Housing Futures 3

The above argument has been given added traction against the recent backdrop of various policy announcements from politicians, think tanks and commentators calling for a revitalised preventative state. The UK Labour Party’s next general election early manifesto refers to outdated, dysfunctional systems, reticence to change borne of cultural, political and structural factors, challenging misguided targets, for honest conversations that are feasible and practical and to rebalance public and private ownership (‘Big Con’, Mazzacuto & Hollingsworth. UK Labour Party press releases May 2023).

Demos’ publication: ‘The Preventative State’ calls for a unifying new model for public services reform, focusing on stopping rather than servicing increasingly beleaguered populations. Using money within our systems more smartly to achieve transformative outcomes, silo busting, devolving power to neighbourhoods and a new universal approach to services to reduce demand in the long run. Others making similar noises include Institute for Public Policy Research, Tony Blair Institute for Global Change, Centre for Progressive Policy and Reform, to name but a few.

Patricia Hewitt, former Health Secretary, Hewitt Review (December 2022) focused on the oversight and governance of integrated care systems enabling their success through greater autonomy with a particular focus on real time data across the system. The report contains recommendations to empower local leaders to improve outcomes, fewer but more strategic targets reflecting local priorities and particular needs of communities. While Hewitt’s remit focuses on England, the issues are universal and therefore will be applicable across Wales, Scotland and Northern Ireland. The important thing to note is a wellness perspective helps generate fundamentally different models for integration between public services and interplay with non-state actors, models of social care, balance between institution and community-based support and future workforces. Importantly, it is also entirely consistent with Bevan’s founding vision of the NHS.

Neither is the argument exclusive to opposition political parties and centre-left leaning think tanks and commentators. “We know that the determinants of health are much broader than what happens in hospitals. They include housing, wider care and education. Joining up is an imperative…”(Helen Whateley, Minister for Social Care)

“Local leaders are best placed to make decisions about their local populations…with fewer top-down national targets, missives and directives and greater transparency to help us hold the system to account.” (Steve Barclay, Secretary of State for Health & Social Care).

And more broadly the levelling up mission retains its laudable aim of improving healthy life outcomes and narrowing health inequalities, albeit without a coherent vehicle to achieve it.

Labour’s narrative is that poor productivity is the consequence of poor health. This has resulted in a policy framework which recognises the high concordance between health and broader economic change. Whilst there are few new ideas there is an overall coherence and concordance of policy proposals. Alongside this is a stronger voice from the grassroots with community, voluntary organisations pressing the case to move away from preconceived, standardised services, empowering people to understand what matters to people and not waiting for permission. The emergence of civil society actors is perhaps the most significant aspect driving a radical agenda for change. In the case of housing associations spanning many decades being significant beneficiaries of state subsidy allowing their growth of huge assets. Crisis more than at any other times calls for mutual reciprocity. In the next section I talk about what would it take for existing institutions to deliver a whole systems agenda.

The consequence of existing structures is funders support individual programmes which generally do not allow for movement from one service to another and do not pay for integration roles, processes and performance measurements. Where there is some allowance, albeit marginal is what is commonly referred to as ‘contract wizardry’ – meaning the ability to figure out exactly what is allowable through each funding stream and then pressing against those limits, taking pieces of funding from various funding streams to develop services or initiatives. Whilst helpful, it can create an uncomfortable position with auditors and commissioners plus it adds to the administrative burden and cost.

How do we then gain enough traction to change the way government agencies do things?

The reality is in uncertain economic times budget constraints leads to often viewing progressive approaches as highly promising, but if unable to demonstrate short-term results the ask is made harder.

“Collaborative behaviours, which are the bedrock of effective system outcomes, are not always encouraged or rewarded in a system which still relies heavily on siloed personal and organisation accountability.” (Messenger Review)

Many of us have talked over the decades about the need to focus on prevention, population health and health inequalities. We have called for a shift from top- down to a responsive to local communities’ system. What makes this feel different this time is the unprecedented degree of cross-party support amidst perpetual crisis and seemingly forlorn hope.

I advocate a three-pronged strategy to convince funders, government and commissioners supporting the wider merits of social housing organisations becoming an intrinsic feature in the ‘whole systems’ response.

