PUTTING THE CITIZEN AT THE CENTRE OF PUBLIC SERVICE REFORM AND TAMING THE VESTED INTERESTS

PUTTING THE CITIZEN AT THE CENTRE OF PUBLIC SERVICE REFORM AND TAMING THE VESTED INTERESTS

Madeleine Clarke, Founding Director of Genio, former Deputy CEO, Barnardos

Introduction

The current climate offers us an opportunity to re-design public services. I am going to talk about some of what is involved in seizing that opportunity. I am proposing that putting the citizen at the centre of the reform of public services is the best way to ensure quality and achieve cost-effectiveness. It also provides a means of achieving a common premise which can appropriately be used to tame and harness vested interests to achieve positive change. Finally, I will describe an example of how to put the person at the centre of the design and delivery of services they need, reduce costs and achieve better outcomes.

Opportunity to re-design public services

The economic boom allowed us the luxury of simultaneously funding some enlightened initiatives while sidestepping certain nettles that still remain to be grasped. We generally did this by adding initiatives on at the margins of large expenditure programmes. The sharp contraction now requires us to face these deferred challenges. These are challenges that are not unique to Ireland. John Jay Chapman’s precept “Reform consists in taking a bone from a dog” may be a safer guide than the chorus of “win, win” optimists, as we set about this task.

What’s involved in seizing the opportunity?

It is important to take the full measure of the challenges involved. We will not be served well by simplistic assumptions and poorly thought through strategies.

One such assumption is that all we need to do is demonstrate evidence of how to design services that reduce waste and produce better outcomes and then widespread adoption will spontaneously follow. It is utterly naive to assume that resistance to change will graciously surrender in the face of irrefutable evidence. Key stakeholders in this terrain are not disinterested empiricists.

Another common assumption is that investment in expensive, professionally staffed services automatically translates into good outcomes. It is true that many leaders and innovators are open-minded, committed professionals. It is also the case that some of the poorest-performing services, in terms of adding value to people’s lives, are led and staffed by highly paid professionals.

Shirking the pain and rigour of hard thinking leaves us prey to superficial, almost sloganeering remedies. Reducing the number of community and voluntary agencies is one such remedy – indeed one which almost commends itself as a ‘no-brainer’. Certainly, the development of locally responsive shared services would be a worthwhile achievement if it reduced duplication of back office costs. Competently incentivised and executed, this could be achieved without insisting that organisations merge, lose their identity or go out of business. An insistence on wholesale culling of agencies would be ill judged and politically risky given the particular origins and ethos of groups in that sector. Sometimes the ‘no-brainer’ epithet contains a literal truth.

The blanket application of crude percentage cuts as a means of reining in expenditure is another example of avoiding serious thought. This acts as a disincentive to efficiency, encouraging agencies to maintain ‘off-radar’ pockets of inefficiency which they know will be needed to be offered up against future rounds of cuts. We need to develop capacity to discern and moderate decisions on the basis of efficiency performance.

More ruthless aligning of resource allocation with national policy objectives is often urged. Linking funding to validated delivery of outcomes goes hand-in-glove with this line of exhortation. As high level objectives these are unassailable. But the complexity of challenge associated with any serious sustained intent to deliver on these objectives requires sophisticated strategies that are adequately informed and considered. Clarity of thought and resilient resolve are sine qua nons of any serious endeavour to land a reform programme of such ambition.

Putting the citizen at the centre – taming the vested interests

The commitment to “a more customer-focused approach to the delivery of public services which puts the public at the centre of public services” [1] contained in the Towards 2016 Social Partnership Agreement has yet to be realised. Social partnership provided what seemed to be ‘win win’ solutions for all concerned – except arguably for those in need of public services, notably those who are marginalised and require supports to become valued, included and contributing members of society. The theme continues to recur as in the Public Service Agreement 2010-2014 which refers to “working together to build an increasingly integrated Public Service which is leaner and more effective, and focused more on the needs of the citizen”. [2]  It is fair to say that the jury is still out on whether ‘Croke Park’ is being implemented primarily in the interests of the public or whether it represents a damage limitation vehicle for embedded interests.

Given the different and conflicting interests, the only safe guide is to put the citizen at the centre of the design of public services. This forces all others into the appropriate position – being of service. The most compelling case for reform can best be put by those to whom it matters most. Putting the person at the centre of the design of services provides a common premise against which the contributions of all can be measured. For this to work, it is essential that expectations are made explicit at both strategic and operational levels. It is the lack of being able to work back to – and forward from – a common premise that is at the heart of our problems in accelerating progress.

Harnessing cross-sector collaboration for reform – the Genio model

The impetus for Genio came from three sources. Firstly, the recognition that there are good and able people in every sector who want to make a difference; secondly the clear need for a more customer-focused and cost-effective approach to providing public services; and thirdly a personal desire to work with others to ensure that people who are marginalised have the best opportunity to become included and valued citizens – not just for their sake but because society benefits by valuing diversity and including the contribution of all of its members.

Genio was established in 2008 with the objective to ‘foster cross-sector collaboration involving key stakeholders’… ‘to promote personalised services’ to people who need them in order to live purposeful and productive lives. I was determined that Genio would not be another organisation offering commentary. Instead we would concentrate on being helpful, adding value where we can to implement good national policy.  The sectors we are working with are public, private and non-profit. The fields we are working in so far are disability, mental health and older people, particularly focusing on those with dementia.

 We have had some exploratory talks in the children’s area. We believe that the model we have developed has wide applicability within the public service, notably where there is an interface between the State and the citizen with a significant – especially an enduring – vulnerability.

