“Why is a Fire Officer in the front seat here talking about the redesign of Public Sector Services?
I was seconded to the local authority in Stoke on Trent City Council for 2 years with a brief from my Chief Fire Officer to develop referral pathways and create opportunities to see where public sector services interlink so that we can do business better
Stoke on Trent were facing unprecedented cuts within the local authority. We had increasing demand in public sector services, we had more households requiring statutory intervention services, from children’s services, adult services, social care demand and we had over £100m to save in the next four years. Like many other authorities, deprivation was on the increase and we saw the restructuring of public services, often where the policies were slash and burn. Such cuts presented a number of challenges to the emergency service net of public services, health, A&E demands, police fire and we started to see a range of activities being forced upon us where potentially we had an opportunity to work differently and reduce demand.
Understanding What was Happening in the System
Across every public sector service we tend to focus at the top of the triangle where the cases are high complexity, high cost and also high reputational loss should we get it wrong. Do we ever start to prevent people escalating?
I want to give you some food for thought, take what I say from this presentation and apply it to your own workplaces and see if some of what we have found in this project is reflective in your own or your partners’ organisations.
We found as we started to work with public bodies that there were some serious concerns. Some service centre interactions were very slack in the way they were being delivered, The service interactions were very transactional. Referrals and referral pathways tended to be the culture in all our organisations. If we didn’t understand the demand we would refer it on hoping that we had referred it to the right place and the service would be delivered.
We then found there was confusion in the part-nership over what the referral meant, where they were going and how they were dealt with. They were driven by targets and measures. That’s what drove our business processes. The number of IT systems that were in place all holding data on individuals but we had problems extracting good quality information in order to deliver our services.
We had a lack of co-ordination and accountability for cases. The culture was “You’re not quite severe enough, we’re going to move you on but come back when you are severe and we’ll deal with you with high complex, high costly cases”.
We wanted to prove this and understand it more. This is what we were hearing when we started to visit the access centres, the police call centres, fire and rescue service centres, frontline staff, care staff.
In order to prop up the system we had multi-agency meetings that are quite costly to what services need to be delivered.
These multi-agency meetings often overlap, often show a high number of cases where there is duplication, often the same cases are talked about in many of the arenas. We started to see exactly where we could work differently. Where potentially these cases could be talked about once.
We considered the challenges we were facing – which agency or which meeting to send resources to to ensure the best outcome for a vulnerable person?, what was the current service capacity to deal with the demand we were facing, to deal with the future demand of welfare reform, of universal credit where people were going to be experiencing financial hardship?, difficulties in gaining access to services? Were the shrinking service resource able to deliver?
Value Work and Failure Demand
We started to categorise the work into two areas. The Value Work where the services are delivered to the citizen and the citizen actually gets what they need and the Failure Demand – the time at which service users entered the system again, from a point of view that they have already received an intervention service interaction and the problem wasn’t solved. That’s a high cost to the public purse.
The cost to an Organisation of Dealing with Failure Demand
We believed that a Referral gets help. This was a real area of concern for us. We looked at a number of referral pathways and we identified a case that came from a police briefing.
Identified Case:
There was a Housing Officer, Police Officer, Sergeant and Inspector talking about a case. This case was a repeat demand case that kept coming back to the police on a daily basis and up to three times a week where service was being requested from the police.
We mapped out this case and we found there were a number of different agencies involved. This was a litmus case for us to identify how much information do we hold on this one family?
From a police perspective we had over 200 incidents at this address and it didn’t flag up as an area of concern for the police because they were meeting their targets, their performance criteria. The system was dealing with it and the individuals were being referred to relevant agencies.
To build some context behind this, it was a young family who in 2004 started to experience financial difficulty because of alcohol addiction. They first identified to the local authority to say they needed help with their council tax and rent areas and the local authority put them on a payment plan. Did we deal with the alcohol issue? No.
Through the years the number of interventions progressed.
There were:
- 25 independent agencies involved,
- over 200 police incidents,
- 25 ambulances called over the last 18 months,
- 500 contacts with childrens social care,
- over 100 contacts with alcohol services,
- 23 independent referrals to alcohol services,
- 13 assessments,
- 8 detoxes,
- 2 multi-agency risk assessments,
- 300 contacts with housing and 40 revenues and benefits enquiries.
