Evaluating Simon Stevens Dowry

After over a year's wait for a blog, two come along inside a week...

After Tuesday's blog describing the discombobulation of NHS England's Simon Stevens when asked  to consider the concept of fairness, I have found myself continuing to think about the dowry proposal made prior to that moment. It needs to be unpacked as a concept because I think it tells us a lot about the thinking that is happening and thinking that is not happening currently.

If we look at the exchange as transcribed here:


Q63 Austin Mitchell: I just want to pursue the financial imperative. The targets were overambitious for financial reasons: the fact that the money did not follow the patient created local resistance to having the patients. Paragraph 2.24 says, “Meeting the needs of people in the community, who NHS England previously funded in hospital, is a material cost to local commissioners. This can affect their ability to provide appropriate and sustainable care packages. Hospitals subsequently experience significant delays in discharging patients while complex negotiations continue”. This must mean that you can speed up the process through a fairer, better financial arrangement with the CCGs and local providers.

Simon Stevens: What makes this complex is that you have two sets of things going on there. One is that there are a group of people who have been in institutional care for a very long time. When you talk about moving them, as we will be when we are closing some of these facilities, you need to take the old mental health model—we talk about dowries and funding endowments that move with people, and those might be partly with the local authority and partly with the local CCG. If you look at the fact that a fifth of people in in-patient settings have been there for more than five years, those are the sort of folks for whom you are talking about dowries. But for people who have been in an in-patient setting funded by specialist care for three or six months, that is not so much about their ongoing support for ever; that is a moment in time when they are getting something. Distinguishing between those two categories is what we have to do. Some of this will have to be dowry-type arrangements; some will just have to be about a recognition that, actually, this is the CCG’s or the local authority’s funding responsibility, and they will have to step up to the plate.


On a superficial reading, the response made by Simon Stevens could be read as though some thought had occurred before sitting in front of the Select Committee. However there are some jarring inconsistencies of thought occurring that are troubling if we are to take the rhetoric seriously.


The first point of contention comes with the notion of the dowry itself. What exactly will NHS England be funding with this dowry? If the care plans are accurately assessed then the needs of the individual receiving the care package have to be statutorily met. So will any such dowries be providing additional non-statutory needs or is this an implicit admission that the funding streams of CCGs/LAs are not sufficient to provide statutory needs? Is this about the needs of the service user or the needs of service funders?

Then there is the usage of years institutionalised to determine whether the individual requires a dowry as oppose to those expected to be pick-up by CCG/LA spending. How exactly will NHS England determine the qualification for this dowry? Will it focus on enablement? A problem with this is that there doesn't appear to be any evidence for that particular cohort being any more requiring of deinstitutionalisation than those who are there for six months or three years. This isn't person-centred policy based on needs but rather an arbitrary qualification of time that seems to have been plucked out of the air. I can't help but think of Mark Neary's excellent blog and that one of the consequences of his son Steven having spent a year in an ATU has been the need to permission-seek for actions such as going to the toilet as a result of his previous institutionisation.

These questions are particularly important in terms of the concept pursued by the members of the Select Committee of "the money following the patient" (NB for the Select Committee - they are people who aren't ill just because they have LD/ASD). In this context, the dowry concept seems less about facilitating this concept as blocking it. My cynicism would suggest that Simon and his colleagues should be viewing this issue as an efficiency opportunity for NHS England. That isn't a bad motivator in itself as it is more likely to see some change forced through. But for that motivator to work, the incentive needs to be that NHS England retains a sizeable proportion of the spending or in other words ensuring the money doesn't follow the individual. The dowry concept with its years incarcerated qualifier would allow NHS England to retain 80% of its spending. But as I said, I'm cynical.

Indeed with the challenge that Simon Stevens has set NHS England of finding £20bn of efficiency savings and our current cohort of politicians indulging in magical thinking as to bringing together two underfunded services (Health and Social Care) and expecting them to find that their deficit funding disappears, its no wonder that throwing a bone such as dowries occurs.

So I have questions for the Select Committee - what exactly are you attempting to achieve by this notion of "the money following the patient"? What exactly are you funding with it and for what purpose? What does fairness look like to you in this context?

