Living good lives in a place we call home.
In my the new year article published on my LinkedIn site I wrote optimistically about the future of the sector. Pointing out how the Sport England investment in places and the expansion of investment in leadership development could be a huge step forward in tackling ingrained inequalities in activity. But it was my conclusion that caught the attention; that to really lever change the sector needed to consider joining with other professionals to convince any incoming government to once and for all solve the social care funding crisis. If this was done I argued it would start to free up councils and Integrated Care Systems to reinvest in prevention and the physical activity sector.
I was then pleased to see and read an article by Social Care Future, ‘Living Good Lives In A Place We Call Home-An Outline Programme For An Incoming Government’. I’m not going to summarise the details because I want you to read it yourselves, it’s very powerful. Yes it calls for additional funding to address the immediate crisis in workforce capacity and rising demand but it goes much further. The report calls for a reimagining of what social care could do for communities and individuals.
“We believe a different approach will bring into being a thriving wellbeing ecosystem of formal and informal services, relationships and resources that we and people we care about can draw on to live our lives with meaning, purpose and connection at every age and stage of life.? More resources are needed, but they also need to be much better used.
Section 1 of the Care Act 2014 places local authorities under a general duty to promote individual wellbeing.? We believe that this, and tackling wellbeing inequality, is the right focus for adult social care policy and practice, and offers a best focal point for coordination and integration with other areas of policy and services, including our health system.? However, the ambition of the Care Act to give effect to a shift from ‘arranging care’ to promoting individual wellbeing has yet to be realised.”
The article goes on to suggest a range of changes based on scaling up existing innovation and good ideas already emerging in a struggling system and calls for the government to go beyond addressing core funding problems and also invest a bit more in these wider system changes.
“ we do see many pockets of brilliance today, with creative, resourceful initiatives, that could grow, thrive and spread to begin the sustainable shift towards our shared vision. They show us that a brighter future is possible. This is the challenge and opportunity for the next government – to take the first steps towards this future.”
What struck me immediately was how much in this article is common with the changes we would want to achieve in the sport and physical activity system and rather than just freeing up resources we now see how by reimagining ‘together’ health, social care and sport and activity we have opportunity to collaborate in places to help achieve better lives for everyone.
We too are now regularly seeing pockets of brilliant innovation. Just this week two great initiatives appeared in my inbox. The first from John Oxley shared some early results from a State of Life evaluation of the Stockport Exercise Referral programme using WELLBY/QALY methodology to illustrate the value of the service and to illustrate the preventative health benefit.
The early highlights are:
The scheme delivers a ￡17,500 benefit per person and is therefore estimated at being 8 times more beneficial than physical activity in the general population.
? This life outcome value is more than twice as big as the wellbeing effect of an unemployed person finding a job.
? If we take the estimate and apply this calculation to the known participants who completed the programme in the same year, this will deliver c￡14M of social value to Stockport.
? This programme’s approach to health intervention is 12 times more cost effective than the NHS highlighting the value of investing in prevention v treatment for ill health.
The evaluation report recognises that this is an early set of results and more work is required but it suggests that establishing a consistent approach to measurement and evaluation across an area and /or sector will result in larger data sets enabling greater statistical power but also enable organisations to clearly communicate and speak with one voice about the positive impact they are having in local preventative health.
Secondly I was sent another evaluation report by Lyndsey Barrett from Sport In Confidence an Occupational Therapist working in Essex. The Prevention and Enablement Model (PEM) was also evaluated by State of Life alongside Essex and Suffolk Universities and again highlights some powerful evidence of impact along with significant learning surrounding the programme. https://www.sportforconfidence.com/our-services/prevention-enablement-model/
The key findings were,
?1. Data compared to Sport England’s national Active Lives Survey indicates PEM may have the effect of improving the physical activity levels of a person living with a disability or long-term health condition to comparable levels of the rest of the population. This suggests PEM can play a crucial role in reducing health inequalities.?
?2. People accessing PEM services show a decrease in self-reported service use (i.e., day care, formal/informal support, GP appointments, 999 calls, and hospital visits). This reduction in service use is estimated to equate to a cost saving of ￡365.23 per PEM participant, per year.?
?3. Evaluation performed by State of Life took the 2021 Wellbeing Supplementary Guidance in the Treasury’s Green Book and applied the treasury recommended WELLBY to monetise the wellbeing value of PEM. The difference in life satisfaction between individuals about to start PEM and those one month into the programme is estimated to equate to a monetary value of ￡22,230 per person per year.?
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?4.? Scaling the value of reduced service use and higher life satisfaction to the typical number of unique users in Community Partnerships/Reconnect (where most data were collected) suggests that the total annual social value could exceed ￡20 million. When this benefit is considered against direct running costs, PEM could deliver up to an estimated ￡58.71 of social value for every ￡1 invested.?
The project in four parts was originally funded through the Essex Local Delivery Pilot (Sport England) but over recent years reduced funding has resulted in elements of the programme being scaled back and commissioned separately by adult social care and public health with some councils and facility operators subsidising some services alongside client self-payments. This suggests to me that an externally funded pilot properly evaluated and evidenced has in this case started to lead to system change.
