Greater Manchester Public Service Reform

The Origins of Reform The reform journey has highlighted the importance of having a clear evidence base to

support implementation

MIERManchester Independent Economic Review demonstrated strength of economy, economic assets, growth potential

GMS

Greater Manchester Strategy priorities of economic growth and reducing dependency

Total Place Total Place mapped total GM spending

CBALeading Cost-Benefit Analysis developed with 10 Government departments - whole system costs and benefits of reform

Community Budgets for complex families and the national Troubled Families programme, generating evidence for reform

Complex families

GM one of four national pilots for Whole Place Community BudgetsWhole Place

CB

GM Growth and Reform Ambition

• A vision to move GM from being a cost centre to a net contributor to national public finances• GM’s economy currently generates £20bn in taxes • BUT requires £27 billion in public spending• We are seeking greater control over the levers and resources available to the public sector to

close this gap

Developing Reform

Core Reform Principles

• A new relationship between public services and citizens, communities and businesses that enables shared decision making, democratic accountability and voice, genuine co-production and joint delivery of services. Do with, not to.

• An asset based approach that recognises and builds on the strengths of individuals, families and our communities rather than focussing on the deficits.

• Behaviour change in our communities that builds independence and supports residents to be in control

• A place based approach that redefines services and places individuals, families, communities at the heart

• A stronger prioritisation of well being, prevention and early intervention

• An evidence led understanding of risk and impact to ensure the right intervention at the right time

• An approach that supports the development of new investment and resourcing models, enabling collaboration with a wide range of organisations.

Reforming Spending

• Despite cuts, spend has not reduced to date due to increases in welfare spending• Work and skills is at the centre of our approach to tackling growth and reform.

Increasing productivity, promoting independence and reducing dependency on public spending

LA public health £0.2bn

We’re committed to delivering improved outcomes

Across GM, we are currently spending far too much on the costs of failure, much caused by issues of complex dependency. The analysis set out earlier in this Plan shows that despite the level of budget cuts to public services the total level of spending across GM has not reduced, with decreases in spending by local authorities, the police and others, offset by increases in the costs of welfare benefits and to a lesser extent, acute care. In order to maximise the benefits of our investment in growth it is critical there is also investment to connect GM residents to that growth and to address both the productivity gap and to tackle the rising costs of public services.

GM Growth and Reform Plan, March 2014

Health and Social Care Devolution

GM SR commitments Existing Reform Programmes

• Improving school readinessrates by 5 percentage points in 5 years

• Reduction in the number of looked after children by 20% in 5 years

• Increasing the number of young people who leave school with 5 GCSEs (A* to C grades) by five percentage points in 5 years

• An 8 percentage point uplift in employment outcomes for the long-term workless in GM over 5 years

• Reduction in the incidence of re-offending among target cohorts by 40% over 5 years

• Supporting 50,000 people facing complex challenges move towards employment

• Engaging and supporting a 27,200 families though the expanded TF2 programme

• Reductions in reoffending due to Intensive Community Orders

• reductions in reoffending due to work of Women’s Centres

• Implementation of Early Years New Delivery Model

• Reductions in duplication through better integrated local service provision

• 64,000 less people with chronic conditions

• 10% less visits to urgent care

• 6,000 less people being diagnosed with cancer

• 25,000 people with severe mental illnesses will benefit from better community-based care, reducing need for urgent services by 30%

• 18,000 children better supported by local services

• 700,000 people with chronic conditions, better able to manage their own health

Health and Social Care Devolution

GM SR commitments Existing Reform Programmes

• Improving school readinessrates by 5 percentage points in 5 years

• Reduction in the number of looked after children by 20% in 5 years

• Increasing the number of young people who leave school with 5 GCSEs (A* to C grades) by five percentage points in 5 years

• An 8 percentage point uplift in employment outcomes for the long-term workless in GM over 5 years

• Reduction in the incidence of re-offending among target cohorts by 40% over 5 years

• Supporting 50,000 people facing complex challenges move towards employment

• Engaging and supporting a 27,200 families though the expanded TF2 programme

• Reductions in reoffending due to Intensive Community Orders

• reductions in reoffending due to work of Women’s Centres

• Implementation of Early Years New Delivery Model

• Reductions in duplication through better integrated local service provision

• 64,000 less people with chronic conditions

• 10% less visits to urgent care

• 6,000 less people being diagnosed with cancer

• 25,000 people with severe mental illnesses will benefit from better community-based care, reducing need for urgent services by 30%