Perhaps I'm being unreasonable to the Public Accounts Committee here but there doesn't appear to be much awareness of how the funding creates action or resistence. Simon Stevens is clearly telling the Select Committee in the answer quoted above that he needs to retain a significant proportion or there isn't the incentive to create change. Hence the discombobulation when Austin Mitchell followed up with the "so you think the funding is fair?" question. Fairness to the individual was the last thing on Simon's mind.

Yet I think Simon has a reasonable argument here given the financial pressures NHS England are under and that if keeping a significant proportion of the spend to allocate elsewhere sees the majority of ATUs shut down then that is a compromise worth making.

What I would advise Margaret Hodge and her colleagues on the PAC is to focus on a more holistic approach to achieving the goals of reducing institutionalisation. Abandon the money following the individual approach and instead split the money being spent on this cohort in three ways: a transitional fund to help CCGs/LAs budgets when any individual moves into the community (this can be graduated for need); developing more community-based specialist mental health services; allowing NHS England to redistribute the remaining savings. The precise proportionality can be debated but lets create incentives to move people into the community and support them when they are there.

The statutory responsibilities on CCGs and LAs to provide care and support  need to be funded properly in themselves. This is where the direction of travel re merging health and social care provision needs to be discussed with honesty rather than magical thinking. Just grabbing part of NHS England's budget as Margaret Hodge suggested to Simon Stevens is also counter-productive as it creates resistence and most likely perverse outcomes. The environment of health and social care post May 7th will be a very contested space regardless of what sort of government emerges.

The need for more thinking about what outcomes you want to achieve and less glib statements that sound good is necessary more than ever. Trouble is I think it will be a long long time before it happens. Perhaps that why this song is in my head this morning.

Simon Stevens Failure is not an Option

Another in a very occasional series of blogs.

Yesterday (Monday 9th February 2015) in the Boothroyd Room of Portcullis House, the House of Commons' Public Accounts Committee chaired by Margaret Hodge met to receive evidence for their inquiry into Care for people with learning disabilities.

As noted on Twitter by Chris Hatton, there was a real disconnect between the mood of the Select Committee and those witnesses appearing in the second half of the hearing. 

Those witnesses were: Una O'Brien, Permanent Secretary, and Jon Rouse, Director General, Social Care, Local Government and Care Partnerships, Department of Health, and Simon Stevens, Chief Executive, and Jane Cummings, Chief Nursing Officer, NHS England.

There was a feisty attitude to the committee members questioning as to why the stated target to move approximately 3,000 Learning Disabled (LD) and/or Autistic Spectrum Disorder (ASD) people out of units following the outrage of Winterbourne View by June 2014 failed.

This was a target that had little bearing on the reality of how commissioning and supply works for LD/ASD people and although traction for the target wasn't helped by the 2012 health reforms, the cultural issues surrounding responsibility and accountability extend further back. It is therefore with a raised quizical eyebrow and copious amounts of salt that I took Simon Stevens commitment to "substantial transition" in the next eighteen months.

This isn't to disbelieve the sincerity of Simon when he states that they "cannot defend the indefensible" but rather that the siren voices of caveats and funding will lure his attempts onto the rocks.

The most significant exchange for me starts at 16:37:30 when Austin Mitchell, whose questioning style is generally languid, starts discussing the failure of the money to follow the LD/ASD individual and that there are disincentives in local authority funding to facilitate the transfer into the community.

This point re local authority funding is vitally important to grasp. To explain, lets use another NHS and local authority cooperation - the transfer of elderly people with care needs out of hospital and into community facilities. This is a constant dialogue between the NHS and LAs with peak demand for flow happening in the winter. To meet the peak demand requires a market response to provide the community spaces and support required and markets respond to funding signals. Yet the funding flow from NHS to LAs operates as if the market capacity responds to a 'just in time' signal. Such an approach is fine if you have automated assembly lines but less so when the largest resource is people. If you are not prepared to pay for excess capacity then time lags will occur and any additional monies thrown at the problem as Jeremy Hunt has done is asking people to retrofit capacity.

So funding flow is important and consistency of funding is important to developing the market capacity required to enable the stated ambitions of Simon Stevens here. Austin Mitchell touches on this when finishing his question by suggesting that the process of transfer could be speeded up by a "fairer" funding settlement.

Simon Stevens response to this is to separate those trapped in the system for a long time (more than five years) and suggests using the dowry model that facilitated the closing of mental institutions in the 1980s with those who been in the system for three to six months where the CCGs or LAs will have to pick up the tab. Note that those who been in the system for 1-4 years aren't being considered in this response.

