Principle 4
Focus on early intervention now to save costs tomorrow
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Jessica Studdert

Deputy Director, New Local Government Network

Traditional models of public service provision were invented in different times to address different challenges. As such, the state-led or market-driven approaches of the past are simply not set up to enable us to move away from crisis mitigation towards early intervention and prevention.

So now we need to make a decisive shift to the community: to mobilise the strengths that exist locally, and harness them in the name of early intervention and prevention. Under this new “Community Paradigm”, public services would be designed and delivered by and with communities themselves.

 

The logic behind the concepts of early intervention and prevention is undeniable. Why wouldn’t we want our public services to intervene in good time to stop problems escalating? Or better yet, to avoid them occurring in the first place?

It stands to reason that this would be both more cost-efficient for the state and better for the individual. But the reality is that our system of social support is set up to incentivise precisely the opposite: crisis reaction and mitigation. Its basic architecture, and the external pressures bearing down on it, create strong systemic incentives to only step in at a crisis stage, and only address people’s problems once they are fully manifested.

Yet there are shifts underway. In our recent report, The Community Paradigm, co-authored with Adam Lent, we set out the innovative approaches that are working in new ways to make early intervention and prevention a reality. These are built on an understanding that to achieve this, services cannot “do to” people. Rather, they must work with them as equal partners to take more responsibility. Making this responsibility meaningful requires shifting power and resource out of public service institutions and into the hands of the communities directly.

But traditional models of public service provision are not capable of doing this – the present system is trapped in previous paradigms. The State Paradigm, which emerged in the post-war period to standardise and universalise support, established a hierarchical system of services led from Whitehall, which persists to this day. It is based on the belief that professionals and bureaucrats know best, with provision reflecting these expert silos, while service users are regarded as passive recipients of treatment and care.

The Market Paradigm emerged in the 1980s to challenge the inefficiencies of a state-led approach. Although it didn’t dismantle the fundamental architecture of public provision, it did inject new dynamics. Public services largely came to be designed and delivered to work like business transactions. The service user came to be seen more as a customer capable of exercising a degree of choice, albeit from a narrow range of provider options.

These two paradigms dominate the institutions, mindsets and behaviours of public services today. But they emerged to address very different challenges to the main pressure that is overwhelming public services today – that of rising demand. As a result, their innate characteristics compound current problems rather than resolve them, as they are proving incapable of adapting to new realities. This is why we call for a paradigm shift towards the community.

The picture of rising demand is complex. The last decade of austerity has created intense financial pressures across all public services. Within these general pressures, services supporting the most vulnerable – like social care – have had disproportionately greater cuts than mainstream services like healthcare. This has created a vicious cycle of higher thresholds for care and support, which in turn has created more pressure on the acute end, as problems not addressed early enough escalate. People are therefore forced to turn to the universal option of last resort: the hospital.

There is a case for a new Community Paradigm now to fully emerge which is capable of mobilising existing assets and capabilities that exist in people and their networks, and harnessing them in the name of early intervention and prevention.

Yet the demand challenge is deeper than a policy issue. Demographic changes are fuelling underlying demand pressures – we are living longer, and many of us with one or more long term conditions. As a result, many people increasingly require support to self-manage their care and live independently, rather than needing clinical treatment.

Demand is also growing due to complexity. For example, the gap in healthy life expectancy is 19 years between the most and least deprived areas. Unless the system is capable of adapting to provide early intervention and prevention, these unresolved problems create pressures on the crisis, acute end of the system. Perversely, this in turn makes the system less able to reform and shift the centre of gravity outside existing public service institutions.

The characteristics of previous paradigms are incapable of sharing power with people directly. The State Paradigm encourages institutions to hoard power, prizing as it does their expert capability over the wisdom of the individual. State Paradigm practice precludes public servants from developing the egalitarian relationships with people that would empower them to take on more responsibility for resolving their own problems. Given its preference for expert-designed and delivered provision, it has a blind spot when it comes to understanding how to mobilise the capacity of individuals and their wider networks of support in the pursuit of early intervention and prevention.

Meanwhile the logic of the Market Paradigm leads to ever-increasing scale for efficiencies, driving down unit costs and attaching them to easily definable actions on the part of the provider. This approach is ill-equipped to deal with complexity, as it encourages a narrow view of what constitutes success. It is not capable of early intervention since the problem that that a provider might prevent escalating cannot be easily quantified. Attempts to remedy this through payment by results contracts, for example, create perverse incentives to game the system or only deal with the simplest cases.

