Tag Archives: quality

An ageing workforce and growing emotional demands call for more sustainable employment

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People Turning in Gears - Synergy

As a result of the global demographic challenge of an ageing population and the increasing diversity of working life, there has been a growing focus on sustainable work over the life course which has also placed greater emphasis on the importance of the quality of work and working conditions. As more and more people are having to work longer before retirement, it is important that they are able to do so.

A recent Eurofound report examined working conditions and their implications for worker’s health. Its findings confirmed a clear link between working conditions and the health and well-being of workers, highlighting the need to make work more sustainable.

Working conditions, health and wellbeing

Eurofound’s report found that this relationship can be depicted in a model based on the European Working Conditions Survey (EWCS), showing that health outcomes are the result of two processes: health-impairing processes (exhaustion) and motivational processes (engagement).

Health-impairing processes are associated with exposure to adverse work demands which tend to increase exhaustion, while motivational processes are associated with access to work resources that support engagement.

Such demands can include:

  • physical risks
  • work intensity
  • work extensity (long working hours)
  • emotional demands
  • social demands

Such resources can include:

  • social resources
  • work resources
  • rewards

It is noted in the report that the demand and resources model partly explains how well-designed jobs – characterised by high rewards, high work and social resources and suitable levels of demands – translate into better health: “Whereas job demands are linked to higher levels of exhaustion (which, in turn, are related to poorer health), job resources are associated with higher levels of work engagement (which, in turn, are related to better health and well-being).”

It is therefore suggested that as job control, social resources and rewarding working experiences all have positive effects, employers should be encouraged to introduce initiatives that focus on motivational aspects of work.

As recently highlighted, the discipline of worker health has traditionally focused on worker exposures to various workplace hazards. However, this has more recently broadened to include the concept of worker well-being, which is seen as increasingly important. Not only is it important for the individual but it is an important determinant of productivity for enterprise and society as well. Indeed, the Eurofound report highlights this growing importance.

Emotional demands

While the report notes that physical hazards have a direct effect on worker’s health and wellbeing and are undoubtedly remain important, these have not increased, but emotional demands have. This, it is argued, underlines the growing importance of psychosocial risks. It argues:

“In the context of ageing societies and services-dominated economies, it becomes more pressing to address these risks as the incidence of exposure increases.”

Other research has also highlighted the significance of emotional demands at work in relation to health. One recent study in the Danish workforce, for example, found emotional demands at work predicted a higher risk of long term sickness absence.

With the growing need for long-term care in ageing societies, it is argued that these demands are likely to increase further and, therefore, require particular attention. Different groups of people also face varying demands and are considered in the report. In particular, gender differences are considered throughout – highlighted as significant in some areas

Gender

The report found that men tend to report better health and wellbeing, and fewer health problems and better sleep quality than women. Men were also found to report fewer days of sickness absence and fewer days of presenteeism.

This is consistent with other research findings that show ill-health is more prevalent in women. One study exploring the association between work-related stress in midlife and subsequent mortality, and whether sense of coherence (measured as meaningfulness, manageability and comprehensibility) modified the association, found that occupation-based high job strain was associated with higher mortality in the presence of a weak sense of coherence – a result that was stronger in women than in men.

The Eurofound report findings show that as women often work in sectors like health or education, they are especially exposed to the psychosocial risks associated with these emotionally demanding jobs.

The report also notes that workers under 25 are most likely to face high demands while having the least access to work resources, and health sector employees in particular, face high emotional and social demands. It is therefore suggested that there should be investment in working conditions for particular risk groups, such as occupations requiring lower skills levels, reporting job insecurity, or witnessing workplace downsizing. Measures to promote high union density, good employment protection and gender equality which are likely to improve working conditions and contribute to workers’ health and wellbeing are also highlighted.

Way forward

The findings of the Eurofound report, and indeed other research, highlight the need to look beyond the ‘traditional’, narrower framework of occupational health and safety to include the psychosocial risks such as emotional demands, along with motivational aspects of work. This calls for a reduction in health-impairing conditions and a fostering of health-promoting ones.

