Features: October 11th, 2002

An Alternative to Cross-charging

By Penny Banks

Cross-charging is getting the thumbs down from all directions. Health care and local government managers are concerned about proposals to impose penalties on social services who fail to prevent delayed discharges. The Health Select Committee’s report on delayed discharges acknowledged risks from cross-charging ‘that perverse incentives will be created that will undermine partnerships that have taken time to develop’. If penalties on either local government or the NHS are not the answer to incentivising partnerships and solving pressures in the service system, how can Government best support health and social services in their work together to integrate care? A recent seminar at the King’s Fund illustrated the gap between the hands-on experience of those making whole systems work and Government action to support this approach. The rhetoric is there to promote work across boundaries and recognise the interdependencies between agencies but political imperative to demonstrate quick results is encouraging old-style central control focusing on parts, not the whole, of the service system.

There is agreement about the direction of travel and recognition that Government has laid an important framework for supporting health and social care partnerships, for example, by removing different legal and financial barriers. This has been significant in shifting the vision and mindset of different partners as well as allowing the integration of management and budgets. A range of models of integrated care are emerging for different service users. Partnerships are being developed to improve services which extend well beyond those using flexibilities. But as Government has staked its reputation on reformed public services by even larger investment, there is ever more pressure to show results. Proposals along the Swedish model of cross-charging have prompted debate about how best to incentivise these partnerships and the type of levers and support needed. Which approaches are most helpful and which are likely to have unintended consequences?

Four key action points for Government emerge from experience in the field, research, user, professional, statutory and voluntary sectors. These are not new messages but nonetheless important reminders from those dealing with complex systems which, as some of the successes in dealing with winter pressures have shown, are worth reiterating.

Tailor support and incentives to different partnerships

The complexity of whole system working and diversity of partnership arrangements suggest there is no one method of improving performance and a judicious mix of supports and levers are needed. Before any introduction of rewards or penalties there needs to be a careful assessment of their impact on the whole service system, across the NHS, local government, voluntary and private sectors, and the likely outcomes for service users and their carers. Whole system simulation exercises may be one way of testing these out.

Give priority to funding development support

Priority should be given to supporting cultural change and equipping managers and staff to work in new ways as well as ensuring elected members, non-executives, users and carers are fully engaged. Although much of this work to support change will need to happen at a local level, Government can support this through funding service development and training opportunities. This may include leadership programmes, for middle as well as senior managers from across all sectors, which focus on partnerships and working across boundaries; networks to exchange experience in whole system mapping and redesign of services; and action learning sets to hear, for example, of practical examples of joint agreements on risk sharing and how decision-making has been shifted further down organisations.

Create a favourable environment for partnerships

Experience of new alliances with PCTs and other developing strategic partnerships reinforce well-rehearsed messages of having time and organisational stability to establish networks and conduct the continual ‘conversations’ needed for working in complex systems. One Director of Social Services talked of the value of regular breakfast meetings with the chief executives from the PCT and acute NHS Trust to get to know each others ‘dirty washing’ and find a common language.

Managers need a ‘safe’ environment where they feel supported in taking difficult local decisions and where Government emphasis is on local solutions rather than prescriptive models. This inevitably calls for adequate resourcing across the service system where no one partner is disadvantaged.

Most importantly to delivering integrated services, there needs to be coherence between policy streams. Examples include bringing into the mainstream some of the developments such as Sure Start and by Government tackling problems created by the charging policy for social care.

Support the development of frameworks to demonstrate progress

This is not to argue that Government steps back completely. Performance monitoring is important and ways of evaluating the outcomes for users and carers essential. However, working together calls for fewer indicators which are more closely related to partnerships and their outcomes, rather than numerous indicators which focus on activity rates in separate parts of the system. Similarly,inspections and performance reviews must reflect whole system approaches both in their focus and in the way they are carried out. It is not only managers who need to model ‘working in partnership’.

Locally, new partnerships are asking for help in evaluating their impact. Support is needed to develop or test out some of the existing frameworks which can be used to evaluate the outcomes of partnerships. These need to address the impact on the lives of users and carers; changes in services; outcomes for the organisations involved and the effects across the whole service system.

These are not easy messages for a government which is under pressure to show rapid results from its investment. Government is trying to achieve change in a complex system and turn around long established ways of working in professional and organisational hierarchies where service users, patients and carers have had very little say. All the evidence from the field and theory about complexity and adaptive systems calls for a Government prepared to set a clear direction backed by selected key targets and brave enough to step back and allow local creativity where people who use and deliver services play a central role in their improvement.

Penny Banks is a fellow in health and social care.