Radical Place Leadership: The Public Money that Falls Between the Silos
- Andrew Laird
- 2 days ago
- 12 min read
This long-read article by Andrew Laird and Prof. Donna Hall sets out a new way of considering public money across a “place” and provides indicative examples of the cashable savings that could be made from a new Radical Place Leadership approach.
Many thanks to Mark Smith and Prof. Hannah Hesselgreaves for support on ideas and data.
What problem are we trying to solve?
Why has the NHS received big year-on-year budget increases - but productivity has fallen? Why are councils spending more money than ever on children’s services with poor outcomes and facing bankruptcy? Is the way we organise public services around silos rather than people in desperate need of an overhaul?
Almost half of all councils in England are at risk of effective bankruptcy within 12-15 months. The issues are particularly severe in people services – both children’s and adults social care, which is the vast majority of an upper tier council’s budget.
The prevailing New Public Management approach forged in the 1980s, would say the sensible course of action is to demand “more for less” from each service area, possibly raising eligibility criteria thresholds, increasing fees and charges or council tax for the public, lowering targets and tightening or cancelling individual contracts with providers. Responding to the budget gap, many Finance Directors will be ordering across the board cuts. Salami slicing 10% or more from each department year on year until they become so emaciated as to be ineffective.
Through this approach, savings may be found and short-term financial targets may be hit – but finding efficiencies in services which remain siloed is not sustainable. There are several main reasons for this.
Focussing on in-service savings fails to address top-line demand in the whole system Over time, these “savings” will be lost as inefficiencies build up again as siloed services are unable to get past their required focus on the presenting issue/condition. Demand for services will therefore continue to grow and in a couple of years, the service will be back in the same situation with people originally referred into the service returning with more 'costly' needs as their situation deteriorates. Unable to cope with demand with Finance Directors asking for yet more efficiencies.
Looking for efficiencies in a siloed service does nothing to address the huge amount of cost (human and financial) of passing people from one siloed service to another. This involves repeated and costly assessments and requires vulnerable people to tell their story over and over again. As needs become more complex, the spaces between services increase in both size and number and costs ratchet up.
It isn’t just repeated story telling that takes up valuable time but the repeated assessment and referral processes. This is where over 80% of People Services spend their valuable staff and commissioning resources – assessing the same people multiple times rather than using this precious resource to support people directly. The money is locked into the handoffs between different agencies.
Linked to this, dealing with siloed services individually will do nothing to address the huge amounts of duplication of support and administration tasks that exist between services and organisations across a place. Any workshop which brings together staff groups from council run adult social care and NHS run community services will expose the full nature of this challenge.
It is often “non-statutory” services which are targeted for savings. Failure to see the connection between prevention and demand and to join the dots across the silos means that statutory services are protected from deep root and branch transformation. Often non-statutory services are the preventative services. Cutting these services only increases demand in the more expensive acute part of the system resulting in increased costs.
Entry points for citizens into public services are often through a siloed front door of expensive specialisms as the first port of call. There is an underinvestment in general practice and community services who could pull in specialisms once triage takes place in a community setting. This is like putting the CEO of an organisation on reception! It occurs in both the NHS and Council services – especially children’s and adult’s social care. A remodelled workforce plan with an increased proportion of generalist relationship builders at the front door in integrated neighbourhood teams will save the time of expensive specialists and reduce waiting times for services.
The community and voluntary sector are valuable partners in local neighbourhoods who can support people in need in imaginative and innovative ways. Frequently they are dependent on diminishing grants where the true value of their impact on children’s and adult’s services and wider health and well-being isn’t recognised. As part of a model of radical place leadership, investing to save in grass roots neighbourhood groups is supported and enabled.
Public service leaders are aware that the current system is not meeting the needs of the people they serve and is increasingly unsustainable financially.
When you look at a council’s budget and see the increasing proportion of spend going on statutory children’s and adults’ services, it must be difficult to resist the temptation to simply try to run a “tight ship”, doing what you must, as efficiently as you can…
When we challenge this way of working, services will often say they are collaborating - but it is usually to solve the specific problem the siloed service is trying to address, once a person has presented with a condition or issue. Generally, it does not get to the contextual, non-service-specific heart of the problem. As set out in the points above, this approach fails to tackle the underlying challenges individuals and families face and therefore also erodes public trust.
Thankfully, there are public service Chief Executives and other senior leaders who are resisting this temptation and now see themselves as “place leaders” not just the deliverers of a set of services. They understand the much wider convening role they can play with other public services, such as the NHS, police, DWP as well as voluntary and community sector organisations.
Systems, Places and Neighbourhoods
What is “place” anyway and is it important? I ask the question as some of the NHS leaders we speak to are starting to focus more on their system (ICB) goals and targets and how they can link those directly to neighbourhood working as their delivery mechanism.
