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Archive for June, 2009

omeletteOn my way to and from work I pass a pub which has recently had a make-over and now advertises as one of its main attractions, ‘world class omelettes’.  I’ve had my fair share of omelettes over the years and while some have been better than others, I can’t say that any stick in my memory.  So it’s got me thinking, what makes an omelette world class?

And you might well be thinking what has any of this got to do with the price of eggs.  Well, it’s not just omelettes these days that are world class.  Politicians of all hues talk about creating world class health services, world class schools and world class railways etc.  The Food Standards Agency has even developed a model of a world class regulator.  Perhaps there’s a clue in that – is a world class omelette one which the FSA has so designated?

Whatever, I intend to do some qualitative research.  The main issue will be deciding what filling to go for, once I’ve determined my key lines of omelette enquiry (KLOOE).

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nutmegThere were always targets for breakfast.  There were always performance indicators for lunch. There were always inspections for supper. 

The civic offices were full of files of data. Nutmeg, the local government apprentice, looked out of the window.  Cllr Nesbit fiddled with bits of things.  Nicodemus, the chief executive, sat in his chair and dozed.

Nutmeg stood up.  ‘I am going for a walk,’ she said.

‘Why?’ said Cllr Nesbit.

‘Whatever for?’ said Nicodemus.

 

‘I don’t know!’ said Nutmeg.  But she went for a walk nevertheless.

Nutmeg walked to the creek and sat and watched the tide come in.  What was that?  There was a bottle at the water’s edge.  There seemed to be a tiny light inside.  Nutmeg opened the bottle.  Outburst a Genie. 

‘I have been trapped for a hundred years, ” said the Genie, for he was the spirit of municipal government past. ‘You have set me free.  In return I shall grant you three wishes.’

‘Three wishes?’ said Nutmeg.  Nutmeg thought and thought and at last she said,

‘I would very much like something different for supper and something different for breakfast and something different for lunch.’

‘There!’ said the Genie, and handed her a magic Spoon.  Then in a flash and a bang he was gone.

Nutmeg hurried back to the civic offices.  The Spoon conjured up all kinds of local ingredients.  The Spoon cooked supper all by itself, without any guidance or recipe books. And that night Nutmeg, Cllr Nesbit and Nicodemus all went to sleep with a smile.

[OK so maybe I changed this a little bit.  For the true and full story of Nutmeg, check out David Lucas’s charming picture book – if you are looking for a bedtime story to read your children, you won’t do much better]

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I had a very interesting afternoon today at the Kings Fund where I was participating in the third in a series of discussions groups organised by West Kent Primary Care Trust as part of a consultation about services for people with complex personality disorders.  The consultation covers services for people throughout London, the East of England, South Central and South East regions – an area encompassing 62 PCTs.  The consultation was triggered by a decision to close the Henderson Hospital which is located in Sutton – one of two residential services in London providing what are called Tier 4 services.

The NHS categorises its mental health services into six tiers. Tier 1-3 services are offered in local communities.  Tier 5 and 6 services are provided in hospitals and other secure facilities for people who are at risk of harming others.  Tier 4 services are for people with complex personality disorders who may need extra care.

The NHS is consulting upon four different structural options, the main difference between the options concerns the balance between outreach community-based teams and the number of live-in facilities (none to four).  The discussion group included service users, clinicians, third sector practitioners and two local government officers.  Three fundamental issues were identified from the outset:

1) the difficulty of looking at Tier 4 services in isolation.  Whatever happens in Tier 4 is related to what happens in Tiers 1-3 and there was a general concern at a lack of integration, compounded by the variability in Tier 1-3 services across the 62 PCTs.  That said, it was also recognised that to try and tackle all the tiers in one consultation was probably not manageable.

2) the starting point should be an evidence-based understanding of people’s needs, the mix of service approaches which are likely to be the most effective and only then is it possible to determine the best structural arrangements.  Trying to identify the optimum number of live-in centres first felt like putting form before function.

