16%, Pharmacy visits increased by 18%
However, the external evaluation found no reduction in use of primary orcommunity care. This RCT found that course participants have:
Gains in patient self-efficacy and energy
Improved quality of life and psychological wellbeing for patients, high levels ofsatisfaction, improved partnerships with doctors, reduced isolation and
increased confidence to manage their condition Reduced inpatient/day case hospital costs making EPP cost effective
Moving Forward:Delivered to 30,000 people already with plans to grow from 12k pa to 100k pa by 2012. New course forcarers and specific conditions. Current group of patients tend to be white middle class and well educated who volunteer to
attend, want to learn and are motivated to help others.
Sources: National Evaluation of the pilot phase of the Expert Patient Programme, DH, 2006
This is a discussion paper. It is not a statement of government policy
Budget holding lead professionals- integrates resources, enables
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
42/72
42
greater personalisation, involves people in commissioning decisions
Description:Similar to personal budgets, budget holding lead professionals allow money, and decisions over how money is
spent, to be devolved to the lowest level possible. Budget holding lead professionals are used where professional intervention isrequired to effectively deploy resources
Key characteristics The role can be taken on by a wide range ofpractitioners, as the skills, competence and knowledgerequired to carry out the role are similar regardless ofprofessional background The amounts of money allocated by the leadprofessional varies. The amount spent is determined onbasis of need e.g. from small sums, for example, 1.50for a bus ticket, to 1,000 for a package of counsellingsessions The lead professional liaises very closely with serviceuser, the family and professionals to allocate resourceseffectively
Target Group:Service users who cannot be granted their own personal budget (e.g. because of age/vulnerability) can havea lead professional coordinate resources and services on their behalf
Current Scope: There have been 16 local authority pilots of budget-holding lead professionals in childrens services.Emerging reports are very positive (full evaluation due in Autumn 2008)
Evidence
Evidence from practice in childrens services, suggests thatthe lead professional role is a key element of effectivefrontline delivery of integrated services.
It ensures that professional involvement is rationalised,coordinated and communicated effectively
Budget holding lead professionals can enable a speedier,
more personalised and more effective response to meeting anindividuals additional needs
Moving Forward: There are proposals to use budget-holding lead professionals in drug treatment services. Their use inchildrens services could be accelerated. There is also potential for their use in resettlement and rehabilitation services
Sources: What is a Lead Professional? DCSF, 2005 Realising the potential efficiency gains from budget holding lead professionals, OPM, 2007
This is a discussion paper. It is not a statement of government policy
Family Intervention Projects- a whole family approach, driven by a
partnership with a strong persistent and assertive key worker
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
43/72
43
partnership with a strong, persistent and assertive key worker,
backed up by an explicit contract of mutual responsibilities
Description:FIPs is an intensive whole family approach to reducing ASB. It provides an out reach service,accommodation in the community and 24-hour monitored residential accommodation for chaotic families. At the heart of it isa relationship between the whole family and a key worker backed up by a contract with sanctions.
Key characteristics Key worker with persistence and assertiveness A contract with the family establishing areciprocal relationship not letting down my keyworker Clear sanctions linked to tenancy Practical learning about routine and structuresof daily living Whole family approach
Encouraging authoritative parenting Establishing trust and listenin Needs highly skilled, highly motivated staff
Target Group:targeted at families exhibiting anti-social behaviour, focused on those who are at risk of loosing theirhousing tenancy or children being taken into care
Evidence
Evidence comes from the evaluation of Dundee FIPs and aSheffield Hallam evaluation of six projects in the North West. Theyfound that 85% of existing participants had reduced or ceased theirASB and the risk of homelessness and family breakdown haddeclined1
Projects cost 8k - 15k per family. Estimates of cost savings
suggested that FIPs saved money by replacing demand for otherservices, although the evidence on cost/benefits and long-term impactis not as robust
Moving Forward:There are currently 53 FIPS that have helped around 500 families. Further money has been earmarkedfor expansion and we aim to support around 1,500 families a year
Sources: Impact Assessment of the Youth Crime Action Plan, Home Office/Department for Children, Schools and Families, Ministry of Justice, 2008
This is a discussion paper. It is not a statement of government policy
Contracts of rights and responsibilities establishes reciprocity,
i h l ib d i
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
44/72
44
recognises what people can contribute and sets expectations
Description:Voluntary mutual agreements are already in use. They set out behaviour expectations and can be used to tackle