• 18,000 children better supported by local services

• 700,000 people with chronic conditions, better able to manage their own health

Current PSR Themes

PublicServiceReform

StrategicDevelopment

Information Sharing

ServicesFor

Children

EarlyYears

JusticeAnd

Rehabilitation

Employmentand

Skills

ComplexDependency

Growth and Reform

Growth and Reform

GM has made significant progress in implementing reform programmes

TROUBLED FAMILIES WORKING WELL JUSTICE & REHABILITATION EARLY YEARS COMPLEX

DEPENDENCY

PHASE 1 OUTCOMES: All targets in phase 1 of the programme achieved

PHASE 2 ON COURSE: 75% (6,600) of GM TF2 allocations for early starter phase and 15/16 are engaged

STRONG STRATEGIC POSITION NATIONALLY: Only sub-region to become an early adopter for phase 2

GM outcomes framework has influenced the national approach

PILOT OUTCOMES: 3,700 people now attached to the programme, 132 people have moved into work

EXPANSION AGREED: Expansion of the programme agreed through devolution agreement, procurement is underway and the expanded service is due to begin in February

INFLUENCING NATIONAL EMPLOYMENT & SKILLS REFORM: WW approach influencing both DWP and CLG strategy on supporting those furthest from the labour market (though discussion with DWP on other areas of reform remains a challenge)

EMBEDDING REFORM PRINCIPLES: Programmes to support women offenders, young offenders, and others are embedding an integrated approach to justice and rehabilitation

IMPROVING OUTCOMES: Only 6.5% of women referred to centres established to support women offenders have re-offended.

561 Intensive Community Orders have now been made, re-conviction rates stand at 19.7% (compared to 32.6% for adult reoffending: GM Probation Trust)

1,512 offenders being managed through integrated offender management model

NEW DELIVERY MODEL: Places implementing different elements of the new delivery model

NEW STRATEGY IN DEVELOPMENT: Early Years strategy development underway, aligning with Health & Social Care reform

DEVELOPMENT OF HUBS: 5-6 LAs now have integrated multi-service hubs in place

PLACE-BASED INTEGRATION: Place-based integration pilots beginning in Tameside and Wigan, other places are lining up to develop their approaches shortly

TROUBLED FAMILIES

Expansion to 27,200

WORKING WELL

Expansion to 50,000JUSTICE &

REHABILITATION EARLY YEARS COMPLEX DEPENDENCY

Challenges identified through a review of existing programmes & integration

• PACE & SCALE: Pace and scale of implementation of new delivery models is variable across GM.

• COHORTS & PROGRAMMES: Families and individuals being worked with often have issues and needs in common. Still divisions into sub-cohorts and programmes - recreates siloes, single issue focus and thresholds. Local and GM Governance reflects this.

• DUPLICATION: Programmes are integrating support from a similar range of services around individuals and families, and have common operating processes (e.g. referral, multi-agency triage, assessment, multi-agency case management). As scale increases, overlap of cases is likely to increase and there is potential for duplication.

• COMMISSIONING & INVESTMENT: Common opportunities to invest at different spatial levels, or in innovative ideas to improve outcomes emerging. Without coordination we make separate commissioning decisions and risk duplication of commissions, and services which don’t integrate effectively and meet the needs of this population.

• OUTCOMES: Implicit understanding of shared outcomes at person or family level, this is not built into practice at GM or local level. Performance management focused around individual programmes or single outcomes.

• QUALITY: Services need to be effective in changing behaviours and increasing resilience. There is currently variation in the means of assessing need and the response or intervention delivered in different places.

• EVALUATION: While we do look across the reform landscape in our evaluations, each programme tends to commission its own evaluation exercise and we are not in a position to bring these together

A place-based approach to reform

1. A new relationship between public services and citizens, communities and businesses that enables shared decision making, democratic accountability and voice, genuine co-production and joint delivery of services. Do with, not to.

2. An asset based approach that recognises and builds on the strengths of individuals, families and our communities rather than focussing on the deficits.

3. Behaviour change in our communities that builds independence and supports residents to be in control

4. A place-based approach that redefines services and places individuals, families, communities at the heart

5. A stronger prioritisation of well being, prevention and early intervention

6. An evidence led understanding of risk and impact to ensure the right intervention at the right time

7. An approach that supports the development of new investment and resourcing models, enabling collaboration with a wide range of organisations.

Our revised reform principles highlight the importance of taking a place-based approach to the delivery of reform, ensuring our reform of public services supports neighbourhoods and communities across the conurbation to contribute to and benefit from growth in GM

GM REFORM PRINCIPLES

Integrated models of reform

Devolution provides GM with a unique opportunity to reconfigure our approach to local services

Given the scale of the opportunity, failing to align our broader approach to reform with the health and social care change programme would be a missed opportunity.