What was the cost of that? This family didn’t even qualify as a troubled family.
We have real concerns – the cost of this family was in excess of £1million
We actually costed the services out by using the Department of Education’s calculator which is a recognised measure within the UK to show the cost of delivering public services from a multi-agency perspective. I asked the question “did any one agency own this case?” nobody, yet we were there working in partnership to deliver services differently.
What are the processes that underpin this way of working?
A mental health case identified by a police officer
- A police officer identifies the case,
- identifies the emergency call out,
- fulfills the relevant referral criteria,
- referral goes off,
- enters the health service
- now starts to enter the community mental health support teams.
We have 45 independent steps in this process
- There were 11 handoffs,
- 10 roles and
- 6 systems.
- It took 12 weeks to deliver this service.
How many steps in this process were value and how many were failure? 4 were value steps – that was the point in time that services linked together to provide a point of service and a point of interaction in a joined up way.
Over a 3-6 month period we carried out tests to understand this demand, we put in a lot of time, effort and expense to find out how we fix the problem.
People have individual needs and no one single agency can meet those individual needs and this is where we saw that it is crucial in a multi-agency environment to deliver services. There is a need for joined up working in a preventative approach that solves the problems that the citizens actually have, not what we think they have.
That was fundamental because we could see exactly where service processes and design of services were fashioned out in such a way that it allowed for public sector service commissioning frameworks to be delivered in a very tight coordinated manner with no, or very little, scope of problem solving, dealing with the real problem or certainly identifying the needs of the citizen.
The Referrals Spaghetti and Working in Silos
We started to look at the system and the thinking behind it mapped across all agencies. We’ve all got different ways of working, strategic indicators, measures and purposes. You can imagine what a challenging environment we were in. Activities are based on targets that are meant to improve our performance. We intervene at the point of crisis because we need to protect budgets. We carry out referrals because the right amount of expertise is not available at the point of contact so we get a cheaper resource at the front end such as a call handler or frontline officer.
Frontline staff can only offer services within their silo and their area of expertise. We’ve all experienced that silo working – this is what we do and we don’t work outside of this. We record things and tell other agencies just to cover ourselves because when we do have a serious case review we don’t want to be left holding the baby and that’s because we worry about risk and reputation.
The Fire and Rescue Service in Staffordshire no longer have any targets and we’re experiencing some of the best performance we’ve seen in years. We have measures and indicators but no targets.
What Does it Feel Like in the Old System From a Citizens Perspective?
It was a revolving door with multiple points of contact. Numerous referrals or appointments, lack of trust and services causes disengagement, unable to challenge the service that was provided, issues not serious enough to be dealt with. This is where we saw people asking for help being turned away because they were not severe enough and this was a real concern.
What Would it Look Like if we Ripped Up the Rule Book, What Would our Public Sector Focus Be?
Early intervention, prevention and improving the lives of our citizens whilst reducing cost. That’s almost a real challenge, how could we put a preventative arm in place that reduces cost but improves service delivery for citizens?
We built a multi-agency team from a number of agencies to be problem solvers, to work differently with a free remit to go and solve problems and deal with what we’re classing as system conditions.
In order to do that we needed a common purpose, whether in prison, health, fire, police, local authority, housing – the purpose was absolutely “To help me resolve the problems I have to enable me to live my life well”.
This was a common purpose and the common set of principles became:
- You fully understand me and the real problems to solve
- You will help me identify solutions to my problems and you will help me help myself and pull on the expertise where it is needed
“Pull on” does not mean referring. We have never referred one case. We pull people in from the areas of expertise. This has created some challenging situations. We are not changing the face of how we operate but these controls are in place to allow us to work and ensure that we are safe with our operation and we maintain safety for our citizens.
It involved taking police, fire, local authorities, third sector organisations and giving them one primary focus and one approach. To solve the problem of the citizen. What would that do to my targets and measures – increase or decrease? We get many different targets – how would that impact? What people do we need in that team? Who do we need from the respective agencies to solve those problems?
One Problem isn’t a One Service Issue
What issues would relate to Fire?
A whole range – mental health, medication, disability, age a whole raft of things would cause fires to occur. The same with the police – reoffending profiles, a whole range of interactions are involved. We looked at drug and alcohol services, mental health, housing, police, education, citizens advice bureaus.
