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Public services have to get better at halting problems in the making in order to cope with growing pressures on services.

1. Preventing and managing chronic health conditions such as diabetes, asthma and heart disease is arguably the biggest single challenge facing public services in the UK. By 2025, an estimated 18 million people in England alone will be suffering from at least one long-term condition, around 3 million more than today.⁶⁰ This will have a significant economic impact: the UK economy stands to lose £16 billion over the next 10 years through premature deaths due to heart disease, stroke and diabetes.⁶¹

2. The UK is not alone. The four big chronic conditions - cardiovascular disease, diabetes, cancer and chronic respiratory disease - are responsible for over eight out of ten deaths in Europe.⁶² Across the world, chronic conditions exact an estimated toll of up to 6.8% of a country’s GDP, and in many developed countries, heart disease alone can account for between 1-3% of GDP.63 Nor have developed countries experienced the peak of the problem - these figures are expected to rise in line with an ageing population and record levels of obesity.⁶⁴

3. Health systems are already starting to reshape around managing these conditions, rather than the traditional threats of infectious diseases and injuries; nearly six out of ten GP appointments and nearly eight out of ten hospital beds are dedicated to them in the NHS.⁶⁵ But if societies are to avoid the human and financial costs of chronic conditions from spiralling, they will need to accelerate measures to prevent ill health.

Greater investment in prevention is crucial, but investment alone is insufficient. Stronger collaboration between professionals and users define world-class services

4. Looking across the world, the case is growing for stepping in to deal with problems early. The evidence of cost effectiveness is not just in health: it runs from reducing reoffending to early years services.⁶⁶ This mounting evidence has meant more weight being given to preventative investments by the UK Government over the last few years, spearheaded by Sure Start Children’s Centres, the Change 4 Life healthy living programme, more targeted services in education such as child and adolescent mental health services, Youth Offending Teams, the Family Nurse Partnership programme and more active employment and retraining advice.

5. Although there is a temptation to cut back on this kind of investment in tough financial periods, the experience of countries like Finland in the 1990s suggests that governments often regret, with hindsight, the long-term costs of making such short-term savings.⁶⁷ The challenge being grappled with in the best systems around the world is not, therefore, deciding whether to maintain spending on prevention, but working out how to get better value out of the money already being invested.

6. There are many potential ways of getting better value for money out of preventative spending - such as rolling out better technology, using medicines such as statins in health care, or using new professional practices in criminal justice and employment services. However, our international research suggests that there is significant untapped scope for driving better value for money by mobilising the time, motivation and energy of citizens. Without an effective partnership between citizen and state, many chronic and complex problems are impossible to prevent - and any spending might achieve very little. It is through such participation that the new relationship we advocate between citizens and services can be most productive. This can require very close, one-to-one relationships between individual professionals and service users. It also relies on mass involvement: prompting millions of patients to better care for themselves every day, and more parents across the country to get involved in their child’s
education.⁶⁸

‘Relational services, such as getting someone out of long term unemployment, have to mobilise the citizen more effectively if they are tobe successful.’ Professor John Alford, Professor of Public Sector Management, University of Melbourne

7. A flourishing of such partnerships between services and users - sometimes called co-production - may sound unrealistic in a time of growing consumerism. In actual fact, the evidence shows that many people want to play a more active role in the services they receive.⁶⁹ A Department of Health survey in 2007 found that over 90% of patients would like to be more active self carers, while a EU survey in 2008 shows that people are willing to contribute more time to public services.⁷⁰

8. People in the UK are already getting more involved in areas such as their health, improving community safety and looking after the local environment than people in other European countries.⁷¹

Figure 3:Levels of citizen participation in public services in EU countries

9. Some services are already developing such partnerships. The Family Nurse Partnership programme, for example, provides guidance for vulnerable young parents from pregnancy until their child is aged two. Central to the Family Nurse Partnership is the relationship between the nurse and the mother. The family nurse uses techniques and practical activities to help the mother build her self-confidence and make changes in her life and behaviour, so she can care well for her baby and lead an independent and successful life. Building on US experience, the programme is now being tested in 30 sites across England, expanding to 70 by 2011.