crime/anti-social behaviour e.g. Acceptable Behaviour Contracts and Parenting Contracts. But, they can also be used to outlinerights and responsibilities in mainstream services such as health, education and social care
Key characteristics of
mutual agreements
Explicit: Clear aims andexpectations on both sides
Shared understandings:Making the agreement leads toshared understandings of roles
and solutions
Social pressure: The partiesshould have a good relationship
with one another so there issocial pressure to meet theagreed expectations (avoid
losing face)
Sanctions: They cansometimes be effectively
backed up by harder sanctions
Target Groups: Wherever more than one person needs to contribute something to achieving an agreed aim. They are mostpowerful where they are made on a 1-2-1 basis with regular contact between the parties e.g. in social care
Evidence
ABCs and Parenting Orders affect individualsbehaviour. 65% do not engage in further anti-
social behaviour after an ABC intervention
Home-school agreements can contribute toschool effectiveness by enhancing relationshipsbetween parents and teachers
Research evidence points to the value ofparenting contracts and orders. It will benecessary to support parents through access toadditional services, such as mental healthservices
The Royal College of General Practitionersargues that general practice achieves the bestpossible outcomes for each particular individualby negotiating an individual care plan with thepatient that makes sense to them, their socialcircumstances and enables them to share theresponsibility for treatment
ABCs are written, voluntaryagreements between a young
person, housing services/school andthe police. The young person agrees
not to carry agreed anti socialbehaviours
Home-school agreements foster apartnership between parents andschools. The agreement clarifies
what the school is trying toachieve and sets out the role ofthe school, parents and pupils
Parenting contracts are negotiatedbetween a YOT worker and theparents of a child involved in
criminal or anti-social behaviour.Parents either work voluntarily withthe YOT or a parenting order can
be put in place. Both parentingcontracts and orders have a
statutory basis
Sources: Think Family literature, Cabinet Office Impact Assessment of the Youth Crime Action Plan, Home Office, Department for Children, Schools and Families, Ministry of Justice,2008 http://www.standards.dfes.gov.uk/parentalinvolvement/hsa/
This is a discussion paper. It is not a statement of government policy
Individual Budgets in social care control over resources and
decisions empowers disabled people, and leads to greater
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
45/72
45
decisions empowers disabled people, and leads to greater
personalisation
Description:Personal budgets are one vehicle for devolving money and decisions over how money is spent to citizens. Other,
closely related, models for devolving more money/power to citizens include budget-holding lead professionals andcollective/community budgets (e.g. Youth Opportunity Fund)
Key characteristics of personal budgets
Devolution to individuals of power over how to putresources to use
Mechanism for promoting professional culture change indirection of making services person-centred
Alternative to a market-based model (e.g. a vouchersystem) which constructs individuals as consumers andwhich are not necessarily person-centred (e.g. servicesseek profitable outcomes/respond to aggregate demand)
Numerous potential benefits include:
increased personalisation of services increased user control better coordination of services improved services for vulnerable groups improved value for money
Target Group:Analyses indicates that personal budgets are useful where citizens have the capacity to make decisions abouthow to allocate resources when their needs can be objectively assessed and where there are a range of available options as tohow a budget may be spent. Even if these three criteria are met it will be necessary to apply broader public resource criteriawhich specify that personal budgets must not undermine equity, efficiency, or the public goods of servicesCurrent Scope:Personal budgets have been piloted in social care services
Emerging Evidence
Evidence collected across 17 local authorities shows that 72% ofbudget holders say they have more choice and control over theirlives than previously, and that 63% say they take part in andcontribute to their communities more when on self-directed support
Early results from a small pilot run by In Control involving 6 localauthorities demonstrate cost savings of between 12% and 67%
Mental health patients in Florida, using personal budgets,reported significant rises in their sense of being respected by those
around them. Budget holders were able to combine traditionalclinical care with non-clinical services such as educational courses,so as to address all facets of their mental health. Moreover, thepercentage of users who felt able to participate in the communityrose from around 30% to nearly 80%
Moving Forward: There are ongoing discussions about where to extend personal budgets. Initial analysis suggests potentialareas for their use include NHS services such as maternity, mental health and LTC services, specialist education services, and
independent living for disabled people
Sources: IBSEN Evaluation of Individual Budget Pilots in Social Care: Final Report Florida Peer Network Bartlett, Leadbeater and Gallagher (2008) Making it Personal, Demos
This is a discussion paper. It is not a statement of government policy
Annex B: Individual Budgets and Budget Holding Lead
P f i l
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
46/72
46
Professionals
This is a discussion document. Not a statement of Government policy
