This is a CTP of initiative: Fair Shares (UK)
This CTP describes the proactive attempt of Fair Shares to introduce Time Banks into the National Health Service (NHS). A research report on timebanking and health care in 2003 presented existing timebanking projects and suggested using timebanking mechanisms to address health-related issues more widely. It explored opportunities of potential interest for the NHS. At the time it was hoped by the authors that this would be a critical turning point for both timebanking and the NHS. However, despite this playing into policy calls being made around the same time for a bigger role for community-based action in preventive health care and co-production of health outcomes, the initiative stalled owing to institutional and other barriers. This is interesting because similar policy proposals for reforming the NHS have since been made and the NHS is currently seeking ways to implement its Five Year Vision, which is along these same lines.
As with most Western European countries, the UK is facing an increasing demand for healthcare services. The 2003 report from Fair Shares summarized several factors which were then (and still are) causing the growing demand for care:
i. demographic change, including an ageing society;
ii. a trend towards singe-person households;
iii. the tendency to do things alone
iv. an increasing lack of trust between people;
v. modern lifestyles, including changing family models and spatial flexibility, causing diminishing social capital in terms of interpersonal relationships and social networks; and
vi. the increase in the proportion of socially and financially disadvantaged people, which affects lifestyles in relation to health.
These trends call for providing alternative approaches to health and wellbeing and elderly care than only through professional health interventions when people get ill. Although, increasing budgets are spent on the NHS, professional staff members are overloaded. Hence, the aim of Fair Shares was to use Time Banks in preventive ways (to avoid ill health and to promote healthier lifestyes) and to support people re-entering the community from hospital. The idea is that problems such as depression (caused by loneliness, fear, and lack of social contact) unhealthy lifestyles, and bed-blocking (where a patient cannot be released from hospital because there is no-one available to look after them in their home after release), could be addressed by timebanking.
In contrast to the predominant institutional logics that casts people as passive recipients of services, timebanking promotes active participation and seeks to build strong interpersonal relationships, social networks and communities based on the concepts of co-sufficiency and co-production. According to Fair Shares, co-sufficiency is defined as “belonging to a mutually supportive local social network [that] sustains our long term well-being (and good health).” and co-production as “an explicit and dynamic collaboration between the ‘client community’ and the helping professionals.”
In 2003, a national report on NHS modernization suggested the need for building relationships among health care providers, patients and the public in order to achieve a “strengthened accountability to local communities, a health service that genuinely responds to patients and carers, and a sense of ownership and trust”.
Fair Shares and UK time banks responded at the time by exploring how timebanking might contribute to achieving these objectives using community time banks and specialised time banks. Evidence was gathered from US and UK experience demonstrating that active participation in timebanking could have positive impacts for health and healthcare systems: e.g. reduce the number of doctor appointments, secure care after hospital stays, contribute towards health education, and provide support for elderly people. One of the first US timebanking demonstration projects had involved experiments with elderly care achieved with financial support from the Robert Wood Johnson Foundation. An independent monitoring study had concluded, for example, that timebanking could help enable the frail elderly to live longer in their own homes.
Fair Shares therefore organized five workshops for concerned stakeholders to present arguments and evidence about timebanking and health with a view to initiating pilot projects within the NHS to explore and experiment with timebanking. Stakeholder groups included policy makers, managers, academics, practitioners, users of public services and Time Bank organisers and participants, The recommendations from these workshops included, inter alia, “that the concept of co-sufficiency is placed at the centre of public health and health promotion policy and practice.”
The high expectations at the time around this potential partnership between timebanking and the NHS were not realised, however. The policy and public debate around the future of the NHS and about engaging the community in self- and mutual- help have continued. Indeed, currently, these same issues are at the centre of the present five-year vision for the NHS. They are central elements under chapter two of the vision and the programme to support implementation.
David Boyle and Martin Simon both point to institutional barriers and resistance to change from within the NHS as reasons for the failure to make progress despite the optimism in the period around 2003. The organizational cultures in large organizations like the NHS are risk averse. The NHS is also a large and multifaceted organisation (in fact it is a set of organisations), so reform can be blocked at many different levels. Even if, in principle, there are calls for reform and support for reform at the very highest levels, there are strong pressures to maintain established practices and procedures at middle (operational) levels.