We know we are approaching the welfare reform stage, we know that there will be people in debt and crisis, in fear of losing their homes, in rent areas. We can predict that they may get depressed or begin to turn to crime. We start to see the impact of crime or they take open risks in their home, they heat their home or light their home differently with candles or open fuel fires. This will lead to an increased demand on my services.
What we actually need is a police, local authority and public sector group of what this demand would look like. Revenues and benefits, job employment, public health, fire and rescue – this is where we had a problem, how do I integrate all of these systems and service structures? This is why we looked at E-CINS for being that mechanism for change.
There’s been some challenges along the way but with the E-CINS management system it has allowed us to start to at least experiment a different way where information is being shared so that everyone within that team can see it. Everyone within voluntary sector organisations could in an app-ropriate way contribute to that because people present again at many different places. Probably not at statutory doors, it could be the voluntary sector, churches or food banks – they are a fantastic indicator for where people are in crisis but how do we reach them? We are still experimenting, we are not there by a long way but we are starting to work very differently.
What Does Success Look Like?
I wanted to know if we were delivering and whether the new way of working was improving things for citizens. Is it affordable and scalable. Are senior managers putting a high level of pressure on there? Is what you are suggesting going to cost me an absolute fortune in today’s times of austerity? Will it reduce demand of the whole system or am I just going to move this demand somewhere else? What are the links to the cross economy systems and problems that they have to solve so health reducing demand on A&E, police reducing the number of both uniformed and non-uniformed staff without compromising service. Social care getting better results with less resources. Impact on having children in care. We want to make people ensure they are self sufficient and supported.
What are the Contextual Demands that are Often Missed?
If we understand those we would know which services to deliver, where there is a frequency within that service structure and what systems needed to be in place.
We started to get people saying “I had a demand come in, help me with my rent arrears”.
You may not see how rent arrears impact on your world but we started to look at the rent arrears in context and what was driving them. We started to map them with a simple tool so we could see where the customer was at the point of initial presentation of need. With a key worker with a dedicated team of work we provide a bespoke service to understand what the customer needed. These are the needs and the problem to solve.
We looked at how many customers we had on the system and what high frequency demands we were going to be facing. In Stoke on Trent the highest demand was “Help me find a job and be self sufficient”. Stoke on Trent at that time through their slash and burn policies decided to reduce the job employment and training capability to allow people to get back into work. That was a startling moment for us. As we started to look at these demands in context we started to see things from a citizen’s perspective, what problems there are within that citizen’s life in order to help them live their life well.
The Cost of Current Service Delivery
What is the cost of current service delivery and how does it impact on how we deliver services, how does it relate to the restructure and spending cuts I am going to have to make to my service?
The cost of an arrest is £2000. How many of these arrests could be prevented? How many accidents, trips to A&E, how many fires could be prevented?
It costs £1.4m for a fire death, a nationally recognised figure. How many fire deaths have we prevented?
We looked at developing a cost model, staffing costs, wage costs, activities. Using the Department of Education calculator providing an itemised account of service delivery we could understand these costs. We looked at the costs from 2 years previously which allowed us to work out accurately how much a case cost the public purse.
Once we understood the demand of people presenting we understood the contextual demand and then started to apply the cost model behind that. Using the same cost calculator we looked at what it cost and what we prevented by having a key worker pulling in staff and solving the problem.
The pre-intervention cost of one individual was £29,000 compared to £3,000 post intervention. That’s not a definitive final cost because people are complex with individual needs, it’s only the initial findings of what we’re starting to see but before we were endorsing that practice of £29,000 in a referral culture of passing people on.
We then looked at number of interventions and costs associated to those pre-intervention transactions over 2 years. We then mapped the number of transactions since working differently. We found it would cost the same initially but are we preventing demand further on in the system?
In order to understand that we’ve got things right we looked at three tiers of individual measures:
Tier 1 – Set up from a citizens perspective. The demands on context, the demands it was costing the public purse to deliver those services. Is what being delivered right for the citizen?
Tier 2 – The front doors where these people are likely to hit – if I have rent arrears what will that manifest into? there are a number of direct links there that would give us an indication of the nature of demand we could be facing in the future. It’s not right yet but that’s the way we’re heading. We want to develop it in such a way that it will predict some of the demand we will be facing.