Genio acts as a catalyst in reconfiguring resources to refocus services to put the citizen at the centre of their design and delivery. We develop a deep understanding of the fields we are invited to work in on the basis of our existing expertise and knowledge and through consultation and research. We assess the capacity and leadership potential that exists in the field and use this as a basis for agreeing specific targets with our funders in the overall context of achieving national policy objectives. We bring private and government funding together. Our funding currently comes from Government through the Department of Health and HSE and from the Atlantic Philanthropies. We are now opening up opportunities for other interested government departments and private investors/philanthropists who feel we can help achieve desired change.

To give you a flavour of our targets in the fields in which we are operating – in disability and mental health we are increasing the numbers of people who are receive person-centred support to:

• • Move from institutions
• • Live in the community
• • Work or participate in education or training aimed at employment or otherwise engage in meaningful activities.

In mental health our agreed targets also include:

• • Redesigning services currently provided in day hospitals and day centres to focus on outcomes important to the service user that support recovery and increase opportunities to regain valued roles in the community.

These targets are agreed in the context of the national mental health policy Vision for Change which proposes a “person-centred treatment approach” with “special emphasis.. given to the need to involve service users and their families and carers at every level of service provision” [3]: and the national disability policy Value for Money and Policy Review of Disability Services in Ireland which proposes a “fundamental change in approach to the governance, funding and focus of the Disability Services Programme, with the migration from an approach that is predominantly centred on group-based service delivery towards a model of person-centred and individually chosen supports.” [4]

In the dementia area, Genio has received funding from the Atlantic Philanthropies and the HSE to:

• • Develop and test new service models which will improve the range and quality of community-based supports for people with dementia
• • Inform developing policy and investment in this area
• • Build the leadership in the field that is necessary in order to capitalise on the potential of the proposed national dementia strategy.

How do we do it?

We work in three ways:

1.  We provide financial support in the form of grants to stimulate the reconfiguring of resources towards innovative, cost effective, individualised supports that foster community inclusion. Applications are invited through the national press and are evaluated against published criteria that reflect national policy. Sustainability and value-for-money are key criteria. Successful applicants must have a compelling sustainability plan to maintain change beyond the life of the grant. Thus Genio funding provided through the Genio Trust is used as ‘bridging finance’ to get from the old to the new. For example, when closing institutions, running costs are needed until the last person leaves. Meanwhile funding is required to develop supports for residents moving to the community to enable them to be appropriately supported to become re-integrated and connected. Once institutions close, resources needed to run them can be used to support people in the community.

Since 2010 we have received 713 applications and have been in a position to award 145 grants to projects all over the country which total over €10.6m. This has leveraged a further €19.7m in matching and reconfigured resources directly, and will hopefully stimulate the reconfiguration of more significant resources as momentum for implementing policy to move away from group-focused services to individualised supports is nurtured and grows. We monitor progress of grantees, making onsite visits three times a year and, on occasion, have taken funds back into the Genio Trust where agreed outcomes were not being achieved. (Part of our ‘value-add’ is to introduce private sector performance expectations into the traditionally more sheltered public sector.)

2.   We build skills and leadership amongst key stakeholders including:

• • people who use services, their families and friends, to advocate to secure the supports they require
• • service providers, policy makers, and service commissioners to refocus service provision in the desired direction.

3.  We measure impact and gather evidence to support refocusing and scaling.  We have commissioned the University of Ulster to identify:

• • changes in the quality of life of those being supported to live more independently in the community
• • costs of providing individualised supports to people with different needs across urban and rural settings
• • what works best in refocusing services.

 What are we achieving?

We are aiming to support and publicise enough demonstrations to achieve momentum in the desired direction that will be self-perpetuating. Through our grant-making and the direct work of the Genio team:

• • 474 people are being supported to move from institutions to live more independent and connected lives in their communities
• • 1,011 young people and adults are being supported to participate more in their communities and to access work, education and training opportunities
• • The families of 382 adults and children are receiving ‘community-based respite’ breaks without being confined to placing their sons and daughters in institutions
• • 2,934 people who use services have received training, information and practical support to enable them to live more independently in the community
• • 1,153 family members have received information, training and support so they can support their family member more effectively
• • 2,074 staff have received training and support directed at service improvement and acquiring the skills they need to support people using services in an individualised way
  • 5,921 people from the general community have attended information events, awareness-raising events and conferences.

 Sustaining collaboration

Identifying strengths, interests and possible barriers to cross-sector collaboration are important to get to the starting blocks. Developing collaborative options that address the interests of the various sectors involved is critical to sustain collaboration. At Genio, we offer the government an opportunity to reroute funding in a policy-bound direction through an independent vehicle that uses a transparent, accountable and publicly defensible process. We offer philanthropists and private business opportunities for high impact social investment through our understanding of how positive change can be achieved and scaled and through our relationships with statutory agencies and other key stakeholders. Crucially, we provide opportunities for private funding to be used strategically to support projects that are sustainable beyond the life of grants provided, avoiding the usual problems associated with philanthropically-backed initiatives.  This is also appealing to government officials who are usually left to worry about the bills when the philanthropist leaves. For the not-for-profit and statutory service providers, we can support innovation and provide an injection of funds and expertise to begin, accelerate, and to sustain reconfiguration. One senior manager in the HSE recently described Genio as ‘an innovation partner’. For those needing services we are driving reconfiguration in a direction that puts them at the centre of design and delivery. For many, this means putting them in the driving seat of their own lives. Finally, for the general public we are achieving and driving good value for public funds.

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