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Accountable Care Determinants Health and Social Care Health In All Policies Social Value

Public sector anchor institutions and inclusive economic growth

Ted Howard from the Democracy Collaborative was in town last week

He was the star turn in a workshop exploring the art of the possible on the subject of public organisations as economic anchors, the context of inclusive growth.

He imparted a lot of wisdom in a short space of time, and left us with a lot to think about

Again, in the spirit of democratisation of knowledge here is my take on key points discussed.

1. Why now?

The economy is a determinant of health and wellbeing, we know the economy and our economic model leads to inequality.

This plays out in many policy areas, across all sectors of the economy.

Opportunity around inclusive economy. RSA report and many other pushes in this space.

SPB want to push on this area. Anchor institutions will be a part of that but we won’t know all the steps in this. Not sure yet what the end point is going to be, just that we want to go on the journey.

2. Why is this issue important?

a)Previous approaches have not been seemingly successful as we wanted

Map of deprivation from the 80s is largely akin to now – aka regeneration has failed

Funding injections didn’t address the mainstream commitment of £ base – the institutions we want to continue to support

This is a route into permanent change of the way an economy works (at least the public economy)

In times of plenty, we didn’t make the mainstream better, we funded stuff at the margins to correct the deficiencies of the mainstream.

And thus we never corrected the problems in our view of allocative value in the mainstream (in everyday language we failed to shift upstream).

b)There’s a growing narrative re. alternative models of economic growth

We know inclusive growth is important.

We know the way the economy works is one of the fundamental determinants of well being

We know there are deep inequities in income and wealth

We know that there’s a great deal that can be achieved though the economic power of anchor institutions

To address health inequalities you need to address social and economic inequalities

For those anchors here is an opportunity to directly address the economic influences on health with your existing budget

c) A strategy with political appeal on both sides, (but try to de politicise)

This is an under the radar and doable strategy that can address some of the underlying economic determinants of health that may never happen nationally.

There are moves (labour) in this direction

This has been going on for 8 years in the states – with support from both sides of the house.

Depoliticise this. Make it not a feature of left or right, or greens, or middle

Find arguments for all brands of ideology. Make it practical fiscal and economic and political sense from lots of different perspectives.

Appeal to all ideologies – This is an alternative model to free market economics. Arguably an approach that all ideologies can agree on and something in it for all sides of argument (liberal and conservative)… not another big federal investment, good for CSR, more efficient way of harnessing and utilising resources in local economy…..then the social reasons…..

Frame not as big “government programmes” but about getting more efficient use of £ already committed AND local multiplier effect AND social gains.

3. Why local matters

Large national providers or commissioners are not invested in place

Can’t respond and flex locally

Not in tune with our local ethos

National v local policy differences.

National providers less able to tie up with other orgs locally across nhs, local gov, or vcs

If there is to be national contracts, local role is to ensure standards, rules, ethos is fit for local circumstances

4. Purpose of the workshop – to explore the art of the possible

We know there’s stuff going on across the city.

Where we are on baseline doesn’t matter.

Trajectory of improvement is what matters

Is it at the right scale?

Has it been institutionalised and built into the woodwork?

Have all the different anchors connected it together and is there a mechanisms to share it, and capitalise on scale?

What does better look like?

What are we aiming for?

5. Economic anchor institutions tend to be:

Non profit or public

Sticky capital, rooted in place. Tend to not move on account of economic factors, they don’t leave when the economic going gets tough. Economic engines – large purchasers, employers and investors

Hospitals, uni sector, local govt

Often large purchasing power

There are 3 organisations that will be here in 20y time – hospital, job centre, local govt. better structural links between the 3 critical”

Strategic question to the anchor institution is

“Dear anchor – conduct your business in a way that reflects your anchor status and builds capacity to address social determinants. Not just as a side issue but 100% of your activity…this leads to better economy – and should be done for economic reasons in addition to intrinsic  health reasons”.

Can we incentivise the way in which you use your funds, systems and processes to impact on health and well being in a more positive way than if you do nothing?