10. However, there are opportunities to go much further. Where people’s resources have been released, the impact can be significant. For example, international analysis shows that students better managing their own learning can improve exam results by the same amount as reducing class sizes by a third.⁷² And self-care programmes for those with diabetes and other long-term conditions can reduce visits to GPs by up to 69% and hospital admissions by up to half.⁷³

‘At the moment, we are only touching the tip of the iceberg in terms of the potential of self care.’ Professor Chris Ham, Professor of Health Policy and Management, University of Birmingham

11. As the evidence for greater collaboration strengthens, the crucial question for governments is working out how to unlock this potential more systematically. Our international survey suggests that there are some common first steps:

• better diagnosis of needs and more intelligent targeting of resources;
• moving towards a problem-solving approach for people with complex needs; and
• a culture of wider measures to empower users, such as through greater peer support and more direct budgetary control, greater incentives to partnership working in performance management and changes in professional culture.

The best services in the world engage users by investing in better diagnosis and more intelligent targeting of resources

12. No service can prevent problems properly if they do not understand exactly what they are trying to prevent and what the underlying causes are. Leading examples of prevention and early intervention across the world therefore take the time to work out the risk factors behind a problem, and invest in ways of identifying them. They collect and use high-quality, real-time data as a trigger.

13. Good diagnosis might seem like common sense, but in fact it marks a significant cultural shift in some senses. Traditionally information has too often been collected on an ad hoc basis or held protectively by the professional - it was not so long ago that patients had to fight even to see their own health records.⁷⁴

14. Good diagnosis is, however, not easy. In health, for example, cancer services are trying to get to grips with the lack of awareness of symptoms among the public, including late presentation among lower socio-economic groups. Employment services are exploring ways of improving their assessment of the support people need to return to work. And in crime prevention, the debate is focused on better understanding risk factors behind offending, so that preventative programmes are only targeted at those with the highest chance of committing crime.

15. Our international survey gives some insights into the opportunities for better diagnosis and, flowing from this, more intelligent targeting of resources. Investing in ‘real-time’ or regularly updated online information is often enormously important if people are to be prompted to act. A good example in policing is the CLEAR Map website in Chicago (see case study box opposite). CLEAR Map systematically publishes data on crime in each local area, allowing officers to direct resources towards areas where new problems appear to be emerging, and citizens to see whether their street or local area is at risk of rising crime or gang activity. Other cities across the USA, such as New York, have well-established similar approaches. While the UK is making big leaps in this direction through the introduction of neighbourhood policing teams and online crime maps, citizens in the USA have access to much more detailed information - down to the time, type and exact location of each individual crime reported.

‘Neighbourhood policing ensures local issues are spotted early and quickly followed up by police working together with the local community, preventing potential problems from arising in the first place.’⁷⁵ Peter Neyroud, Chief Constable and Chief Executive, National Policing Improvement Agency

16. CLEAR map works by making high-quality information accessible online in a format that the public can easily use. But the possibilities of new communications technology in diagnosing risk go much further than simply making information available. It is increasingly used for two-way remote conversations between services and users. For example, the gold standard of care for chronic conditions such as diabetes is not a weekly trip to the doctor’s surgery. World-leading care is now based on regular doctor/patient email contact, underpinned by daily self-reporting of symptoms by users and remote monitoring by professionals (see case study box on page 52).

17. This approach, which is already being used successfully in countries such as the Netherlands, France, Germany and the USA, and is currently being piloted in some areas of England, keeps patients out of hospital by providing early warning signs. Given the average cost of an NHS bed is around £200 per patient per day, initiatives which keep people out of hospital offer huge potential for managing the rising cost of chronic disease.

