Imagine two identical health programmes serving deprived areas. Both are hitting their outcome targets, but one is doing a whole lot more.
Somehow, its service users are not just in better health, they are also happier and more confident. A small but significant number who were unemployed have found jobs, in some cases taking whole families off benefits. These families are eating better and taking more exercise. Their children’s attendance at school is better and their results are improving.
It is obvious which approach is more satisfying for healthcare professionals, and more attractive to cash-strapped funders. But how does that unit do what it is doing? It can point to organisational beliefs about rights and responsibilities, excellent links with other services and the quality of its relationship with service users - but how did it develop these? And how does the other unit catch up?
Capturing the secret of this extra impact is the ambitious goal of a social value group, set up by the Centre for Innovation in Health Management.
CIHM director Becky Malby says: “Many social value tools are in an early stage of development. There are no approaches that work well for complex social change. We need social value metrics now in health, so we’ve got on with it.”
The group is one of a few key projects being taken forward by the centre’s international arm, the Shaping Health Systems network. This brings together doctors, managers, social entrepreneurs, community leaders and academics from across the globe. By gathering diverse experts from the most effective healthcare systems in the world, the network aims to generate new possibilities for change. It takes a ‘complex systems’ approach - a scientific method that looks at how parts of a system determine the behaviour of the whole.
The social value group has members from China, India, South Africa, Thailand, the UK and the US. So how does this international team understand social value?
Dr Narayanan Devadasan, who is on the faculty at India’s Institute of Public Health, tells a compelling story from the late 1980s. He had just graduated from medical school and joined an NGO, Accord, working with an adivasi (tribe) that had been evicted from their home in the forest. They had lost their entire way of life, and were extremely vulnerable. The government gave them land, but they could not read and were tricked into signing over ownership. The first generation to use money, they were given the wrong change in shops. If they went to hospital, medical staff would bully them and demand payment.
Accord helped the adivasi begin a community dialogue which led them to realise they had strength in numbers. First, they held a massive demonstration, demanding protection for their land. Then, while the government was mulling the matter over, they formed a union.
“If anyone’s land got taken the union was informed, who went round the villages and mobilised the menfolk,” says Devadasan. When a hundred angry adivasi confronted a man who had driven a tractor across a tribal’s land, crushing his banana trees, the results were swift - the police registered the first case about a crime against a tribal.
“When Accord started working with the tribals it became clear they had a very poor self-image - they thought they were scum of the earth,” says Devadasan. “After our work, we could measure changes to behaviour such as a drop in land grabbing, or more children going to school. But we couldn’t measure the absence of fear, the fact that the tribals now had confidence, and dreams for the future.”
Alissa Caron describes the work of Bangkok-based NGO the Population and Community Development Association, where she is a planning officer. The Positive Partnership Project tackles the stigma and discrimination suffered by HIV-positive Thais, which keeps many from coming forward for treatment and exacerbates their poverty. Participants are asked to form a partnership between one person living with HIV and one person without the virus. The pair recieve business skills training, and microcredit to set up a business. They become public example that HIV-positive people can live and work side by side with HIV-negative people.
The project was named best practice by UNAIDS in 2007. A UNAIDS report, The Positive Partnerships Program in Thailand: Empowering People Living with HIV, said: “Many people living with HIV reported that they no longer felt they must accept being discriminated against. They were intensely relieved to feel as though they need no longer hide and had found support and assistance from others who understood their experiences. They have now become leaders in their communities’ HIV awareness campaigns.”
Caron says: “Efforts to support HIV-positive populations must include not only medical care and support, but economic and social empowerment as well. Projects like this have several dimensions - with the toolkit, we’re developing rules that are multidimensional enough to capture what’s going on.”
Another member of the social value group, Lance Gardner, is projects director at North East Lincs PCT. He set up Open Door in Grimsby, a social enterprise that works with the NHS to provide primary and community care to people who may have never received any healthcare - the homeless, criminals, or those with mental health problems.