It was thought that the NHS reviews around 2003 that called for reform of the NHS might mark a critical turning point for timebanking. Fair Shares was proactive along with NEF in seeking to promote co-sufficiency and co-production, but despite organising successful workshops with policy makers and NHS stakeholders this did not mark a significant moment of change either for time banks or for the NHS. The issues are still, nevertheless, unresolved and are still under discussion today.
Relevant actors in this endeavour included Martin Simon of Fair Shares and David Boyle of the New Economics Foundation. They were motivated to promote timebanking and use its potential to help improve health care and wellbeing and to support the NHS. The ambition was to reform the British healthcare system by introducing strong elements of preventive health care, self-help, mutual-aid and care in the community.
The initiative was influenced by the early US experiences with time credits and health care related initiatives and the New Economics Foundation (NEF), particularly by the close cooperation with David Boyle. The NEF is an independent think-tank addressing economic and political challenges to improve the lives of people, to allow them to” take over control again and to take more control over decisions and resources that affect their lives today […]”. Hence, healthcare and the NHS reform always have been high on its agenda.
The initial aim of setting up Timebanking UK (TBUK) in 2000 was to establish a sister organization to TimeBanksUSA (TBUSA) for future co-working, also on health related issues. The idea was for the two civil society organizations to collaborate on this issue. However, due to systems differences of local care provision conditions (private care provision in the US and public care provision in the UK) the discussions centred around health projects were not so easily carried forward jointly. Hence, the organizations started together but continued with their local initiatives separately. TBUSA had been established by Richard Rockefeller, who was, himself, a physician. Richard Rockefeller was one of the founders of Medecins-sans-Frontieres and had a strong interest in community-building as a means to promoting social security, health and wellbeing.
The link to preventive healthcare, community care and home from hospital care arrangements, as well as to the psychological and physical health benefits of being active has been a continuing theme for TBUK since the organization was founded based on the role of timebanking in establishing closer interpersonal relationships. It has also been seen as a potential source of funding for the organization and for local time banks.
The 2003 initiative involved organizing workshops with stakeholders. It received support from two NHS Trusts as workshop co-organizers and hosts. In total 86 stakeholders participated, including NHS managers, health practitioners, health service workers, health service user group representatives, policy makers, academics and proponents of timebanking. In addition, Time Banks across the UK and the US contributed evidence about the positive impact of timebanking on health and on health systems. These included the Rushy Green Time Bank in London, which experimented with ‘prescribing’ timebanking as a way to combat loneliness and isolation, which was a cause of patients visiting surgeries. By addressing social isolation, prescribing timebanking had led to a reduction in doctors’ appointments.
However, the workshops, evidence-gathering and resulting report on health arrangements in the UK had much less influence on the health system than anticipated. The system was found to be very bureaucratic and to have a culture that was resistant to change. Especially, the processes of organizing, financing and auditing health service budgets are highly regulated and all actions are predetermined by budgets. The ‘system’ restricts the autonomy of commissioners and this limits the scope for reform.
Important related events include the introduction of timebanking to the UK from the US in 1998.
Important related events in the US included the support of the Robert Wood Johnson Foundation for a nationwide experiment involving six projects over three-years (from 1987 to 1990) to explore the relation between time exchange systems and health. These trials had focused especially on the health and wellbeing of the elderly. Over this period, the Robert Wood Johnson Foundation invested US $1.2million to explore whether timebanking could reduce the need for nursing home care by enabling people to live in their own homes longer. The demonstrations had been evaluated by the Center for Health Policy Studies at Georgetown University, Washington D.C. The report of the study [Feder J., Howard J. and Scanlan W. (1991) Helping Oneself by Helping Others: Evaluation of Service Credit Banking Demonstration] became a key reference for the health impacts of timebanking. The evaluation had concluded that the programme facilitated support services that “were necessary to the independent functioning of an older, frailer population with potentially limited social supports” and recognised the “community-building benefits of the program” noting that the programs “developed less as anonymous or mechanical exchanges than as community member organisations”.
This study had paved the way for 17 US States to enact laws mandating the creation of service credit programs for the elderly. In 1992, the US Administration on Aging formally endorsed the approach and recommended State and Area agencies to use it. The federal government in the US had also committed funds to experiments with service credit exchange systems.