18. Good diagnosis also starts a long time before a problem materialises. In Japan, for some years citizens aged between 40 and 74 years old have been entitled to an annual check to see if they are at risk of developing adult lifestyle diseases such as diabetes - a model which is now being introduced in England through the ambitious NHS Health Check programme which aims to prevent cardiovascular disease, diabetes and kidney disease. It is estimated that this five yearly check will prevent at least 9,500 heart attacks and strokes a year and protect 4,000 people a year from developing diabetes.⁷⁶

‘Leading health care systems across the world are doing more and more real-time, proactive identification of problems.’ Nicolaus Henke, Head of McKinsey’s European Healthcare Practice

19. Alongside initiatives to prevent problems in adulthood, there is a growing recognition that what happens in the very early life of a child - and even before he or she is born - has a huge impact on their chances throughout life. In the USA, an initiative called Kids Count, developed by a private charitable foundation, is systematically gathering data from across the USA to track the characteristics that contribute to early childhood risks. The aim is to provide a tool which benchmarks child outcomes and risks to child wellbeing, such as the percentage of low birth weight babies, to allow policy-makers at a local and national level to develop policies which tackle the key risk factors which have a negative impact on outcomes in later life.

20. However, Kids Count relies on private initiative and investment. Our survey suggests that while public services across the world are often intervening early with school-age children or teenagers when they exhibit signs of a problem, they are not yet systematically looking at risk factors in very young children to halt problems before they happen. This is partly due to legitimate fears of stigmatising children and parents unnecessarily and partly because the evidence for taking this approach is still relatively fresh.

21. It could be argued that Britain, in this respect, is among the world leaders. For example, the ‘Think Family’ programme, which is being rolled out to every local authority, seeks to secure better outcomes for children, young people and families with additional needs by coordinating the support they receive from children, adult and family services. This means that parental risk factors such as going to prison or having a serious drug or mental health problem are identified and addressed alongside support for children and other family members.

22. Evidence shows that intervening early and in a coordinated way to support these families is cost-effective. For example, Family Intervention Projects, which coordinate the support provided to the most challenging families, have proved effective in reducing a range of risk factors for families such as antisocial behaviour, risk of homelessness, offending, poor parenting and poor school attendance, and the average costs per family are around £14,000 per year. This expenditure is nominal when compared with other costs to the taxpayer that can be incurred by these families - which one study estimated at being between £250,000 and £350,000 per family per year.⁷⁷

23. Similarly, the Healthy Child Programme (established for the first years of life in 2008 and currently being developed for 5-19-year-olds) will outline good practice frameworks for the delivery of services so that children and young people’s needs are met early to prevent the onset of serious health problems later in life. But all countries are likely to need to get better at diagnosis, interventions and sharing data without undermining people’s privacy.

World-leading services recognise that success in complex cases relies on a problem-solving approach with coordinated action between different agencies

24. In the late 1990s, with crime levels in New York still high, much of the justice system was absorbed in processing the arrests being made by the police, and the focus of managers was on getting as many offenders through the courts as quickly and efficiently as possible. But in one part of Brooklyn they were taking a different approach. In the neighbourhood of Red Hook, the concept of problem-solving justice was developed. This approach sought to quickly get to the root cause of persistent reoffending and bring together the combined resources of criminal justice agencies, other public services and the wider community to ‘solve’ these issues. Opened in 2000, the Red Hook Community Justice Centre has pioneered practical ways of punishing offenders, such as painting over graffiti or sweeping the streets, and ways of successfully tackling individual and community causes of crime, from job training to rehabilitation courses.

25. The Liverpool Community Justice Centre, which opened in 2005, is reproducing this problem-solving approach in the UK, with successful results - well over eight out of ten of those brought to justice in the area plead guilty, compared with six out of ten before the Centre was opened. The Government has already rolled out aspects of the approach to other areas across England and Wales and is creating Community Justice Teams in 30 areas of the country.

