Increasingly we are on our own. As the government promises us further austerity targeted at the most disadvantaged, we are are also to get greater devolution (see Local Solutions for a Healthy Nation and The Local Health Service?). It is therefore our responsibility to ensure stronger collaborations between services and most importantly with citizens.
We know that we need to integrate services – not just across health and social care – but more widely in order to address the social determinants of health
One of the biggest challenges we face is that the organisational cultures and behaviours we have been trained to use work against co-production with citizens, integrated service delivery and shared responsibility.
A key part of this are the performance management systems that all statutory agencies work within and that define the relationship (through contracts) that statutory funders have with local voluntary organisations.
One of the most eloquent critiques of the deficit of current performance management approaches comes from Toby Lowe – who has worked for many years in the voluntary sector in Newcastle but is now an academic at the University of Newcastle.
In essence Toby argues that the performance management system we use starts from simplistic definitions of the outcome that is desired (which has to be measurable) and then works back to identify actions that will produce that measurable outcome.
He argues this can lead to actions that:
- don’t address the real problem
- gaming to achieve targets
- reclassifying what counts as success (see recent government changes to Child Poverty measures)
- Making up the figures
(You can listen to Toby run through a more detailed account of his work here)
I would go further and say that this approach also:
- Pushes agencies to only worry about their targets rather than taking a shared responsibility for the wellbeing of communities. So, hospitals worry about their performance targets but don’t take responsibility for what happens to people once they are discharged back to the community.
- Takes attention away from the strategic and pushes it towards the operational. So, in the health world we often spend time at the highest strategic level on performance measures that focus on tiny operational failings such as trolley waits or failures to hit 4 hour targets in A&E while at the same time we devote less time to real strategic issues such as the relevance or quality of whole services or the reduced life expectancy of whole communities.
In this new devolved world we have the responsibility, incentive and opportunity to develop a local performance management system that is better than the bean counting Westminster driven system.
The work that I have been doing recently as part of my work at Leeds Beckett University offers some solutions. We have been working with Health Watch England to develop a common approach to helping local Healthwatch and their stakeholders understand whether they are effective or not.
This has involved developing a set of Quality Statements which we have produced through working with over 40 local Healthwatch. The Quality Statements cover the range of local Healthwatch activities from the operational to the strategic.
The idea is to use them to create a platform where local stakeholders who have some responsibility for making Healthwatch work can have a shared dialogue about the effectiveness of their local Healthwatch.
The aim is to move away from trying to measure impact and instead trust the expert opinions of a range of stakeholders who work with and are affected by local Healthwatch.
We think that responsibility for local Healthwatch does not just rest with Healthwatch or with the local authority commissioners but with a range of other stakeholders (we are not prescriptive here because local circumstances vary) but they are likely to include:
- The Healthwatch Board
- A range of local authority officers – not just the contract managers
- Members of the Health and Wellbeing Board
- Healthwatch staff
- Local Voluntary Organisations
- Advocacy Agencies
The approach we have trialled involves using confidential questionnaires sent to individuals from the above groups followed by a facilitated discussion based on the survey.
Early trials have been positive. It provides for a collaborative discussion about effectiveness and impact and as importantly a recognition that there is a shared responsibility for the Healthwatch function – which is ultimately about using citizen experience and knowledge to improve health and wellbeing.
I think that this sort of approach has a much broader application. It could be used with other key services – for example General Practice or a Citizens Advice Bureau.
It helps to develop a more inclusive approach to understanding and improving how services work to meet need. Along the way it also builds capability and understanding about services and how they work – and can help unite service providers, commissioners and citizens in a shared view about what is important and what is possible in present circumstances.
What do you think?
(with thanks to Jennie Chapman, Toby Lowe and David Walmsley for collaboration and inspiration!)