Public services as if people matter: Doing commissioning differently in Liverpool

How can we run public service in a way which treats people as fully-rounded human beings? As people with strengths as well as needs, as people whose strengths and needs are unique to them, and which change and develop as they change and develop? And crucially, how do we fund and manage public service in a way which makes this real, rather than a platitude in a brochure?

In order to find answers to these questions and others, The Liverpool City Region Combined Authority is applying a Human Learning Systems approach to the commissioning arm of its Assertive Outreach programme. Using government Trailblazer funding, the Assertive Outreach team advises and supports the region's homeless, or those at risk of becoming homeless, focusing on improving their physical and mental health and reducing rough sleeping. To support its focus on health, the nine-strong team includes two community psychiatric nurses and a nurse practitioner, with support and guidance from the contract review lead who acts as the “systems steward”. It commissions charities such as Liverpool's Whitechapel Centre and the Salvation Army - which runs hostels like Salisbury House in St Helens - to provide accommodation for the homeless.

A year into their implementation of the HLS pilot programme, we caught up with key participants Toni Morgan and Alex Palmer of the Assertive Outreach team, Katie Owen, a commissioning lead, and Dave Carter, the Whitechapel Centre's CEO.

One goal of Human Learning Systems is to act as a lens through which to view complex, often intractable problems - such as homelessness and rough sleeping. As Dave Carter observes, homelessness is more than just a housing issue. “People end up in homelessness services because they can't get the services they need, whether that's a mental health service, a substance issue service, or a central service. What springs immediately to my mind is how complicated the system is.”

A breakthrough moment in building trust

One of the key challenges facing public services is that people frequently don't “fit” the predefined categories that have been created in public service, so they fall between the cracks. In order to address this, the Human Learning Systems approach recommends putting decision-making authority into the human relationships that workers develop with those they are serving, because it is the person being served - and the worker who knows them - who have the knowledge to really understand the situation and what to do about it. And to enable this to happen, public servants in different parts of the system need to build relationships of trust, so that they understand and act on one another's judgement.

As an example, one of the issues for the Assertive Outreach team was that rough sleepers could not access the Salvation Army's “sit up” services or its “crash pads” in one of the local authorities they work with. As Dave explains, the local authority had allocated these spaces to another group of clients - who were not viewed to be in such dire need as rough sleepers. “So, from an outreach point of view,” he says, “we were trying to make change happen, but then the system would stop us from taking that next step.”

In this case, the Assertive Outreach team developed such a trusting relationship with the local authority, that they were given the ability to directly refer rough sleepers into the sit up services and crash pads. This “kept the focus on eligibility criteria, but it also made the change actually happen,” says Dave. His view is that the onset of the pandemic speeded up this process: “when COVID hit, everybody had to change what they were doing”.

This marked a breakthrough moment for team manager Toni Morgan. “The most amazing U-turn I've ever seen. The change regarding the crash pads is a really good example of what Human Learning Systems can do.”

Rather than asking the public to fit into predefined categories, the Human Learning Systems approach starts with the person and then asks: what can we do to help you? It seeks to join up the broad system of public service help by refocusing on each person's unique life. To do that, it requires people to build trust throughout the system - between public servants and those they serve, and between individual public servants.

So what has the team learned so far?

1. The pivotal role of the systems steward

Alex Palmer is the systems steward for the Assertive Outreach team, a role that HLS describes as “making it easier for people to connect and collaborate, so that our systems work to serve the people they are supposed to benefit”. Formerly, the relationship between the Liverpool City Region and its constituent local authorities was reviewed infrequently, perhaps no more than once a year. Now, they have monthly contact with the Assertive Outreach team, and “they're constantly being fed with what's going on. So, we're actually being told the reality of the rough sleeping, the reality of homelessness,” says Alex.

She is very close to the problem, and is therefore able to make informed decisions and coordinate the Combined Authority's response. She recognises that this can be difficult when they are often dealing with emergencies and “people are stretched for time, and resources are tight, which is always going to be the case in the public sector”. Katie Owen says that Alex overcomes this by being tenacious in the role, but “politely, diplomatically, and she doesn't let anything go. And local government is starting to understand that they're getting into the detail, which they have never done before, really.”

As a result of the success of Alex's stewardship role in the Assertive Outreach team, the combined authority is now looking to recruit systems stewards elsewhere in the region. Katie believes that this “speaks volumes about the impact that Human Learning has had, all the approaches the Combined Authority and the Whitechapel have taken. They want a different approach, from someone who can come in with a monitoring lens but with understanding of the system, willing to be a learning partner and build relationships.” They are saying “we want a systems steward, because we don't really understand what's happening. We've got all these services, but we don't really know what they're doing.”

Katie says that government investment often fails because of this lack of understanding, for example of the close connection between health and homelessness. “More and more funding is released without fully understanding that those systems aren't in place. It's fundamentally wrong,” she adds, “to commission stuff where you know the systems don't work and don't communicate, and they're broken.”

2. The importance of building rapport and trust

Alex is helping people to connect with each other: “I'm not saying I get it right all the time, but the role is around facilitating an open conversation. For me, it's always having an attitude of listening and learning. I'm not coming in as the expert, I don't deliver on the frontline.” Another aspect of the stewardship role is to help with “building rapport, building trust”. She is able to be proactive by inviting the right people into the conversation, and the team is trying to focus on learning and adaptability and creating the context in which they can develop good relationships with different service partners.

“Human Learning Systems help us to communicate in a positive way with other services and local authorities,” Alex says, particularly the ones that are naturally receptive to the Human Learning Systems approach. “Because of the relationships the team has with the local authorities,” she continues, “the conversation has happened almost organically and is a lot more open and free-flowing than before.” The investment in communication has increased levels of trust, especially with providers - such as the Whitechapel Centre - whose willingness to communicate regularly “really helps move the service forward from a Human Learning Systems perspective”.

3. In local authorities, “culture change takes a really long time”

These regular meetings have enabled a culture change within local authorities in “how they see commissioning as a service, the purpose of it, what it looks like to deliver, and how that can be measured,” says Alex. However, not all local authorities responded with initial enthusiasm to the Human Learning Systems approach, and Alex has learned that culture change can be “slow going”, particularly “in the areas which don't want it as much”. However, Toni is convinced that now “they definitely do see the value in it, because we hear it through other means”.

“The difference that we're seeing in the local authorities' understanding,” Alex concludes, “shows that there's starting to be a little shift in the culture.” Dave believes that the pandemic has accelerated this change: “I think COVID has allowed us to break down those doors, strengthen those partnerships”.

Alex has been invited to more meetings than before, because they are held online rather than in physical spaces. “We're going back to have meetings with local authorities, to ask about what their needs are and to say, ‘we're still here. Even though the crisis is happening, we're still here. How can we help now?' That's really demonstrated, in action, the positive aspects of the Human Learning Systems approach.”

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