Was asked a q on Friday about social impact bonds and the prospect of their use in the context of heavy drinkers who are frequently admitted onto gastro wards.
It’s a spin on pay for performance…but the twist is give money now and I keep some of the return in the future.
So I guess one might characterise social impact bond as a cross between P4P (well established evidence base) and risk sharing contract (increasing experience, not much empirical evidence from context of USA ACO).
Form of social venture capital?
General gist on p4p is that:-
Mostly unproven on outcome per se
Mixed results on processes of care – the GP QOF scheme being the worlds biggest experiment in such matters
Probably work best in simple systems and simple processes with a neat chain between intervention, measurable care process (or outcome). Maybe more difficult in a more complex system with more moving parts and less control over any one of them.
If it were a drug, it would be listed in the bnf with a black box and a “not yet proven” banner.
PIRU have written some amazing stuff on P4P.
The best thing I’ve ever read on risk share contracts is here
Written a lot more on the concept of risk sharing contracts and can bore you at length if you want
Caveats, caveats, caveats…..
- Necessary? Desirable? Replacement for state funding?
- We would do well to watch for Unanticipated impacts
- Concerns about cashability of the ROI and even countability and attribution of intervention to outcome, especially in the context of complex adaptive systems we don’t understand.
- Tendency to focus concentration on identifiable high risk individuals, and consequent loss of focus on population level / ecological type of focus. Don’t get me started on that one. Focusing in on identifiable individuals is the obvious thing to do, but in some policy areas there’s clear and well developed evidence it is NOT the net save we all hope for.
Thus applying this mindset to social impact bond may give some clues in the level of risk the funder might be prepared to take and what return they may expect.
I guess some consideration to the system in which the intervention is happening;-
- how simple or complex,
- the population (neat, nice, clean and compliant, stable or highly transient and in flux, or not so),
- the intervention that’s intended to achieve the desired outcome (how goods the evidence base),
- the comparator and the starting point (easy to get gain if there’s a low starting point and the comparator is ineffective)
- the outcome (how measurable, when can it be measured, cash able)
what others have written
Cabinet Office have some good stuff – https://www.gov.uk/guidance/social-impact-bonds
RAND Corp are also interested in this space – http://www.rand.org/pubs/perspectives/PE141.html
some good evidence
More prominent the Peterborough prison scheme – http://www.rand.org/randeurope/research/projects/social-impact-bonds.html#key-lessons
I’ve been waiting the results of this one for a few years
Looks – and I’ve only skimmed – that the process report is available not the impact.
The Peterborough social impact bond financed a pilot initiative to reduce reoffending. This involved individualised “through the gate” support for prisoners before, during and after their release from prison. The initiative provided help with housing, substance misuse, finance and employment, among other issues.
Many aspects of the Peterborough initiative were innovative, or new and different compared to what was previously available.
The pilot introduced a new service—there was previously no such support for short-sentenced prisoners in the area. Another innovative feature was that the social intervention was adapted and changed in response to local conditions and the needs of prisoners, for example, by adding a job-training initiative.
However, providing individualised and responsive services and encouraging flexibility in the implementation of programmes are not unique to social impact bond initiatives. Indeed, virtually all of the innovations identified at Peterborough (other than the social impact bond financing mechanism) can be found in other traditionally funded initiatives—not financed with social impact bonds—currently or previously in place in the UK. Our findings suggest that innovation might be more likely to be present within initiatives that are novel (such as pilot programs), involve dedicated and enthusiastic partners and a focus on outcomes. Social impact bonds are one tool that can encourage these sorts of initiatives.
RAND have suggested that there is no strong reason to believe that social impact bond financing was essential to these innovations being realised in Peterborough. These new practices would have been possible whether the funds had come from a social impact bond, another social or “impact” investment vehicle, another kind of payment-by-results contract, or direct funding from government. Additionally, social impact bonds are not used only to finance innovative interventions—a number are supporting programmes that have an established evidence base or have been tested elsewhere.
The important questions arising from our findings in Peterborough are:
• How can the fresh-thinking evidenced in some social impact bonds be replicated in interventions financed or funded in other ways?
• What can service commissioners and delivery organisations learn from social impact bond environments?
• How can these lessons be put into place as part of different approaches to commissioning and funding public services?
Another key message stemming from our research is the need to evaluate the social impact bond financing approach separately from the impacts of the interventions they finance. This would test whether the same interventions under a different financing or funding approach might bring similar results.
To the evidence on SIB itself
The commentaries and development of this area is generally accompanied by claims that they would encourage innovation in the social interventions that they pay for.
Empirical evidence is less clear. Well….there isn’t much.
- Good overviews here – http://theincidentaleconomist.com/wordpress/the-existing-pay-for-success-social-impact-bond-projects/
- and here – http://theincidentaleconomist.com/wordpress/social-impact-bonds/
This Brookings Institute report highlighted that social impact bonds have not generally encouraged innovation in service delivery
- http://www.brookings.edu/~/media/research/files/reports/2015/07/social-impact-bonds-potential-limitations/impact-bondsweb.pdf/ It’s v helpful
- PIRU writing and doing some good stuff in this space. http://www.piru.ac.uk/events/widening-perspectives-on-social-impact-bonds.html
- And this interim report of the eval of SIB in health and social care – http://www.piru.ac.uk/projects/current-projects/social-impact-bonds-for-health-and-social-care.html
Key findings from the documentary analysis and interviews in the nine Trailblazers are that:
- SIBs require complex negotiations amongst multiple actors and organisations that have not worked together before. There may often be delays in agreeing SIB contracts and accessing requisite development funding to aid SIB development.
- SIB negotiations currently appear to have high transaction costs. Some health and social care SIBs are motivated by a desire to develop innovative services, whilst others focus on scaling up established service models delivered elsewhere or at smaller scale.
- SIBs have a significant impact upon how activity and outcome data are collected, frequently leading to more extensive and considered techniques of both data capture and analysis. However, informants expressed concerns around how to attribute outcomes to services.
- Learning points from two of the first operational SIBs in health and social care include: firstly, the importance of establishing clarity of data requirements and then building internal or external capacity to do this; and secondly, the importance of extensive collaborative working between all parties to ensure operational success despite the requirement to tender services.
Here’s the file – http://www.piru.ac.uk/assets/files/Trailblazer%20SIBs%20interim%20report%20March%202015,%20for%20publication%20on%20PIRU%20siteapril%20amendedpdf11may.pdf
Looks a bit preliminary re the outcomes actually reported
All up….. Yes definitively of interest. But as with all these things needs careful thought and evaluation.
Providers and payers may jump in without thinking of such caveats – especially when providers are cash starved and are also on a headlong rush to be “outcome based”. I hope we won’t be all disappointed.
The small print is dull, but an important part of due diligence on all sides.