For the NHS – What can NHS system DO about social and economic determinants?

6. Defining the anchor mission

Historic- the approach has been through a small office, not bending the mainstream mission

Aim should be to transform the mission of the organisation towards social benefit

ALL functions of the institutions

Part of the business propositions – triple bottom line.

Be accountable for all out impact – Social, Environmental, Economic, Health, Ecological

7. Domains of the business to look for progress and opportunity 

All the assets of your institution should be “in” – e.g.

Employer, Annual spend, Annual procurement, Investment and portfolios and endowments

HR, Technology, Treasury, Research, Community benefit, Comms, Environmental, Service delivery

I.e. Not really the core mission of delivering great services, but something much wider.

Turning from slightly left field mission to one of using the core architecture to make better/develop/grow

Economic assets are felt to be key

Hiring and workforce

Procurement and purchasing

Place based investment. Investments/endowments/portfolios

An early ask was of the Cleveland Clinic ($1.8bn) = how they incentivise themselves around local supply chain

25% of supply chain has to conform to green and local metrics

Hard edged indicators that were set were met.

What is/can be the role of anchor re: Building, Housing, poverty, Employment/training

The local lettuce story – Cleveland experience

Cleveland can buy lettuces from California $0.03 cheaper

But carbon cost (the externality) not accounted for

And by growing local you get 7 extra days of freshness (thus less wastage)

And grow local creates jobs and economic stimulus, multiplier effect.

Develop the local supply chain

Full Business Model – thus important

7. Q&A points and critique

Mix of leadership and development staff and architecture to make it happen, make it institutional and not “a project”

Could be concern that this about changing the dynamic of economy towards isolationism (although things have swung very far the other way)

Is thisjust total place again (although clearly we still have much left to do)?

Issues to contend with

Rules and regulations regarding procurement

Competing priorities

Local vs cheapest. Local =? Define. Set metrics

Short vs long term

Overcoming the inertia of large institutions

Leadership – needs visible commitment

Organise within the institution – may need resource, more likely need mindset shift.

Visible and tangible goals – specific.

In the Business Plan

Incentive structure – is it right to encourage success in this space?

Breakdown of contracts to smaller more meaningful chunks, smaller lots –  maybe issue re greater administration workload on institutions?

Embed the mission into SOP and structures

Local knowledge and context are a part of the criterion of contract

Targets – set them(same as some have done for green)

DON’T displace local business and plan for success (there can be unitended consequences, e.g. gentrification

Barriers include 

Corporate ritual/custom and practice

Policy

Legislation

Benefit of Brexit? – EU Procurement – we have more latitude

2013 Legislation re Social Value Procurement – Not well known about or enacted. Using this can change the nature of process– we can do these things

Create workarounds where legislation is a barrier – e.g, disadvantaged business entities (example given when someone pointed out that positive discrimination in favour of black owned businesses was illegal in New Orleans)

Apply Principals of:

Powerful narrative/alternative vision (the boss may need to change the narrative)

Multiplier effect re keeping to local – creating local jobs, tax base

Full economic and social case, not just the money

Triple bottom line addressing the externalities in a way procurement officers don’t often account for.

Other points raised in discussion

Mobilise economic and human capital:

Student brains, 60k in the city

Mentoring

Potential for Two-way skill exchange across anchors

Culture change – move the conversation from ‘should’ to ‘have to. Show them how.

The futures of our instituitions are dependent on a thriving society. Our institutions doesn’t have a bright future unless we solve the image of Sheffield…

8. Business case.

What is the formal system of accountability where you combine financial accountability with social and wider economic accountability – Triple bottom line accounting 

Got to make it hard edged enough that the CFO say this is the right thing, and doesn’t unravel when times get tough.

