A citizen-led approach to health and care: Lessons from the Wigan Deal

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Part of Lessons from the Wigan Deal

Overview

  • Over a period of six years, public services in Wigan have been through a major process of transformation, based on the idea of building a different relationship with local people. The new approach to delivering services has become known as the ‘Wigan Deal’.
  • This report provides an independent critique of the Wigan Deal drawing on in-depth research, including interviews with key stakeholders, focus groups with members of the public and evidence from data analysis. It explores what local authorities, NHS organisations and others can learn from Wigan’s journey of transformation.
  • The Wigan Deal is an example of ‘asset-based’ working, in which public services seek to build on the strengths and assets of individuals and communities to improve outcomes. Although other areas have explored similar approaches, Wigan is notable for the scale and consistency with which these ideas have been applied.
  • Widespread cultural changes are needed in public services to realise the full potential of this kind of approach, and this involves challenging engrained ways of working. In Wigan this has been achieved through bold leadership and a long-term strategic commitment to working differently with local people and communities.
  • To build a new relationship with the public there needs to be a shared way of working across all of the services operating in a place. In Wigan, the local authority has led the development of the Deal, but a key part of the process has been closer working with the NHS, voluntary sector organisations and others to establish a common approach.
  • Wigan’s journey shows it is possible to achieve substantial savings while protecting or improving outcomes, but only if services are genuinely transformed and upfront investment is available to help bring about new ways of working. The Deal is not a panacea, but it does illustrate the kind of work that is needed to shift to a new model of public service delivery in which patients, service users and communities are involved as active partners in improving health and care.

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The need for radical change

The relationship between public services and the people who use them needs to be transformed to allow people to take greater control of their health and wellbeing. Existing ways of delivering services can sometimes disempower the people they are there to help, leaving people feeling unable to make positive changes in their lives and their communities. In the case of health and social care services, changing this means striking a new relationship that puts more power in the hands of patients and service users and emphasises ‘working with’ rather than ‘doing to’.

Financial pressures have also made it necessary to explore new approaches to delivering public services. Since 2010, local authorities in England have needed to make unprecedented financial savings in response to dramatic cuts in funding from national government.

In Wigan this has amounted to an effective reduction in the council’s budget of around 40 per cent, phased in over 10 years, and the loss of around a fifth of its workforce. Ongoing financial pressures across the country mean bold thinking is needed about how best to provide services.

These two strands of thinking – the moral argument and the financial one – came together in Wigan through the ‘Wigan Deal’ – a major transformation programme that has taken place over the last six years. The Deal has been an attempt both to manage demand for services and to transform how public servants and local people understand their roles in creating successful, healthy communities.

Our research

Core elements of Wigan’s approach

The transformation in Wigan has included four main components: asset-based working, permission to innovate, investing in communities and place-based working.

Asset-based working

There has been a major drive to work with local people in a different way that seeks to recognise and nurture the strengths of individuals, families and communities and to build independence and self-reliance. This started with social care workers being trained to have more open-ended, exploratory conversations with their clients, and has now become a new way of working for the council as a whole and, increasingly, for other organisations across Wigan. While asset-based working has been explored in many parts of England, Wigan is notable for the scale at which this approach has been adopted and for the consistency of implementation.

Permission to innovate

Leaders in Wigan Council have created a culture in which innovation is encouraged and frontline staff are permitted to take decisions for themselves and rethink how they work, based on their conversations with people using services. This has meant taking a different approach to risk – positive risk-taking is encouraged if the potential benefits for clients are believed to outweigh the potential harms. It has also involved moving away from a ‘blame culture’ towards one which emphasises learning from what has not worked.

Investing in communities

Wigan Council has invested in local voluntary sector organisations and community groups through a dedicated community investment fund. Beneficiaries have mainly been small grassroots organisations that have been helped to increase the scale and impact of their activities through financial support and access to expert advice. More broadly, the council has moved to a collaborative approach to commissioning in which voluntary and community sector organisations are seen as partners and are actively supported to develop and improve. There has also been a focus on growing citizen leadership through roles such community health champions, dementia friends and autism friends, and on supporting social prescribing using community link workers based in general practices.

Place-based working

As in other parts of the country, partner organisations in Wigan are attempting to work together in a more integrated way, working flexibly across organisational boundaries within local neighbourhoods. A distinctive feature of Wigan’s approach to this is the breadth of organisations involved – in addition to health and social care teams, multi-agency working within the borough’s seven ‘service delivery footprints’ involves the police, housing, employment and welfare services and others. This creates opportunities to tackle the broader determinants of health and wellbeing in a more coordinated and flexible way.

How the transformation happened

Above all else, the Wigan Deal is a story of profound cultural change within the council and its partners. At the heart of this new culture is a set of positive beliefs about the potential of frontline staff and local people to bring about improvement. For other areas seeking to replicate the Deal, fostering this set of beliefs and the different behaviours that go with them should be the first priority.

