London Councils Total Place final report · spent more effectively, most commonly through service design around the citizen. Our brief from London Councils was to examine the opportunities

London CouncilsTotal Place – towards a new service model for Londoners

January 2010

PricewaterhouseCoopers LLP2

Contents

Section Page

Introduction ................................................................................................................................................... 3

Background to this project ........................................................................................................................ 3

Total Place – London Councils’ contribution............................................................................................. 3

Total Place – a new way of working? ....................................................................................................... 3

Methodology ................................................................................................................................................. 5

How the mapping was done...................................................................................................................... 5

How the service themes were chosen ...................................................................................................... 6

How the strands were brought together.................................................................................................... 6

Public expenditure in London ....................................................................................................................... 7

Mapping expenditure in London ............................................................................................................... 7

Managing chronic care ............................................................................................................................... 13

Introduction ............................................................................................................................................. 13

What is the problem and why is this a particular issue for London? ...................................................... 13

The current system and its flaws ............................................................................................................ 15

A proposed new system and why this is better....................................................................................... 17

Conclusion .............................................................................................................................................. 20

A whole systems approach to young people exhibiting anti-social behaviour ........................................... 21

Introduction ............................................................................................................................................. 21

What is the problem and why is it a particular issue for London? .......................................................... 21



Conclusion .............................................................................................................................................. 29

Tackling obstacles to employment ............................................................................................................. 30

Introduction ............................................................................................................................................. 30

What is the problem and why is this a particular issue for London? ...................................................... 30



Conclusion .............................................................................................................................................. 39

Overarching analysis and making the case for change ............................................................................. 40

Introduction ............................................................................................................................................. 40

Extrapolation of findings and potential savings....................................................................................... 44

Annex: Non-departmental public bodies operating in London ................................................................... 45


Introduction

Background to this project

In September 2009, London Councils appointed PricewaterhouseCoopers (PwC) to help develop thinkingon Total Place at a pan-London level.

In this paper, we set out the background to Total Place, both nationally and in London, analyse publicexpenditure in London using the preferred Total Place categorisation of spending, and outline the workwe have undertaken with London Councils on the deeper analysis of three important public service areas.Finally, we draw out relevant conclusions from the three thematic analyses that we believe may help todevelop the wider public service landscape in London in the Total Place context and highlight the scale ofthe potential benefits that could be secured.

Total Place – London Councils’ contribution

London Councils aims to make a distinctive and considered contribution to the debate on Total Place inthe capital. As a representative, pan-London body, London Councils’ goals in so doing arecomplementary to those of the Boroughs undertaking Total Place projects. London Councils is in aposition to join up important themes that impact on all Londoners and to see the pan-London position onpublic services. In that sense, London Councils has the unique advantage of being close to, but not partof local government service provision in the capital.

PwC’s commission was to map expenditure for London at the headline level and apply Total Placethinking to three public service themes. The three themes need to be seen as exemplars of a way ofworking through Total Place at this early stage: they are certainly not the only relevant Total Place ideasfor London. They are:

Managing chronic conditions

A whole system solution to the impact of anti social young people

Overcoming obstacles to employment.

In each case, the objectives were to build a case for more effective joint working by the public sector inLondon on the chosen theme and then to begin a debate on reasonable and practicable alternatives tothe present pattern of service provision. We are not presenting these to London Councils as perfectlyworked up solutions; instead, we are putting these forward as ideas that need further expert input andpublic debate. However, in each case, by applying Total Place thinking, it is already possible to see thepotential for significant financial savings, service improvements and better outcomes.

Total Place – a new way of working?

Total Place is a programme aimed at all localities in England and has its origins in pilot work undertakenin Cumbria under the banners Counting Cumbria and Calling Cumbria. Public sector partners in thecounty cooperated in a process that produced a map of total public sector expenditure in Cumbria andbegan the process of exploring together how they could be more effective in spending this resource.


The term “Total Place” was adopted for this activity by Sir Michael Bichard in his contribution to theOperational Efficiency Programme (HM Treasury, April 2008). Sir Michael’s first recommendation was:

Roll out Total Place, a programme mapping total public spending in a local areaand identifying efficiencies through local public sector collaboration to at least 12pilot sites with a high level reference group to identify how to increase incentivesand eliminate the barriers for joint working and with ministerial sponsorship toensure that issues raised are addressed swiftly across government.

Government has chosen to launch the programme at 13 pilot sites, two of which (Lewisham andCroydon) are in London.

Total Place is an ambitious and challenging programme that, in bringing together elements of centralgovernment and local agencies within a place, aims to:

Create service transformations that can improve the experience of local residents and deliver bettervalue

Deliver early efficiencies to validate the work

Develop a body of knowledge about how more effective cross agency working can deliver costsavings and/or better services for citizens.

The Total Place pilots have undertaken two complementary strands of work: the ‘counting’ process thatmaps money flowing through the place (from central and local bodies) and the thematic/service focusthrough “deep dives” that explores links between services and identifies where public money can bespent more effectively, most commonly through service design around the citizen.

Our brief from London Councils was to examine the opportunities across London as a whole,complementing the Total Place work that is being undertaken at an individual London Borough level,whether in the two official pilots (Croydon and Lewisham) or by other councils in London.


Methodology

How the mapping was done

London Councils commissioned PwC to map public expenditure in London against: services; spendingbody, funding sources and demographic group. Because of limitations in the data, we were not able toidentify expenditure against demographic groups within the capital with sufficient confidence and so havenot included that element of the analysis in this report.

Summarised in this report are the expenditure data showing spending by service area and spendingbody. The reference year chosen was 2008/09 as the latest from which complete data sets are available.The expenditure has been allocated to service blocks using the United Nations’ classification of functionsof government (COFOG) definition of public expenditure categories. This is the system used by HMTreasury (HMT) in their national and regional public sector statistical analyses (PESA) and has beenadopted as a common language amongst the Total Place pilots.

COFOG is a taxonomy system that breaks down to at least three layers of detail. At level one (thehighest category) the COFOG classifications used in the analysis are:

Defence

Economic affairs

Recreation, culture and religion

Education

Health

Public order and safety

Social protection

Housing and community amenities

General public services

Environmental protection

Defence.

The data in this document are sourced from HMT’s PESA set for 2008/09 and the relevant annualaccounts for public bodies. The data were segmented into expenditure by national, non-departmentalpublic bodies (such as government agencies) and local bodies (which include the GLA family and primarycare trusts). Unlike in other Total Place pilots, we have not undertaken detailed work on the budgetbooks of local bodies in London. There are more than 40 such bodies and so that task alone would haveconsumed the resources for this project.


How the service themes were chosen

The project was managed by a team from London Councils. A project steering group (with leaders, chiefexecutives and finance directors as members) and a number of officers working at a senior level in localgovernment, helped to choose the themes for in depth analysis. It was considered important to choosethemes that ranged across a number of public services and partners while also selecting areas where itwas clear that the lives of many Londoners could be changed for the better if the services could beimproved.

Clearly, the three topics are not the only challenges facing the capital; doubtless some would argue thatthere are other, more pressing issues that should be considered as part of a Total Place approach toimproving outcomes for Londoners. Nonetheless, they provide a helpful starting point for the applicationof Total Place in London because they:

Affect large sections of London’s population, either directly or indirectly, and attract large volumes ofLondon’s total public service expenditure

Require whole-system engagement with vulnerable groups of Londoners who face challengingpersonal circumstances

Are areas where the governance, fiscal and delivery landscape is complex and where such whole-system engagement is therefore difficult to achieve.

In summary, these topics exemplify the types of challenges that Total Place was designed to tackle.They provide both a frame of reference and a ‘test bed’ for a genuinely transformational approach topublic service management and delivery

How the strands were brought together

The selection of the themes for further analysis was informed in part by the results of the expendituremapping exercise. The selected topics sit in some of the higher spending COFOG categories, forexample social protection, health and public order and safety, and have the potential to impact uponexpenditure in a number of other categories. They also involve interactions between some of the largerinstitutions that make up the delivery of local public services in London – not only local authorities butalso Government departments (such as Department of Health, Department for Work and Pensions andMinistry of Justice) as well as a number of the key NDPBs such as Jobcentre Plus and the Youth JusticeBoard.

In addition, we were seeking to identify any common themes that could have wider application indeveloping Total Place solutions to London’s challenges. Examples of these include:

The potential benefits – in fiscal and outcome terms – of early intervention and a preventativeapproach

Testing the importance of effective and more integrated case management in reshaping the local statearound the needs of its citizens

Achieving an appropriate balance between central control where it is needed, and devolution to eitherthe local state or the individual where it makes sense

The possible need to reshape the role of public service professionals to support Total Placeapproaches to solving London’s pressing social challenges.

Within the three themes that we studied, we have postulated savings in total of around £1.5bn each year.By applying both the general principles set out above and the learning from the thematic studies, we havesuggested that the potential benefits of Total Place approaches that could accrue to the public purse inthe capital could be as much as 15% of the £73.6bn total spend per annum: or some £11bn each year.


Public expenditure in London

Mapping expenditure in London

London is like no other city in the UK – and arguably, it is like few other cities in the world. So in mappingpublic sector expenditure in London, it is important to acknowledge that London contains theinfrastructure of a world city and much of the architecture of the government of the UK. London hasmany major transport hubs and much of the national infrastructure. It also has a governance structureunlike any other UK city with the office of the Mayor, the Greater London Assembly (GLA), many nondepartmental public bodies (NDPBs) and the London-wide bodies set up by the boroughs. Even withinthe South East region and sub regions, London predominates more than any of the other regionalcapitals in England. London’s social and economic influence extends wider and more deeply than anyother UK city across a large swathe of England.

For the calculation of London’s share of national expenditure, we have relied on the PESA data which donot disaggregate local (and in London’s case, pan London-controlled) expenditure into the more detailedsub-categories – that is, the information is not available below the top level COFOG headings. So whilethe expenditure mapping methodology we have used is largely comparable with our other Total Placeprojects, the results of the mapping need to be seen in London’s particular context.

The headline results

Total public expenditure in London in 2008/09 was £73.6bn. This amounts to around £10,000 for eachLondon resident.

London’s complex travel-to-work pattern makes this hard to compare to other places as many servicesand assets - for example the transport system or the police - are heavily used by people who work inLondon but live elsewhere.

The figure below shows that collective expenditure by local bodies1

accounted for 58% of the totalfollowed by national departmental expenditure (34%) and NDPBs (8%). London has a more substantialextent of local control (both at the London-wide and borough levels) than other parts of the country due tothe additional extent of London-wide government, especially in areas such as transport and economicdevelopment.

1 “Local bodies” in this report include London Boroughs, London-level government, the PCTs and NHS Trusts. “Locally accountable

bodies” refers to elected bodies


As shown in the figure below, the largest areas of aggregate (national, NDPB and local) expenditure aresocial protection (£25bn), health (£15bn) and education (£12bn). This reinforces the expectation thatmuch public sector activity is based around meeting the needs of individuals, many of whom are indifficult circumstances. This is similar to the distribution seen across the country, although we wouldexpect some small differences given London’s younger population and smaller geographical area.

The largest share of expenditure (about two-thirds) is dedicated to meeting the needs of individuals andcommunities. Any move to increase public sector efficiency and effectiveness significantly will need toconsider these areas carefully. Activities that lessen the need for state intervention – especially in socialprotection and health – while at the same time maintaining positive individual and societal outcomes,must be key opportunities to focus upon for potential savings; as these are where the money is spent andwhere it is possible to limit any potential adverse impact on individual and community outcomes.

The table below shows that when the global total is broken down by central government, NDPBs andlocal bodies, the split of expenditure in London by COFOG category was:

Public Expenditure in London (£m)

NDPB

National Govt

Local

£0 £5,000 £10,000 £15,000 £20,000 £25,000 £30,000 £35,000 £40,000 £45,000

£5,600

£25,100

£42,900

Public Expenditure in London (£m)

NDPB

National Govt

Local

£0 £5,000 £10,000 £15,000 £20,000 £25,000 £30,000 £35,000 £40,000 £45,000

£5,600

£25,100

£42,900

Total Expenditure for London (£m)

£10

£1,200

£1,200

£1,300

£3,200

£6,400

£7,700

£12,500

£15,500

£25,000

£0 £5,000 £10,000 £15,000 £20,000 £25,000 £30,000

Defence

Environment protection





Economic affairs

Education

Health

Social protection


National departmental expenditure

Government departments spend over £25bn a year on behalf of Londoners. This is dominated byexpenditure which goes directly to meet individual needs as national entitlements, for example, pensions.

Over 60% of national departmental expenditure in London is accounted for by £15.6bn of socialprotection spending which largely comprises state pensions (£6bn), family and income support (£5bn)and disability support (£2.5bn).

Economic affairs account for £2.4bn in expenditure with the largest components in transport (especiallythe rail network) and support for employment and economic development programmes. Educationaccounts for expenditure of £2.4bn which is largely routed to tertiary education and non-compulsoryeducation (PESA considers schools funding to be local, not national expenditure). Public order andsafety is largely accounted for by the law courts and prison services as policing and fire are locally-controlled activities.