Of course, the world of work will continue to change, particularly in an increasingly digital world. However, striking the right balance between demands and resources through coordination between different policy fields could contribute to a higher quality of working life that is sustainable, regardless of the ever changing environment.

Follow us on Twitter to see which topics are interesting our Research Officers this week. If you enjoyed this article you may also like to read:

Beneath the headlines: record high employment rate, but what’s more important – quantity or quality?

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Competition for new jobs

The UK employment rate has hit a joint record high of 76.1%, according to the latest official figures. The unemployment rate was estimated at 3.8%; it has not been lower since 1974. The economic inactivity rate was also close to a record low.

It’s not surprising that such record figures are often highlighted as ‘good news’ headlines. However, there has also been an increasing focus on quality of work over the past decade and the impact this has on people’s lives – reflecting concerns regarding developments in working practices, as highlighted by a recent City-REDI briefing paper. It has therefore been argued that the record employment rates are not necessarily representative of a ‘good news’ story.

Concerns

Concerns over working practices include the rise of the gig economy, unequal gains from flexible working, job insecurity and wage stagnation, to name but a few. The City-REDI paper outlines a number of ongoing concerns related to:

  • weak productivity growth;
  • employment insecurity and precarity;
  • in-work poverty;
  • skills shortages and skills polarisation; and
  • the impact of automation, technological change and the gig economy on the nature and experience of work.

Indeed, analysis has shown that much of the recent rise in employment is due to a ‘surge in low-value work’, which is holding back productivity growth. Many people are stuck in low paid insecure work, all of whom are contributing to the high employment rate.

Recent research from the Joseph Rowntree Foundation has reported that four million workers live in poverty, a rise of over half a million over five years – meaning in-work poverty has been rising even faster than employment. The causes of this increase include poorly paid jobs – particularly under temporary and part-time contracts – and a lack of progression routes for people in low-skilled work.

In addition, the rising gig economy shows no signs of slowing down, more than doubling in size over the past three years and now accounting for 4.7 million workers, according to a new report. An interesting finding of the report is that the majority of gig economy workers use this platform to supplement other forms of income, suggesting that workers are not getting enough of an income from their primary employment.

It has also been shown that advances in technology have pushed some workers into poorer quality jobs than those lost, something which cannot be addressed without some kind of policy intervention.

Health impact

Not only is poor quality work bad for the economy, it is also bad for people’s health.

A recent report which examined the impact on social inequalities of policy initiatives and reforms to extend working lives in five European countries, highlighted that working conditions are also known to influence post-retirement health, and for those with lower socioeconomic status, workplace arrangements may be causing or contributing to poor health.

A number of studies have highlighted the link between good work and health and wellbeing. As stated by a What Works for Wellbeing briefing paper, “Being in a job is good for wellbeing. Being in a ‘high quality’ job is even better for us.” It has also even been suggested that being in a poor quality job is actually worse for health and wellbeing than remaining unemployed.

Moves towards improving quality

Recent developments in the UK to address such challenges for the future and quality of work include:

  • the establishment of The Work Foundation’s Commission on Good Work in 2016, which aims to better understand the factors shaping change, and the nature and scale of opportunities and risks, so as to promote policies to achieve ‘good work’;
  • The commissioning and publication of the independent Taylor Review of Modern Working Practices in 2017 which called for policy to address the wider issue of creating quality jobs for all; and
  • the Government’s Good Work Plan, published in December 2018, which sets out the reforms planned to help improve quality of work – the first time the UK Government placed equal emphasis on the quality and quantity of work.

In addition, the Chartered Institute of Personnel and Development (CIPD) launched the UK Working Lives survey, the first robust measurement of job quality in the UK. This has since contributed to government thinking and recommendations around ‘good work’ in response to the Taylor Review.

Despite the widespread agreement over the need to adopt ‘good work’ principles, however, there remains no agreed set of indicators of exactly what it encompasses nor metrics for measuring progress towards it.

