(Paul will be blogging again soon – in the meantime here is a piece he was recently invited to write by Rich Taunt, chair of Kaleidoscope Health and Care )
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I’ve grown up (and grown old) working in public sector institutions. During all of my decades, they have increasingly recognised both the need for robust internal governance but also the importance of the organisations’ outputs for the public.
Of course, there are still public organisations that seem to feel happy just serving themselves in a shambolic way and having little thought about how they might serve the public better. But generally, in 2023 – compared to, say, 1983 – more public organisations take the adjective public before the word organisation as meaning something.
Most schools now worry about the results that their pupils achieve, and they worry for their pupils and for themselves, if their pupils’ results go down.
Many hospitals review their flow of patients to optimise the use of their expensive beds and equipment and worry about how their clinical governance provides assurance about achieving good outputs.
Local authorities are now much more used to being judged by how the services they are responsible for are actually experienced by local citizens.
Important progress
This is important progress, but just as we are getting there, just as we are cementing institutional responsibility, there is now a growing recognition that the real experience that matters to the public is not the outputs that each service organisation achieves, but how they work together to provide the public with services that actually create better lives.
What matters to a hospital patient is not just the clinical governance of the hospital providing them with a good service, but also how that service works with others.
Will my GP know that after my operation I now need different medicines and will the hospital have told them? Will my housing association provide the adaptations I need in my home before I go home rather than 12 weeks later? Can I rely on social care being there to help me stay at home from hospital and be safe and sound?
Pathway fails
It is now very likely that each of these organisations can demonstrate how they can meet their internal requirements. But for the members of the public that is just not good enough. Organisations being internally good means very little unless a very wide range of organisations’ internal systems are working together.
And let’s face it, this is hard. To be part of a pathway of service relationships means that the whole pathway fails if one bit doesn’t work and well, that bit is nothing to do with me and my organisational autonomy, so in the nicest possible way – tough.
But this is not only not good enough for the public – at a time of very tight public sector budgets, it wastes a lot of money.
If what really matters is working together then the work has to be done in between these organisations. What’s needed to make this work are ‘inbetweenies’.
If we now have better internally organised organisations, but the important public work happens in the gaps between these organisations, it’s the inbetweenies that matter. And for that to really matter, it means moving beyond the strong institutions we have built to walk among the lives of the people that use them.
What people want
Nearly 10 years ago the health charity National Voices set out a number of statements that summarised what people wanted from integrated public services – especially health and social care and related services.
A narrative for person centred coordinated care- a selection of ‘I’ statements.
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- I can plan my care with people that work together to understand me and my carers, allow me to control and bring together services to achieve the outcomes that are important to me.
- I work with my team to agree a care and support plan.
- When I use a new service my care plan is known in advance and respected.
- I always know who is coordinating my care.
- I tell my story once.
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I’ve used these in hundreds of different talks and discussions. They nearly always elicit two responses from people.
First they seem (and are) entirely reasonable. Just to take the last one. It really is not asking the earth to expect to only have to tell your story once rather than the many different times you have to tell it to different services or even different branches of the same service. It really is a moderate demand.
And the second reaction is that it’s entirely impossible. It may be your story but we need to be told in our way and our way if different from their way – and you can’t expect us to use your story the same way as that other organisation.
I find this combination of reactions important. It is both reasonable but, given the siloed organisations that we talk about, it is impossible.
I remember working in 2015 with NHSE’s New Care Models. Across different services one of the aims was to develop genuine one-stop shops. I recall the happiness about the success of reform when we got it down to three one-stop shops. Now that is better than 10 but it’s still not what it says on the tin.
This is why inbetweenies matter. Unless we can get forceful arguments being made for working together – to power inbetween these important organisations – then we will waste time and money, and increase people’s distress.
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