Famously, Open Door persuaded a long-term criminal, classed as Grimsby’s public enemy number one, to keep out of trouble. This man had been arrested on average every two weeks. Each arrest required up to eight police officers, as he always resisted. The estimated savings to the public purse are £48,000 a year. But the man also had a baby with his partner. This baby was expected to go straight to adoption, but with intensive support from Open Door his parents kept him, and his father is perceived to be doing a great job. The £48,000 is dwarfed by the money that will be saved through improving the baby’s life chances.
In today’s cash-strapped environment, social value creation is not a luxury or a lofty ambition. Malby says: “It’s a very complex world, there’s a lot of a choice. Social value metrics are about what sort of things you should be investing in as money gets tighter. ”
She adds: “People don’t do this because it reveals things. People like big clinical metrics because they can hide behind them and show they are effective without actually being all that effective. Say you’ve got two units both hitting targets, but one provides additionality. How do you have a conversation with the other unit that allows it to get a much bigger bang for its buck?”
The group has developed a handbook which will address this question. It is targeted at the thorniest type of social change, where no-one agrees what is valuable, and is not clear which inputs will make a difference - tackling poverty or improving the care of people with disabilities for example.
Kojo Parris is chief executive of Social Private Equity South Africa and the group’s co-ordinator. He says: “We are developing our work against the background of some tremendous work being done by colleagues globally in this field and continually borrow and adapt relevant aspects of the existing body of knowledge – we neither seek to recreate the wheel or claim exclusive insight.
“But we need to move beyond the reliance on hard numbers that dominates decisions about how resources are invested, to devise robust, replicable and transparent approaches to capturing non-financial value. This is obviously not simple - we would be horrified if the surgeon turned up for keyhole surgery brandishing a meat cleaver - but people need to be able to use it in situations where resources and data are scarce. So we have to aspire to a complex, but uncomplicated, methodology.”
The handbook sets out four stages:
- Generating meaning Conversations with and between all the stakeholders, including those who find it hard to speak up. These conversations explore agreement and disagreement, and generate a shared understanding of the intended social value of your activity
- Measuring output value Using new and existing metrics to analyse what your organisation or project is achieving
- Measuring process value Assessing the fitness of your organisational culture to make the most of the resources it has
- Making judgments Making decisions, based on stakeholder conversations, about where to invest.
Where this handbook is unique is that it requires all these steps to be in play at the same time, in recognition that social problems are not linear. The group has dubbed it the ‘fair chance’ approach - it gives your programme a fair chance of working, and creates fairness in society.
The name acknowledges that with complex issues you cannot guarantee success, you can only create the conditions for it. Martin Fischer, a CIHM associate and group member, says: “Fair chance is honest, it recognises you don’t have control and everyone has to keep trying. It’s a shift to a living dynamic, requiring continuous effort, it’s not just done and passed on.”
Creating social value
Co-production - designing and delivering services in partnership with users and communities - is at the heart of the group’s work. Except in very simple situations, social value cannot be created any other way. The process described is also iterative. Malby explains: “You as providers may have said one thing to funders, but as you develop metrics and understand the group you are working with, you might decide what you were doing isn’t good enough. Now you’ve got choices to make and you’ve got to make them collectively because what you think will be different from what other stakeholders think. It isn’t for you as provider to go off and make those decisions in isolation, then have them challenged.”
The handbook sets out a range of metrics but does not prescribe which ones to use. This does not prevent comparisons being made - paradoxically if everyone used the same metrics it would distort the result, as organisations need to use metrics that are relevant to them.
Malby adds: “Comparison is made possible by the overall framework, which is flexible but captures the relationship between elements in a consistent way - between the project, it’s outcomes and what is seen as locally socially valuable.”
Members of the social value group are now trying the toolkit out by applying it to existing projects, and aim to report on the results by October.
If the approach works, it is likely to be of interest far beyond the health sector. As Parris says: “While the work is being developed primarily in the health space, group members are from a wide range of sectors and bring their different competencies and experiences to bear.”
And there is a much broader need - a recent report by Demos, Measuring Social Value: The Gap Between Policy and Practice, looked at charities and found that “overall, no single group of third sector organisations proved particularly adept in measuring and communicating social value”.
The network’s handbook is poised to contribute to a radical evolution in the public and third sector across the world, in which healthcare could lead the way on social change.
Becky Malby is director of the Centre for Innovation in Health Management, Leeds University Business School