What is good work?

As the City-REDI briefing paper and other studies indicate, defining good quality work is complex as quality means different things to different people.

A range of factors contribute to different people’s perception of quality and fulfilling work, including pay, flexibility, security, health and wellbeing, nature of work and job design. The CIPD survey highlights seven dimensions of job quality:

  • pay and benefits
  • employment contacts
  • job design and nature of work
  • work-life balance
  • work relationships
  • voice and representation
  • health and wellbeing

Of course, there is no one size fits all solution.

Final thoughts

While productivity and employment rates undoubtedly remain important, they alone are clearly not enough to understand the health of the labour market; the quality of work also needs to be considered.

As shown by the visible shift from quantity to quality of work in recent years and the recent developments from the government and others, ‘good work’ is undeniably on the policy agenda. However, as the City-REDI paper suggests, there should be a focus on promoting ‘good work’ amongst the most disadvantaged groups such as the young, people with disabilities and those working in hotels and restaurants. It is also suggested that there is scope for further research on good practice in promoting ‘good work’ in establishments of different sizes and in different sectors.

As highlighted in the Taylor Review, “All work should be fair and decent with realistic scope for development and fulfilment.”

You may also be interested in some of our previous employment-related posts:

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Turning the tide on perceptions of value: what do students think value for money really means?

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A little over a year and half since we last wrote about the value of higher education (HE), which highlighted a downward trend in perception of value, it would seem the tide may be turning.

As we previously highlighted, one of the headline findings of the Higher Education Policy Institute’s (HEPI’s) 2017 Student Academic Experience Survey was falling perceptions of value for money, with the percentage of students perceiving university not to be value for money almost doubling in the previous five years. But the 2018 survey highlights a distinct turnaround, with students reporting “statistically significant improvements in perceptions of value for money from their higher education experience.” Could this be the start of a new trend?

‘Promising upturn’

Among the main highlights of the 2018 survey, which describes a “promising upturn”, include:

  • 38% of students in the UK perceive ‘good or very good’ value from their HE course – an increase of three percentage points from last year’s survey, reversing a five-year downward trend
  • fewer students studying in the UK (32%) perceive ‘poor’ or ‘very poor’ value, compared with 34% in 2017
  • there is a clear, statistically significant, improvement among students from England, representing the largest number of students, where 35% report ‘good’ or ‘very good’ value
  • there has been an improvement among students domiciled in Scotland (though not statistically significant) where 60% of students surveyed perceive ‘good’ or ‘very good’ value, continuing to report the most positive opinions overall, while students from Wales and EU students studying in the UK report similar perceptions of value as last year, 48% and 47% respectively. Perceptions of value in Northern Ireland remain in decline – albeit not statistically significant
  • Students at institutions which secured a Gold award in the Teaching Excellence Framework are more likely to perceive they have received good value, but there is no noticeable difference on this measure between Silver and Bronze-rated institutions

While it should not be forgotten that almost a third of students still perceive poor value, which remains a concern, this reversal of a five-year trend is undoubtedly encouraging. Moreover, what makes the latest HEPI survey particularly interesting is that for the first time, it includes evidence on what lies behind these perceptions.

What does value for money mean?

As our previous blog showed, the increasing cost of HE has contributed to the decline in perceived value for money as many believe the financial cost is not worth the career prospects. But it isn’t all about the financial element, although, as has been previously argued, perceptions of quality are not always clearly articulated. To help make things clearer, the latest survey incorporates new sections on: what factors relate to good or poor value, happiness with subject choice and experiences of different ethnic groups.

These new sections provide greater insight into just what students perceive as value for money. Interestingly, when asked about what factors influence their perceptions of value (chosen from a pre-defined, randomised list), 68% of students who felt they received ‘good’ or ‘very good’ value for money regard teaching quality as the most important factor behind this, followed closely by course content (67%) and facilities (62%).