The Government has already made relevant announcements and
undertaken pilots of individual budgets across a wide variety of
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
47/72
47
undertaken pilots of individual budgets across a wide variety of
policy areas
NHS
Programmes
Services for
disabled
children
DrugTreatment
Recent commitment in NHS Next
Stage Review to explore and pilotuse of personal budgets in the NHS
A public consultation has beenfollowed by DCSF
commissioning a scoping studyfor the development of pilots
The 2008 Drug Strategy refers tothe piloting and more effective useof new approaches such as IBs
Social CarePilots have been followed by acommitment to the rolling out
of personal budgets
Users want to and are able to commission theirown care package according to their own needs,
within the constraints of the individual budget
There could be varying rationalesdepending on the service. Example services:
LTC management, Continuing Careand mental health services
If professionals hold a (notional) budget then therewill be better coordination of services/personalinterventions and prevention will be incentivised
Families with disabled children want toand are able to have choice and control
over the funding and services they receive
Education
and
Skills
DISU/Learning and Skills Councilsare piloting Adult Learner Accounts
Adults want and need to be able to select theeducation and skills services relevant to them. To
avoid misuse an accreditation system will be used
Stage of DevelopmentPolicy Area Rationale
This is not intended to bean exhaustive list
This is a discussion document. Not a statement of Government policy
Individual budgets are embedded in a new citizenship model of
public services through which citizens are empowered as members
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
48/72
48
Community
p g p
of the community1
It is useful to distinguish between the professional gift model and the citizenship
model of public services1
Services arenegotiated
between the
professionaland thecitizen
Citizens who are entitled tofunding are recognised as
members of the community notjust recipients of public services
(1) See: Unlocking the Imagination, Duffy, S., 1996 and, Transformational Care in Oldham, Maybury, B. and Rolfe, A., 2008 and The Keys to Citizenship, Duffy, S., 2005
The old professional gift model1
Community
Government
Professional
Person inNeed
Contribution
via taxation
Funding forservices
Assessmentand support
Citizen
Professional GovernmentContributionvia taxation
Entitlementto funding
Negotiationof service
The new citizenship model1 for
individual budget funding systems
This is a discussion paper. It is not a statement of government policy
A key characteristic of both individual budgets and budget holding
lead professionals is the devolution of control to the lowest possible
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
49/72
49
level
Services users are consumers in the marketplace they do not commission services
Service users and/or professionalshave commissioning role
Budget/fundsman
agedby
State/professional
Budget
/fundin
gmanaged
byserviceuser
Per capita
fundinge.g. of
hospitals/schools
Budget
holding lead
professionals
Individual
budgetse.g. in specialist
services
Mass
voucher
systems
e.g. for masseducation
Key Characteristics of individual budgetsand budget holding lead professionals
Per capita funding and mass voucher systemsaim to give service users more choice bymaking them consumers in a marketplace
Individual budgets and budget holding leadprofessionals mechanisms empower front line
professionals and service users by giving thema commissioning role, not just through moreconsumer choice
Budget holding lead professionals hold andmanage an allocated budget (this gives thefreedom and flexibility to front line professionalto coordinate services around the service user)
where the service user is unable to do so
Both individual budgets and budget holdinglead professionals achieve high levels ofpersonalisation Budget holding lead professionals control
and manage a budget where individual
service users are unable to do so
This is a discussion paper. It is not a statement of government policy
Areas where the benefits of individual budgets are likely to be
strong can be identified using three basic criteria
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
50/72
50
strong can be identified using three basic criteria
Where these are in place there is good reason to consider whether
individual budgets or budget holding lead professionals should be introduced
Individuals have unique and valuable resources (e.g. knowledge of theirhealth condition and their needs and individual motivation) that are noteasily substituted by professionals/the state
Citizens have
valuable
resources
Alternative
provision is
possible
There are genuine alternatives as to how an individuals needs are met
which give rise to a set of ongoing decisions that have to be made
Private Goods
and PublicGoods are
aligned
There is a significant degree of compatibility between the private good
outcomes of the service and the public good (i.e. the public goods of theservice and the public good in general) e.g. adult social care, aspects ofhealth care, crime prevention/offender management
This is a discussion paper. It is not a statement of government policy
There are clear benefits that can be derived from the introduction of
individual budgets
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
51/72
51
Increase user
control and
sense of
responsibility
individual budgets
Improve service
responsiveness
Increase
opportunities for
preventative