Austin Mitchell then asks the killer question at 16:39:40: "so you think the funding is fair?"

To use cricketing metaphors, this was the equivalent of a medium paced mid-70s mph trundler bowling a 90+ mph throat-high bouncer that Mitchell Johnson would have been proud of. Watching Simon Stevens body language disintegrate faster than an English batsman facing Mitchell Johnson was quite amusing.

Simon then pulls himself together with the cop-out phrase "its an accident of history". Ladies and gentlemen - welcome to the bullshit zone.

I have to thank Austin Mitchell for asking the right question here as it exposed the thinking here as being limited to "Houston, we have a problem". I don't knock the acknowledgement as the journey has to start with this step but its clear that the stated aspirations as reported by David Brindle haven't remotely been thought through.

This is why two and a half years down the line, work around pooled budgets remains at the starting gate when discussed at the PAC yesterday. A fair settlement starts with what it means to live as a LD/ASD person in their community and to live life to the full. Not as Jane Cummings suggests "as normal as possible" but to live a messy life of their choosing. Any funding settlement needs to follow and facilitate those principles. Its why campaigns such as the LBBill are so important - these need to be legal rights. Those committee members agreeing with a rights-based approach should take note.

My lasting impression of yesterday was that any thinking around this was couched in terms of the conflict of funding streams between health and social care rather than cooperation. The contested space that is the Better Care Fund which is being used more to retain existing LA services than developing new cooperative working as the NHS resents the top-slicing occurring as they experience real terms cuts to their budget. Against this background, it felt as though costs were expected to be pushed from one part of the system to another. Any idea of "fairness" in funding was therefore a shocking concept.

The top-down instruction to get people out of ATUs isn't a bad thing but we need to pool our intelligence to design the mechanisms properly else we'll Heath Robinson the process and create problems down the line. So thinking of Apollo 13 again, this scene resonates somewhat...

Film Review: Crust

Film: Crust (2003) Mark Locke

Shown by Stirchley Happenings at Stirchley Working Men's Club, Birmingham (May 16th 2013)

A film about a West Midlands publican seeking his dreams with a 7 foot mutant crustacean and learning some lessons about life along the way. Crust is a charming, low budget film which has at its heart a story about what makes life meaningful.

The put-upon downtrodden Bill Simmonds (played by Kevin McNally) sees a chance of redemption from a fighting shrimp that the wheeling dealing Hamid Choudhury (Madhav Sharma) happens to possess. Exactly why a 7 foot Mantis Shrimp from tropical climes has turned up in the West Midlands is never answered since any questions about the shrimp is responded to with the phrase "its the 21st century, who gives a shit!". Yet despite yourself, you do start to care about the three protagonists of Bill and his partners in crime Steve Crump (Perry Fitzpatrick) and Shaz Smyth (Louise Mardenborough) as they head to the bright lights of London to attempt to pitch the fighting crustacean to TV companies. You even begin to care about the shrimp which looks like this:

The reason why you care is that writer/director Mark Locke has a deft touch in terms of both the humour and pathos (yes pathos) elicited from McNally, Fitzpatrick and Mardenborough as their characters have their illusions stripped from them. Locke even manages to draw out Ulrika Jonsson finest acting performance during her cameo appearance. The film's warmth carried me throughout and had me laughing throughout from the sharp humour in the dialogue to the absurdism of the film's climax.

I recommend that this film is watched in good company after a couple of beers and allow yourself to be carried away by its charm.

Many thanks to Stirchley Happenings and the IWW union for showing this tonight. For those wanting to know the shady background as to how the film came into existence then I recommend Adam Curtis' blog The Bitch, the Stud and the Prawn.

Birmingham's Autism Strategy for Adults consultation launch

It was the 6th World Autism Awareness Day on April 2nd as officially designated by the United Nations General Assembly to raise awareness of autism across all communities and societies. You may not have heard of WAAD but those involved in local government and the NHS across the UK are having to raise autism awareness among their staff. Not for a day but permanently.

The 2009 Autism Act and the subsequent national strategy published in March 2010 Fulfilling and rewarding lives: the strategy for adults with autism in England places statutory duties on local authorities and NHS bodies to develop strategies for increased awareness of autism and adaptation of service provision to enable autistic users to access services easier. The act also calls for reasonable adjustments to remove barriers to access and participation in public life.