None of the top five reasons for perceiving ‘good’ or ‘very good’ value related to financial cost, whereas price dominated the list for poor value where two out of the five most popular answers related to cost – tuition fees (62%) and cost of living (37%). The survey suggests that these findings indicate that cost and value are difficult to separate in the minds of students and that a perception of value for money can be difficult to attain given the level of current fees.

Career prospects and campus environment and university buildings were also cited as significant factors driving good value. This suggests that investment in the physical environment should be included among other priorities, given its status as a ‘major contributor’ to the student experience.

No time for complacency

Despite these promising findings about the student experience, there are still real concerns. Perhaps somewhat worrying is the finding that past gains in teaching quality have not been built upon, with students’ ratings of teaching staff down slightly on last year. Given the importance of teaching quality in perceptions of value, if this does not change it could very well contribute to a return to the downward trend in value perceptions.

Other concerns highlighted by the survey, include  perceptions of the wellbeing of students, which remain relatively low and continue to fall. In addition, some ethnic minorities tend to experience barriers and have lower perceptions of value.

As highlighted by Nick Hillman, Director of HEPI and a co-author of the report, the survey “exposes the areas where improvements are needed.” He also argues that “institutions have to work harder to ensure all students are catered for in full.”

Nevertheless, the survey emphasises that the fact the student experience remains positive should be recognised, particularly given the level of financial burden that students take on and the widening range of alternative routes available. Hopefully, the next survey will reveal a continuation of the upward trend in perceptions of value.

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Making the planning system more customer-friendly

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By Donna Gardiner

Local authority planning departments are more often associated with bureaucracy than with delivering good quality customer service.

However, as the current reform of the planning system in Scotland puts the need to develop a modern, efficient service in the spotlight, thoughts have turned to how planning authorities can focus on the human side of delivering a good quality planning service.

Last month (August 2018), the Scottish Government published a report on customer service in the planning system.  It examined different approaches to customer service across a range of private and public sector organisations in Scotland, with a view to identifying the lessons from these that could be applied to the planning system. Although focused on Scotland, the lessons are transferable elsewhere.

A number of challenges

The research found that while planning authorities in Scotland viewed high quality customer service as highly important, they faced a number of challenges to delivering this in practice.

Limited staff and financial resources are a key constraint affecting planning authorities’ ability to deliver high quality customer service.  For example, customer expectations of the frequency and responsiveness of communication are often higher than what can reasonably be delivered.

There are also issues of inconsistency of service, both within and between local authorities in Scotland.  This is due in part to different interpretations of specific legislation, as well as different levels of investment in, and commitment to, customer service within individual planning authorities.

The risk of individuals confounding ‘customer service’ and ‘outcomes’ – where the planning decision reached affects the individual’s perception of the quality of service they have received – is another key challenge when measuring the customer experience.

Current approaches

Each year, planning authorities in Scotland must prepare an annual Planning Performance Framework (PPF) report, which details their performance over the previous year.

At present, the PPF has no specific measure of customer service delivery.  Instead, planning authorities must submit a ‘narrative commentary’ of their customer service performance, along with relevant case studies that demonstrate their actions.

This means that individual planning authorities decide how best to gather information about their own customer service performance.  Some of the key methods used include:

  • Customer charters – which communicate customer service commitments to customers and employees
  • Customer satisfaction surveys – mainly online, however, some were still postal
  • Forums – the use of customer forums or focus groups to engage with customers
  • Complaint handling procedures – published details of organisational systems, protocols and SLAs for registering and responding to complaints
  • Customer service standard accreditation – g. Customer Service Excellence (CSE), Investors in People (IiP), ISO9001, Customer Satisfaction Measurement Tool (CSMT) etc.

So what can be done? The benefits of e-planning

The report identified a number of ways in which customer service within the planning system could be improved.

First was the need to achieve a greater consistency of processes, enforcement and quality of service across Scotland.  Clearer national guidance on implementing legislation would go some way to achieve this. Establishing a national survey of customer service in the planning system is also a priority. Lessons could be learned from the building standards system, which currently incorporates a Key Performance Outcome relating to improving the customer experience.