Centralised health expenditure of £1.7bn consists largely of national management of the NHS andsupport services for local health professionals and institutions.

The next table shows that fourteen government departments are each estimated to spend more than£100m in London. The largest two departments – DWP and the Chancellor’s Departments (HM Treasuryand HM Revenue and Customs) – are largely accounted for by social services payments.

National Expenditure for London (£m)

£5

£120

£220

£250

£430

£1,700

£2,200

£2,400

£2,400

£15,600

£0 £2,000 £4,000 £6,000 £8,000 £10,000 £12,000 £14,000 £16,000 £18,000

Defence





Health


Education

Economic affairs

Social protection

4%£3,150£1,840£1,190£120Housing and community amenities

2%£1,160£870£80£210Environment protection

2%£1,280£980£50£250General public services

2%£1,170£710£40£430Recreation, culture and religion

10%£7,670£4,520£770£2,380Economic affairs

9%£6,390£3,930£300£2,160Public order and safety

17%£12,450£7,550£2,580£2,380Education

21%£15,440£13,500£280£1,700Health

34%£24,900£9,050£350£15,510Social protection

100%£73,600£42,900£5,600£25,100Total

0%£15£10£0£5Defence

%TotalLocalNDPBsNational£ millions

4%£3,150£1,840£1,190£120Housing and community amenities

2%£1,160£870£80£210Environment protection

2%£1,280£980£50£250General public services

2%£1,170£710£40£430Recreation, culture and religion

10%£7,670£4,520£770£2,380Economic affairs

9%£6,390£3,930£300£2,160Public order and safety

17%£12,450£7,550£2,580£2,380Education

21%£15,440£13,500£280£1,700Health

34%£24,900£9,050£350£15,510Social protection

100%£73,600£42,900£5,600£25,100Total

0%£15£10£0£5Defence

%TotalLocalNDPBsNational£ millions


Department £m Share

1 Work and Pensions £11,200 43%

2 Chancellor's Departments (HMT and HMRC) £2,800 11%

3 Health £2,700 10%

4 Children, Schools and Families £2,100 8%

5 Transport £2,100 8%

6 Innovation, Universities and Skills £1,500 6%

7 Home Office £940 4%

8 Justice £920 4%

9 Communities and Local Government £510 2%

10 Culture, Media and Sport £450 2%

11 Defence £290 1%

12 Environment, Food and Rural Affairs £240 1%

13 Energy and Climate Change £140 0.5%

14 Business, Enterprise and Regulatory Reform £120 0.5%

While most expenditure is in departments’ traditional areas (such as the spending of the Department ofHealth on health), there is also significant expenditure outside these areas based on national shares ofdepartmental spending by COFOG category. As an example, the Ministry of Defence spendsapproximately £300m annually in London on military and civil services pensions which count as socialprotection not defence expenditure.

The expenditure of non-departmental public bodies

We have identified 156 NDPBs that spend more than £100,000 and have an influence in London. Theyare listed in the annex to this paper. NDPBs spent £5.6bn on London and Londoners in 2008/09. Thelargest area of expenditure is education which accounts for just under half of all expenditure, largelyfocussed on further and higher education.

NDPB Expenditure for London (£m)

£0

£40

£60

£80

£280

£300

£360

£780

£1,200

£2,600

£0 £500 £1,000 £1,500 £2,000 £2,500 £3,000

Defence




Health


Social protection

Economic affairs


Education


The table below shows the fifteen largest NDPBs by expenditure. As can be seen, these are dominatedby two large education bodies (HEFCE and LSC) and the combined housing funders

2.

NDPB £m

1 Higher Education Funding Council for England £1,083

2 Learning and Skills Council £875

3 Home and Communities Agency £693

4 Housing Corporation £439

5 Legal Services Commission £275

6 Office for Fair Access £250

7 Jobcentre Plus £171

8 Big Lottery Fund £171

9 Medical Research Council £161

10 Engineering and Physical Sciences Research Council £118

11 Teachers Training Agency £116

12 Science and Technology Facilities Council £93

13 National Policing Improvement Agency £86

14 Youth Justice Board for England and Wales £74

15 Arts Council England £66

These fifteen bodies together account for 83% of NDPB expenditure in London. However, expendituredoes not necessarily equate directly to policy influence as some of the large spending bodies are drivenby funding formulas determined outside of their own control, whereas some of the smaller spendingbodies may have significant power over policy direction and delivery (a good example of this being theinspectorates, who have a relatively small operational spend but a large degree of influence.)

Some sense of the crowding of some types of spending bodes in London arises from a comparison of thenumbers of bodies spending by the major COFOG classifications. For example:

Education and Housing and Community Amenities, which, combined, account for 67% of NDPBexpenditure in London have only 29 (out of 169) major spending bodies identified in London

Economic Affairs has the largest number of spending bodies (58) but accounts for only 14% of totalNDPB expenditure

Recreation, Culture & Religion has the second highest proportion of bodies (35) but accounts for lessthan 1% of total NDPB expenditure in London.

UN COFOG Expenditure (£m) Spend Share Bodies

Economic affairs £772 14% 58

Recreation, culture and religion £36 1% 35

Education £2,576 46% 23

Health £276 5% 14

Public order and safety £300 5% 14

2 The 2008/09 financial year included activities of both the HCA and the former Housing Corporation


UN COFOG Expenditure (£m) Spend Share Bodies

Social protection £354 6% 9

General public services £53 1% 6

Housing and community amenities £1,190 21% 6

Environmental protection £80 1% 4

Local expenditure

The usual way to derive a picture of local expenditure is to interrogate the budget books of the relevantbodies. We did not do this here given the scale of such a task in the context of the size of thiscommission. Some of the local expenditure estimates are therefore from different sources and are notdirectly comparable.

London-based bodies spent £42.9bn on public services. About half of this expenditure was made bybodies operating at the pan-London level or as part of the National Health Service.

The COFOG analysis does not enable the net spending of local government to be identified with anyaccuracy. Separately, the Chartered Institute of Public Finance and Accountancy (CIPFA) collects detailsof local government expenditure annually and for 2008/09, the general fund service expenditure ofLondon Boroughs combined was in the order of £15bn. This number excludes some important serviceareas such as money flowing through housing revenue accounts but includes others such as HousingBenefit expenditure.

London ‘regional’ bodies (Greater London Authority, London Development Agency, Metropolitan Police,London Fire Brigade and Transport for London) accounted for some £7.5bn expenditure in 2008/09. Ofthis, two-thirds was for the police and one-sixth for transport.

London local health bodies – both Primary Care Trusts and other NHS Trusts – spent some £15bn in2008/09. While not directly accountable to elected local representatives, their boards are required toreflect the needs of local communities.

Health expenditure accounts for 31% of local expenditure mostly through NHS Trusts (both foundationtrusts and PCTs). Local social protection expenditure accounts for 21% of local expenditure and is acombination of social services and some locally-controlled transfers such as housing benefit. Educationis largely for primary and secondary education which is controlled at the borough level. Economic affairsinclude transportation which is a major share of the funding of Transport for London. Public order andsafety is largely spent on the Metropolitan Police with the London Fire Brigade also included.

Local Expenditure for London (£m)

£9

£710

£870

£990

£1,900

£4,000

£4,600

£7,600

£9,100

£13,500

£0 £2,000 £4,000 £6,000 £8,000 £10,000 £12,000 £14,000 £16,000

Defence






Economic affairs

Education

Social protection

Health


Managing chronic care

Introduction

As average life expectancy extends, more and more people are affected by chronic conditions, both inthe developing and developed regions of the world. In 2005, chronic conditions caused approximately 35million deaths

3worldwide and this number is expected to increase by almost a fifth in the next decade.

When compared with the global pattern, the chronic disease impact upon populations in the westernworld is disproportionately borne by older people, rather than the economically active. This holds trueboth in England as a whole and in London in particular.

This topic was chosen as an area for deeper examination because:

It represents a significant proportion of the total of £74bn of public expenditure each year andencompasses some of the biggest service providers in London

A significant proportion of that public expenditure is borne by local government, but in a system that ischaracterised by considerable interdependence between providers

The problem of chronic care is escalating significantly and, if not addressed more effectively, willpresent further challenges to London’s public services in the future.

What is the problem and why is this a particular issue for London?

Chronic conditions, as defined by the Department of Health are “diseases which current medicalinterventions can only control not cure

4. The life of a person with a chronic condition is forever altered –

there is no return to normal.” Some of the more common chronic conditions are diabetes mellitus; chronicobstructive pulmonary disease (COPD); asthma; arthritis; epilepsy and mental ill health.

In England, more than 15 million people have chronic conditions, with a quarter of these reporting two ormore conditions Prevalence varies suggesting that there are a number of factors driving the variations,including age, lifestyle and so on (ibid). However, age is the most significant driver of chronic conditionsin the UK (ibid).

Prevalence of chronic conditions in England 2006/07 (Quality and Outcomes data, DH)

Numbers affected

Coronary heart disease 1,899,000

Heart failure 420,000

Stroke and transient ischemic attack 863,000

Hypertension 6,706,000

Diabetes 1,962,000

3 WHO: An estimate of the economic impact of chronic non communicable diseases in selected countries, Abegunde, D and

Stanciole A4

Raising the profile of long term conditions: A compendium of information, Department of Health 2004


Numbers affected

Chronic obstructive pulmonary disease 766,000

Epilepsy 321,000

Cancer 489,000

Severe mental health conditions 380,000

Asthma 3,100,000

With declining birth rates and the increases in life expectancy that come from advances in medicine andmedical technology, chronic conditions are more likely to affect the populations of Northern Europe.There are a significant number of people over the age of 40 who report having multiple long term chronichealth conditions

5. The trends for an ageing population are likely to increase the pressures in terms of

people with chronic conditions. By 2025, there will be 16% more people aged 40 and over in Englandand 42% aged 65 and over

6. Based on these trends, the number of people in the national population with

at least one chronic condition could rise to 18 million by 20257. People who have chronic conditions are

high users of social care and community services.

Although the demand for long term care is not synonymous with chronic care, the two are hard toseparate: public expenditure on long term care is estimated to reach almost £16 billion and total long termcare expenditure is projected to reach approximately 1.8% of gross domestic product by 2022

8.

The Government’s objectives in relation to chronic health conditions

Joining up health and social care is on the national and local agenda. The Government is looking toachieve the following outcomes across health and social care.

9

Better health and well-being for all – helping people to stay healthy and well, empowering people tolive independently and tackle health inequalities

Better care for all – the best possible health and social care, offering safe and effective services, whenand where people need help, and empowering people to make choices

Better value for all – delivering affordable, efficient and sustainable services, contributing to the widereconomy and the nation

The following indicator has been set to measure improvements as part of the National Quality andOutcomes Framework (NHS 2008/09):

For people with chronic conditions, improving their satisfaction with the supportthey are given to be independent and in control of their condition and reducingthe number of emergency bed days

Chronic conditions in London

There are at least 3.5 million Londoners with some degree of chronic condition10

, (some of these will bemild or early stage – for example, musculo-skeletal problems) with 1.3 million registered NHS cases of

560% of UK adults report having at least one chronic condition (Department of Health 2004), and 26% report have three or more

chronic conditions (British Household Panel 2001)

6ONS population projections 2006-2031

7Based on ONS projected population aged over 40 of 29.5 million and a 60% rate of chronic conditions among adults (DH 2004)

8Long-term care expenditure for older people, projections to 2022 for Great Britain PSSRU 2005

9 See DH Our Health, Our Care, Our Say Jan 2006 or Shaping the Future of Care Together July 2009


the major chronic conditions. Approximately 900,000 people have more than three chronic conditionsand more than half of GP visits in London; 65% of outpatient appointments; and 72% of all hospital beddays are associated with chronic conditions in some way.

11

People with chronic conditions are twice as likely to have mental health problems, three times as likely tosuffer from depression and have an increased likelihood of suicide.

12Chronic conditions place a

significant limit on the potential for employment. Chronic conditions also affect both the nature andamount of work undertaken. Households that include someone with a chronic condition are more likely tohave lower incomes. In 2007/08, the cost of DWP benefits payments in London directly associated withchronic conditions, (that is: Attendance Allowance; Carer's Allowance; Disability Living Allowance;Incapacity Benefit/Severe Disablement Allowance) was £2.1bn being 14% of all benefit expenditure(DWP statistics service).

Our research suggests that expenditure on chronic care in London is at least £5bn pa (approximately 7%or more of total annual public expenditure in the capital), with primary care trusts spending at least £3bnper annum on chronic conditions across all care settings. We have estimated that social servicesexpenditure in London related to chronic conditions and needs is at least £2bn pa as set out in the table(that is approximately 13% of the estimated £16bn total expenditure in 2008/09 by London Boroughs.)The category “other adult services” includes expenditure on substance misuse and vulnerable people.

Estimate of social care costs of chronic conditions to London Boroughs

(NHS Personal Social Services Expenditure and Unit Costs data set)

Completed Assessments Provision of residential

care (people-years)

Net total expenditure

(£m)

Older people (65+) 53,550 19,437 1,105

Adults under 65 with

Physical disability

12,560 1,409 261


learning disability

1,575 5,715 564


mental health needs

15,145 2,649 271

Asylum seekers 9

Other adult services 5,295 85

TOTAL 1,955

Thus, the burden of chronic disease in London is a serious one. It affects the quality of life of Londoners;causes premature death and disability and creates large and underappreciated economic effects onindividuals, families, across communities and for London as a whole.