Better integrated working at a neighbourhood level is the right goal for public service reform -but de-emphasising “place” is a mistake. “Place” is the space between systems (the emerging Strategic Authorities, ICBs/ICPs) and neighbourhoods (integrated neighbourhood teams) where public service leaders need to get together to create an enabling environment for truly joined up and collaborative neighbourhood working. This isn’t possible at a system level – there are too many players and it’s too large a scale to be able to think locally and forge the relationships that are needed. This collaboration happens best at a place level and usually on a council footprint.
Thankfully, many in the NHS, police and wider public services now get the need for their work to integrate with services which can more readily impact the wider determinants of health and wellbeing and ultimately control demand for their services.
The concept of “place” is also important as an emotional connector. Rebecca Madgin and Michael Howcroft made this point beautifully in a recent report for the Arts and Humanities research council. They set out the difference between a "place" and a "space". Both are geographic locations - but a space is a "realm without meaning" while a place is a "centre of meaning comprised of feelings, emotions and experiences".
Systems are really just big spaces and hold very little meaning for residents. We know from experience that this makes it very hard to engage with partners and the public on future ambitions/goals/missions or to establish meaningful buy-in in the way Wigan did with the "Wigan Deal" and Sheffield is doing with its "City Goals".
Radical Place Leadership
What do we do about this?
This is where the concept of Radical Place Leadership comes in.
The Mutual Ventures Team, working with Mark Smith and Georgina Cox, are very focused on how we can help stop the tragic waste of public money and poor outcomes for citizens caused by siloed services. We have been working with several councils and health and care systems to design a new model of Radical Place Leadership. This builds on the experience of designing and implementing the Wigan Deal and also from Changing Futures Northumbria and the “Liberated Method”, developed by Mark Smith. Our focus is on how you create an enabling environment so that the type of properly integrated neighbourhood level working becomes the local system, rather than having to fight against it.
We do this by getting the leaders in a place (Council, NHS, third sector, police and others) to look at the evidence and accept that without better collaboration and a more person-centred approach, none of them will be able to achieve what they need to achieve on cost savings or outcomes. To make it real and practical, we identify the top shared challenges they all face. For example, in a London Borough, homelessness is a common challenge across services and organisations. It is a real problem that does not respect service silos.
Having common priorities, missions or goals acts as a catalyst to bring leaders together to create the enabling environment for innovations like the Wigan Deal or the Liberated Method to thrive and be sustainable.
The ultimate ambition is integrated working at a neighbourhood level, with co-located teams of public service professionals and community leaders across all service areas who are equipped and enabled to do what it takes to support people out of their crisis cycle. These teams are empowered to really get to the core challenges people are facing. There will be no need for costly repeated assessments and referrals or duplication of effort as there will be a single plan for every vulnerable family and individual.
The critical element is that the leaders within the “place” are signed up to it and the work doesn’t exist in a fragile bubble which could easily burst.
It's also worth saying that this isn't about reinventing the wheel. There will be things in existence in your place like community hubs and the emerging health-driven Integrated Neighbourhood Teams or council driven family hubs. This is quite often about stitching together what's already there in a way that makes sense to the people you are trying to support.
Identifying savings
The ultimate goal of Radical Place Leadership is to enable more relational and collaborative support to vulnerable people who are stuck in crisis and are costing the system a lot of money.
There are a number of examples of where more relational ways of working have been deployed – albeit usually in a “bubble” rather than as an approach adopted by a whole system or place. Research from Prof. Hannah Hesselgreaves and Prof. Toby Lowe shows that local Human Learning Systems or “relational” approaches are showing an average drop in public service use of approximately £50,000 per person per year (for particular individuals this can be a lot higher – see Brian’s case study below). Using government estimates of 363,000 people experiencing severe and multiple disadvantage (at least three of homelessness, mental ill-health, substance misuse and violence and abuse) implies savings of over £18 billion in England alone. Broadening this out to include all 586,000 who experience severe disadvantage (at least one of the problems listed above) and the potential saving rises to £37 billion.
The practical experience of the Changing Futures Northumbria Programme led by Mark Smith has shown that savings are rapid.
Brian’s Case Study – Changing Futures Northumbria
A case study example of one person from the Changing Futures Northumbria programme, utilising the relational Liberated Method, demonstrates a saving of £2m over 10 years for Brian. This is a big number but may still underestimate the full cost of supporting a person in a disjointed, siloed way.
Brian’s interactions – Pre-Liberated Method
- 3355 total interactions with public services (minimum).
- 1000+ health interactions (Brian is a former #1 attendee @ A&E).
- 1000+ police/Criminal Justice interactions.
- Brian suffered declining outcomes throughout alongside an escalation in consumption.
- £2M (minimum) total cost of interactions over 10 years.
Brian’s interactions – Post-Liberated Method
- 161 Liberated Method support interactions.
- 7 public service interactions in <12 months since the start of the Liberated Method approach.
- Brian is now in recovery and building his own support network.
- Changing Futures Northumbria spend circa £80k a year supporting Brian, mostly on accommodation.
This pattern is broadly replicated across the Changing Future Northumbria cohort.
Driving out cashable savings
Identifying where costs lie and reducing demand individual by individual is the first part of the solution. The second part is actually driving out the costs into cashable savings. The best example of where this has been successfully achieved is in Wigan.