Planning authorities also overwhelmingly believed that e-planning had improved customer service.  The benefits included:

  • more efficient information flows
  • better prioritisation of work
  • reduced printing costs
  • greater transparency
  • easier access to information by the public

What is clear is that the move to e-planning is bringing a ‘culture change’. By speeding up the planning process and making more efficient use of resources, e-planning frees up both time and money to be spent elsewhere in the planning process.  As one planning authority notes:

“It’s about how you work with the customer to bring them on the e-planning journey with you and change their mindset. In the long run the customer benefits because it speeds up the service.”

As technology and customer expectations evolve it will be important that e-planning solutions reflect this in the future.

Future directions

Good quality customer service helps to make the planning system easier to understand and processes more accessible and usable.  This in turn opens up the system to those who might otherwise feel that it is too complex or time consuming to participate.  This may be of particular importance when encouraging young people to become involved in consultations.

Improving customer service within the planning system is not something that is just ‘nice to have’. Planning has changed significantly over the years – and with change comes the need for reliable, cost-effective processes to drive end-to-end efficiency.

For 30 years, Idox has been supporting the work of local government planning departments. iApply, a planning application submission portal launched by the Idox Group in 2015, offers local authorities the opportunity to benefit from an out-of-the-box end-to-end digital solution that makes submitting planning, building and licence applications simple for customers and cost effective for the authority.

The private rented sector: meeting demand and improving data

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The private rented sector (PRS) has grown recently, to become a more than significant part of the housing market in the UK. A shortfall in social housing availability, and extortionate deposit costs for first time buyers has meant that demand in the private sector has grown exponentially since the 1990s, the sector now taking in clients from across the demographic spectrum.

But research has shown the demand for private rent housing is not just about finance. Increasingly, many young professionals actively choose to live in the private rented sector because they like the flexibility and locational benefits of private rents. Renting privately can mean they are able to move freely for jobs without being constrained by a mortgage, and live in city centre locations, with short commutes and close proximity to amenities like shops, restaurants, gyms and cinemas.

Despite the growing “young professional” market, the sector also (in some areas) has something of an image problem. Characterised by rogue landlords charging extortionate rents for poor quality homes, with the ability to remove tenants without reason or much notice. This negative aspect, which centres on the issue of tenant rights and security within the private sector, is something which has been discussed widely at a number of events recently, for example, at the UK Collaborative Centre for Housing Evidence (CaCHE) event we attended in Glasgow last month. It is also something which last year the Scottish Government legislated to try and mitigate.

Ensuring quality in a place people can call home

One of the other major issues that is often highlighted with PRS is the need for a minimum quality standard, bringing private lets into line with the minimum standards (supposedly) adhered to in social housing. The legislation and policing of this element of the PRS is proving more complicated to navigate, although it is something which is being discussed within the Scottish Government.

There is also the growing issue of the short-term rented sector. You cannot have failed to notice, whether you work in housing or not, the rise of sites like AirBnB and HomeAway which allow individuals to list entire properties or spare rooms out on a short-term basis. Concerns as to the growth of this market have been raised the world over. The major issues are the impact on permanent residents, who can find having new neighbours each week disconcerting, and on the local housing market more generally, as the rise of short term lets then reduces the pool available for longer term private lets. Cities like Barcelona are, however, beginning to look at how regulation and use of permits can address the negative impacts, and are being watched the world over to see if their actions will work.

How can we meet demand?

It is often said that housing is a complex flux of different sub-sectors, and that, more often than not, one cannot function effectively without the other. The PRS, the housing market and social housing are all reliant on each other to help control demand and prices and ensure that everyone, regardless of circumstance, has somewhere that they can call home.

One of the major issues with meeting demand is space and land to build; another is funding and another is understanding exactly who needs homes, and what type of homes they need. In many cases people view the private rented sector as being a stop gap for those not able to get social housing, and not able to afford a deposit for a mortgage. Although in many instances they may be right, the demographic of those renting privately now is changing, and becoming more and more varied year on year, with many young professionals and families with children now renting privately.