The process of building a new culture is still a work in progress and it has not always been an easy one. Nonetheless, there are some clear lessons to take from Wigan’s journey.

The most striking feature in Wigan is the constancy of purpose evident both in the senior leadership team and at other levels in the council. A common vision was forged early on between executive and political leaders, and a clear narrative developed about the changes the council wanted to bring about and why they were needed. This core narrative has been consistent over time, with leaders making a long-term commitment to changing how the council works with local people.

While the overall approach and the values underpinning it have been nonnegotiable, an enabling style of leadership has meant that staff have had considerable freedom to develop their own ideas about how the principles of the Deal can be put into practice in their work. Senior leaders in Wigan Council emphasise the need for humility and ‘servant leadership’. Political leadership has also played a vital role, with councillors willing to make the Deal a non-partisan issue and to find common ground despite political differences.

The changes in Wigan have been marked by a series of bold decisions rather than incrementalism. These have included training all staff across the council and partner organisations in having different conversations with service users, radically changing the composition of the workforce in adult social care, and replacing staff who were unwilling or unable to change how they work with local people. A key theme in the story has been the need to ‘hold our nerve’ in the face of significant obstacles.

A huge amount of energy has been put into communications and marketing to build a shared sense of purpose. The concept of the Deal and the principles it encapsulates are reinforced at every available opportunity. Stories from staff and service users have played a particularly important role in this, providing tangible examples of how local people have benefited from the changes under way and showing staff that the permission to innovate is real rather than simply rhetoric.

What has it achieved?

The Deal has given public servants and others in Wigan a set of guiding principles that inform how they work with each other and with people using services. The examples described in our report paint a compelling picture of professionals feeling liberated to practise in a different way, making better use of the strengths of service users and the communities they live in.

These individual case studies are given further credence by improvements seen in several key metrics. Healthy life expectancy has increased significantly, bucking the trend for stagnation seen in the England-wide figures. Care Quality Commission assessments indicate that the quality of social care services in Wigan has improved, and Wigan performs well compared with national and regional benchmarks at supporting people to leave hospital and to remain in the community rather than in long-term residential care. Staff engagement has improved, and in March 2019 the Local Government Chronicle named Wigan their Council of the Year.

While there is evidence that significant changes have been made in terms of the way staff in Wigan see their role and how they work with service users, the perception of the wider public appears to have been harder to shift. Our focus groups found that people’s concerns about issues such as crime and antisocial behaviour appear to be overshadowing progress being made on other fronts that are less visible to the majority of residents, such as social care or public health. This demonstrates how challenging it is for one local system to build a new relationship with the public in isolation.

Implications

Wigan does not offer a simple, ready-made solution that other areas can adopt overnight. The Deal has been at least six years in the making and is still a work in progress. However, it does provide a powerful example of what can be achieved when public services see communities as assets and commit to working in a different way that builds on people’s strengths.

Importantly, Wigan shows that asset-based working should not be seen as a technocratic quick fix – it is not a tool to be adopted, but rather a culture to be grown. It is about rekindling hope in our public services and overcoming fatalism about people’s capacity to change. As such, it requires bold leadership and a longterm commitment to challenging engrained ways of working.

Local authorities and NHS organisations have an important opportunity to work together to forge a new relationship with the public and agree a vision for health and care that harnesses the strengths of individuals and communities. This kind of approach is likely to have the greatest possible impact when it becomes a shared way of working across all of the services operating in a place. A key question for the NHS is whether it is willing and able to adopt a culture that gives patients more control and allows frontline staff greater freedom to innovate.

Wigan’s journey also shows that it is possible to achieve substantial financial savings in public services while protecting or improving outcomes, but only if services are genuinely transformed and upfront investment is available to help bring about new ways of working. Wigan Council was able to take an invest-to-save approach, using reserves to fund transformation. An ongoing squeeze on public sector budgets may make it harder for others to take a similar path.

Comments

Julie Ann Racino

Position
Cornell and Syracuse University Alumni,
Organisation
Cornell University and Syracuse University
Comment date
29 June 2019

I was delighted to work with the King's Fund back in the 1990s! And David Towell and I say hello from wikipedia, community integration online in the UK, too. Regretfully, I was not able to stop back over in 2015; however, are deeply concerned about the exit from the European Union and served on ASPA's Health and Human Services Administration and the International Chapter in 2017-2018. Books online at amazon.com and Barnes and Noble.

zieda ali

Position
Lay member NED public and patient engagement,
Organisation
Bolton CCG
Comment date
09 July 2019

although Wigan is leading the way , we at Bolton CCg have some best practice to share , it would be great to shine the light on our comms team who have been led really well by our associate director for comms and engagement , Nicola Onley ,
i would love to nominate her and her team for an award or some recognition

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