The current system and its flaws

There are many flaws in the current systems for treating chronic conditions which lead to increased costsand lower satisfaction. These can be summarised as follows:

Organisation of the model of care

Despite many attempts to re-orientate the service model, service provision in health has continued tofocus on the acute hospital and the acute episode of care rather than the systematic prevention of those

10Extrapolated from DH UK figures 2004

11Extrapolated from DH UK figures 2004

12Raising the profile of long term conditions: A compendium of information, Department of Health 2004


at risk from entering the acute system. To deliver more appropriate care to people with chronic conditionswill require a step change in approach to focus on prevention and timely intervention. The position insocial care is a little different with more progressive local authorities making large strides towards earlierintervention and more self directed care; other councils still have some way to go on this.

Organisational boundaries cause fragmentation of services and support, with inherent delays andinefficiencies in service delivery. Better collaboration – even integration – has yielded some excellentresults in individual localities, but, despite some first-rate local initiatives, the joint model of care inLondon requires a ‘step change’ in approach and delivery to avoid a system where the care is onlyoffered to people with chronic conditions when their needs are most acute.

Customer expectations

The public, carers and service providers are not routinely involved in service design or configuration.Most people living with chronic conditions would like more say in where and how their care is providedand how services to support their independence and well-being are configured.

Many people who have long term conditions also want access to information about their conditions sothat they are empowered to manage them better. The more likely they are to want to take care of theirown health, the more likely they are to want to work and to feel more socially included.

Financing the system

Different political parties will postulate different spending positions, but the fiscal and economic outlookfor spending on health and social care is poor in the short to medium term, whichever party forms thenext government. Reduced spending will impact on individuals, families and communities and is likely tomean more means testing, co-funding and further reliance on the role of individuals, families and carersin dealing with complex health and social care issues.

Funding streams do not easily support the multi-agency working that can deliver the best possibleoutcomes for the public. Not only does this lead to conflicts in governance and duplication of effort, butcan conflict with the objective of providing value for money. Thus it is difficult to determine whetherinitiatives are delivering good value for taxpayers and individuals as reporting is done by organisation (topdown) rather than by individual, family or community (bottom up).

Individual budgets across health and social care are accepted as a positive initiative13

but are notroutinely used as a means to empower individuals, improve efficiency and gain better user satisfaction.Information is not easily shared between agencies and this is a significant barrier to adopting a citizen-centred approach to health and social care.

Design principles for a future delivery model

Research internationally and in the UK14

has identified four requirements that underlie the prevention andalleviation of chronic conditions. These should influence any new model of care.

Self management of chronic conditions in the context of promoting healthy lifestyles

Investment in prevention and resources to encourage healthy lifestyles continues to be a challenge forthe NHS and local authorities. Whilst the Comprehensive Area Assessment is driving closercollaboration, more work is required for these partnerships to mature.

Inequalities in health outcomes persist15

and the social determinants of health need to be addressed in asystematic manner.

Prevent unnecessary deaths and disabilities arising from chronic conditions

13 See SCIE Research Briefing 20: The implementation of individual budget schemes in adult social care

14 Improving Care for People with Long term conditions: HSMC University of Birmingham and NHS Institute for Innovation and

Improvement15 Post 2010 Strategic review of health inequalities – The Marmot Review DH 2009


Personalised care planning and the provision of useful and relevant guidance and information areessential for self care and management as this will prevent future complications.

Treat chronic conditions effectively and in the most appropriate care setting

Individual case management and a whole system approach with citizens at the centre can ensure that theright care is delivered in the right place at the right time. Effective treatment is most often early treatment,with the appropriate supporting infrastructure, for example, access to diagnostics.

Provide appropriate and tailored care and support for those living with long term conditions

Self care and self management should be the goal of all people living with chronic conditions. Serviceproviders should be encouraged to support individuals to achieve this, no matter how difficult theorganisational boundaries.

A proposed new system and why this is better

Our recent work with national and international social care organisations has emphasised the importanceof early intervention and self directed care. We explore in this section whether such learning specificallyapplied to people with chronic conditions could offer a significant improvement on current care pathways,especially in the provision of appropriate healthcare.

The new model is predicated on a number of reforms to the current system including: a shift in resourcecommitment on the part of the NHS to earlier intervention across the system; a greater emphasis on self-directed care; a common service pathway and a common system of case management.

The graphic overleaf sets out three health and social care pathways for people with chronic conditions.The first box “Current health and social care model” outlines the way in which most people access healthand/or social care at present – often too late, and under the guidance of professional social workers.While there is user involvement, too much of the care on offer comes in predetermined packages.

The second box “Emerging model of social care” represents the way in which a number of leading localauthorities (in London and elsewhere) are developing the Adult social care agenda: and is in tune withShaping the Future of Care Together (the adult social care green paper 2009 – DH). It shows a greaterlevel of self determination – some “de-professionalization” of early care interventions and concentratesthe self-directed care at prevention and/or re-enablement.

The third box shows the most recent thinking and takes the principles of self-directed health and socialcare to a pathway for chronic care by describing an emerging model of integrated health and social care.This model:

Places the citizen at the heart of service design and the planning of appropriate care and medicalintervention

Articulates the need for investment in prevention rather than cost at the point of acuity or servicecontact but does not quantify it in economic terms

Promotes early re-ablement support as being key to ensuring care is provided in the right setting byfacilitating independence.

Recognises that service users may require services and care packages that are bespoke to theirparticular needs.

There are many innovative aspects to the new care pathway model but at its core is the recognition that agreater level of self directed care should be a genuine three-way endeavour between the citizen, localgovernment and the NHS. The key to putting such a change in place would be to commit significant NHSresource to help fund the preventative care package. To put this in a way that ordinary service usersmight understand, it needs the NHS to spend health money on you when you’re not acutely ill.


Crystallising and bringing forward acute health spending is not the only feature of the model. A greaterlevel of self-direction in care is also judged to be a social and economic good of itself: and the modelworks best when the care assessment process is a common one between health and social care. Thatis, a single caseworker helping citizens to access what to date has been care in two different systems.

A proposed new model of health care for people with chronic conditions set alongside old andnew models of social care

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Micro-commission of services byindividual. To include traditionaland non traditional services.

Eligibility isvalidated bysocialworker

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Risk based review – are services stillrequired? Prediction & prevention

Applying this new model to the treatment of people with diabetes

Type two diabetes is one of the most intractable chronic conditions with an increasing prevalence dueboth to lifestyle factors and an ageing population. According to the London Health Observatory, there arearound 320,000 registered diabetics in London (reference year 2005/06). However, early intervention inlifestyle behaviours and good care and management of the condition can significantly improve people’slives. It is a formal objective of the NHS in London to work to prevent people with diabetes presenting inan acute setting.

16

We therefore consider the treatment of people with diabetes to be a good exemplar to use in order toexplore the way in which a new service model consistent with the principles of the care model describedabove might work. Particularly whether it could change outcomes, deliver public satisfaction and securebetter value for money services.

There is relatively little information available on the detailed costs of care for Londoners with diabetes.So what follows is a set of broad assumptions that we made for the purposes of modelling new outcomes.While the cohorts we describe below probably mirror the reality of life for people with diabetes, we do notclaim an absolute triangulation with objective London-wide information on costs of care or care outcomes.For the purposes of testing a new model of care, we made assumptions about the characteristics of thepopulation of Londoners with diabetes and allocated them into four notional cohorts:

Cohort one: are the 90% of patients who generally self-manage and require relatively little extrasupervision and care management, though they have annual ‘upkeep’ cost for drugs and extra GPs visits

Cohort two: 2.5% of patients do not self-manage and require emergency admissions

16 NHS Healthcare for London Programme


Cohort three: 5% of patients need additional assistance to in order self-manage, but who would like tomanage their own conditions more effectively

Cohort four: 2.5% of patients have co-morbidities with conditions such as mental health disorders.

Indicative costs allocated to each cohort

To model new outcomes, we derived assumptions about the direct current costs of care. Again, theseassumptions are based on real life experiences, but are necessarily indicative at this stage. For cohortone, we have allocated drugs and GPs’ costs; for the remaining cohorts, we have allocated differentmixes of emergency admissions (between two and four per year), home care services (three times perweek), meals on wheels (five times per week) and funded nursing care (three times per week).Aggregated up, the costs of these interventions are in the table below.

Based on these assumptions, the annual costs of managing diabetes in London would representapproximately 11% of the annual chronic care expenditure. This is approximately £590m of the £5bnannual expenditure that we identified earlier. Significantly, these costs are for the relevant health andsocial care services: we have made no wider assumptions about the cost benefit to London’s economy orcommunity of better diabetes care. The direct costs are summarised in the table below.

Patients NHS Costs (£m) Local Authority Costs (£m) Total Costs (£m)

Cohort 1 256,462 18.2 0 18.2

Cohort 2 8,014 63.9 90.9 154.8

Cohort 3 16,029 95.7 181.9 277.6

Cohort 4 8,014 47.9 90.9 138.8

TOTAL 320,577 225.7 363.8 589.4

Managing chronic care – the potential savings around diabetes

We then modelled some interventions which reduce the assumed needs of the cohorts for health andcare based on the principles of the new care pathway above. For example, we assume that:

With earlier intervention and better case management , half of the cohort two patients have only twoemergency admissions per year and after six months, their home care packages reduce to once aweek

Half the cohort four patients have no emergency admissions and gradually reduce their needs forhome care services

Half of the cohort three patients are helped to realise their ambition to manage their condition moreeffectively.

The new costs of provision and savings associated with the new model are in the table below.

NHS Costs (£m) Local Authority Costs (£m) Total Costs (£m)

New costs 203.9 281.6 485.6

Savings 21.7 82.2 103.9

We suggest savings of more than £100mn are achievable on the modelled expenditure for diabetes care;a reduction of almost 20% of the total assumed cost. And as a reminder, neither the costs nor thesavings encompass wider benefits of better care. These savings accrue principally as a consequence ofpeople being treated in the most appropriate care setting, and more particularly, of being treated beforeconditions become so acute that emergency health intervention is needed.


Can we extrapolate these benefits across other chronic conditions?

The primary purpose of this document is to make the case for change – not to work up a finely tunedsolution. But organisations around London – for example, NHS Barnet on vascular disease; LewishamCouncil and NHS Lewisham on whole systems commissioning; and Well London on healthy eating andliving – have all made progress in this field by adopting a model loosely based on:

Emphasising prevention or early intervention

Jointly building the systems around the customer/patient

Boosting the level of self-direction in care.

Postulating the wider potential benefits of change is complicated. The American Diabetes Associationestimates that around 10% of the USA’s wider healthcare costs are attributable to diabetes. In this paper,we have suggested that this cost in London is around £590m - which is just over 11% of the £5bn weidentified as the cost of chronic conditions to health and local government as a whole. So theseestimates of the proportion of expenditure are broadly in line. We suggest savings of more than £100mnon the assumed direct expenditure on diabetes: a saving of just under 18%.

Our examination of the benefits of the new model of care for the treatment of diabetes is also relevant tothe treatment of other chronic health conditions. It is therefore reasonable to assume that a similar levelof savings could be secured through reform to the treatment of these other conditions. If comparablereductions in expenditure could be made by applying similar models of care across all chronic conditions,we estimate that direct savings of £880mn could accrue on the annual direct cost of £5bn. For localgovernment, our assumptions at the broadest level would suggest that savings in the region of 25% ormore may be achievable on the costs of chronic care, but these are unlocked by a relative shift in NHSspending towards preventative care/earlier intervention.

While we acknowledge that our suggestions need more work, we would also argue that we have not yetcomputed any wider savings to the economy and community of London from improving the treatment andcare of people with chronic conditions.

Conclusion

We believe that a package of reform based primarily on policy realignment around earlier interventioncould enhance outcomes for Londoners and result in savings of about £880mn out of the total £5bncurrently spent on treating and caring for people with chronic health conditions. This package of reform isnot dependent upon structural reorganisation within the capital’s public services. Rather, it requires aredirection of resource within the NHS from acute settings to focus more on prevention; a move towardson self-direction and self-service by users; and more effective case management. This presents a set ofchallenges both to health and social care professionals and organisations, but with a significant potentialprize on offer.


A whole systems approach toyoung people exhibiting anti-socialbehaviour

Introduction

Compared to other areas of criminal behaviour, anti-social behaviour (ASB) by young people is not aparticularly well researched area. It has only been a focus of Government action in the past decade or soand there is limited statistical information available about it on a national or regional basis. Data onvolume and impact of the problem are not collected through official channels because most forms of ASBare not classified as crimes. The evidence base is focused on public perceptions rather than empiricalresearch. Data on costs (to the public sector and to society) are also highly patchy and at a high level.