Understanding these trends will be key to meeting demand. In order to do this the data on housing, particularly within the private rented sector needs to improve. Research from the Urban Big Data Centre and CaCHE found that data is lacking, and that we need to improve it if we are to improve the PRS more generally.

A recent evaluation by the Welsh Government of Rent Smart Wales found that Rent Smart Wales and its database of registered landlords has provided good quality information and guidance to local authorities and landlords, as well as driving up standards within the PRS in Wales. Learning from how data collected on the Rent Smart Wales database can be maximised to provide an accessible source of information on the PRS in Wales is very important going forward, and this is something we are seeing increasingly across the sector – the desire for more data, to help those within the sector make better decisions.

What next?

A report released by LSE in June 2018 found that while the PRS has grown significantly, projections suggest that it will start to level out, and reach a state of stasis, or even decline in the coming years. Other reports have contradicted this, however, stating that unless there is an intervention or significant change in house prices, more people than ever will be forced to live within the PRS.

What does seem to be agreed upon is that better data and understanding of the sector and how to manage it is necessary and that ultimately, standards will improve across the board, with or without government intervention, but the way we view private rented sector accommodation will also change.

PRS properties will not only be buy-to-let houses, converted into HMOs, or tiny bedsits where 5 people share 2 rooms. Instead the market for sectors like build-to-rent are growing, and changing the expectations of the new generation of renters about what to expect from PRS accommodation.

In the future the ambition is for high quality, stability and housing which is suitable for a range of different tenants and their needs from young professionals and families with children, right through to older people living in retirement villages managed by a corporate landlord. It is hoped this will help stabilise rents and improve standards across the board, creating affordable places that people can plan to live in long term, with security and quality at their heart.

If you are interested in this topic, you may also be interested in the following blog posts:

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Who am I? The importance of life story books for looked after children

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paper family on hand

By Heather Cameron

Every adopted child in the UK should have a life story book – an account of a child’s life in words, pictures and documents containing information on the child’s birth family, care placements and reasons for their adoption – which is given to them and their new family when preparing for a permanent placement.

Local authorities have a statutory duty to create life story books for all adopted children, providing them with a sense of identity and understanding of their early life before adoption. They are a well-established practice in the UK and most local authorities provide guidance on preparing them.

However, research has found that the quality of life story books varies hugely.

Variation in quality

The research, conducted by the Voluntary Adoption Agency, Coram, in collaboration with the University of Bristol, focused on adopters’ perspectives on their children’s life storybooks, which it identified as lacking from the academic literature.

Although adopters welcomed the idea of life story books, they were critical of their execution. And despite accounts of positive experiences, there was a broad consensus that:

  • many books were of poor quality;
  • children had been poorly prepared to explore their histories;
  • adoption professionals and agencies did not seem to prioritise life storybooks; and
  • adopters felt poorly prepared in how to use and update life storybooks with their children.

While 40% of adoptive parents said their books were ‘good’ or ‘excellent’, a third said they were ‘terrible’.

Issues were raised around lack of communication, opportunity to provide input and what was included in the books. One adopter said “We did not have the opportunity to discuss but what I would have said was this is rubbish – all of it is rubbish”. Another said “I can never show my daughter hers because there is stuff in there that I don’t ever what her to see”.

Another theme to emerge was an excessive focus on the birth family, foster family or social worker rather than the child, and the use of inappropriate language.

For those who regarded their books in a positive light, they believed the story was told well, was age appropriate and honest, and didn’t construct a ‘fairy tale’ that would give the child an unrealistic view.

Invaluable

For adopted children, life story books can be key to providing details of their history and background, providing continuity in their life histories and preparing them for a permanent placement.

Often, they are the only thing an adopted child has by way of personal, accurate and detailed information on their past. As one mother commented on the importance of birth photos, “It’s all they have left of their own babyhood”.