3) There was a general view that individual PCTs are not willing to fund Tier 4 services and this was cited as the reason for the closure of the Henderson hospital.  Funding for Tier 4 services should be allocated centrally, it was suggested, otherwise whatever model of service provision was adopted it would not work.

The participation of service users in the discussion group was very positive and brought a dimension to the debate which I felt would otherwise have been missing.  For example, in emergencies some people with personality disorders may need residential treatment and one of the service users was able to talk powerfully about the impact of being locked up with psychotic patients (i.e. Tiers 5&6) in hospital in the absence of any alternative facilities.

While there seemed to be a general feeling that some kind of live-in treatment facilities were likely to be required, some participants emphasised the outcomes that could be achieved through providing intensive community-based services to out-patients.  In some ways it is a debate which is similar to the ‘care in the community’ discussion – to what extent are people’s best interests served by enabling them to continue living independently?  One clinician suggested that it was important to emphasise that the role of the NHS was to provide treatment not accommodation.  He suggested that perhaps partnership arrangements with housing providers should be explored in a new model of provision rather than NHS residential centres.

One of the ideas which emerged from the discussion was that rather than putting all the available resources into a combination of community teams and residential facilities, a significant proportion of the available funding could be put into building capacity – improving the training available to staff, developing an evidence base to improve understanding of which interventions are most effective and ensuring that best practice and knowledge is shared more effectively.

I took away a number of things from the session including a much better appreciation of the complexity of the issues around mental health service provision; how faced with this kind of complexity we often take refuge in structural arrangements and above all, the value in bringing together a disparate mixture of people to problem-solve in this way.

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‘Local government in Britain needs to be less passive and resist the central diktat on policy that has undermined local services and engagement. Authorities need less, rather than more guidance, and they need to be brave enough to drive fundamental change themselves.’

So says Michael Frater, Surrey CC’s interim chief executive in an essay in a new collection called, Beyond the Downturn published last week by Civica. At the moment there seem to be plenty of prophets of doom lining up to tell us about the years of misery that lie ahead for public services. So I found Michael Frater’s article helpful because he sets out some clear ideas on what local government can do to handle the difficult times ahead.

I’ve picked out six key areas he highlights in the essay:

1. Discretionary services like arts, culture, libraries and leisure are unlikely to survive in their current form and re-engineering and outsourcing of both core and discretionary services to the market is likely to happen on a scale much greater than previously imagined.

2. Councils need the power to act and raise funding locally. When difficult choices have to be made about which services to keep and which to cut, local needs and views must be the determinant, not Whitehall.

3. The government should look to reduce spending on regulation

4. Rather than continuing to fund separate governance arrangements for police, primary care, further education colleges, councils should become the commissioners of these services.

5. Councils need to turn their organisations on their heads so that the new generation of workers will want to work for local authorities because they are empowered, trusted and adaptable.

6. Councils need to recruit, harness and exploit the creativity, enthusiasm and energy of a new young generation of employees, many of whom have knowledge of the true potential that technology offers.

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How long do you need to be in a job to have a positive impact?  It’s a question that springs to mind seeing an analysis by Demos of changes in the average length of time that cabinet ministers spend in their jobs.  The analysis, highlighted in this week’s Economist, shows that cabinet ministers now spend less than a year and a half in their jobs compared to an average of around three years between 1979 and 1987.  Some might interpret this state of flux as ensuring a constant stream of challenge and new ideas as ministers take on different portfolios.  But it does also mean that cabinet ministers have less time to become familiar with their briefs and are perhaps less inclined to tackle long term issues.

 

This instability is also reflected in seemingly constant structural changes to the number and remit of Whitehall departments.  In a telling phrase the civil service refers to these re-organisations as ‘machinery of government changes’. It may be this idea of a government as a machine which fosters a pre-occupation with restructuring.  It is something which seems to be deep-rooted and linked to the still pervasive idea that a minister in Whitehall can pull a mechanical lever and at the end of a long delivery chain, the desired outcome will materialise.