This area was chosen for deeper examination because, although the direct costs associated with theissue are relatively small when compared to the two other themes we have studied, it is characterised bycomplexity in administration and the involvement of a large number of public sector bodies. It is also anarea where, as this section highlights, significant “lifetime” costs associated with truancy and broadercriminality are incurred by the public sector as a result of a failure to intervene sooner and moreeffectively.

Given the nature of the data, it is not possible to present with accuracy detailed, costed recommendationsfor the future. Rather, we suggest a number of areas where we believe improvements to the current,highly fragmented delivery model might be made, which London Councils may wish to explore furtherwith key partners in this sector. We believe these improvements present opportunities for efficiency gainsand have the potential for producing better outcomes for Londoners, with significant financial benefits inthe longer term as a consequence.

What is the problem and why is it a particular issue for London?

Definitions

Anti-social behaviour (ASB) is defined by the Home Office as “any aggressive, intimidating or destructiveactivity that damages or destroys another person's quality of life”. By definition, ASB is not criminalbehaviour (ASB interventions such as ASBOs are civil not criminal penalties), but can have a similarlyadverse impact on the communities and individuals affected by it.

The Home Office has developed a typology of anti-social behaviours17

which highlights the following:

Drug/substance misuse and dealing

Begging

Kerb crawling

Abandoned cars

Street drinking

Prostitution

Sexual acts

Noise

17Defining and measuring anti-social behaviour: Home Office 2004


Rowdy behaviour

Hoax calls

Intimidation/harassment

Vehicle-related nuisance/inappropriate vehicle use

Nuisance behaviour

Animal-related problems

Criminal damage/vandalism

Litter/rubbish

The size of the problem – numbers and cost to public services

The focus of this analysis is upon youth-associated ASB but it is important to note that young people donot have the monopoly on ASB. Much is committed by adults, concerns environmental problems, or isrelated to general rudeness by people of all ages. But it is not unreasonable to say that a significantproportion of the responsibility for perceived ASB is placed at the door of young people. As the chartbelow from the current British Crime Survey shows, most people in the UK think that ‘teenagers hangingaround’ is the number one ASB issue for them.

Perceptions of anti-social behaviour by strand, 2001/02 to 2008/08

0

5

15

25

30

35

2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09

Teenagers hanging around on the streets

Rubbish or litter lying around

People using or dealing drugs

Vandalism, grafitti and other deliberatedamage to property

People being drunk or rowdy in public places

Noisy neighbours or loud parties

Abandoned or burnt-out cars

10

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Estimating the number of young people exhibiting ASB in London is not straightforward. It would take agreat deal of new, primary research to do so with any notable degree of precision. However, we haveproduced some indicative figures for the purposes of this project, based on extrapolations of national datasets.

2006 Home Office research suggests that every year, between 200,000 and 300,000 young peopleacross London commit criminal and/or anti social behaviour within their communities. Most of theseactions are relatively small scale and involve a limited number of incidents; they will be towards the ASBend of the continuum, rather than the criminal end. We judge that an extrapolation from nationalevidence on anti-social behaviour allows us to estimate that approximately 180,000 London young peoplecommit anti-social behaviour every year.

Proportionally, London has fewer youth offenders than the North West, South East, West Midlands andYorkshire regions based on official sanctions, but given the city’s size and transport links there is aperception that ASB and youth crime can occur anywhere in the city. The table below

18shows that the

overall perception of ASB is no higher in London than it is in Birmingham or Manchester. However, it is

18 Home Office Anti-Social Behaviour Action website


noticeably higher than the London average in East Inner London and the outer areas surrounding it andlower in the more secure areas in the West and the South.

West Inner London 20.8%

East Inner London 33.8%

East and North East Outer London 28.9%

South Outer London 20.9%

West and North West Outer London 24.4%

London 26.7%

Greater Manchester 27.0%

West Midlands 27.4%

Home Office research into the impact of anti-social behaviour highlights the degree of activity and itscosts to the public service.

19Based on an analysis of a single day’s activities across England, the

research calculates that ASB costs the public sector £13.5mn per day, or £3.4bn each year. The largestareas of costs are criminal damage/vandalism, intimidation/harassment, litter/rubbish, nuisance behaviourand vehicle-related nuisance.

£3.375bn£13,500,00066,107TOTAL

£42m£167,0001,011PROSTITUTION, KERB-CRAWLING, SEXUAL ACTS

£49m£198,0001,286HOAX CALLS

£114m£458,0002,546ANIMAL RELATED PROBLEMS

£132m£527,0002,920DRUG/SUBSTANCE MISUSE AND DRUG DEALING

£126m£504,0003,239STREET DRINKING AND BEGGING

£90m£360,0004,994ABANDONED VEHICLES

£249m£995,0005,339ROWDY BEHAVIOUR

£249m£994,0005,374NOISE

£496m£1,983,0005,415INTIMIDATION/HARASSMENT

£355m£1,420,0007,660NUISANCE BEHAVIOUR

£340m£1,361,0007,782VEHICLE RELATED NUISANCE

£667m£2,667,0007,855CRIMINAL DAMAGE/VANDALISM

£466m£1,866,00010,686LITTER/RUBBISH

Est Annual CostsEst Cost per DayCount

£3.375bn£13,500,00066,107TOTAL

£42m£167,0001,011PROSTITUTION, KERB-CRAWLING, SEXUAL ACTS

£49m£198,0001,286HOAX CALLS

£114m£458,0002,546ANIMAL RELATED PROBLEMS

£132m£527,0002,920DRUG/SUBSTANCE MISUSE AND DRUG DEALING

£126m£504,0003,239STREET DRINKING AND BEGGING

£90m£360,0004,994ABANDONED VEHICLES

£249m£995,0005,339ROWDY BEHAVIOUR

£249m£994,0005,374NOISE

£496m£1,983,0005,415INTIMIDATION/HARASSMENT

£355m£1,420,0007,660NUISANCE BEHAVIOUR

£340m£1,361,0007,782VEHICLE RELATED NUISANCE

£667m£2,667,0007,855CRIMINAL DAMAGE/VANDALISM

£466m£1,866,00010,686LITTER/RUBBISH

Est Annual CostsEst Cost per DayCount

We have estimated that the proportion of this cost falling to London’s public services in respect of theASB committed by young people is approximately £500mn per year. Around two-thirds of this cost fallsupon local authorities and the remainder to the Metropolitan Police. Much of the expenditure is remedial,for example, dealing with the consequences of evidenced ASB.

These are the direct costs of ASB to the public purse in London. Including the direct costs to privateindividuals, companies and organisations would increase this significantly. The additional emotionalcosts of lives restricted by fear and worry would be even higher. This is because ASB more broadlyimpacts on the living standards and costs of London residents, workers and visitors. It breaks down thesocial ties and trust which underpin sustainable and prospering communities. Faced with ASB, peoplefeel less comfortable undertaking their day-to-day activities, feel the need to spend money on protectingthemselves and their property, and worry about the impact on friends and families.

We have not focused on these broader costs to non-public sector bodies and the immediate wider socialimpact of ASB in this examination. Instead, we have considered the impact to the public purse of a

19Economic and social costs of crime in London – Based on data from Home Office (2005). The economic and social costs of crime

against individuals and households and 2008/09 crime data from the Home Office RDS website


failure to address ASB effectively. The main result of this failure is that those who show this behaviourduring their youth then descend into more serious criminal activity over a prolonged period of time andthis has associated (and escalating) costs. We have also examined the potential benefits to other areasof public expenditure in the short term in more successfully addressing ASB by means of earlierinterventions.

ASB and youth offending – the wider costs

The dividing line between ASB and youth offending is not precisely defined, but there is a substantialbody of evidence that demonstrates the links.

20Most young people exhibiting ASB do so infrequently and

without progressing into recognised criminal activity or becoming subject to the criminal justice system.At the same time, it is reasonable to assume that a clear majority of recognised youth offenders have, atsome point, exhibited ASB. Therefore for the purposes of this examination, the youth offendingpopulation has been regarded as a subset of the broader population of 180,000 young Londonersexhibiting ASB.

The transition to youth offending happens when young people move on to more serious offencesinvolving violence and property crimes. The annual reoffending rate of juveniles is 40% on average, butover 80% for those who have committed more than 10 crimes; who also commit more serious and costlycrimes. Therefore, “nipping ASB in the bud” can have a big pay back.

We have focused on the activity of Youth Offending Teams (YOTS) across the capital as a means ofassessing the broader costs associated with youth offending. YOTS are designed to bring together theservices of police, health, local authorities and others to support their work in reducing youth re-offendingand escalation of criminal careers. Currently, some 15,000 young Londoners are on the books of YOTs –in short, approximately 8% of the current population of young people exhibiting ASB can also beconsidered to be young offenders.

The budgets of YOTS and the cost of youth custody are a direct cost associated with the management ofthis population of young offenders. The YJB spends £74mn in London on both custody and YOTS. Inaddition, there are other costs associated with the operation of YOTS and the management of the courtservice. We estimate that total annual expenditure on dealing with youth offending in the capital is in theorder of £150mn.

In total, therefore, our examination of youth ASB is concerned with direct public sector costs annually ofapproximately £650mn. This is made up of the £500mn of direct costs we estimated from the nationalcosts and some £150mn of YJB, court and others costs.

Longer term costs

Our exploration of this theme has also concentrated on other costs that are, in part, attributable to ASBamongst young people. Specifically, we have looked at the links between ASB and truancy, and theimpact of ASB on future levels of criminality and the criminal justice system. Our reason for examiningthese areas is that more effective action in tackling ASB earlier should help to avoid these future, higherlevels of expenditure.

There is a substantial body of evidence demonstrating the links between school truancy and youth ASB.Some 11,400 young Londoners are persistent truants with an estimated lifetime cost of £500mn in total.Interestingly, the research cited

21notes that the impacts on long-term prospects from regular truancy can

exceed that for young people who are excluded, as the persistent truants do not receive support to makeup the ground that they have lost, whereas excluded young people often get specialised, focusededucational provision.

The great majority of young people grow out of ASB, but for a minority it can be the precursor to moreserious problems. There is strong evidence linking ASB – especially early on-set (that is childrenyounger than ten) – to future more serious offending which can lead to greater damage to both people

20Report of Policy Action Team on ASB – Social Exclusion Unit

21New Philanthropy Capital (2007) Misspent youth: the costs of truancy and exclusion


and property and to further public sector cost. Descent into extensive offending can reduce the life-longopportunities for the young people involved in crime: they can lose out on educational opportunities; find itharder to find employment; damage their personal and familial relationships; and risk spending time inprison.

The more significant public cost therefore arises from the failure of public services to prevent youth ASBfrom developing into more serious offending. Based on separate research that we have undertaken, webelieve that the costs of associated with a “life time” of crime would on average easily run into manyhundreds of thousands of pounds per individual.

Unpublished PwC research for the Ministry of Justice suggests that a very large majority of male criminalsnow in custody started offending at a young age. There are currently around 18,000 adult Londoners inprison and the costs associated with this level of imprisonment amount to approximately £900mn peryear. This number highlights the inability of the present systems dealing with ASB and youth offending toprevent London’s youth from progressing to more serious criminal activity.

It is apparent therefore that tackling ASB amongst young people more effectively should lead tosignificant reductions in the £500mn lifetime costs associated with truancy and the £900mn annual costsassociated with the management of London’s imprisoned offenders.


The current systems for dealing with ASB and its consequences are complex; as are those for preventingthese activities from escalating to more serious criminal activity.

There are multiple, overlapping providers and commissioners of services to address ASB. The activitiesthey carry out fall uncomfortably along the line between services that are under the jurisdiction of thepolice – with a remit to ensure public safety and to tackle crime -- and under the control of localauthorities who have a remit to ensure the liveability of their areas and community cohesion. Nationalagencies such as the Youth Justice Board also play an important role in funding and monitoring YOTs aswell as purchasing places in secure units for the most serious child offenders. A lack of clearcoordination at the local level leads to patchy provision depending on the priorities of assorted nationaland local bodies. These objectives can often clash, especially where there are very specific targets thatthe various bodies are looking to meet. A target to increase the number of incidents which are pursuedby the police may well run contrary to a local authority’s desire to limit the number of local young peoplewho are being criminalised at an early age.

The diagram below shows the range of agencies involved in service provision for this group, frompreventative work with families to rehabilitation work with older offenders who have entered the adultjustice system.


Draft working paper

Young Old

Prevent

ReformRising costto taxpayer

FamilyInterventionProjects

Pupil Referral Units

Anti-Truancy work

Mainstreameducation

Surestart

Early years& childcare

Parentingadvisors Youth service

Youth custody

Probation

Prison

Neighbourhood policing

Neighbourhoodwardens

Housingassociations

Local governmentregulatory services

YouthOffending

Teams

Under the current arrangements, there are essentially two types of intervention which are undertaken:

Personalised interventions which focus on specific individuals, families or specific small groups ofindividuals. These can have a significant impact but are costly as resources can only be focussed ona relatively small number of people at a time. Therefore, the interventions are often focussed onthose who already have a significant history of ASB and offending. While these people are more likelyto commit greater numbers of future crimes, personalised interventions can do little to prevent peoplefrom entering a criminal career. Rather, they minimise the impact once one has begun;

Social interventions which are applied to entire groups or areas: for example, they may involveworking with local residents or students in specific schools. Such interventions can lower the overallimpact of ASB and youth offending, but it is harder to measure a specific impact from them as theindividuals involved are deterred from committing crimes in the first place.