And on World Autism Awareness Day at Think Tank, Millennium Point, the Birmingham Autism Partnership Board (BAPB) officially launched its Autism Strategy for Adults in Birmingham 2013-2016 as a consultation document.

Presenting the strategy were councillor Steve Bedser, Birmingham City Council Cabinet Member for Health & Wellbeing, Dr Ashok Roy, Chair of the BAPB who specialises in the psychiatry of learning disabilities, and Jonathan Shephard, Chief Executive of Autism West Midlands. Sitting amongst the audience were senior BCC officers who are grappling with the implications for service delivery from the budget cuts announced up to 2016-17. Dr Roy stated that this was an optimistic strategy. In this age of austerity for Birmingham, optimism is at least a free commodity.

The draft strategy sets out six areas where the BAPB wants to deliver progress: implement training and raise awareness; implement pathways for diagnosis; improve on opportunities for employment & education; improve access to services; improve transitions from childhood; and improve interactions with the criminal justice system.

These are all worthy challenges to pursue in aid of a more inclusive city. While there has been considerable attention to autism in childhood there remains large gaps in the understanding of how autistic adults in society function despite autism being a life-long condition. There were considerable difficulties in obtaining information about adult autistic service users because they often weren't being recorded. For example NHS trusts were particularly weak at information recording although this is changing with the NICE clinical guidelines issued in June last year.

Yet the barriers to inclusiveness for those on the autistic spectrum are not as obvious as say providing an access ramp for wheelchair users. Rather, it requires a cultural shift across service provisions within the NHS and local government to meet the needs of users with an autistic spectrum disorder. This represents some interesting challenges in terms of both recognition of someone on the spectrum and making reasonable adjustments for them by front-line public sector service staff.

It is worth reflecting on this truism: "if you met someone with autism, you met one person with autism". Autism is a developmental disorder where the brain has developed differently which can come from a myriad of physical causes. How someone's autism presents itself is diverse. Having an awareness of autism doesn't necessitate an understanding of autism or identifying what reasonable adjustments should be made when presented with an individual on the spectrum. Recognising a difference is merely the start of a communication process and requires freedom of agency from service staff which may not always be possible if the service provision is proscriptive in nature.

A major challenge to the ambitions of this strategy is the austerity that Birmingham is currently experiencing. Whilst the establishment of the Health and Wellbeing Board required by the 2012 Health & Social Care Act will support the strategy through a specific Joint Strategic Needs Assessment for autism, this remains the most challenging of times to attempt to reconfigure service provision and provide additional services given the cost pressures being experienced.

Yet the process currently being undertaken in preparation for BCC's consultation this summer on Adult Social Care provision from 2014 onwards should be identifying current costs being incurred to the city by those on the autistic spectrum across department budgets where possible. If genuine societal costs can be identified then some modelling can be undertaken to assess the cost-effectiveness of preventative work. This could then be widen out to involve the Police & Crime Commissioner/panel and NHS bodies which would also improve data gathering and assessment. From such work can negotiations for joint funding of preventative services or submissions for central funding take place as proposals could then be evidenced.

Therefore the biggest challenge facing an autism strategy for adults is the quality of information available and the lack of information from certain sectors. Whilst the BAPB has identified areas that will improve the lives of autistic adults if implemented, it does so from an incomplete picture of the city. If by 2016 we have considerably more quantitative and qualitative data from across the public sector then there could be a more informed debate in terms of service design rather than just spreading awareness. Such information would also inform a more detailed level of scrutiny regarding outcomes as they impact the city rather than just internal project milestones and outcomes. 

This strategy document is a welcome step forward for the city's autistic inhabitants and their families. The challenges will be how far the targets and/or aspirations laid out are able to be delivered and whether in 2016 the city has a more detailed picture of the needs of autistic adults within its boundaries. For this strategy to be truly excellent, a specific commitment to information gathering is required for me. 

The consultation runs until the 26th of June and information can be found here.

The tactical errors that cost Portpin control of Portsmouth Football Club

There's been a lot to take in over the last month from when Portpin asking for peace terms the night before the court hearing and the agonising wait for terms to be agreed and accepted by Mr Justice Peter Smith in courtroom 30 of the Rolls Building. The scramble to get the paperwork completed in order was achieved ahead of a celebratory and exuberant Fratton Park crowd with Sheffield Utd playing the perfect party guests. Since then, Guy Whittingham has been appointed permanent manager, players have started to sign on for the League Two adventure, and new senior off-field staff have arrived in the form of CEO Mark Catlin and Engagement Manager Micah Hall. After five years of a spiralling drift downwards, the club is taking the steps to rebuild its foundations for a better future.