On the basis of these earlier positive experiences in the US, it was expected by timebanking proponents in the UK that calls for healthcare reform offered an opportunity for breakthroughs in UK timebanking. There was optimism, also, because the cause of timebanking had been taken up in the US by Richard Rockefeller, a very high profile and highly-respected individual who, by vocation, was also a doctor. This added to the credibility and legitimacy of the venture. Richard Rockefeller also lent his support to the early UK time banks.
Important related events in the UK include the successful implementation of Fair Shares as the first Time Bank in the UK, the early success in spreading timebanking in the UK (including the establishment of TBUK as a joint initiative of Fair Shares and the New Economics Foundation), the founding of the Rushey Green Time Bank (1999), and experiments already undertaken there successfully. Dr Richard Byng, one of the doctors at Rushey Green surgery, had integrated timebanking into the practice and, from 2000, this had enabled patients to be prescribed timebanking or could be referred to the time bank, for example, in the case of long-term depression. The early evidence from pioneering projects was positive. Research at Rushey Green surgery showed that 70% of patients suffering from a combination of physical and mental problems reported some remission of their condition within six-months of joining the timebank. The experiment had been evaluated independently by the Social-Medico Research Group at King’s College, London. It had found that those participants who were most actively involved in timebanking experienced the most improvement in their physical and mental health.
In the context of the ‘Third Way’ politics and policies of New Labour under the government of Prime Minister Tony Blair, there was strong political interest in timebanking. Charles Falconer – an advisor to the Blair Government – was very positive about timebanking. Fair Shares received calls from the government about ambitions to establish timebanks in GPs surgeries throughout the UK. This was against a backdrop of long-term trends of increasing demands being made on health care services, increasing costs of providing health care, and health budgets and services being increasingly overstretched. Demographic and life style trends were also relevant here, including the increasing numbers of people living alone, more people living in large cities and more people having fewer close social contacts. Isolation and loneliness had become a significant factor contributing to depression and mental health problems.
Around the same time as Fair Shares was developing its overture to the NHS, a process of formal review of health was in train in the UK. This led to the publication of the Wanless Report (2004). This focussed on improving public health and reducing health inequalities in England and urged the government to develop a more coherent strategy to reduce preventable illness.
The basic issues of concern in 2003/2004 are still the same today: the long-term trend in increasing demands on health system, the lifestyle factors which are a growing element in escalating costs, and the inefficiency of delivering all services using professionals when many could be provided by and in communities. A dominant concern, today, for example, is to reduce bed-blockings by elderly and frail patients who stay in hospitals, although they are experiencing no condition that requires any medical intervention. The problem of bed-blocking arises because there is no home-based support available to hospital patients after being discharged.
The venture to promote time banks in support of health services experienced setbacks, which arose from organisational barriers linked to the different cultures of the organisations
Fair Shares was aware of potential barriers. Martin Simon stated: “For many people, there is a history of bad experiences; patient involvement can be feared and resented by health professionals, and viewed as cynical and inconsequential by service users.” For this reason, the suggestion was made to first implement pilot projects to enable experimentation and exploration of possible negative effects and to find ways to address any problems. However, no progress was made. No official project for experimentation or demonstration was taken up at the time by the NHS.
Part of the problem is that, as an approach, time banking is asset-based. Timebanking focuses on the skills people have and defines them by their assets and what they can contribute. By contrast, government systems (the NHS-included) are set up on a deficit model, so systems for evaluation try to measure the strength of interventions in relation to bringing about outcomes that somebody else – somebody from the outside – has defined. “As you start dealing with people and want people to lead, the last thing you want to do when entering the relationship is to get them to define themselves in terms of all their problems and issues. Yet the first thing the evaluation requires you to do is baseline how awful the situation is.” The deficit-based mindset and evaluations based on it are just incompatible with Asset-Based Community Development.
Also, all expenditure has to be accounted for and justified. There are significant accounting and auditing constraints, which limit the possibilities to exercise free judgement. It is possible to justify expenditure on interventions only when there is clear-cut evidence that these are cost effective. Such requirements systematically bias decision making against interventions that are preventive, indirect, and work over time in association with other factors. Instead, they favour direct interventions where the cause-effect relationships are easier to theorise and monitor.