In addition to ASB itself, addressing the wider fall out from truancy and school exclusion is not widelydealt with in a coordinated manner across education, criminal justice and social services, despite somespecific individual projects that address the issue.


There is certainly greater scope for cooperation across the public sector in providing services thatcontribute to the prevention of ASB and youth offending by working with young people at risk – and theircommunities – and to reducing re-offending by working with young offenders. The national policy debateis moving in the direction of incentivising locally-led preventative action with young offenders. Thisproposition is a key part of the Ministry of Justice’s (MoJ) Transforming Justice programme. Localauthorities need to be ready to offer help in those areas where they are best able to support other publicsector activities, but also need to ensure that the activities of other public bodies support the work of localauthorities.

As we have noted earlier, London's local authorities end up picking up many of the direct costs and aneven greater proportion of the indirect costs of this social problem. At the same time they are thedemocratic bodies closest to their communities and with the best community knowledge. We thereforepropose that councils should have a much stronger role as a unifying organisational link between the


other bodies at work in this system and that they be strongly incentivised to intervene much earlier in thecycle of a young person's criminality.

The diagram below highlights the areas where we believe there is a strong case for amending thesystem.

Young Old

Reform

FamilyIntervention

Projects

Pupil ReferralUnits

Anti-Truancy work

Mainstreameducation

Surestart

Earlyyears &

childcare

Parentingadvisors Youth service

YouthOffending

Teams

Youth custody

Probation

Prison

Neighbourhood policing

Neighbourhoodwardens Housing associations

Local government regulatoryservices

Prevent

More Borough influence over key decisionsabout children ‘at risk’ of ASB – truancy,exclusions

Local authority leadership of existing youthASB agencies – simplification of funding,audit, governance

Reintegration of ex-offenders intocommunities (on the Tower Hamlets model)

Locally led intensive support for parents and youngchildren. Early identification of ‘problem families’ byCDRP/police intelligence

This proposed new model has the following key features:

Locally-led intensive support. Much of the evidence and cost analyses point towards the benefits ofearlier interventions to prevent anti-social and criminal behaviour. Local authorities have many of therequired tools and information to be in the lead for early interventions but will need to work with otherlocal bodies, such as the health services and schools, to identify and work with families and individuals atrisk. This may require co-operation at a pan-London level to share best practice and tackle commonissues such as data sharing.

Aligning the evidence and resources available can enable an appropriate intervention at a time whenit is more appropriate and when families are vulnerable, such as when an older sibling has got intotrouble with the police and may be about to serve time in prison.

Children at risk. Local authorities need to strengthen their work to identify children showing early signsof ASB and criminal behaviour and ensure that interventions are being joined-up across relevant publicbodies. Persistent truancy and the development of behavioural problems and examples of these signs.Steps can then be taken to provide the appropriate support to ensure that their underlying issues areaddressed and that the young person does not start to offend and further damage their future potential.

Control over youth ASB agencies. We suggest that local authorities should take control of YOTs andensure that they are fully integrated with the local provision for young people, including education andalcohol/drug treatment teams. Central bodies such as YJB, Home Office and DCFS could give localauthorities greater latitude to respond to local issues by providing a series of funding pots and matchfunding which allow authorities greater flexibility to match resources to the needs and objectives thatreflect local circumstances and resonate most with local communities.


Offender re-integration. Local authorities can provide an important service to prevent re-offending byolder offenders – including those coming back from youth offending sentences – by ensuring that there isa re-integration service available for those that have been serving time in prison. Most offenders willreceive minimal re-location support and limited probation time as they are not judged to be at high risk.However, they have a high likelihood to re-offend, especially if they are not able to establish themselvesin housing and employment. Working with the prison service and Youth Justice Board, we believe localauthorities should take a lead to ensure that these individuals are met by a support worker and helped toobtain the housing, health, educational and other support they need to allow them the chance to becomeproductive citizens. This would have a beneficial impact for the community both in terms of reducing theindividual’s likelihood to re-offend (if they do re-offend, it is likely to occur near to where they live) but alsoby ensuring that the young people and others in their family and community networks are given the rightsignals about the ability of people to pull away from a criminal career.

The benefits and costs of a reform package

This reform proposition focuses on London Boroughs playing a new, or more developed, role in respectof young people exhibiting ASB in their local areas. It suggests that local authorities play a coordinating,end-to-end role, interjecting at key points in the life of young people to help prevent them from developingfrom ASB to more serious offending behaviour. The focus on prevention will have long term benefits forthe public purse by reducing the need for expensive spending on criminal justice interventions. There arenumerous examples of local authorities playing this kind of role (Tower Hamlets and Lambeth forexample in respect of offender reintegration), but they suffer from short term funding and uncleargovernance arrangements.

The Government has set itself a target of reducing re-offending (both adult and youth) by 10% over thecurrent spending review period. We believe our package of proposed reforms will help significantlytowards the achievement of that target in the future. We further believe that our proposals could reduceyouth ASB by a similar amount.

On the assumption that an average criminal “career” spans about ten years, the application of thesereforms could therefore also result in reduced direct expenditure associated with youth ASB andoffending of approximately £65m of the estimated £650m annual costs. The majority of the savingswould flow from the benefits of earlier intervention that would reduce the immediate incidence of ASB andthe consequential costs associated with youth offending. There are also savings within this estimatedtotal to be secured in the administration of the system through the greater clarity and efficiency in the flowand administration of funds, and in the activities of the various bodies. The new model depends on a‘justice reinvestment’ proposition, that opens up a pool of funding for local authorities and their partners toinvest in preventative work on the basis that this will reduce overall spending on palliative interventionsacross a number of financial years.

We suggest that a ‘kick start’ to a more flexible form of funding that emphasises social investment couldbe delivered by decentralising a large part of the YJB, DCFS, OCJR and Home Office funding for YOTs tolocal authorities, removing the costs of multiple administrative functions at the centre. This would be inthe region £20m per year.

Changing the funding regime in the current climate will be difficult, but it this sort of ‘justice reinvestment’idea has been discussed by academics and lobby groups in the sector

22and is starting to gain traction

with Government. Justice Reinvestment makes the case for reallocating funding for expensivecorrectional services interventions (it costs £250k per year to keep a young person in a secure children’shome) to preventative services over a reasonable time period (the three years of a spending review).

It would therefore be a propitious time for London Councils to engage in this debate because it featuresstrongly in two major reform programmes:

The Transforming Justice programme, being run by the Ministry of Justice which includes aprogramme to ‘invest in prevention to reduce youth crime’, including by exploring better ways of‘incentivising’ local authorities to focus on this area; and

22Reinventing Justice, Esmee Fairburn Foundation 2003


The review of the Youth Justice Board which includes exploration of the feasibility of devolvingbudgets for custodial services to local government.

Both projects are at the stage of developing strategic business cases which may well help LondonCouncils develop and inform new thinking in this area by providing a local perspective on the topic.

Conclusion

There is currently an estimated £650mn spent annually by London public services on dealing with ASBand consequential youth offending. We estimate that our proposed reforms, focused on earlierintervention, simpler administration and an enhanced role for local authorities to “fill the gaps” in currentarrangements should reduce overall costs by as much as 10%. They can also deliver better outcomes inthe form of reduced occurrence of ASB and lower reoffending rates. This will require some significantinvestment on the part of London’s public services.

The benefits, however, go much broader than the direct costs highlighted above. By reducing ASB andyouth offending, London’s public services will also be tackling the costs associated with high levels oftruancy (£500mn lifetime costs) and with early offenders descending into a lifetime of crime (£900mn perannum on Londoners in prison). These are important objectives to pursue.


Tackling obstacles to employment

Introduction

London is paradoxically both the engine room of the United Kingdom economy and one of the areas ofthe country most affected by worklessness. There are around 1.6mn workless Londoners, a figure whichnot only reflects the recent economic downturn, but also illustrates a longer term challenge that has notbeen addressed in the period between 1997 and 2007 when the economy was growing strongly.

This service theme has its own distinguishing characteristics and was chosen for deeper analysisbecause:

It is an area with a relatively large commitment of direct public expenditure covering a range ofCOFOG headings

Many national, NDPB and local agencies are involved as providers and commissioners

At face value, it has the potential to facilitate wider benefits beyond savings in expenditure – forexample, increasing taxation revenues, or even the social benefits inherent in moving people intoemployment.

What is the problem and why is this a particular issue for London?

London’s economic activity rate is 75.8% compared to an England average of 79.5%, and itsunemployment rate is 8.9% compared to 7.9% for England.

23The economically active gap between

London and the English average therefore represents 189,000 additional individuals who are not in workor who are looking for work in London. London’s unemployment gap – the difference between London’sunemployment rate and the English unemployment rate – equates to an additional 209,000 people out ofwork; roughly equivalent to the population of the London Borough of Merton. Even adjusting for the highproportion of students within London, this higher local level of unemployment in London may seempeculiar, given the strength of London’s economy relative to other areas of the UK. Available evidencesuggests that the problem of worklessness in the capital is driven by:

A higher prevalence of individuals at risk of worklessness relative to the UK average

A claimant population who in many cases are claiming for longer than elsewhere in the UK

The effects of migration and competition for jobs

The nature of London’s labour market.

We expand upon each of these characteristics in more detail below.

Higher prevalence of individuals at greater risk of worklessness

There is widespread data highlighting the demographic trends behind worklessness in the UK, and anumber of these highlight particular problems facing Londoners, 30% of whom face two or more key

23 ONS London Labour Market Statistics, August 2009


barriers to work, against a UK average of 23%.24

Unemployment rates are higher amongst minorityethnic groups across the UK as a whole, and Black/ Minority Ethnic unemployment levels in London are41% compared to 38% for the rest of the UK (ONS, 2009). Patterns of worklessness are also closelycorrelated with measures of poverty and exclusion, where London has a disproportionate sharecompared to the English average. Almost 17% of London’s homes are local authority-owned, comparedto 13.1% in England25 and nearly half of all households living in social rented accommodation wereworkless (47%) compared with 21% for households living in privately rented property, and 8 per cent forthose living in owner-occupied accommodation.26

Longer term claimants with poorer employment prospects

Around 3,000 Londoners have been claiming an unemployment benefit for more than six months, whichis broadly in line with the England average, but the number claiming benefits for more than a year isgreater in London than the national average.27 A total of 6.1% of those of working age claim IncapacityBenefit (IB), below the national average of 7.3%, but 55% of London’s claimants have inadequateNational Insurance contributions to claim contributory IB compared to 34% outside London, suggesting aworse work history in the capital (HMT, 2007). London IB claimants have poorer employment prospectsthan elsewhere with only 35% of those moving off IB finding employment of over 16hrs a week comparedto 63% nationally (ibid).

Migration, competition and London’s labour market

Although the number of jobs in London increased by 700,000 in the decade between 1997 and 2007, theoverall employment rate remained largely unchanged due to increases in the working age population overthe same period. Domestic and international migration brings a constant stream of new workers into thecity and increases competition, compounded by the fact that the demand pattern within London’s labourmarket has changed significantly in recent decades. Between 1981 and 2001 low skilled jobs fell as aproportion of London jobs from 12% to 10% (HMT, 2007).

On the supply side, London has an unbalanced skills structure which ‘sags’ in the middle, with moreNVQ4+ individuals, but with fewer NVQ1-3/trade apprenticeships than the England average. There is ahigher proportion of skilled labour seeking employment than elsewhere in England, which can excludethose with fewer qualifications and less experience.

Building up the wider costs of worklessness in London

An assessment of the total costs associated with worklessness is dependent upon the scope of benefits,credits, employment support and associated administrative costs that are included in any calculation.Based on our analysis, we estimate the figure for London to be at least £5bn per year, representingaround 7% of the total spent on public services in the capital.

Expenditure on worklessness can be allocated between ‘direct’ and ‘indirect’ costs. The direct costs arethose unemployment benefit payments directly attributable to worklessness, including Income Support(‘IS’), Jobseekers’ Allowance (‘JSA’), and Incapacity Benefit (‘IB’, replaced by the introduction of theEmployment Support Allowance in 2008).

The total expenditure within London on those working age benefits was £2.645bn in 2007/08 set out inthe table below.

24 Labour Force Survey, Spring 2005, quoted in HMT 200725 2001 Census from Neighbourhood Statistics26 ONS, Labour Market Trends, November 200427 Employment opportunity for all: tackling worklessness in London – HMT 2007


17.018.78.1LONDON AS % GB

381.11,672.8591.0LONDON

2,039.38,062.56,409.1ENGLAND AND WALES

2,243.68,948.17,308.5GREAT BRITAIN

Jobseeker's AllowanceIncome SupportIncapacity Benefit/SevereDisablement Allowance

17.018.78.1LONDON AS % GB

381.11,672.8591.0LONDON

2,039.38,062.56,409.1ENGLAND AND WALES

2,243.68,948.17,308.5GREAT BRITAIN

Jobseeker's AllowanceIncome SupportIncapacity Benefit/SevereDisablement Allowance

Source: http://research.dwp.gov.uk/asd/asd4/expenditure.asp

The costs of administering these benefits are not easily available. While these costs are hard toapportion at a regional level, London has 14.3% of the total numbers of IS, IB and JSA customers

28, and

apportionment of the administrative costs of JCP on the same basis would give a figure of £450mn.