CSR – Tesco have made great strides, the NHS has barely started

NHS Sustainability Unit have made some interesting arguments with respect to the 24 month Return on Investment, expressed Financially / Health and well being of community / Carbon. There are a number of case studies. See references at bottom

Benefits may not be readily tangible

The ‘Ah but we can’t see the benefits, they are intangible or long term…., thus we shouldn’t’ line –

Compare the Risk and benefit of doing this

Compare this to the risks and benefits of not heading down this path

9. Key advice from Ted Howard

Keep creating and recreating a big picture vision of what is possible

Keep sharing examples of where things have worked despite local or national defaults

If you want to do this job – you need to be intentional and hold feet to fire

This path is NOT the path of least resistance

Make public commitments

Hold yourself to account to progress back to the community

10Wrap Up & Next steps

we need to to reflect on discussions and push forward on developing a shared vision and framework

The vision is not as crystallised as it needs to be yet. Probably can’t be controlled. Is there a need to connect the institutional approaches together and scale them? Under the framework model perhaps?

Risk appetite – what is the risk appetite ?

Where are the opportunities?

Risk of doing it vs risk of doing nothing

Move away from project approach but building maximum approach

Political conversation about whether we want to push on this model.

What are our assets and existing projects?

How well Organised are we to leverage these assets?

Not about current story, there’s good stuff going on. How do we share, How do we scale, how to we set the trajectory towards Better?

Leverage collaboration – ? at expense of competition, use the collaboration to attract external funding

10a)Should we set up an anchor network?

To help each participant accelerate their own mission and spread the model more widely

And invest wisely to achieve the broader social aim

Meet x times a year

Define the org imperative

Build the evidence base

Collaborative with wide range of stakeholder

Working groups – for significant themes

How does/could/should this fit with existing partnership structures? And local leadership programmes. Is it possible to use City Partnership Board or others to bring this together? How do we avoid duplicating effort but have maximum impact?

There are many, many opportunities (through existing networks and with new networks), the q of “what” is reasonably settled (the toolkits are available, opportunities will arise)

Multiple anchor collaborations – the opportunity to Leverage the current:

Investment

Human

Economic

Procurement

Bit by bit and building into the woodwork so as it becomes part of the mission not “a project”

Ongoing work with anchors (supported by Partnership Board) around ‘progressive procurement’ and ‘joined-up education, skills and work’ – need to push this forward and influence across the organisations, as well as looking for new opportunities to start pushing on some of the other themes.

Appendix

NHS specific issues

NHS is behind here. Give tools to the NHS to catch up.

What do the regulators have to say on this matter in NHS context? This might be a driving factor.

Is STP about service sustainability or transforming the model?

The NHS matters to local economy in many ways – Estates, Social inclusion, Workforce, Local spend (do we know and understand our local supply chain and impact), Commercialisation of research

There will be no central message telling us to deliver this, or measure it

Localism is a challenge to nationally centralised system like the NHS 

NHS is massively centralised

Challenge for NHS is how it responds to devolution and this agenda.

Natural path will be to centralise

In the Paris climate change talks, it was the case put by the USA Mayors that changed the game

National is to set the context, local is what matters.

The creativity is local.

And we can influence through what we do locally.

Best way of protecting from market forces, Brexit, etc is local……this cannot be done from a centrally managed system.

This agenda is part of health creation.

Help needed from national bodies

Regulatory bodies need to acknowledge the concept of social value in their inspection regime or how they regulate the orgs.

Triple bottom line accountability is well documented in the private sector…..is it not built into the mission of the NHS…. much to learn.

NHSE and NHSI – not at top of shop but some levels below.

Unleash the creative potential that already exists.

Opportunities for NHS

In ACO model what we trade is health services…

In a wider model the traded commodity is health and well being

Link it to a contemporary policy and service problem

Inclusive growth is huge opportunity and role / place of NHS debate

Skill escalators – short term apprenticeships

Sources referred to –

Democracy Collaborative Anchor Mission Playbook& Hospital Toolkit

SDU (2012). NHS England Marginal Abatement Cost Curve.

SDU (2015). Healthy Returns from Sustainability Actions.

SDU-Smart Healthcare – Low-Carbon and Resilience Strategies for the Health Sector, see p25-16.

slides on “triple bottom line” health and care

2 replies on “Public sector anchor institutions and inclusive economic growth”

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