The new 'Liberated Public Services': what if a revolution happened and no-one noticed?
Latest developments with Liberated Public Services, including Demos’ ground-breaking report. And does it need access to Population Health Management dashboards to achieve the wide impact it deserves?
Through the decades of Thatcherism, Blairism and beyond, public services have come to be run on a 'Markets, Managers, Measurement' ethos.
Its desired upsides of efficiency and strategic control are now increasingly eclipsed by the reality of exhausted and demoralised workforces, extensively gamed targets, deep silos and a conveyor belt of disconnected services that often overlook the underlying issue that the person actually has. The level of costly waste in our current approach – sometimes labelled ‘failure demand’ – is immense.
The intrinsic motivation that’s vital for happy and effective staff is too often crushed under this approach. No-one would deny that it can work for simple, short-term, transactional types of challenges – but with complex problems in particular, it often falls way short of what we need.
In my earlier Substack post ‘The possibility of autonomous Buurtzorg care teams across the UK: tantalising hope vs organisational rigidity’ (part 1) here, I shared the findings of one report that talked about how “Patients would be seen by a procession of different professionals and providers, each of whom was responsible for a different aspect of their care, none of them spending more than a few minutes in their home. Patient satisfaction declined, and the nurses themselves became increasingly demotivated to the extent that many left the profession”.
The system is not a system – it’s a whole series of efficiency drives
– Mark Smith
Little wonder that the tide has begun to turn against that destructive and short-termist ‘efficiency’ and an alternative is spreading. (Gateshead’s Mark Smith points out: “The system is not a system – it’s a whole series of efficiency drives”).
The quiet local revolution: Demos’ new report on ‘Liberated Public Services’
By now there are a growing number of local examples of reactions against the reigning ethos and Demos have done a great job bringing it all together: "We have not moved to a new national vision, but a revolution in thinking has happened locally", they explain.
Do have a read of Liberated Public Services: A new vision for citizens, professionals and policy makers.
What’s crucial is that these Liberated Services-type approaches are happening round the UK, as the Demos report describes. From Gateshead to Wigan to Plymouth to Kirklees. And in Scotland and Wales it’s even the national NHS improvement organisations that are supporting this work. (See lots of case studies here).
The report identifies these four key characteristics:
Designing for complexity, instead of assuming the world is simple and linear.
Understanding human behaviour as intrinsically motivated, rather than just responding best to external motivators, for example punishments and rewards (e.g. targets, sanctions etc).
Building resilience to unlock prevention, not always seeking to deliver more efficiency.
Experimentalism, not command and control§
Others might want to explicitly name ‘Learning as a Management Strategy’ or highlight the ‘bespoke by default’ aspect or the importance of a community- and Strengths-based approaches, but I think we all can get the gist.
Liberated Services – in a one day?
You don't even have to create a whole new permanent service to start using the 'Liberated Method' kind of ethos. For example, just last week I helped to organise a Zoom (view it here) about the novel and inspiring 'Community Appointment Days' organised by the Muskuloskeletal (MSK) physio team in Sussex. The first of them saw three hundred people who’d been stuck on the waiting list who were invited to a hall where they were guaranteed to see a Physio – but a wide range of related services and physio groups were invited to be on hand too. All the diverse support that a patient might need to solve their challenges. In others words, support that went way beyond their musculoskeletal condition, into prevention and health promotion.
It was such a joy to watch, the buzz in the room was just amazing
- Laura Finucane
The whole approach was very patient-centred, strengths-based and far from the usual industrialised, medical model of care. The conversation was ‘What matters to you?’ not ‘what’s the matter with you?’: a relationship, not a conveyor-belt.
“It was such a joy to watch, the buzz in the room was just amazing,” says Laura Finucane, physiotherapist and Clinical Director for Sussex MSK Partnership and the initiator of the Community Appointment Days.
“It’s really about letting go of the ego”, she explains, which perhaps is why it’s so effective for the patients – as well as leading to a huge reduction in waiting lists (ie the wait was cut from 19 weeks to 8 weeks), even though this was a never set up as a waiting list initiative. It is, instead, a new model of care.
And former New Local Chief Executive Adam Lent (now at The King’s Fund) followed Laura by sharing initiatives with a similar ethos from around the UK.
Demos' certainty about this quiet, local revolution could even reflect a real change that's taken place in early 2024. Might we look back and decide that the first ‘Liberating Public Services’ conference in March 2024 was a 'tipping point'?
Why do I suggest a revolution’s happened and "no-one's noticed"? This is admittedly to take a painfully Westminster-centric view of power, where it indeed doesn’t seem to have been noticed. Labour's health team seemingly aren’t yet interested. NHS England isn't yet investigating these innovations, whilst nimbler nations are already out there leading and supporting them. (Fingers-crossed the Demos report could begin changing this current balance - especially if you diligently start sharing it with the right people!).
Also, there is no obvious big political champion yet, to really help usher in a replacement of the long-prevailing - and ultimately failing - 'Markets, Managers and Measurement' fixation of the ‘New Public Management’ approach.