Finally, this number is further increased by some £450mn spent on employment policy within Londonduring the same period.

29Thus the benefit and administration costs combined of direct benefits are in

excess of £3.5bn.

We believe that the resulting figure understates the total expenditure on worklessness in London, since itignores those working age benefits for which the worklessness of the claimant is likely to have a majorbearing on the claim. Specifically, workless people are typically eligible to claim housing benefit andcouncil tax benefit, and for some, their worklessness is a key factor driving the claim. Total expenditureon these other working age benefits was £4.821bn in 2007/08.

Finally, housing benefit administration costs in London totalled £71.6mn in 2003/04,30

the last year forwhich figures could be obtained from public sources.

This adds up to a combined total direct and indirect spend of more than £8bn on benefits, administrationand related services, as set out in the diagram below.

JobSeekers

Allowance£381.1m

Income Support£1,672.8m

IncapacityBenefit£591m

Housing Benefit£4,151.3m

CouncilTax

Benefit£670.2m

NB: Relative sizes andoverlaps indicativeonly

Unknown otheradministrative

costs inc.£71.6m Housing

Benefit

ApportionedJCP costs:

£450m

Employmentpolicy£450m

JobSeekers

Allowance£381.1m

JobSeekers

Allowance£381.1m





Housing Benefit£4,151.3m

CouncilTax

Benefit£670.2m

NB: Relative sizes andoverlaps indicativeonly

Unknown otheradministrative

costs inc.£71.6m Housing

Benefit


£450m


£450m



28 DWP Statistical and Accounting Data29 HMT PESA data30 http://hansard.millbanksystems.com/written_answers/1996/feb/22/housing-benefit


On the basis that not all of the benefit expenditure for housing benefit and council tax benefit can beapportioned to worklessness, we have assumed, conservatively in our view, that it is reasonable toapportion £5bn of these total costs to worklessness.


The current customer journey

In examining the potential for reform to the current system for tacking worklessness, we have applied aprocess of “customer journey mapping” to better understand the experience of people who are workless.The diagram overleaf illustrates in broad terms some of the strengths (highlighted in green) andweaknesses (highlighted in red) of the customer journey through the existing welfare administrationprocess.

1

WorklessIndividual

Calls contactcentre

Eligibility

assessment

Interim JSAawarded

Healthassessment

‘Support’awarded

‘EmploymentSupport’ awarded’

£

£

Ongoingreassessment

JCP advisorPathways towork prog.

Max1 weekExcept in cases of large scale

redundancy there is little emphasis onprevention, before individuals require

benefit support

£

£

£ Telephonecontact

AssessmentFace to facemeeting

Payment

Pathways has a poor successrate despite the extra cost

JSA awarded andpaid by benefitdelivery centre

JCP advisor mtgNew Deal prog.

VacanciesCourses

etc.

Max 8 weeks

Assessment of awardand payment is

relatively swift andefficient

Ongoing reassessments are not tailored to theindividual’s condition

There is a long gap betweenpayment and personal

support

JSA route

ESA route

The health assessment is againstnational criteria and consistently

applied

Strengths are that the initial award of benefit is swift and relatively efficient. The award is made nationallyand therefore consistently. The system is relatively joined up; for example, claimants only have to proveeligibility for JSA/ESA in order to receive housing benefit and council tax benefit support.

However, there are also a number of weaknesses in the current process. The initial weakness is that,except in cases of large scale redundancy, there is limited preventative support to help people at risk toavoid worklessness. Research suggests that earlier interventions are more successful in supportingpeople into work

31, yet in the current system significant delays can occur before customers with more

complex needs are identified and offered support.

Current approaches to welfare support

Available research also indicates that the different welfare programmes adopted in recent yearsdemonstrate relatively poor performance in London. For example, Work Based Learning for Adults, asmeasured by the percentage of leavers going into work is much less successful across the board inLondon than nationally.

32The correlation between national performance by ethnic minority groups and

London’s performance, suggests that it is London’s higher proportion of these groups which makes a keydifference in London’s underperformance. The causality is not with ethnicity but that ethnicity further

31 DWP Contracting support for the hard to help http://www.dwp.gov.uk/docs/wr-chapter-3.pdf32 http://research.dwp.gov.uk/asd/asd1/wbla/jul2006/wbla_jul06_table1.pdf


correlates with underpinning factors of unemployment such as skills levels, language capacity, networksand some social choices (for example, female employment outside the home).

There is, more generally, a paucity of data which could be used to analyse the return on investment ofthese programmes, which in itself is a negative feature of the status quo.

One available source document, DWP research report 525, highlights that the Pathways programme hadbeen ‘rather limited’ in impact. For example, the additional impact of this programme on employmentchances, when compared to a control group was an increase of only 7%. This is compared against anadditional cost of around £300 per claim.

33

Key themes in recent thinking on welfare reform

More generally, the failings of the current welfare system and what can be done about them have beenthe subject of much recent thinking by both Government and a range of other interested parties. Perhapsmost prominently, a report by David Freud

34identified a number of weaknesses in the process for helping

individuals into work. Freud highlighted that individuals with multiple characteristics of worklessness werenot being sufficiently catered for by the existing ‘New Deal’ client group approach, and emphasised amore personalised approach where public, voluntary and private providers drove up standards throughcompetition.

Recognising the challenge of personalisation, the introduction of the Flexible New Deal was announced inJan 2008. Alongside this, programmes such as Pathways to Work have sought to support those onIncapacity Benefit into work. In December 2008, DWP published the White Paper Raising expectationsand increasing support: reforming welfare for the future.

35This was billed as ‘a decisive step towards a

personalised welfare state’. The Treasury has also noted that the challenge of worklessness needsgreater input from the local dimension; a recent policy paper stated that ‘Local autonomy is important toallow the flexibility to address area-specific problems’.

36

In summary, there is a strong case for considering new ways to tackle worklessness, and this is all themore pressing in London given the scale of the challenge facing the capital. We set out below ourproposals for a radical Total Place proposition to reorganise the delivery of welfare support services toLondon’s most vulnerable job-seekers.


Outline design for a new delivery model in London

We propose a new delivery model anchored in the following design principles:

Citizen-centric – creating a system that builds tailored welfare support around the circumstances ofindividuals and local labour markets in the capital;

Devolutionary where it matters – devolving responsibilities and resources to individuals and to localgovernment to support a more personalised approach;

Centralised where it makes sense – JCP retains an important role in processing and standard-setting to ensure consistency, fairness and efficiency;

Incentives and sanctions to support an early return to work are built into the system - andaligned to individual and organisational accountability; and

The provision of employment advice should be further professionalised and locally organised -by passing responsibility for performance management of these roles to local government and re-emphasising a case management approach.

33 http://research.dwp.gov.uk/asd/asd5/rports2007-2008/rrep525.pdf34 http://www.dwp.gov.uk/policy/welfare-reform/legislation-and-key-documents/freud-report/35 http://www.dwp.gov.uk/docs/fullversion.pdf36 HM Treasury, Employment opportunity for all – tackling worklessness in London March 2007


Our suggested approach proposes a seismic shift in central and local roles and responsibilities forworklessness in London, alongside a ‘staged’ approach to supporting workless people into work. Thediagram provides an overview of this proposition, whilst the following sections set out how this might workin practice.

JCP

Local authority(ies)

WorklessIndividual

Other fundinglinked to

individual’scircumstances

HB/CTB

Benefitspend (JSA/

ESA)

Share of existingemploymentprogramme

spend

Singlepot

Individually-purchased support,

e.g. skills,transport,

rehabilitation,supplementary careIndividual

Individual choices supported by Personal Advisor

Appointment and performancemanagement of personal

advisor support

Convenes localagencies and

manageslocal supply market

Enforces standards inprovision of PA

and welfare support:local authoritiesand suppliers

Initial assessmentand payment

processing

Ensures consistentapplication/enforcement

of benefit eligibility

Appliessanctions

to individuals whererequired

Provider market

In this model, the individual continues to be given an initial assessment and award of benefit through theexisting Jobcentre Plus initial award process. An initial assessment of their support need is made inrelation to a number of criteria, including:

The individual’s work history and the extent to which they have maintained a steady track record ofprevious employment

The individual’s current skills levels and any aspirations they have for further training

Their own view of their confidence and capability to find work in the future.

From the assessment individuals would be grouped into those likely to require limited personal support tofind a job, and those who will require more hands-on, personalised support. In the model we propose,the former continue to be managed by JCP.

The latter would be referred to a personal advisor, employed and managed (whether directly or throughcommissioning) by the local authority. They are responsible for helping the individual decide how best touse their own ‘personal budget’ – the pot of allocated expenditure which traditionally would have beenpartially devolved to them directly, and partially spent on their behalf.

Local government would be responsible for supporting the development of a provider market, from whichthe individual is encouraged to commission welfare and related support services. This could enable morepersonalised, individually relevant support which can be better linked to an individual’s needs – forexample, childcare and rehabilitation. The underpinning rationale is that the local authority is well-placedto help individuals with complex needs both navigate through the myriad agencies that could help them,and advise on how they can best use the resources locally set aside for their use – including health andsocial care budgets for some individuals.


JCP would maintain responsibility for the bulk of individuals who are well-placed to find work relativelyeasily with limited support. JCP would also take on a role as standard setter and enforcer, includingapplying sanctions to individuals not using the opportunity of personalised budgets appropriately.

The model recognises the local authority’s unique strengths, in having reach on the ground to otherpublic, private and voluntary bodies and the holistic responsibility for an area which enables it to act asthe convenor of services around an individual. It follows the hypothesis that support for well being andsupport into employment are complementary, rather than distinct, activities. It also reflects a wider rangeof learning and skills support outside of the traditional, course-led offer which could be better utilised. Forexample, work experience, job shadowing and peer support. For London in particular, it could provide amore holistic approach to supporting individuals with multiple and complex needs.

The diagram below illustrates the range of theses services across the key dimensions of health and wellbeing, skills and experience, and finding and staying in work.

Worklessindividual

Health and wellbeing

PCT

Socialcare YOT

Mentalhealth

Skills andexperience

Connexions

Colleges

Employersgroups

Voluntaryorgs

Mentoring

Leisure Probation

Finding andstaying in work

Vacancymgt

Localbusiness

EqualityDiversity

Transport

Economicdevelopment

Spatialstrategy

Tradingstandards

Group levelsolutions

Key roles and responsibilities in the new framework

Workless individuals

Workless individuals have a new responsibility for their own personal budget, to be used to purchasewelfare and other support services to suit their needs. The right to resources comes with a responsibilityto deliver an ‘into work plan’ agreed with their advisor, with a ‘ladder of sanctions’ approach; meaningthey progressively sacrifice resource control if they fail to meet their commitments.

Local government

Local government acts as the strategic commissioner and market manager for the area, taking advantageof local knowledge of the labour market. It also acts as the convenor of a range of local services andgalvanise public, private and voluntary sector interventions towards preventing and reducingworklessness, such as using local area agreements and similar mechanisms.

Jobcentre Plus

Jobcentre Plus continues to provide the initial assessment and payment function to all claimants –efficiently and consistently – on a national basis. JCP is able to share evidence about ‘what works’ inwelfare interventions to support local authority market management activity and become a knowledgebroker, rather than delivery vehicle for these services. It sets ‘kite mark’ standards for welfare providers


and the personal advisor role to support minimum quality standards; the role here would be akin toestablishing a set of ‘professional standards’ to which providers and personal advisors should adhere,based on JCP’s existing experience and understanding of what is most effective in the delivery of welfareservices and welfare advisory support.

There is also potential for JCP to act as an ombudsman in the event that local providers fail to meet theirobligations – providing a ‘voice’ option in addition to the market effect of individuals voting with their feet.

Managing the risks associated with personal budgets

The potential advantages of personalised budgets have been demonstrated in the course of theirincreasing adoption within health and social care. Nonetheless, personal budget approaches carry risksthat individuals make more or less effective decisions about resource allocation. One way to manage thiswould be to build risk mitigation into the new framework, and the following are set out below asillustrations of potential approaches that could be taken:

Potential approach: ‘Ladder of sanctions’

%fu

nd

ing

HB &CTB

ESA

Blue = centrally controlled Green = individually controlled

EmploymentPolicy

Current position

HB &CTB

ESA

Progressive sanctions

HB &CTB

ESA

Flexiblesupport

Direct control

HB &CTB

Jobseekersupport

Individual budget: personal advisorguidance linked to agreed back-to-work plan

Sanctions applied: individual hascompulsory support areas andrequires approval for other spending

Individual relinquishes personalbudget and the totality is directed bythe personal advisor

1

1 2 3

2

3

Approved

Compulsory support

Directlycontrolled

Currently, housing and council tax benefits are generally paid on the individual’s behalf, directly to theirlandlord (which in many cases is a social landlord). The Employee Support Allowance or JSA is paiddirectly by DWP, to the individual claimant. Any further support – for example, the costs of courses andpersonal care in the case of individuals with conditions – is spent on the individual’s behalf by variousagencies, including Jobcentre Plus, local authorities and the NHS.