26. The application of tightly-managed problem-solving approaches to prevention is, however, relevant across a far wider range of public services. The more difficult, personal and varied the problems a person has, the more that success depends on focus and coordination from services and a level of commitment from the user

27. North of Red Hook, the Harlem Children’s Zone is taking a similar approach in coordinating action to address children and young people’s needs across the board, rather than considering each issue in isolation. Harlem Children’s Zone is intended to provide support from birth to college across a huge range of services, acting as a counterbalance to the problems faced by many poor families and their children, such as a severe lack of money, the threat of crime and violence, the prevalence of drugs, poor housing, inadequate schools and substandard health care.

28. While Harlem Children’s Zone is a not-for-profit community organisation, parts of the public sector in the USA are also at the forefront of developing innovative problem-solving approaches (possibly reflecting the greater intensity of complex social problems in parts of the USA). For example, the ‘Justice Reinvestment’ concept is a process where funds which are currently spent (or planned for the future) on imprisoning offenders are instead used to support locally-based initiatives which tackle the underlying reasons behind crime. One recent example is the Justice Reinvestment programme in Texas, which diverted money from prison building to provide a huge range of coordinated rehabilitation services, halting the fast-growing prison population by reducing reoffending. A similar initiative in Oregon combining reparation with treatment, training and other support for young offenders, reduced youth imprisonment by 72%, saving $17,000 for each person not sent to prison.⁷⁸

The best systems are leading the way in putting relationships at the heart of public services

29. World-leading examples of preventative health, education, policing and welfare systems also indicate that it is not enough to roll out individual preventative programmes, better diagnosis and problem-solving approaches. These are all important developments in delivery practice but, in isolation, they are an insufficient response to the challenges of chronic disease and the need for greater engagement in education, reskilling and reducing crime. The underlying challenge is to create a systematic culture of partnerships with citizens, based on valuing the contribution which people can bring to addressing their own needs.⁷⁹

30. Our analysis indicates that achieving this culture shift requires some wider developments:

• Empowering people with greater confidence and control. Personal budgets, such as the scheme for mental health patients in Oregon discussed in chapter 3, are one way to change the power relationship between services and users. Encouraging greater peer support can also be particularly important for empowering people to work with services. The Joint Care programme in Denmark (see case study box opposite) shows that bringing patients together to support each other’s recovery can have a huge impact.

‘Public services in Denmark are recognising the enormous potential for bringing citizens together to share their knowledge and expertise - it is being shown that this approach improves outcomes for everyone.’ Christian Bason, Director, MindLab, Denmark

• Changes to performance management systems to reward collaborative approaches and the achievement of long-term outcomes. In Singapore, for example, teachers and schools are assessed according to a broad range of well-balanced performance criteria rather than narrow short-term outputs. Across the world, inspectorates and commissioners of services often need to give more weight to assessing the quality of relationships with users.

Figure 4: Principles underlying a culture partnership

• Developments in professional culture - embedding awareness of the strengths and potential of user knowledge and resources from the start of professional training, and throughout a professional’s career. For example, in Denmark, health visitors facilitate peer support networks for new mothers called ‘Mummy Groups’. This not only supports mothers directly, it can help integrate professional and user cultures.

Conclusion

31. Considering the various lessons from international leading practice, the challenge for service managers is not just to seek to maintain or increase preventative budgets in tighter financial circumstances. They need to examine whether their preventative programmes are as collaborative as possible, including whether different agencies are genuinely focused on the problems which create greatest risks for people and whether they are targeting the right people in the first place. Such collaboration is probably the most important element of developing a new relationship between citizens and services in years to come. Only such partnerships between individuals, communities and services can address the rise of chronic health conditions, the persistent challenges of giving all children the best start in life, the need for people to retrain for new employment opportunities and unacceptably high levels of antisocial behaviour and crime in much of the developing world. The design of other elements of this relationship - entitlements, information, personalisation and professionalism - should therefore all be considered with the objective of strengthening such collaboration.