spending
Improve
coordination of
services
Citizens
involved in
policy
development
A study of self-directed care reports
that personal budgetscan help people meet
their distinctive andpersonal needs3
Evidence collected across 17 localauthorities indicated 72% of budgetholders said they had more choice
and control over their lives3. Theevaluation of IB pilots also found that
all user groups reported increasedlevels of control1
Services centred
on good
outcomes for
users
Drive
professional
culture change
Secure good
outcomes for
individuals with
complex needs
Budget holding lead professionals cancoordinate services around an individualsneeds and build a strong relationship with
service users and their families. Evidence fromwork with children and families4 indicates thiswill help secure good outcomes, especially for
individuals with complex needs
Mental health service in Florida used their IBto access services not traditionally provided inclinical care models, with good outcomes. The
number of patients who participated in theircommunity rose from around 30% to nearly
80%2
The IB pilots in adult social care involved
identifying funding streams for integration.Initial findings indicate some LocalAuthorities are keen to integrate fundingmore quickly than national government1
Communities of service
users contribute to thedevelopment of InControlinitiatives and the pilot
schemes
(1) IBSEN Evaluation of Individual Budget Pilots in Social Care: Final Report (2) Florida Peer Network (3) Bartlett, Leadbeater and Gallagher (2008) Making it Personal, Demos (4)For example, pilots of budget holding lead professionals in childrens services family intervention projects and family-nurse partnerships
The decision on whether to develop individual budgets will involve
weighing up the benefits with a set of potential risks
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
52/72
52
weighing up the benefits with a set of potential risks
Individuals do not
have the capacity
Professional
attitudes
or culture hinder
improvement
Needs assessment
is ineffective/
inefficient
A viable supply
side does
not develop
Increased
expenditure during
transition
period
Benefits of collective
consumption
are undermined
Funding is used
fraudulently
Loss of financial
control
or predictability
It may be very challenging
to objectively andtransparently assessindividuals needs making it difficult to
devise robust, transparentand joined-up resource
allocation systems
Variations in individual capacity could lead to
significant variations in quality of servicesindividuals receive with implications for equityof service provision. Importantly, individuals will
be able to top-up their service provisiondepending on their access to financial resources
Efficiencies that come fromeconomies of scale of
collective provision and thespin offs from collectiveconsumption could be
undermined
Alternatives will not berealisable unless a viablesupply side is established
within which users canmake decisions on whichservices to commission
Increased awareness of
entitlements and demand forfunding could necessitateincreased expenditure. In
addition, double running (overthe short or long term) would
lead to increased pressures onexpenditure
In some service areas
(e.g. mental health, andprovision of employmentservices for individuals
with learning disabilities)professional culture
change will be needed torealise benefits of IBs
Political risks
Shifting funding from provision ofcollective services to IBs is likely to
lead to changes in demand etc.,which will require the cessation ofsome services this is likely to beunpopular with some service users(e.g. closure of day care centres)
Service users
exposed to
increased risk
This is a discussion paper. It is not a statement of government policy
In reaching a decision on whether to move forward it will also be
important to consider the potential to mitigate some or all of the
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
53/72
53
relevant risks (1)
Risk Risk mitigation strategies
1. Clear guidance for potential and actual suppliers2. Evolutionary development of regulation of supply side, with ongoing evaluations of itsdevelopment feeding into changes in regulation (e.g. lowering/raising barriers to entry)
A viable
supply side
does not develop
Loss of financial
control or
predictability
1. Sound financial management, including top-slicing global budgets for collective commissioningof preventative and social capital (e.g. peer support) services and for contingency funds
2. Careful piloting with ongoing process of learning the lessons of previous pilots3. Resource allocation systems may need to be redesigned comprehensively to integrate needsassessments and to better predict/control expenditure
Professional
attitudes orculture hinder
improvement
1. Professional training and support alongside introduction of these funding systems
2. Mechanisms to compensate for professional attitudes e.g. ring fencing specific funding streamsto ensure it is used to benefit the service user in the best way
Individuals do not
have the capacity
1. Establish systems of guidance, support and advice for budget holders, including professionaladvice, as well as peer support (e.g. building social capital)2. Carefully consider the different needs of distinct groups of users (e.g. older people)
1
3
4
5
Increased
expenditure
during transitionperiod
2
This is a discussion paper. It is not a statement of government policy
1. Shift funding away from provision of collective services to individual budgets on a fundingstream by funding stream basis (or at least elements of funding streams) to ensure there is not