We acknowledge that personalisation of some of these benefits is controversial, but in the new model,they are devolved into one ‘pot’ controlled by the individual, empowering them to make decisions onwhere it is spent. The personal advisor’s role is help them navigate the market, and agree an ‘into workplan’ which will set out different conditions the individual has to meet to continue to have ownership oftheir funds. Failure to meet these conditions – for example, not attending interviews – would result in theactivation of a sliding-scale of control being taken back by the local authority.

Naturally, the proposed model has significant implications for financial control and governance ofresources. There are a number of ways this could be managed, which would need to be subject todetailed analysis as part of further development of the model. These could include:

Retaining responsibility for each element of the ‘pot’ within the individual agencies who devolve thefunding;

Appointing a ‘lead agency’ to take overall responsibility and ownership of the resources on behalf ofthe key organisations involved; and/ or

Creating a bespoke, arms-length entity with specific responsibilities for the governance of the funding


involved, as a way of managing the risks associated with this kind of devolutionary approach.

A localised approach to commissioning additional employment support

The Government has recognised the need for more direct forms of labour market support for certaingroups of individuals, most recently in its Pre-Budget Report announcement of guaranteed work ortraining for 18-24 year-olds who are unemployed for more than six months.

We propose that this proposal could be expanded to support wider groups of workless individuals backinto work, potentially through investment in local social enterprise drawing on a blend of public and thirdsector expertise. Given their existing economic development responsibilities, local authorities are well-placed to use local partnerships to establish such social enterprises, aimed at raising skills andexperience among target groups and building social capital in deprived areas. This option might beconsidered for those individuals for whom individual support interventions have proved ineffective orwhere the most appropriate skills and experience support that could be given would be experience of aworking environment.

We recognise that this has the potential to become a ‘crowded space’ given an existing and vibrant socialenterprise market in some areas; we suggest that this type of intervention be focused on those areaswhere local authorities can use their local leadership role to stimulate support of this nature where it isless well-developed. The return on investment would be through reduced benefit costs as well as thelocal value generated by the enterprise. Jobs created in this way could be fixed term and aligned directlywith local labour market needs, to ensure the flow of individuals back into the private economy.

LB1

LB3

LB2LB4

Commissioned through local partnerships

Enterprise 1 Enterprise 2 Enterprise 3

Workless individuals

The potential financial implications of the proposed model

Identifying the potential financial implications of this proposed approach is challenging, given thecomplexities in articulating the full costs of the current system. However, it is possible to develop someoutline estimates of the potential savings available, by making a number of assumptions based on theavailable evidence about the effectiveness of existing programmes that have focused on greaterpersonalisation of welfare support. We summarise below both the results of our analysis and a summaryof our approach to undertaking it.

Our approach has been to focus on the potential savings in direct and indirect benefits expenditure thatwould result from getting more people back into work more quickly than the current system, since theserepresent the lion’s share of the £5bn costs of worklessness we identified earlier. We have alsoundertaken a high-level assessment of the potential additional ‘tax take’ on the earnings of those peoplemoved back into work, which would otherwise be lost to the Exchequer.

Our initial estimates suggest a potential for savings of almost £630mn on benefits costs. Thesavings assumptions are set out in the table below.

Savings area Savings assumptions (maximised) (£mn)

Reductions in JSA payments 60.7

Reductions in IS payments 148.1

Reductions in IB payments 52.3


Savings area Savings assumptions (maximised) (£mn)

Reductions in HB payments 367.4

TOTAL SAVINGS (£m) 628.5

As soon as workless individuals are back in work, wider benefits accrue. For example, we estimate thatthe increased ‘tax take’ from getting Londoners back into work could be around £440mn, taking the widerpicture of savings and benefits combined to more than £1bn.

Our savings assessment is underpinned by many assumptions. The key ones include that:

The proposed model succeeds in closing the gap in unemployment levels between London and theUK average for the entire ‘excess unemployed’ population

The ‘excess unemployed’ reduce the average time they spend claiming JSA by 35%

The savings generated in reduced IS, IB and HB payments are half of those generated by reductionsin JSA payments (reflecting the fact that IS/ IB claimants have been historically harder to move backinto employment than those claiming JSA, and that there will be a commensurate saving in HB linkedto claimants returning to work)

An additional ‘tax take’ is generated by 50% of the excess unemployed entering the workforce, basedon an assumed average salary of £22,861 (equivalent to the bottom quartile for London as a whole);and

The administrative costs of the proposed model are broadly equivalent to the existing system andtherefore cost-neutral.

Conclusion

Clearly, some of these assumptions are optimistic and further financial analysis will be required in order tobetter develop a more robust assessment of the costs and benefits of the approach we propose.Nonetheless, the scale of the challenge facing London in relation to worklessness, and the potentialfinancial and other benefits of an improved approach to tackling this challenge, suggest an urgent need toconsider radical alternatives to the current system.

We advocate more detailed work to develop a model for testing, based on the principles and outlinedesign that we have set out here, which puts workless individuals at the centre of a more personalisedapproach to welfare support, supported by local authorities as the agencies best-placed to co-ordinatethe support services required to help people back into sustainable employment.

Our headline conclusions at this stage are that reforms along the lines that we have proposed couldresult in savings of almost £630mn of the current £5bn spent annually on addressing worklessness inLondon. In addition, there are the broader benefits of a further £440mn from increased tax revenues as aresult of getting Londoners back into work.


Overarching analysis and makingthe case for change

Introduction

The deeper analysis around the three themes was not undertaken solely to look at how services could beimproved and/or costs reduced in these areas; an equally important aim was to identify opportunities forsavings, service change or organisational realignment that could have application across public servicesand public spending more generally in London.

The three areas that we have examined in detail account for an estimated £10.65bn of expenditure: thatis, almost 14.5% of total annual public expenditure in the capital. We have not even reviewed the totalityof the systems of provision in each of these, yet our analysis already suggests that there is the potentialfor efficiency gains to be secured in the region of 15% of current expenditure across the three themes assummarised in the table below:

Theme Current estimated cost

£mn

Potential saving

£mn

Savings as a percentage

of current costs

Chronic care 5,000 880 17.6

Young people with ASB 650 65 10.0

Worklessness 5,000 629 12.5

Total 10,650 1,574 14.8

The potential for improvement and efficiency is based on addressing a number of flaws that characterisecurrent arrangements for delivering public services and outlining solutions to address them. There is ahigh degree of overlap in the analysis of the problems and generation of solutions between the threeservice areas we have explored. But more importantly, we believe that both the flaws and potentialremedies identified are applicable more generally to public services across London, and therefore that thetotal potential financial and service improvement prize is considerably greater than that outlined in theabove table. This range of reforms with more general applicability is summarised below.

Policy realignment around earlier intervention

The analysis of all three topics suggests that a significant weakness in existing arrangements is thatinsufficient attention is given to early interventions that avoid greater and more expensive problemsoccurring later. The consequence of this is less effective, and more costly, reactive responses byLondon’s public services.

The current arrangements for the management of diabetes illustrate this clearly. Despite steps in theright direction, resources to care for those with the more severe effects of diabetes remaindisproportionately focused on the provision of episodic care within acute settings. The development of amore preventative approach, alongside other changes, has the potential to deliver more effective forms oftreatment that are better aligned with the wishes of most people with diabetes and secure significantefficiency gains.


This principle extends more widely across public services in London, for example, from health to criminaljustice, from worklessness to homelessness. In particular, we believe that a greater focus on earlierintervention and prevention is at the core of helping to address the particular demands placed on localpublic services by what are frequently termed “the most chaotic families”.

Realising the full potential of the benefits from early intervention presents a significant challenge to theway public sector organisations are currently configured – our example of diabetes and also ourrecommendations concerning ASB both highlight the need for a considerable shift in resource to enableinvestment in preventative and early intervention measures.

There is an important leadership role for local government in London to play in pursuing this case forchange, if only because London Boroughs stand to benefit disproportionately from the changes that weare advocating. In our example of the benefits of early intervention and prevention concerning thesystems for treating diabetes, the gains to local government (£82m per annum) are potentially in theregion of 23% of current expenditure compared to benefits of approximately 10% to the NHS (£22m)against current levels of spend.

This raises a broader and substantive challenge to public services and to Whitehall in terms of the designand delivery of efficiency programmes. The scale of the fiscal crisis facing public services is likely toengender another period of scrutiny of expenditure and now gives an opportunity – even an imperative –to put in place the necessary policy realignment across existing organisational boundaries to effectradical change based upon principles of early intervention and prevention.

Previous efficiency programmes driven from Whitehall, for example Gershon, have largely tended toreflect organisational boundaries both within central government and at the more local level. By taking awhole systems approach to complex challenges, our analysis suggests that the next wave of projects thatsecure substantial efficiencies within local government will in part be dependent upon reform within otherparts of the public sector. Without that commitment to change, local authorities will increasingly find itdifficult to secure their share of the efficiency gain in their position at the end of the “supply chain”.

Overall, our analysis indicates that, when planned correctly, almost everyone can benefit in a system builton earlier and more effective intervention.

Self direction/self service by customers and citizens

Our analysis suggests that another key and common strand of the reform that underpins greaterefficiency is more self-direction or self-service by customers. This is not a new theme - “personalisation”has been at the heart of changes in the social care system for some time now but applicability beyondthat is still relatively limited. In a separate study that we undertook in 2008, we estimated that the amountof current expenditure that met one of the four “personalisation criteria” of individual control; individualinfluence; community control; and community influence; amounted to only about 6% of that localauthority’s budget. However, there was the potential for greater personalisation of services to apply in upto 50% of the local budget, so there is much more to play for here.

The revised models for service delivery that are explored in this paper are built upon a premise of greaterself direction by the citizen/customer. Not only is this compatible with ideas of greater choice in publicservices; it is also consistent with the view that giving power to patients/customers/citizens to have ahand in shaping the services delivered to them is a social good in its own right. Critically, this move doesnot have to cost more. Indeed, we argue that it will cost less in most cases providing that the publicsector agencies work hard to cut back that element of service provision that was built around the olderservice model. Our models are predicated on efficiency gains being secured for example through thetransfer of funds to individuals in the form of a personal budget to assist them in seeking and securingwork.

Self direction/self service is a theme that resonates across much of the public service beyond the threeareas that we have examined. It has a role to play in education, cultural provision, housing and someelements of the criminal justice system. The range of potential areas for further investigation andanalysis is significant – as a relatively small example, the option to give parents the budgets to spend ongifted and talented children as opposed to supporting provision through schools.


The extension of personalisation to secure these financial and other benefits again requires significantpolicy realignment across public services, including within Whitehall. Again, we believe that localgovernment has a clear leadership role to play here drawing upon its experience to date of extendingpersonalisation in the area of social care.

The importance of effective case management

Our analysis has shown that, in some areas, current arrangements for service delivery are overlycomplex because of the involvement of multiple public sector bodies with occasionally overlapping rolesand functions; sometimes contradictory objectives and targets; and at times inappropriate arrangementsfor the tasks in hand. We have resisted the obvious temptation to suggest a reduction the number ofagencies involved in an overly-simplistic redrawing of roles and responsibilities as this often tends torecreate problems elsewhere within the system. Instead, we have identified three types of reform thathelp to underpin our analysis of the potential for savings within the three areas that we have studied butthat also, we believe, have wider applicability across public service provision in London.

In our analysis of the whole system approach to young people who behave anti-socially, we highlight thecomplexity of the existing service delivery landscape. It has multiple agencies responsible for a variety offragmented interventions designed to ‘nip’ anti-social behaviour and low-level criminal activity ‘in the bud’,and limited co-ordination of the sanctions and support for individual offenders and their families. Wearticulate a new approach to the management of anti-social behaviour amongst young people that placesat its centre an integrated case management approach led by Youth Offending Teams under the controlof local authorities. This development of a case management approach is the first of the three areas ofreform that we have identified.

By case management, we mean more flexible, end-to-end management and organisation of the publicservice support that an individual needs, overseen by a key worker, case officer or similar. While thisapproach has been rolled out across a number of individual services, with mixed success, there havebeen fewer attempts to develop a single case worker role to co-ordinate and shape the delivery ofmultiple public services around the needs of individuals or even households. This is an important themefor the future: earlier intervention requires more intelligent predictive strategies to avoid later costs. Selfdirection/self service necessitates rounded and appropriate help for individuals or households seeking tonavigate their way around the system. And more integrated approaches to service delivery by multiplepublic sector agencies require someone to act as the integrator.

All these needs point towards a better system of case management for individual citizens, especiallyaround key transition events in their lives. This need becomes even sharper in the case of householdswho have multiple needs and who access services from many organisations. There has beenconsiderable focus recently on the part of a number of local authorities, including some LondonBoroughs, on the needs and demands of high service users – such as the “top 100 families” in an area.These examinations have highlighted the very considerable requirements that relatively small numbers ofhouseholds place on public services through their complex needs and frequent interactions with multipleproviders. Our advocacy of effective and integrated case management should be an integral part ofemergent local strategies both to deliver more effective solutions to these individuals and families and tosecure substantial efficiency gains for the public purse.