The requirement for clear-cut evidence is a barrier to the involvement of time banks in public health care provision schemes, because “if you are really dealing with people, there is no linear (simple) cause-effect route” and there may be no immediate effect.”
The organisational culture of the public health system also constrains the kinds of experimentation that can take place. Services are highly professionalized. A major (and overriding) concern of the NHS, as with many large public service organizations, is to secure compliance with legal regulations and to limit exposing the organization or its personnel to liability suits. The internal governance of large organisations is a factor here. Governmental entities are characterised by a strong hierarchical governance structure. Many official representatives of the NHS were positive about the idea of bringing timebanking into public services and healthcare. However, the question they always had to ask was: “Who would be covering our back?” The issue for NHS decision makers is how to: “ensure non-responsibility for the public staff in case of failure” rather than “how to ensure effective outcomes. If you’re dealing with people and lives, people have got to feel that they are in control” and if progress is to be made “they have to be allowed to make mistakes”.
Fundamentally, the culture of the NHS is risk averse and this gets in the way of experimenting and innovating in other than conventional and controlled ways that are in-line with its organizational logics and modus operandi. New ways of organising health delivery would require new ways of organising the NHS as an organisation, so reform is very difficult and unlikely.
The US experience created high hopes and expectations for a successful implementation of timebanking into the UK healthcare system. Also the establishment of TBUK as a ‘sister’ organization to TBUSA to work collaboratively on health care projects contributed to positive expectations for collaboration between the US and UK on timebanking in health care. Due to the structural differences of care provision in the US and UK, these collaborative expectations were not met. In the UK, care provision is a public sector responsibility and is accompanied by immense bureaucratic machinery.
There was nevertheless high motivation at Fair Shares and in the UK timebanking movement to try to support system change within UK health care; on the basis of experience, this motivation turned into resignation.
“Yes, we thought they [the NHS] would turn around and say ‘Yeah, this is good stuff! Let’s look at working together [so] that we can actually stop [the] majority of resources being spent on accountants and office workers monitoring that money is spent properly and let’s get money into the community.’ “
The scale of the barriers and setbacks encountered were insufficiently anticipated by Fair Shares. “In the early days we were working from a… naïve [perspective] that we thought we could reform the system.”.
Although, the CTP is not perceived as a development with negative impacts on Fair Shares, it is experienced more as an unrealised ambition for timebanking more generally in the UK and for health care provision in the UK. This is all the more significant since, at the moment, this same ground is being visited again. The impetus, this time, comes from the government, which is anxious to control the (escalating) costs of the NHS and improve services by promoting care in the community and community-health initiatives.
The initial motivation and expectations of grassroots initiatives was that they could be driving forces in changing society and its systems and all that was needed was to work cooperatively with government and public agencies, such as the NHS, as partners. However, in the course of the years, the experience with public institutions and organizations has caused some disillusionment and, for Fair Shares, an emerging awareness that this was perhaps too naïve.
“We thought we could reform. […] But then you come across practice managers who want to keep control of all that is going on.”
Martin Simon says that the problem is deep-rooted in the bureaucratic approach to financial accounting and control. “How do they account for how they have spent the money. That’s where we have the major problem.” The immense accounting and monitoring systems prevent financial resources from being allocated directly to the communities for them to control and use. Money can only be given to achieve aims set by outsiders and used in ways that outsiders dictate.
The problem is not limited to the NHS but to many agency funders.
“With all the evaluations of all Time Banks, they [the local time banks] have to end up creating arbitrary evaluation processes, arbitrary targets, which absolutely have nothing to do with what is going to happen. If you are really dealing with people, there is no linear route from where we are now to a cohesive community.”
This realisation was decisive for the future development of Fair Shares as it has led the organization to seek ways to sustain operations based upon creating its own, independent and sustainable funding streams and to maintain a high degree of financial independent.
“The biggest change is that I’ve come to realize over the years that you can’t reform the services. The system is too big for individuals to have any chance of changing it.”
This impression has been re-enforced through the experience of Fair Shares with the prison service [see separate CTP].
“You can’t change [the system]. So the shift that I made, I cannot say that all timebanking people made this, is to accept that what we are about is a culture of community and any day that I am not contributing to a culture of community I am not doing my job."
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