Taken together, the State and Market paradigms reinforce an overall approach which “does to” rather than “works with” people. There is a compelling case for a new Community Paradigm now to fully emerge which is capable of mobilising existing assets and capabilities that exist in people and their networks, and harnessing them in the name of early intervention and prevention. Under the Community Paradigm, public services would be designed and delivered by and with communities themselves, sharing power with individuals recognised as active and equal collaborators with professionals. The key shift from previous paradigms, to make this responsibility real, would be to take power and resource out of public service institutions and place it into the hands of people themselves.

In many pioneering areas and organisations, this power shift is already underway. The Wigan Deal is an informal agreement between the council and the community to work together to make it a better borough. One of the initiatives to give this commitment teeth is The Deal for Communities Investment Fund, which committed £10 million over five years to groups and projects working towards improving outcomes for local residents. Calderdale Council has a major commitment to community asset transfer and supports community groups to take on council-owned buildings or land if they would be of wider community value.

The shift is occurring in specialist services too. In Bradford, funding from the NHS and local government was diverted to the voluntary sector organisation the Cellar Trust, to run mental health recovery services. The frontline is staffed entirely by peer workers so people who use the service are supported by people with first-hand experience of mental health problems and recovery. Professional specialist staff such as nurse practitioners are available should they be needed, but rather than leading assessments, they are patched in as appropriate.

So how could we draw on these examples of emerging innovation to inform a deeper paradigm shift towards the community? The function of commissioning is an area ripe for reform and provides a route to creating this shift in practice.

Place-based budgets which pooled resources between separate services would be more capable of aligning the risk and reward of investment in early intervention.

Currently, when deciding on what basis to provide services, commissioners are bound by two options: to make or to buy. The State Paradigm response is to make – in other words power and resources are in the hands of the state. The Market Paradigm response is to buy – which transfers power and resources to the private sector.

Under the Community Paradigm, commissioners would pursue a third option: to communitise. This would involve a process of transferring power and resource into the hands of communities. So, for example, could drug and alcohol recovery budgets be handed over entirely to a local network of recovering addicts and their families to design appropriate support? Could a neighbourhood work together to decide how public health funds would best be used?

Whereas traditional services are only capable of doing everything or doing nothing, handing more of a role over to communities themselves presents the opportunity to operate within the largely untapped ecosystem in between – of local networks, existing social capital and community activity. In practice this means bringing in people and groups to directly design and deliver support – which may or may not take the form of a service – to participate in shared deliberative processes and to form self-governing networks. It also implies a very different role and skillset for the public servant – of enabler and facilitator rather than direct provider. This presents the opportunity of “keeping it local” – shifting power and resource out of public service institutions, to enable communities themselves to develop ownership of problems and routes to resolving them determined by, and befitting the assets of, their members and localities.

Yet presently the wider financial and regulatory system militates against commissioners thinking small and local in this way. On one level, in a time of budget cuts, a focus on costs is inevitable. But austerity aside, the financial framework of separate services accountable to different Whitehall departments is set up to reinforce organisational silos and the territorial grip of institutions. Place-based budgets which pooled resources between separate services would be more capable of aligning the risk and reward of investment in early intervention. They would also take a long-term view of resource in the round, which is necessary for prevention to make financial sense. The current short-term approach to cost control within separate service budgets creates deep accounting blind spots to the amount of money wasted on crisis interventions across the system. Such devolved collective budgets would also create an opportunity for commissioners to be more radical with their purchasing power to make it work with, rather than bypass the existing capacities and assets of people and places.

A deep shift along the lines of the Community Paradigm is now required to embed early intervention and prevention, and effectively stem rising demand. Traditional models of public service provision, invented in previous eras to address different challenges are simply not set up to enable the collaborative approach required for early intervention and prevention. As long as these paradigms persist, innovative new approaches will only ever occur at the edges of the present system. They will always be operating outside of its prevailing logic and against the strong systemic financial and organisational incentives towards the status quo. A deeper paradigm shift needs to overhaul practice, culture and mindsets of existing institutions – and hand real power and control over to communities themselves.

 

Keep it Local is brought to you in partnership with Lloyds Bank Foundation for England and Wales which specialises in funding small, locally based charities tackling complex social problems.

Case Study
Cambridgeshire’s Neighbourhood Cares Pilot