We do not underestimate the scale of the challenge presented by this reform. The sorts of changesoutlined above, and the more detailed propositions set out in relation to each of the key topics for thisstudy, will require a new breed of public service professional to deliver them. Historically – and for soundreasons – public service professionals have been anchored in specific institutions and professionaldisciplines – and accountable upwards for performance to those same institutions. The service deliverymodels developed in our topic analyses suggest the need for more flexible public service workers, whoare able to convene interventions by multiple public service organisations, engage proactively and earlywith individual citizens, and who are encouraged to feel more directly accountable outwards to theindividuals they serve.

Once again, local authorities are ideally placed to take the lead here. Their existing construction as multi-purpose organisations with highly diverse workforces means that they have the broad outlook and role totake the lead in championing new models of public service workers.


Organisational complexity and the delivery of local services that are place-appropriate

This paper highlights that the current systems for dealing with young people who behave anti-socially andfor managing chronic conditions are both characterised by the involvement of a large number of publicsector bodies (nine for ASB and eight for chronic care) and a lack of clear co-ordination between them.Indeed, on far too many occasions, the objectives and targets of one public body can clash with those ofanother – an oft cited example is the requirement for hospitals to hold patients longer than medicallyrequired as they await social care provision to be available in their homes and/or for move-onaccommodation to become free.

These areas are not the exception. The multiplicity of organisations that provide services does not seemin general to have a strong logic: as we highlight in the earlier text, the relatively low spending field of“economy” has 60 spending organisations, whereas in education, with three times the spend there areonly 21 spending bodies.

As we have noted above, we have resisted the temptation to call for a widespread dismantlement ofexisting public sector structures. There is a case to be made for that and it has been rehearsed byothers. But widespread structural change can be expensive and disruptive, and is no guarantee in itselfthat services improve and that better outcomes are achieved. Notwithstanding that reservation, ouranalysis suggests that greater simplicity, with the added potential benefits of enhanced service deliveryand better value for money can be delivered through some reallocation of responsibilities between publicsector agencies within London. We further suggest that London Boroughs are ideally placed to assumethese responsibilities.

For example, our analysis of current arrangements for tackling anti-social behaviour amongst youngpeople emphasises the importance of an enhanced role for local authorities to ensure that YouthOffending Teams are deployed more effectively. We believe London Boroughs are best-placed toassume these greater responsibilities because they:

Are the public sector bodies that are typically closest to their communities and with the bestcommunity knowledge

Often incur significant additional costs at the end of the service delivery chain as a result of failed (orabsent) interventions earlier in the system. In extending their role, there is a greater motivation forthem to secure greater efficiency overall for the public purse.

In each case, our proposals therefore advocate greater authority for local councils who, we propose,should take responsibility for a greater proportion of the existing systems. Our analysis further suggeststhat the three areas we have examined in detail are unlikely to represent the sum total of the potential forefficiencies to be secured through the transfer of responsibilities to local authorities – witness our findingsconcerning the number of organisations associated with economic development. This in turn may callinto question the viability of a number of agencies and bodies – as we say, this was not the starting pointfor our investigation but it is conceivable that a broader extension of this analysis across other areas ofpublic expenditure in London will identify this as an appropriate course of action.

Organisational complexity and the gaps in provision

Our analysis has also identified that, in some cases, there are gaps in current public sector provisionwhere appropriate intervention can secure better outcomes and greater efficiency. For example, atpresent there is insufficient attention given by public service providers to support young people in thetransition to secondary education and to those youngsters who are excluded from formal education andwho become associated with anti-social behaviour.

We have argued that London Boroughs are ideally placed to fill this current void for the range of reasonsset out above. The extent to which this analysis and remedy can be repeated across other areas ofpublic service provision is at present unclear, but it is reasonable to assume there are other areas ofcomplex service delivery and/or community needs where “gaps” exist at present and consequentlyindividuals’ problems are not addressed effectively and additional costs are incurred later by a range ofpublic service organisations.


Extrapolation of findings and potential savings

London Councils chose three important themes for us to explore in this paper – and within these, wehave postulated savings that combine at more than £1.5bn each year. For the most part, these are thedirect costs associated with those areas. We have identified still broader benefits in terms of enhancedtax revenues through effectively tackling worklessness and reduced future costs to society at largethrough earlier and more effective intervention in addressing anti-social behaviour.

We have highlighted the more general applicability of our reform principles to public expenditure at largewithin the capital. We therefore believe that the suggested savings of almost 15% that we believe wouldaccrue in the three areas that we have reviewed, would apply equally to the total public expenditure inLondon of some £73.6bn per annum. In short, through general application of the reform principles wehave set out above, we believe that the potential benefits accruing to the public purse in the capital couldbe as much as £11bn per annum.

Clearly further work is required to give greater certainty to this initial analysis and investment will berequired to secure this level of savings, but our examination suggests there is a significant prize to besecured in delivering better services for Londoners at better value for money.


Annex: Non-departmental publicbodies operating in London

The list of bodies in the table below is based on Cabinet Office’s Public Bodies 2008 publication. Weselected those with a level of spend over £100,000 in that year and with a direct or significant indirectimpact on London in that financial year. We have netted off income generated in normal operations (forexample admission fees), in coming to a view about yearly operating costs.

Departmental reporting/responsibility COFOG category (PwC allocation)

Cabinet Office

1 Capacitybuilders Economic affairs

2 Commission for the Compact General public services

3 National School of Government General public services

Communities and Local Government

5 Community Development Foundation Economic affairs

6 English Partnerships Housing and community amenities

7 Firelink Public order and safety

8 Housing Corporation Housing and community amenities

9 Home and Communities Agency Housing and community amenities

10 Independent Housing Ombudsman Ltd Social protection

11 LEASE (The Leasehold Advisory Service) Social protection

12 London Thames Gateway Development Corporation Social protection

13 Rent Service Executive Agency Housing and community amenities

14 Standards Board for England Social protection

15 Valuation Tribunal Service Housing and community amenities

Department for Constitutional Affairs

16 Legal Services Commission Social protection



Department for Culture, Media and Sport

17 Arts Council England Recreation, culture and religion

18 Big Lottery Fund Economic affairs

19 British Library Recreation, culture and religion

20 British Museum Recreation, culture and religion

21 Commission for Architecture and the Built Environment Housing and community amenities

22 English Heritage Recreation, culture and religion

23 Football Licensing Authority Recreation, culture and religion

24 Gambling Commission Economic affairs

25 Geffrye Museum (London) Recreation, culture and religion

26 Horniman Public Museum and Public Park Trust Recreation, culture and religion

27 Horserace Betting Levy Board Economic affairs

28 Imperial War Museum Recreation, culture and religion

29 Museum of London Recreation, culture and religion

30 Museum of Science and Industry Recreation, culture and religion

31 Museums, Libraries and Archives Council Recreation, culture and religion

32 National Gallery Recreation, culture and religion

33 National Heritage Memorial Fund Recreation, culture and religion

34 National Lottery Commission Recreation, culture and religion

35 National Maritime Museum Recreation, culture and religion

36 National Museum of Science and Industry Recreation, culture and religion

37 National Portrait Gallery Recreation, culture and religion

38 Natural History Museum Recreation, culture and religion

39 Olympic Delivery Authority Recreation, culture and religion

40 Olympic Lottery Distributor Recreation, culture and religion

41 Public Lending Right Recreation, culture and religion

42 Sir John Soane’s Museum Recreation, culture and religion

43 Sport England Recreation, culture and religion

44 Tate Recreation, culture and religion

45 UK Film Council Recreation, culture and religion

46 UK Sport Recreation, culture and religion

47 Victoria and Albert Museum Recreation, culture and religion

48 VisitBritain Economic affairs

49 Wallace Collection Recreation, culture and religion



Department for Children, Schools and Families

50 11 Million Education

51 British Educational Communications and Technology Agency Education

52 Children and Family Court Advisory and Support Service Education

53 National College for School Leadership Education

54 Office of Her Majesty's Chief Inspector Education

55 Partnership for Schools Education

56 Qualifications and Curriculum Authority Education

57 School Food Trust Education

58 Teachers Training Agency Education

59 Training and Development Agency for Schools Education

Department for Environment, Food and Rural Affairs

60 Agricultural and Horticultural Development Board Economic affairs

61 Agricultural Wages Board for England and Wales Economic affairs

62 Agricultural Wages Committees for England Economic affairs

63 British Potato Council Economic affairs

64 Consumer Council for Water Economic affairs

65 Environment Agency Environmental protection

66 Food from Britain Economic affairs

67 Gangmasters Licensing Authority Economic affairs

68 Home Grown Cereals Authority Economic affairs

69 Horticulture Development Council Economic affairs

70 Joint Nature Conservation Committee Economic affairs

72 Marine and Fishery Agency Economic affairs

73 Milk Development Council Economic affairs

74 National Forest Company Environmental protection

75 Natural England Environmental protection

76 Royal Botanic Gardens, Kew Recreation, culture and religion

77 Sea Fish Industry Authority Economic affairs

78 Foods Standard Agency Economic affairs

Department for International Development

79 Commonwealth Scholarship Commission in the UK Education



Department for Transport

80 British Transport Police Authority Public order and safety

81 Highways Agency Economic affairs

82 Rail Passengers Council Economic affairs

83 Railway Heritage Committee Economic affairs

84 Renewable Fuels Agency Economic affairs

85 Trinity House Lighthouse Service

86 Office of Rail Regulator Economic affairs

Department for Work and Pensions

87 Health and Safety Commission Economic affairs

88 Health and Safety Executive Economic affairs

89 Jobcentre Plus Economic affairs

90 Independent Living Funds Social protection

91 Personal Accounts Delivery Authority Social protection

92 The Pensions Advisory Service Economic affairs

93 Pensions Agency Economic affairs

94 The Pensions Regulator Economic affairs

95 Working Ventures UK Economic affairs

Department of Health

96 Alcohol Education and Research Council Health

97 Appointments Commission Health

98 Commission for Patient and Public Involvement in Health Health

99 Commission for Social Care Inspection Health

100 General Social Care Council Health

101 Health Protection Agency Health

102 Healthcare Commission (Commission for Healthcare Audit and

Inspection)

Health

103 Human Fertilisation and Embryology Authority Health

104 Human Tissue Authority Health

105 Monitor – Independent Regulator of NHS Foundation Trusts Health

106 National Biological Standards Board Health

Department for Business, Enterprise and Regulatory Reform

107 Advisory, Conciliation and Arbitration Service Economic affairs

108 Competition Commission Economic affairs

109 Competition Service Economic affairs

110 Consumer Council for Postal Services (Postwatch) Economic affairs

111 Gas and Electricity Consumer Council (Energy Watch) Economic affairs



112 Hearing Aid Council Health

113 Local Better Regulation Office Economic affairs

114 National Consumer Council x 3 Economic affairs

115 Natural Environment Research Council Environmental protection

116 SITPRO Ltd Economic affairs

118 UK Atomic Energy Authority Economic affairs

Department for Innovation, Universities and Skills

118 Arts and Humanities Research Council Education

119 Biotechnology and Biological Sciences Research Council Economic affairs

120 British Hallmarking Council Economic affairs

121 Construction Industry Training Board Economic affairs

122 Design Council Economic affairs

123 Economic and Social Research Council Education

124 Engineering and Physical Sciences Research Council Economic affairs

125 Engineering Construction Industry Training Board Economic affairs

126 Higher Education Funding Council for England Education

127 Investors in People UK Economic affairs

128 Learning and Skills Council Education

129 Medical Research Council Health

130 National Endowment for Science Technology and the Arts Economic affairs

131 Office for Fair Access Education

132 Quality Improvement Agency Education

133 Science and Technology Facilities Council Education

134 Sector Skills Development Agency Education

135 Student Loans Company Education

136 Technology Strategy Board Economic affairs

137 UK CES Social protection

Foreign and Commonwealth Office

138 British Council General public services

139 Great Britain – China Centre General public services

140 Marshall Aid Commemoration Commission Education

141 Westminster Foundation for Democracy General public services

Government Equalities Office

142 Equality and Human Rights Commission General public services



Home Office

143 Independent Police Complaints Commission Public order and safety

144 Independent Safeguarding Authority Public order and safety

145 National Policing Improvement Agency Public order and safety

146 Office of the Immigration Services Commissioner Public order and safety

147 Security Industry Authority Public order and safety

148 Serious Organised Crime Agency Public order and safety

Ministry of Defence

149 National Army Museum Recreation, culture and religion

150 Royal Air Force Museum Recreation, culture and religion

Ministry of Justice

151 Criminal Cases Review Commission Public order and safety

152 Criminal Injuries Compensation Authority Public order and safety

153 Information Commissioner's Office Public order and safety

154 Judicial Appointments Commission Public order and safety

155 Parole Board Public order and safety

156 Youth Justice Board for England and Wales Public order and safety

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London Councils Total Place final report · spent more effectively, most commonly through service design around the citizen. Our brief from London Councils was to examine the opportunities