Alex Fox's hard-hitting new book "A New Health and Care System" suggests it's time to revisit how we understand scale
This week Nesta hosted the launch of a new book “A New Health and Care System: Escaping the Invisible Asylum” by Alex Fox who leads Shared Lives Plus. Simon Stevens kicked off the launch with reflections on why this is an important issue and you can watch the recording of it here, if you weren’t able to join us.
The book critiques the way so many public services squander the potential of both people with health conditions and front-line workers; and sets out principles to design sustainable and human ways to care, which are locally grown and enable people to live good lives.
Fox’s critique of public services is devastating: over-professionalisation that destroys trust; transactional services which make people worse; markets that don’t work; and research that excludes what’s most important to measure, to name just a few. And all this underpinned by gut-wrenching examples of the repression and marginalisation of people by state interventions.
Yet, despite the hard-hitting critique, the book also offers hope. Hope that more humane and socially just approaches are not only possible, they already exist. We've seen this through our People Powered Health work which has supported over a hundred organisations - many in the voluntary, community and social enterprise sector - with over £20m of funding in recent years. We've supported Shared Lives since 2012/13, during which time their work in England alone has grown by 30 per cent. And we're now working with them to grow their work with older people across the UK with our partners the Big Lottery Fund in the Accelerating Ideas programme.
Yet, we also know that despite progress and support, these approaches remain marginal to the mighty scale of mainstream public services. But this isn’t inevitable. As Alex put it during the discussion: it’s a choice as to whether or not we decide to invest in these alternatives. Shared Lives is a strong example of how to grow impact well through combining a ‘tight-loose’ organisational structure that allows for local flexibility within an overarching framework and good evidence of impact. Shared Lives has managed this while retaining its core values and ability to broker authentic human relationships - and so has much to offer other organisations looking to grow their impact in ways that remain both human and local.
Following on from this, the book has important reflections on how to successfully scale social innovations. Fox argues for an approach to scale which enables large numbers of people to benefit from many, many locally-embedded and locally-adapted solutions. This is a direct challenge to the orthodox understanding of scale that involves a single, fixed model being replicated or rolled-out nationally.
At Nesta, we've been interested in devolved and participatory models of scaling for some time. In 2010 we published Mass Localism which argued for an alternative approach to scale based on combining local action with national impact. This challenged the traditional model of roll-out, which is always vexed by the issue of context: just because something has worked in Barnsley, doesn't mean it'll work in Brighton. A Mass Localism approach turns this on its head: it starts with the specific context and builds a model that works for that place, drawing from elsewhere but not trying to reproduce it.
Since 2010 we’ve supported and explored many different models of scale that devolve and distribute power and resources, including networks, social movements and social franchising. Our People Powered Results approach is another example of using participatory methods and local adaptation to achieve scale and take-up - by creating more ownership of change by local leaders and frontline staff, it creates the conditions in which new solutions can be adapted quickly and effectively. Through all of this work, it has become clear that local and participatory versions of scaling can achieve significant impact and offer a compelling alternative to the imposition of a one-size-fits-all, roll-out approach.
So, as well as being a thought-provoking contribution to the health and care field, Alex’s book is also a helpful prompt to rethink what we mean by scale and how it can be achieved. It calls for something we've recognised through our work and which deserves further development: Mass Localism 2.0.