Both these initiatives are starting to provide the sort of real data evidence that will be critical to future commissioning relationships with both ICSs and social care. However whilst both projects are demonstrating real cost benefits to social care and ICSs their continuation will still depend on?funding coming from individual clients or from operators, councils and ICSs if access to services for the most deprived communities is to be facilitated. Unfortunately it is when this sort of innovation collides with financial reality that system change can either stall or fly and why we must continue to invest in supporting the sector to better influence and lead change.
Change is finally now happening and gaining some momentum. The ￡250m roll out of place working is gaining a pace, we have completed the training of 20 facilitators to deliver local leadership programmes and held a leadership programme for the first group of local place leads and a briefing for elected members. Sport England are progressing the wider universal offer to other places including a major ￡6m procurement exercise leading to a further investment in leadership development, learning, evaluation and coaching and mentoring to expand their support to places and system partners. CIMSPA have recently published a new strategy ‘Releasing the Power of our Profession’ showing how they will support the sectors workforce. Progress is being made to expand the Moving Communities Data Hub to provide participation data across places and not just individual facilities. Together with all the many local initiatives emanating out the Local Delivery Pilots and the many community based initiatives facilitated by numerous sport for development and community organisations such as Streetgames and the Active Wellbeing Society lots is happening. The momentum for system change is finally building but I still remain concerned that all these separate initiatives are not yet adequately aligned into a cohesive strategy and they may not be enough to counter the more negative developments.
Things still continue to look bleak financially. Central government are we hear considering the choice between tax cuts or further cuts in public services. Councils are frantically trying to balance next years budgets with higher council tax and the threat of bankruptcy. Any pending election appears to offer little immediate hope of increased funding although Andy Reed and Sport Think Tank have done a great job at bringing together in a manifesto over 100 policy ideas for any incoming government to consider. There is inevitably a visible tension between these pockets of positive initiatives of change and the shadows cast by the worsening financial landscape which means our and other change journeys face significant risks that we must manage strategically.
In January 2023 the Nuffield Trust published a report capturing ICS learning to date, ‘People, partnerships and place: How can ICSs turn the rhetoric into reality’. In response in November I published on Sports Think Tank a paper that compared their learning with our own place expansion journey suggesting we would face similar challenges and risks. https://www.sportsthinktank.com/learning-from-ics-roll-out.html
?Both reports discuss six risks. ?
? A lack of common language and shared understanding.
? Culture, behaviours and inter-organisational power dynamics.
? Organisational complexity, duplication and overlapping focus.
? Resources, funding and capacity constraints.
? Difficulties in defining, measuring and evaluating integration.
? Staff fatigue, burnout and integration overload.
What became very clear when we did the training with facilitators and the place leads was that these risks were now becoming very real and apparent across the sector. We are still lacking a common language and shared understanding about the change we are trying to create; culture, behaviour and power dynamics are getting in the way; we are realising we are dealing with complexity in a context where resources and capacity are limited and fatigue, burnout and overload is growing; and we continue to find measuring and evidencing our impact hard going.
All this suggests to me that we are now finally starting to embrace the change we need to survive and address the challenges our communities face. Many of you will know the Kubler-Ross Change Curve, a well-respected model of change and leading change. It identifies seven stages that people go through when change happens. Shock, Denial, Frustration and Depression are the negative downward stages in the curve as people try to come to terms and understand why change is needed and what change needs to happen to succeed. Experimentation, Decision and Integration are the positive upwards stages as people embrace the change and become participants in the new future. Unfortunately among any group of people the journey happens differently at different speeds. Very often the leaders quickly find themselves integrated in the new end state, but they would do being the leaders. But often they fail to realise that others in the group or team or organisation remain in shock, denial, frustration and even depression for a long time. Some will not understand either why change is needed or what the future actually looks like so remain concerned or frightened about the change particularly if communication is poor. Some will be angry even fighting the change and trying to prevent it happening at all. Leadership is how we help and support people through this journey and is why leadership development is absolutely central to our current change journey.
This is what is now happening across the whole sector. While we have some early adopters of system change and place working in the LDPs and other pockets much of the sector remain behind in the curve. Some are starting to engage and experiment with their own approaches but in isolation and without support are finding it hard. Some ‘don’t get it’, they don’t understand what system change is all about and what is now expected of them. Some do see the need to change but simply feel overwhelmed by the challenge. Some however are not yet convinced about the direction with some voices even questioning the focus on health and activity rather than sport and leisure and hoping to continue ‘doing what we have always done’.
It’s very clear however that the status quo is not even an option for the sector. Neither central government or councils will be able to fund us to do what we have always done. Councils are having to embrace radical and difficult decisions about their priorities. The Integrated Care Systems despite the financial challenges are finally coming to terms with the gradual switch to prevention and working differently with partners across places. The new report on the future of social care calls for the same sort of radical shifts in thinking and action. We are not on our own in our change journey, we can collaborate as respected and valuable partners in place based system change. This is already happening in pockets where there is the right leadership of change, behaviour change and an acceptance that we must work differently. The challenge now is to scale this up and join it up so that change happens everywhere, in every community. We are now on our way but the next five years will be exceptionally hard and challenging but the opportunities are ripe for the taking. Let’s not let them slip from our grasp, let’s help people ‘live good lives in places they call home’.
Martyn Allison
Feb 2024.