Done well, they can be invaluable, as described by one adopter:

‘a good quality life storybook builds a bridge back to that huge part of her that we didn’t see and it is her main link to her past’

It has therefore been argued that life story work should be prioritised and appropriate support provided.

Ingredients for success

Coram’s research highlighted several key things for successful life story work; one being having staff dedicated to life story work.

Bournemouth has been highlighted as an example of good practice for their life story work. Their separate adoption department appointed a dedicated family support practitioner to take on responsibility for the life story books for children adopted in Bournemouth.

In 2012, the council received an ‘outstanding’ rating by Ofsted and was named as joint adoption service of the year.

Also highlighted by the research, was that gaps in the narrative were not helpful, and support for adopters is paramount, as is training for social workers.

To improve the quality of life story work across the board, Coram’s report urges adoption agencies to make considerably better use of life story books and invest in improved training for professionals, while monitoring the quality of books produced and providing better access to support and guidance for adopters to engage in such important work with their children over time.

Bournemouth illustrates the importance of doing life story work well. And as the research concludes, “linking a child’s past and present is crucial ‘bridging’ work in enabling permanence in placements”.

If you enjoyed reading this, you may also like our previous articles on kinship carers and the value of foster care.

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Focusing on the end result: outcomes based commissioning in health and social care

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In March 2016, the government announced that it was pairing up with the Blavatnik School of Government at the University of Oxford to create the Government Outcomes Lab (GOL). The aim of this partnership was to create a centre for excellence in commissioning research and practice – to find new and innovative ways for the public sector to commission projects, provide on the ground support to local commissioning teams and become a world class research centre on effective models of commissioning.

belangrijke-sales-opdracht2

Payment by service vs payment by results

Traditionally, governments contract third-party service providers on a ‘fee for service’ basis – so commissioners prescribe and pay for a particular service that they believe will lead to a desired outcome. More recently however, commissioning teams have started to introduce elements of ‘payment by results’ or ‘pay for success’ when commissioning services – so providers only get paid in full if they deliver the desired outcomes.

Social impact bonds

Social impact bonds (SIBs) are a tool to help outcomes-driven providers deliver on their projects, by giving them access to financing and management support from “socially-minded investors”. The idea being that this will broaden the pool of skilled providers, encourage smaller more locally based providers to tender for projects (who may have been reluctant to previously because of cost and lack of support) and, potentially, increase the chances of the service being successful.

One of the primary aims of the Government Outcomes Lab is to consolidate and promote as far as possible the use of social impact bonds to align social value based commissioning with commissioning for measurable outcomes – to promote a social value as well as an economic value in the way providers deliver on contracts. There are now 32 Social Impact Bonds across the UK, supporting beneficiaries in areas like youth unemployment, mental health and homelessness.

Gear

Benefits and challenges to outcome based commissioning

While to many people it may seem almost impossible to question the principle of outcomes based commissioning (to move from a system focused on process measures and targets to a system that is focused on improving the outcomes that matters to citizens and patients) the reality for commissioning teams, providers and service users is, in some cases, very far removed from this ideal.

In April 2012, the Audit Commission published its guidance on Payment by Results (PbR). This generated fairly positive messages around PbR but also advised commissioners to be aware of the risks:

“At its best, PbR can deliver savings and bring in new resources at a time when budgets are under great pressure. It also defers costs to commissioners to allow time to realise the benefits of change and preventative work….. However, PbR carries extra risks to securing value for money and requires higher level commissioning skills than more traditional approaches”- Audit Commission (2012)

Much of the literature on outcomes based commissioning models emphasises the importance of:

  • transparency;
  • agreed objectives;
  • agreed measurable outcomes;
  • communication and clear definitions of accountability between commissioners;
  • any social investors or third sector bodies with input;
  • providers;
  • and any secondary providers who may be awarded subsequent sub contracts

A more comprehensive list of pros and cons to outcomes based commissioning can be found here.