 

Within local government there are also restructurings and executive councillors likewise move in and out of different positions but my hunch would be that a Demos type analysis across a number of councils would show greater stability.  With the prospect of significant cost reductions in the public sector, it is possible that restructurings will again loom large. It may well be that sometimes restructuring is valuable in ensuring the organisation is more efficient and able to achieve its aims but increasingly it appears that the effectiveness of public service organisations will be less about our internal structural arrangements than about how well we inter-link with external social networks.

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Anne Frank

anne frankAnne Frank was born 80 years ago today.  She began her diary on her thirteenth birthday and in her second entry, eight days later she sketched out her life to date.  She describes how she and her family lived in Frankfurt until 1933 when they emigrated to Holland and the arrival of the Germans after May 1940.  In this extract she describes what happened with their arrival:

‘Our freedom was severely restricted by a series of anti-Jewish decrees: Jews were required to wear a yellow star; Jews were required to turn in their bicycles; Jews were forbidden to use trams; Jews were forbidden to ride in cars, even their own; Jews were required to do their shopping between 3:00 and 5:00 P.M.; Jews were required to frequent only Jewish-owned barbershops and beauty parlors; Jews were forbidden to be out on the streets between 8:00 P.M. and 6:00 A.M.; Jews were forbidden to attend theaters, movies or any other forms of entertainment; Jews were forbidden to use swimming pools, tennis courts, hockey fields or any other athletic fields; Jews were forbidden to go rowing; Jews were forbidden to take part in any athletic activity in public; Jews were forbidden to sit in their gardens or those of their friends after 8:00 P.M.; Jews were forbidden to visit Christians in their homes; Jews were required to attend Jewish schools, etc.  You couldn’t do this and you couldn’t do that, but life went on.  Jacque always said to me, ‘I don’t dare to anything any more, because I’m afraid it’s not allowed.’

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Back in March when the Chief Medical Officer, Sir Liam Donaldson, suggested a minimum price for alcohol, the Government quickly dismissed the suggestion.  But few would dispute the social harm that alcohol mis-use causes.  Alcohol is involved in more than half of all A&E visits and the range of fact sheets produced by Alcohol Concern gives an indication of the many social problems with which alcohol misuse is associated.

So, I was interested this week in a new Joseph Rowntree Foundation report Tackling Alcohol Harm: lessons from other fields. The report is based upon research into seven cases studies each designed to bring about changes in attitude, behaviour or policy making.  The case studies cover issues like smoking in public places, gambling, gay and lesbian mental health, speeding and promoting environmental sustainability.  The idea of the research was to see if there were lessons from these case studies applicable to initiatives designed to tackle alcohol mis-use.  The research is part of a wider piece of work JRF are doing on the social evils of our time.

Five key points from the research are very pertinent, I think, to local authorities seeking to promote behavioural change:

1) by adopting a society-wide perspective you can encourage broader ownership of a problem and collective responsibility for tackling it;

2) changing behaviour often means changing social norms;

3) successful initiatives are based upon a sound understanding of the target group’s attitudes, values and needs;

4) successful initiatives address competition to the desired policy or behavioural change;

5) messages based on humour and empathy may be more effective than messages based on fear and shock.

There are a number of interesting issues raised by the case studies.  To pick out a couple – a project seeking to discourage young people from smoking found that while young people were not really interested in the health consequences of smoking, they were more engaged in the idea of not supporting the tobacco industry.  In Scotland, the Scottish smokefree campaign recognised that politicians were more receptive to a ban on smoking in public places when it was presented as a way for the new Scottish Government to demonstrate its independence from England.

Social attitudes towards alcohol are, in the words of the JRF report, ‘complex and ambivalent’.   But if as councils and together with our key public sector partners – health and police – we are serious about behavioural changes, tackling alcohol harm is something that we shouldn’t side-step.

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