And yet this feel-good moment might not have occurred had Portpin restructured a couple of financial arrangements more carefully to legitimise their usage and therefore secured a third period of ownership. Thankfully despite the restrictions placed on Portsmouth Football Club 2010 Ltd by the Football League, old habits were difficult to contain during their tenure between October 2010 and June 2011. That period left a number of questions that Portpin were unwilling to answer in order to satisfy that they were "fit and proper" enough to pass the Owners & Directors Test of the Football League.

You might think that the behaviour that saw Pompey become the only Premier League side to enter administration would have been enough to disqualify the members of Portpin from taking ownership of a football club previously. Yet it didn't and Portpin took control in October 2010 setting an important precedent.

The rules of the Football League regarding ownership allows for a second chance for owners even if you had put a club in administration before. Whatever their misgivings, the Football League were rule-bound to give the members of Portpin a second opportunity of ownership of Portsmouth Football Club in 2010. The consequence of this was that had that period between October 2010 and June 2011 been unremarkable in terms of its governance then an application for a third period of ownership would have likely been approved.

As leopards cannot change their spots so Portpin couldn't change their behaviour from their first to their second period of ownership. Not only did they leave behind the equivalent of a burglar’s calling card for CSI to clean up in terms of unpaid debts owed but they enacted two specific financial manoeuvres which questioned their consideration as being "fit and proper". These were the transfer of the debentures on Portsmouth City Football Club Ltd to the newco Portsmouth Football Club 2010 Ltd and the Hiroshima Ltd season ticket arrangement which saw £800,000 of PFC income diverted to a Hong Kong black box.

The illegitimacies of the debentures transfer and the season ticket monies have been discussed here and here. These actions were fundamental to demonstrating Portpin's inability to pass the Owners and Directors Test. Yet had Portpin been a little bit cleverer and less short-term in their thinking then they could still be in control of Portsmouth Football Club today.

The first area where they could have been cleverer was with the debentures. No doubt there was strategic reasoning for them to accept the transferring of them by Andrew Andronikou to their newco company in January 2011. Yet with their negotiations with CSI, they could have quietly retired the transferred debentures and created a new and legitimate debenture for £17m over PFC and its assets as part of the sale agreement. Such an arrangement would have given Portpin a stronger negotiating position in dealing with the Football League and the administrators BDO as it would have allow them to show clean hands.

The second area is to do with the Hiroshima season ticket deal. Essentially the reason why the Hiroshima deal was shown to be problematic was that there weren't any goods or services that Hiroshima Ltd had provided Portsmouth Football Club 2010 Ltd. In their haste to put one over on CSI, Portpin had failed to provide a reasonable-looking debt to cross-knit with the financial arrangement agreed between themselves, Hiroshima Ltd (owned by Balram Chainrai) and Zebra Finance. This I suggest illustrates that Portpin were not thinking of a third ownership when they sold to CSI. Had they thought about covering their actions with a cloak of legitimacy then it would have been possible to muddy the waters sufficiently to justify the transaction though a paper exercise.

In both case with the debentures and the Hiroshima deal, Portpin had the opportunity to restructure these financial arrangements to 'legitimise' their existence. By not sufficiently covering their tracks gave the opportunity for the Pompey Bloggers Collective to identify the illegitimate practises which resulted in the articles written by Micah Hall and Dodgy Curry linked above. Those articles, amongst other submissions, formed the basis for some of the unanswered questions that the Football League put to Portpin surrounding their ownership of Portsmouth Football Club 2010 Ltd.

In the cold light of day, short-term and insufficient thinking during their period of ownership between October 2010 and June 2011 undermined Portpin's position in their attempt to regain control of Portsmouth Football Club for a third time. In their quieter reflective moments, I hope they understand that was their actions and inactions that cost them control. Not the administrators BDO or the PST or the bloggers or that Keith Harris couldn't substantiate a meaningful bid. They brought it upon themselves. Both the debentures and the Hiroshima issues could have been nullified making it exceedingly difficult for the Football League to refuse their application on the Owners and Directors Test.

I suspect it grates considerably.