Tier 3 – The multi-agency measures – there were 35 multi-agency measures developed between the partnership, those are a whole range of things, they are not static, we might want to watch them all because if we see an increase in Council Tax areas it could manifest into ASB, crime, fires etc.
This is how we are starting to approach our tiers of measurement – no targets. There are no performance or target indicators on there, we’ve allowed these measures at the top to just perform and see by working differently here what impact does that have up here?
Tier 1 links to Tier 2. What’s the demand? Is the demand increasing? It will probably hit in about 2015 when we are going to have a nucleus of activity which is the outcome of the Welfare Reform Bill.
Tier 1 links back into Tier 3. It’s a consistent review so that I know what service infrastructure I’m designing. Delivery and what effect it has on the ground to the citizens. If it’s not working the measures will inform me of that, if it is working we can see improvement outcomes for the customers and reduce costs to public sector services.
It’s still in development but how can I achieve the above without a multi-agency, integrated system that allows a preventative approach to service delivery? That’s what we’re using E-CINS for. I know it’s heavily used within the prisons and police environment and I have taken the concept and started to develop it somewhere else now.
Are We Succeeding at This Moment in Time?
- We have a 13.9% decrease in rent arrears from dealing with things differently, actually putting support in for people who first presented so that’s linking in with Citizens Advice Workers,
- We have seen ASB cases reducing because eduction welfare officers are being pulled in to help people stay in school and offer them wider education programmes.
- Crime reported cases – no change, we’ve seen its a good thing because everywhere else its on the increase.
There’s still more to do. We’ve reduced health and police demand but we’ve increased fire demand – not because of more fires but because we now have more opportunities to prevent a fire occurring.
My infrastructure now allows me to deliver service very differently. Local authority commissioning frameworks are being influenced to prevent this demand escalating through the roof. We might see an increase in one place but the question is from a partnership point of view is how do we fund that? Are we prepared to invest in this model to allow this to grow? Is it affordable?
We picked 7 cases to indicate and projected these costs. With one case the number of interventions were projected to go to 1480 with the old way of working. When working differently it shows an absolute different trend, that’s projected to show 1010 service interventions – 470 less interventions shows we are saving money.
Across the partnership as a whole post-intervention costs on the 7 cases were £337,000 worth of service delivery and infrastructure. When working differently we saw a service delivery of £233,000 projected indicating a £104,000 saving. This was just on seven cases. This means about £1,400 worth of savings per case, this is an indicative cost of what we could save as a partnership.
So What Has E-CINS Allowed Us To Do?
It’s allowed us to work in a more coordinated way, intuitive of what the system is enabling us to find out, the opportunity to work as a partnership and case manage individuals through the system. It’s not a finalised product, we’re still experimenting.
Terms are different across agencies so we are looking at titling reports and feed that information back to the Empowering-Communities team so we are evolving as we go. We haven’t sat back and said we have a finished product here.
The great thing about Empowering-Communities is that they have allowed me to experiment, check and challenge with other key workers to change the way E-CINS is being delivered and they have been more receptive to that information to start to say “Can we improve the way we deliver E-CINS and co-ordinate E-CINS?”. E-CINS has allowed us to deliver some of these outcomes for citizens.
Are We Achieving Citizens Outcomes?
Citizens lives are improving, they are becoming less vulnerable and less chaotic which is reducing the amount of expenditure we need to spend on them. We have a number of challenges to look forward to though, system conditions – we can’t do anything about this because that is the way government services are set up to deliver services, we are influencing these but it is challenging and it’s about thinking differently about what your service delivery method needs to be. We’re looking at restructure of departments and roles, an example of this is that we’ve reduced the number of people we’ve got in enforcement and rent collection because demand is dropping – we’ve repurposed their roles to become more of a key worker role.
Cross sector working
We can only be as good as the information on E-CINS. E-CINS needs to be across a number of platforms, not just in one area – we can develop it within Fire and Rescue Service to manage our risk reduction but that may not be beneficial to the wider partnership so it needs to be integrated. Also there’s a political element, whenever we work in a local authority there are always politics that throw a curve ball in for us but we’re influencing, providing the data and information and what politician would dispute the fact that you are improving citizens lives and well being?”
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