The achievement of our health and social care ambitions are also dependent on services outside these sectors: an integrated response is required

GM H&SC reform Broader GM reform

Early intervention and prevention strategy:

Improvement & Efficiency:

• Our strategy should include implementation of a single Early Years strategy, wellness offers and should tackle complex dependency (early intervention and prevention must be part of universal and specialist service plans)

• Ensuring GM residents and communities are supported to avoid escalation risk (equally applicable to medical and non-medical risk)

• Supported by effective use of data (understanding level and location of need and assets across GM)• Delivering and integrating services in ways that recognise the interdependencies in outcomes (i.e. positive

mental health outcomes associated with employment)

• Identifying appropriate cross-sector (or cross-locality) back office savings through integration and collaboration• Working in clusters to improve standards of service through development of sectors of excellence (e.g. approach to

some elements of the Services for Children review)• Implementing GM standards (not standardising) – ensuring all GM residents are able to access support shown to have

positive impact• Providing integrated packages of support to GM residents, requiring collaboration across sector. This should be

managed proactively in localities, based on robust use of data that helps us identify risk, ensuring integration is being managed in a coordinated way.

Working at different spatial levels across GM

Proposals for implementation of health and social care reform are also supported by a place-based model. Planning is based around four distinct spatial levels

Supporting a place-based, integrated model of reform

GM

(3+ million people)

Clusters

(0.5-1m people)

Localities

(~250,000 people)

GM decision making should be informed by clear performance information and tracking of outcomes. The impact of neighbourhood, locality, and cluster delivery arrangements can then inform GM strategic decision making

Integrated strategic decisions, across GM and across sectors…

…enabling the development of clustered centres of excellence (for some service areas), providing high quality and efficient services for all of GM…

…supported by integrated local leadership, coordinating to ensure the right mix of services are available in a place and can be sequenced at the right time.

Frontline problem solving teams enabled to work collaboratively, incorporating specialist provision when needed (from teams that have an understanding of the place)

Integrated GM strategic decision making will only deliver improved outcomes if supported by integrated governance, leadership and accountability at all spatial level

Neighbourhoods

(~50,000 people)

Key findings and learningKey findings and learningfrom Place-based early adopter sitesfrom Place-based early adopter sites

Demand Analysis

48 Cases

1,235 Incidents of demand

Receiving Specialist Service27% of cases

43% of demand

Not Coping39% of cases

40% of demand

Well adapted34% of cases

17% of demand

Hyde Area

85% known to >1 Agency63% known to Mental Health

49% of Police demand known to Mental Health

The current system is set up to deal effectively with just 17% of demand

The other 84% of demand requires a tailored response

Just over half of this would come under ‘Specialist Service’ leaving 40% of demand not meeting threshold but in need of more than just universal service

Demand Analysis

Demand moves around or presents variably in the system

Triage, assessments and referrals dictate workflow

Offer interventions from a ‘menu of options’

We deal with demand as it ‘presents’ not necessarily in ‘context’

Focus on what is wrong with people

Pass/escalate to specialists without truly understanding the problem

Interventions are often at the point of crisis, we miss the opportunity to intervene early

Silos within and across organisations

System Study Findings

System Designed Constraints & Blockages

Redesign Operating Principles

Understanding what is required in the redesign of frontline roles through the experiment

Competencies, Skills and Powers Framework

Understanding the degree to which specialist and targeted services are required at the frontline to inform commissioning strategies and deployment of resource at different spatial levels

Redesigning Frontline Roles

A performance management framework that links individual outcomes (‘citizen value’) to wider population outcomes and is used to assess system performance

Understanding and Measuring Citizen Value

“Understand ‘where people are’ and what strengths and assets can

help”

“Join up what we have”

“Work around the system madness”

“Get it to the right agency the first time or as quickly as possible”

Evolving A

ssumptions

“Measures of organisational performance based on citizens achieving ‘what matters’ to

them”

“Design for what is needed”

“Design out the system madness”

“Understand and act on the problem to solve holistically in an integrated way”

Place-based Integration – What’s Different?

Next steps

Implementation of integrated place-based leadership• The integration place-based pilots currently rolling out across GM provide an opportunity to test integrated place-

based leadership at scale in 2016-17, potentially paving the way for implementation of a GM model in 2017-18.

• Convergence of PSR programmesSingle framework for operational delivery with agreed standards developed for GM and single outcomes framework.

Alignment with Health and Social Care• As locality health and social care leadership and delivery models emerge, alignment with wider locality based

planning will be required.

Information sharing • GM proposals to strengthen information sharing were approved in January and this will strengthen GM’s ability to

move to a more integrated local service model.