The prospective Labour MP for Shipley, Anna Dixon, is an advisor to Public World, the Buurzorg support organisation. Maybe she will prove to be a future champion for ‘Liberated Public Services’? (I’m always meaning to dig into Richard Cockett’s book Thinking the Unthinkable – Think-tanks and the economic counter-revolution, 1931-1983 about the decades of behind-the-scenes work that enabled Thatcherism to triumph. That earlier revolution was conducted only ‘by about 50 people’, said Cambridge historian Maurice Cowling).
Next steps for Liberated Services?
My first guess is that – beyond the reports already out there - there probably needs to be a multi-author fieldbook showcasing the disparate practice that's bubbling up, as there was with Peter Senge's Learning Organisations movement (a kindred movement?). There's currently confusion, I think, as plenty of people presume that the Human Learning Systems approach, pioneered by Prof Toby Lowe, is the new method of choice, when in reality it has only ever aimed to be a sort of method-agnostic overview of what these newly emerging relational, complexity-informed approaches generally look like).
Interestingly, Prof Amy Edmondson is in the midst of producing exactly such a collaborative fieldbook for Psychological Safety (yet another kindred movement, I think?).
Yet facts, graphs, data can be remarkably unconvincing!
Buurtzorg was – I’m told - only able to thrive after they successfully persuaded an interested Dutch Government Minister to visit them for a day, and experience a real immersion in their new community/strengths-based way of working, with its self-managed teams.
Story-telling, visits etc seem key (Gateshead hosted a visit last week).
Does there need to be a link-up with cutting-edge Population Health Management tech for Liberated Services to spread?
Mark Smith's work in Gateshead is the epitome of Liberated Services, with its ‘bespoke by default’ method that relies on a two-person team to work closely with individuals, no longer bouncing them between numerous services.
Mark shares the example of ‘John’ who was bounced between services (homeless, mental health, criminal justice, NHS et al) for 9 years, at a cost of £2m – yet never got what he really needed. The Liberated Method then solved his underlying challenges for a tiny fraction of that cost.
I was at the big NHS Confed conference in Manchester last week, and from first impressions a ‘Population Health Management’ (PHM) project in Lincolnshire I heard about there seemed very similar to Liberated Services’ ‘bespoke by default’ approach: reduce the 9 teams the high intensity user – in this case ‘Betty’ – has to interface with down to one team, put a High Intensity User Worker at the heart of it. Move away from the usual expert-led ‘Medical model’ to a “Done with, not done to” relationship. Really shift to proactive preventative interventions. To a non-expert like me, it certain sounds along the same lines as Mark’s Liberated Method work in Gateshead.
Lincolnshire are also lucky enough to have an effusive Chief Finance Officer/Deputy CEO who was also there speaking about it. It's now ‘business as usual’; it enables efficient resource allocation decisions ("Manna from heaven for a Finance Director", he said). The potential value of new interventions is easy to forecast.
The instant Population Health Management (PHM) data available on dashboards in places like Lincolnshire (for all 815,000 people in that NHS Integrated Care System area) is something I don't think any Liberated Services/Human Learning Systems type projects yet have access too. Yet the resulting PHM interventions (eg with high-intensity service users) seem very similar, as shown above.
I believe Gateshead's Liberated Services project got such detailed retrospective data for just three people (including ‘John’), not 815,000 people! It was arduous work. PHM dashboards could presumably steer such novel Liberated work on a far wide scale? (I hope to contact the analyst in the Gateshead team, Ron Charlton, to find out more).
It certainly feels like the integration of ‘Liberated Public Services’ and Population Health Management systems could together unlock many of today’s gnarly problems – not least because of how convincing the comprehensive health and budget data seems to be to leaders, and those holding the financial purse-strings. (Predictably, today’s PHM analysts round the UK are too often far from free to spend their time on the kind of high value work seen in Lincolnshire, but that’s a whole other challenge – that people like NHS England Chief Data and Analytics Officer Ming Tang are certainly aware of).
Mark is currently working, with Toby and others, on the idea for an Institute for Prevention and Reform. With PHM at the heart of it, one hopes it could become a truly compelling approach, reaching out way beyond the couple of hundred people who came to that first Liberating Public Services conference in March.
Liberated Public Services: A new vision for citizens, professional and policy makers (Demos, 2024)
Community Appointment Days: cutting waiting lists, building wellness (2024) (Zoom video)
The Liberated Method - Rethinking Public Service (great overview of this ‘bespoke by default’ method)
Liberating Public Services Conference: Reflections on Rebellion (didn’t make it to Gateshead for the March conference? Have a listen to these reflections on the day instead).
Joint venture: how an NHS physio waiting list was shrunk in just two days (New Local blog, 2023)
Changing Futures (great new podcast about ‘Liberated Services’ in Gateshead, with Mark Smith, Rob Parnaby and others)
Hope in the Gaps & Dancing on Hills (fab blog by Wendy Landsdown about the Liberating Public Services conference)
Human Learning Systems - A practical guide for the curious (Healthcare Improvement Scotland, CPI, IRISS)