1. As a solution its already on funders’ radar
2. Cost efficiencies
3. Quality of service and improved life outcomes

There are few comparators with the reach, credibility, legitimacy, trust, capacity and resources to deliver such an ambitious and transformative programme particularly given the socio-economic makeup of the customer base. Worth a reminder here that almost one in two social housing households are headed by a person with either a registered disability or long-term limiting illness. Given the data limitations it is widely understood the actual numbers which does not currently include other household members is higher. The cumulative impact of two decades of austerity, public service cuts, pandemic, energy, food and cost- of-living crisis are most starkly felt in social housing. Soberingly reflected in the Cwm Taf Morgannwg University Health Board Local Housing Associations research which showed social housing customers were the most adversely impacted by the pandemic – more hospital admissions and more deaths.

In the context of housing associations, the ambition to be dually focused as utility providers focusing on service delivery, but also systematically transforming life outcomes is exciting and transformative. And, in doing so, creating the conditions for care on our estates as well as designing care into the centre of how we organise, manage, contract, employ, subcontract, fund and govern. Based on the principle of a seamless service where one provider can support people along different stages of their personal journey in community settings.

While there are advocates of this approach equally, I understand there are others who will be less enthusiastic citing lack of capacity, resources, competing priorities and expertise. With heightened public scrutiny, greater customer demands and expectations and financial challenges it will be seen by others as not ideal timing even if they were willing. For my part that is a narrow, unhealthy outlook and does not lend itself to the core of why we exist which requires organisations to periodically reform as they evolve through their phase shifts.

In the current circumstances it requires an intentional act of rebuilding solidarity, mission and mutual accountability with customers, communities and local partners and stakeholders. However, neither do I advocate a solo mission approach by housing associations. I share colleagues’ frustrations and get the desire for targeted sector-led interventions, but years of trying to knock on this door has taught me this is not how it works. What we need is being recognised as part of the fabric, a safety net of social connection, action and purpose. That is what keeps people well; restating previous utterings made by the likes of myself that this is about becoming part of a movement for change. Sectoral interests need to be put aside as we collectively improve health and wellbeing and with it drive ambition, confidence and prosperity.

“The world does not change one person at a time. It changes as networks of relationships formed among people who discover they share a common cause and vision of what’s possible. Community is the answer. The only way we get through tough times is together.” (Margaret Wheatley)

The next section examines some of the practical considerations becoming a multi-service provider.

Placing aside any moral drivers, the ask requires committing to a major transformation of business model, workforce and ways of dealing with customers, communities, funders and stakeholders. It would be like turning the organisation inside out to think through ingrained habits and very ingrained ways of thinking. I set out a three-stage process.

Step 1

• What is the case for change?
• How will you structure the process? How would you measure results?
• Can you afford to do this now?
• What would be workforce implications to equip existing colleagues and filling gaps through recruitment?
• What would the payment model look like?
• What would be the governance and leadership implications?

Step 2

• Which customers will you focus on?
• What outcomes do you want to achieve?
• What services do you need to help achieve these outcomes?
• What internal administrative and system changes will be needed?

Step 3

• How will you evaluate the pilot project? How much will it cost?
• How will you pay for it?
• How will you use the learning to go to larger scale implementation?

Finally, there is the option to wait for permission or alternatively be bold by starting somewhere and going everywhere, continue to subscribe to segregated services which are part of the problem or work with customers and communities, so they are not constantly having to navigate complex systems, being tested against arbitrary thresholds and fighting for what they want/entitled to.

Evidence from elsewhere such as USA, Australia and Europe show people-focused services have spent too long concentrating on a single factor but have come to the realisation long-term success comes when we focus instead on all the barriers. As an example, take child poverty in Wales which we understand to be disproportionately impacted in social housing. The impact we understand is not only related to lack of income, but to access of opportunity and life quality outcomes. It has a multidimensional perspective.

In Italy, a collaboration between Milan Municipality and Bocconi University has developed a targeted approach to identify those children with access to support services (demand) as well as those with certain contextual characteristics that may not manifest a need but are in situations of vulnerability (potential demand). This programme provides a comprehensive way of analysing child poverty to target policy interventions. Such policy tools could similarly facilitate housing associations to work with partners to ensure targeted, joined-up interventions and make a significant difference. And, be replicated across other policy areas such as older people services, which in the context of housing associations is becoming more aged and infirm.

This is not rocket science but within the realms of the possible. It is about taking the active interest in data to enhance population management so we are better at identifying those who will be most vulnerable and getting help and support to them earlier. The simplicity lies in the beauty of established vehicles that within the right system, support and resources can serve as the perfect mechanism.