The Wigan Deal case study
Under the leadership of Professor Donna Hall, Wigan Council implemented the “Wigan Deal” and over a seven-year period were able to cut £180m (cumulatively from the council budget) and reduce headcount from 7,500 to 5,000.
The key steps which were taken to not just identify but to drive out the savings are set out below:
· They took a corporate and whole system approach to setting the budget and cost reduction each year rather than the traditional departmental approach. This is a huge problem in the NHS also. After it was trialled it in Adult Social Care and achieved huge cost savings there was a change of focus year on year.
· Cutting each department by 10% a year fails to address where real cost lies. It just erodes preventative non-statutory services, in turn increasing cost.
· They looked at the costs of failure demand with specific individuals and families (like Brian).
· The council and partners identified those who needed intensive support through risk stratification. Names and addresses were found and targeted through GP led integrated Neighbourhood Teams.
· Support was redesigned for these individuals and families based on a liberated approach, where front line staff are freed up to support in relational ways.
· Staff were given the permission to innovate with courage as a core value. Frontline teams can see the wastage and poor outcomes every day.
· Demand for acute services was reduced by shifting resources across NHS and council towards prevention as a long-term strategy.
· A £12 million Community Investment Fund where grassroots organisations submitted innovative proposals to reduce cost and improve outcomes enabled stronger support in local communities.
· The focus was on the biggest areas of spend, i.e. children’s and adult social care services. These were the areas which generated most savings. They reduced the 26 different adult social care access points with separate teams and eligibility criteria. The focus was on preventive support in children’s – e.g. PAUSE, community respite support, CAMHS in the community and in schools.
· All aspects of the workforce were restructured using a “one front door” triage model across all services.
· Staff costs were reduced by deploying generalists rather than expensive specialists at the front door; pulling in specialist support as and when required.
· A reduction and streamlining of multiple contracts for the same thing across health and care, e.g. 10 different duplicatory contracts and access points for musculoskeletal services!
We have included some additional sources of evidence for the cost savings which can be achieved through this way of working in Appendix A.
To support those who want to make the case for Radical Place Leadership, the team at Mutual Ventures are working with partners to further model the cost reductions and avoidance this way of working can achieve.
Watch this space!
Andrew Laird
Prof. Donna Hall
The authors would like to thank Mark Smith and Prof. Hannah Hesselgreaves for reviewing and contributing ideas to this article.
Appendix A – Additional resources
Highland Hospice example
“Many aspects of spending on the last year of life are unknown, including informal care from family and carers, social services, community nursing and core general practice. Of the spend we do know about, the amount spent on people in the last year of life in NHS Highland Health has remained much the same over the period 2017-18 to 2019-20, with £44 million being spent in 2019/20. 71% (£31 million) of that £44 million is spent on emergency admissions. Bed occupancy related to emergency admissions for people at the end of life has increased from 25.2% of all emergency beds in January 2016 to 29.7% in July 2022. Spending on GP out of hours services for people in the last year of life increased by 18% Hospice 7 charitable service spending has increased by 27% over the period 2017-18 to 2019-20 (in line with 23% increase of inpatient activity, and 124% increase in outpatient hospice activity).”
Crisis/PWC analysis on homelessness (2018)
“Homelessness generates a financial, social and economic burden for society. In 2015-2016, local authorities spent more than £1.1 billion on homelessness (excluding any wider costs from the impact of homelessness on public services such as health services). More than three quarters of this was spent on the provision of temporary accommodation.3 In 2014, it was estimated that Scottish local authorities spent £94 million on temporary accommodation for homeless households.4 Recent research for Crisis suggests that, if current policies continue unchanged, the most acute forms of homelessness are likely to increase by more than 15% in the next decade and almost double by 2041.5 Moreover, if current policies continue, research shows that ‘wider’ homelessness, defined as a range of situations where people are at risk of homelessness or have experienced it, is also likely to increase.”
The cost of late intervention: Early Intervention Foundation analysis (2016)
“Nearly £17 billion per year – equivalent to £287 per person – is spent in England and Wales by the state on the cost of late intervention. This is in line with EIF’s previous estimate, which was also just under £17 billion. While the estimated total is as before, our latest analysis shows that the profile has changed. For example, expenditure related to domestic violence and abuse has risen, while spending on late intervention for young people not employment, education or training has fallen. There are other changes driven by movements in the underlying data or improvements to our own methodology.”
“Nearly £17 billion per year is spent in England and Wales by the state on the cost of late intervention – in line with EIF’s previous estimate.
This works out at around £287 per person.
The largest individual costs are:
· £5.3 billion spent on Looked After Children
· £5.2 billion associated with cases of domestic violence and abuse
· £2.7 billion spent on benefits for young people who are not in education, employment or training (NEET)
The cost of late intervention is spread across different areas of the public sector, with the largest shares are borne by:
· local authorities (£6.4 billion)
· the NHS (£3.7 billion)
· DWP (£2.7 billion)”
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