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Making what matters measurable: why we need an outcome-based approach to health and social challenges

Jonathan Senker, Chief Executive 29 January 2024

Our Chief Executive, Jonathan Senker, reflects on how we’re currently rewarded for the efforts that we put in, not the changes we empower people to make in their lives.

Locked out of the flat, there was no choice but to call the locksmith. He broke in, and over a couple of hours, replaced the lock, repaired the door frame, and cleared up the mess made. £200 poorer, but thanks to the care and attention the locksmith had provided, safe. 

The next time it happened, another locksmith arrived. It took her just 10 minutes to pick the lock, and she charged £100.”

A quicker result at a lower cost. So why was there a sense of feeling a little bit ripped off? And how does this relate to social care and commissioning? 

The example isn’t mine (I’m probably overcautious and have left keys with several neighbours – just in case) but it comes from behavioural science literature, illustrating the ‘duration heuristic’.

We tend to value time and effort, not results. I think it gives us another perspective on why, despite decades of talk about outcome-based commissioning, its practice remains notable by exception.

It’s not what we do but what does it

It’s perhaps understandable why there’s a tendency to pay for time, and its ease of measurement, rather than results. A lack of trust, and an increased volume of scrutiny, between commissioners and providers make it more attractive to use proxy measures to justify expenditure. And justify they must. 

As a wave of austerity landed on public services in 2010 following the banking crisis, we saw a spawning of do more with less’ and work smarter, not harder’ sloganeering. Now councils are counting the costs of systematic underfunding, coupled with growing need. 

We’ve seen Birmingham City Council have to cut £57 million from its children’s services budget and Bristol City Council feel obliged to cap spending on a person’s care in such a way that drives people into residential care. While Nottingham City Council’s officers have proposed a £23m saving, including closing the Chronically Sick and Disabled Persons Telephone Service and an activity centre for children and young people, and reducing community protection services. 

The list goes on. 

These are not decisions councils ever want to take. The sad irony with Nottingham is its financial peril can be traced to the Robin Hood Energy scheme an example of councils doing exactly what they were told to and trying to achieve more with less. 

We’ve all become wise to the reform’ or rationalisation,’ which are simply codewords for cuts. As we face several more years of increasing demand and insufficient resource, solid substance is required more than ever. The temptation to water down statutory requirements, including those under the Care Act, to the legal minimum must be avoided. If there’s not enough money, let’s have the decency to state that and then work out what to do rather than pretend. 

These difficulties exist in the third sector, too. As the chief executive of one of the UK’s leading advocacy and involvement charities, I’m naturally hugely proud of the work my colleagues do.

I also, however, recognise that we’re overwhelmingly paid by councils for the efforts that we put in, not the changes we empower people to make in their lives.

We want to change this, and consider the following core principles to be key in how we do this:

  1. Pay for what matters in people’s lives, not for the effort spent. This may mean challenging and supporting providers to work collaboratively to achieve changes which go beyond any one of them. For example, the Lambeth Living Well Collaborative brought together people who have lived experience of mental health issues and carers with a group of commissioners and providers of mental health and social care services, with the principle that each person’s perspective and contribution was as valuable as the next. Together, they developed three big outcomes with a holistic approach, focused on recovery and staying well, people making their own choices and achieving personal goals, and participating on an equal footing in daily life.
  2. Build trust between people, public commissioners of services, and providers of them. VoiceAbility’s communities of practice bring together commissioners in a safe space to discuss common challenges and share solutions. Peer learning, particularly in times of crisis, can unlock novel and innovative ways of working. At the very least, it provides companionship to navigate the sea of troubles. Research into collaborative, relational commissioning approaches by the King’s Fund found better outcomes in their service delivery.
  3. Make what matters measurable (however imperfectly at first) and incrementally shift investment towards it. The Essex Recovery Foundation (ERF) took a bold step, handing over the power of strategic commissioning to the people who use the drugs and alcohol service. In taking a bottom-up approach to the commissioning process, the ERF spends less time focusing on the number of people in recovery and more on developing genuine impact. 

Advocacy and participation services provide fertile ground to take a truly outcome-based approach. They are at the forefront of challenges across social care and health but are on a small enough scale to test, trial and learn new ways of commissioning. It will require a shift in thinking: to value relationships and soft outcomes over an exclusive reliance on hard data, and ensure clarity of definition between outcomes and outputs (or even inputs). 

However, commissioning is one of the most important levers to effect wide-scale change. It’s more than procurement; it’s place-shaping. Every public service relies on the process, and through that mechanism local standards are set. 

If we shift our commissioning processes to be outcome-led, people-led, then we have a real chance to change our neighbourhoods for the better.

We’re facing multiple locked doors, but I believe that we have the keys to open them keys which are often in our and our neighbours’ hands.