One high-profile intitiative which has faced more challenges than it has produced benefits is the “troubled families” programme. which aimed to support families with long-standing problems. The programme was heavily criticised for its payment by number (number of clients processed) rather than payment by specific outcome. The issue here appeared to be the lack of definition of outcomes and what was going to be expected of the provider in terms of service before they could be paid.

In this instance the organisations delivering the “troubled families” programme in some areas were being paid for the number of people who went through the service, rather than the number of people who completed the programme successfully, or saw notable improvement as a direct result of the input of the programme, and without taking note of the professional view of the quality of the service being provided (which was considered in some areas to be poor). This resulted in providers being paid for a service which, while many people used, did not actually achieve the expected outcomes. This is something which future commissioning bodies must take note of and act upon to ensure that any future agreements do not contain such massive loopholes with regards to payment.

Outcome Flow Chart

Outcome Flow Chart via Roma Learning Leaders

Outcomes based commissioning in health and social care

A number of different policy areas have begun to use outcomes based commissioning models with varied success (although as we have seen this can be as much to do with the quality of the provider and the transparency of the contract as it is about the implementation of an outcomes based model). Rather than focusing on inputs (e.g. number of doctors) or outputs (e.g. number of operations conducted, or amount of drugs administered), these commissioning models are based on achieving specific, predefined and measurable ‘outcomes’ (e.g. improved health).

In a specific health and social care context, outcomes based commissioning can, if done well, form a key part of a wider prevention agenda, as well as helping to improve personalisation of services. In Wiltshire for example, the council has employed outcomes based commissioning techniques in relation to its domiciliary social care teams. This example shows that when the right providers are selected and clear outcome measures are defined, the impact for service users can be significant, in a positive way: there is a strong focus on getting the best possible result for the customer in the way that suits them; with every visit having a clear purpose and a focus on achieving greater independence for the older person wherever that is possible (which is the overall wider outcome the commissioning teams were hoping to achieve – greater independence of service users and less reliance on the social care teams in the long term).

Some specific challenges in a health and social care context include coordinating payment for outcomes with direct (or personal) payment schemes and agreeing on realistic and well defined outcomes and time frames with service users (which if done well can have a very positive impact on the personalisation agenda of services) Attributing outcomes specifically to one set of interventions in health and social care can also be difficult, particularly if a service user is in receipt of a number of different strands of care, for example, primary care and domiciliary social care as well as having access to some remote telehealth facilities.

Commissioning for long term outcomes

If the issue of defining or attributing outcomes is a challenge for outcomes based commissioners, then the issue of planning for long term outcomes is even more difficult. This approach requires commissioners to have a long term view of the strategic aims of a programme, as well as requiring them to consider any factors which may influence or change these aims, and additionally to consider the scope of need in the future if other preventative measures are successful.

Advice for councils

The LGiU and academics at Oxford Brookes University, as well as many others, have published guidance for local authority commissioning teams, giving them some direction in relation to best practice in outcomes based commissioning. Some of the key “pointers” for councillors include:

  • Take time to get the right set of providers in place to deliver the new model and collaborate with them to get the best possible system in place – be thorough in research and consideration of tenders.
  • Be very clear what the likely outcomes are that any specific service is being asked to deliver.
  • Make the payment mechanism as simple as possible. Consider whether any rewards will be paid for good performance in delivering outcomes. Consider if payments should be made on each individual outcome achieved or for outcomes for sub-sets of the population e.g. hospital discharges.
  • Make use of the public, their opinions and data collected about them to assess the needs of the population and reflect this in the agreed outcomes.
  • Try to implement outcomes based commissioning as part of wider transformation within the organisation – in order to improve quality, reduce costs and improve efficiency (particularly in health and social care) other infrastructure and practices (such as IT systems and skills development in staff) need to be addressed in addition to commissioning models in order to bring about change.

Further reading about health and social care on our blog

Co-production in social care … a need for systems change

Why a holistic approach to public health and social care needs a wider evidence base … and how Social Policy and Practice can help

What’s happening to make big data use a reality in health and social care?