A case study of a council and place that scores higher in this aspect
We work hard to base all service provision on “what do you really need?” conversations with citizens. We give social workers and others who have these conversations a lot of discretion to meet needs directly, based on these conversations (within budgetary limits), and pilots show that this reduces the overall cost of care. We have expanded this to an advocacy/case management role when appropriate. A few years ago, we mapped out entire user journeys and found that our own systems being unable to hear what people were actually asking for was costing us millions in incorrect specifications with serious knock-on effects. It has been a long journey to build everyone’s trust in a focus on understanding and meeting needs opposed to formal assessment processes, and we are going through another version of that journey now as we introduce more community options and social prescribing. We have some senior politicians on board and a new DASS who is really supportive. A breakthrough moment came when we took the finance director on a site visit, and they saw that we were working on real value not on budgets – but that it was also good for budgets.
To be honest, our approach has probably slowed integration and we are still struggling to make it work in the NHS, but we have confidence we will get there. We are linking to the NHS “Getting It Right First Time” (GIRFT) programme, to try to communicate it better. We also now have enthusiastic fans amongst the user base, who are powerful advocates. We still have lots of traditional contracts and formally assessed provision – but at minimum we are including user feedback (“did you get what you needed?” and so on) as part of the evaluation criteria and building in learning and adaptation – our big lesson has been that learning is key.
A case study of a council and place that scores lower in this aspect
We attempted once to create a marketplace for self-funders from which we would also call off services, and a combination of technological and market challenges and leadership challenges meant that it was seen as a failure, so there is a real fear of being too ambitious in this space. We are working hard on social care and health integration and hearing a lot about avoiding ‘unwarranted variations’ in provision.
We are really pushing to move to what are called ‘outcomes-based contracts’ – in fact, our providers are leading us to some extent on that. But that is usually based on our assumptions and definitions of outcomes. We are aware that access to our services is messy and confusing, and it is hard for people to get what they really want, so we have commissioned two specialist information advice and guidance services (for dementia and carer support) as tests.
Equality and equity considerations with this aspect
Equality and equity must be central to this aspect, because making assumptions about care outcomes or forcing individuals into standardised processes, services, and systems of care presents perhaps the greatest risk to a fair and equitable system. At the same time, attempts to ‘put citizens in the driving seat’ also risk a bias towards historically privileged groups and meeting or supporting the needs of those who are best able to access decision-makers and communicate in familiar and accepted ways. Therefore, co-production and advocacy must enable appropriate representation and must be done in a way and in a context that guards against these risks.