inefficient double running (where collectively commissioned services run simultaneously withIBs)
In reaching a decision on whether to move forward it will also be
important to consider the potential to mitigate some or all of the
l t i k (2)
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
54/72
54
relevant risks (2)
Benefits of
collective
consumption are
undermined
1. Top-slice budgets to continue to fund collective provision to maintain positive externalities2. Do not move to funding systems to individual budgets where loss of benefits of collectiveconsumption (including economies of scale) is likely to undermine quality or provision of services
Funding is used
fraudulently
1. Locate most likely source of fraud (e.g. providers/budget holders etc) and design preventionsystem (e.g. Learner Accounts pilots are using an accreditation model for providers)2. Carefully define what constitutes fraud so that the decisions ofcommissioners are assessed against standard and predictable criteria
Needs assessment
is ineffective/
inefficient
1. Sound advice on transparent and robust, but not overly rigorous, systems of needs assessment,accounting and audit will be required (e.g. Audit Commission is beginning to provide guidance onthis)
2. Professional training and culture change, so that users needs are assessed in a way thatrecognises the users own contribution
Political risks
Service users
exposed to
increased risk
1. Consultation with service users through which the likely consequences of a shift to individualbudgets are clearly presented and discussed2. Piloting of new systems in areas where there is political will and professional capacity to makethe systemic changes required
1. Development of good quality relationships between professionals and service users and soundprocedures to underpin that relationships, while simultaneously encouraging peer support2. Supply side systems (e.g. an accreditation system) to minimise risks
Risk Risk mitigation strategies
This is a discussion document. Not a statement of Government policy
6
7
8
9
10
If the risks of service users holding an individual budget are
considered too great, then budget holding lead professionals should
b id d lt ti
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
55/72
55
be considered as an alternative
Individuals do not
have the capacity
Funding is used
fraudulently
Loss of financial
control
or predictability
Service users
exposed to
increased risk
Budget holding lead professionals manage and control an individual budget drawn from
a variety of different funding streams. This mitigates some of the risks of service usersholding a budget themselves, but many benefits will still be reaped
Budget holding lead professionals mitigate some of the risks arising from individual budgets
Where individuals are unable orunwilling to manage and control abudget themselves budget holding
lead professionals can be used
Professionals will manage the individual budgetwithin professional and institutional governancestructures making loss of financial safeguards
and fraud far easier to prevent and to rectify
Professionals have farmore control and the final
say on commissioningdecisions
Budget holding lead professional models reap many of the benefits of individual budgets
Improve service
responsiveness1
Improve
coordination
of services2
Preventative
spending
Services
centred on
good outcomes
for users
Strengthen
relationships
between
professionals
and users
(1) Budget holding lead professionals can enable a speedier, more personalised and more effective response to meeting an individuals additional needs (Realising the potential efficiency
gains from budget holding lead professionals, OPM, 2007) (2) Evidence from practice in childrens services, suggests that the lead professional role is a key element of effective frontlinedelivery of integrated services. It ensures that professional involvement is rationalised, coordinated and communicated effectively (What is a Lead Professional? DCSF, 2005)
We have drawn up a long list of areas where individual budgets and
budget holding lead professionals could be introduced. This led us to
consider which services could become gateways
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
56/72
56
consider which services could become gateways
Adultsocial care
Offendermanagement
Independentliving for
disabled people 16-18 educationand skills and
learner support
Housingservices
Employmentservices
Specialeducational
needs
Drug
treatment
Adult educationand skills
Maternityservices
Family andparenting
support
Mental healthservices
NHS continuingcare
Young peopleexcluded
from mainstreameducation
Public services often need to work together to meet an individuals distinct personal
needs. Bringing funding together within an individual budget (sometimes controlled by abudget holding lead professional) can improve joining up of these services
The links indicate where servicesshould ideally work together to
meet an individuals needs
Management ofLong term health
conditions
Blue circles represent potential gateways that is, services that should ideally work with
many other services
This is a discussion paper not a statement of Government policy
Consider extending individual budgets to further specific funding
streams and explore the development of budget holding lead
professionals
-
8/9/2019 Co-produccin en los Servicios Pblicos. Un nuevo acuerdo con los ciudadanos
57/72
57
Community
professionals
(1) See: Unlocking the Imagination, Duffy, S., 1996 and, Transformational Care in Oldham, Maybury, B. and Rolfe, A., 2008 and The Keys to Citizenship, Duffy, S., 2005
Citizen
Professional GovernmentContributionvia taxation