The 2020 Public Services Trust Blog

The Commission’s health working group published Improving Health Outcomes earlier this month – written by myself and Dr Greg Parston, the group chair.  The Monday following the report, Secretary of State Andrew Lansley announced his white paper, and the debate has shifted again.  So how do the two match up?

Well first of all , we never intended to produce a set of hard policies that the whole group would advocate.  It is pretty obvious from the white paper that generating consensus over the direction ahead is hard to do.  So what we did was to provide a manual for decision-makers – a set of ideas, barriers, archetypes and instruments that would give people the best chance of taking short term decisions on health reform with broader 2020 goals in mind.  The Commission’s shifts in culture, power and finance are at its heart, and the consensus that did emerge was over the need for (1) a more integrated commissioning model for health and social care; (2) more home-based and socially-delivered health and care services; (3) maintaining a focus on social outcomes as a driver of change and a determinant of commissioning.

This ends up looking quite different from the white paper.  I have a few reflections:

• The government’s proposals are bold, radical, and certainly blow open the myth that change would be merely rhetorical, and protection of NHS budgets would stifle reform.
• The reforms also follow a market logic (Matthew Taylor has talked convincingly about civic markets recently) – extending choice, empowering professionals, nominally strengthening downwards accountability and provider competition.  This is all coherent and could generate benefits, obvious concerns over equity and information notwithstanding.
• However…..
• There are questions around the model of GP commissioning that might emerge.  Problems of coordination, legitimacy, scale, access to information and professional and citizen capacity all seem germane, and from what I have read it does not seem obvious at all that GPs are falling over themselves to extend their existing roles within the service.
• But the problem of integration is the most important to my mind.  In the Commission, most of our thinking has been about how to integrate across public services – starting with the citizen, working from this point up, thinking horizontally and about people and place.
• Devolving power is positive, but not if the service remains within the traditional silo model.  What about all of the thinking being done around integrating health and social care spending within localities?  In this sense the proposals feel like they miss out a chunk of really good recent policy thinking.

These are initial reflections, and the medical and policy world are still chewing over the implications of these proposals.  The size of the commissioning consortia that emerge will be important, and the impact of NHS restructuring on jobs will be (righly) keenly watched.  Our own proposals – backed with Ipsos MORI deliberative work – emphasised the need to engage citizens and professionals in the change they see happening around them.  From manifesto to white paper, Im not sure to what extent this has been the case here.

Was the Budget fair?  The Chancellor characterised his measures as ‘progressive’ in that the rich stand to lose more than the poor.  But not everyone agrees.  The IFS calls the claim ‘debateable’ http://www.ifs.org.uk/budgets/budgetjune2010/chote.pdf , largely because it leaves public services out of the equation.  It is poorer households that tend to be the biggest public service users, with in-kind benefits of £6,300pa for the bottom fifth compared with £3,900pa for the top fifth.  There is a clear and serious risk that a sharp reduction in the funding of public services over the next few years will widen social inequality.  

Can we organise our public services differently, so that an age of fiscal austerity doesn’t also become an age of accelerating inequality?  Yesterday we published Equality, Cohesion and Public Services, a research report that asks how to ensure that poor and disadvantaged individuals, families and communities are not left behind.  It looks at some of the many different approaches to reducing inequalities and improving social cohesion that have been deployed in recent years to ask what’s worked, what we should keep, and where we need to do much better. 

Some important strides have been made, but the evidence presented here is a sobering reminder of just how profoundly unequal we remain in many respects, despite years of reform and substantial investment, so that outcomes in education, health and criminal justice, for example, remain strongly related to social background, race and gender.  Public service interventions in support of equality and cohesion take place in a dynamic environment, often against considerable contrary economic and cultural pressures.  Even where gaps have narrowed, it can be hard to pin down what actually made the difference.  It appears both top down and bottom-up service reforms have made a contribution, although quasi-markets have the potential to exacerbate inequalities in some circumstances.   Targeted investment has helped, but targeting in a way that captures all – or even most – of those who need support is notoriously difficult. 

Our public services have focussed on the fair distribution of entitlements.  In itself this has been reasonable and necessary; but of itself it is clearly not sufficient to move us to a more equal society, underplaying as it does the importance of converting entitlements into valued outcomes.  Key to making this ‘conversion’ happen is a system of public services that gives all citizens a far greater say in deciding their own valued outcomes, and enables them to play a bigger role in achieving these.  The 2020 PST trust believes that our efforts to reduce inequality have been hampered by a besetting habit in public policy making which sees professionals defining the nature of the problem to be ‘solved’, finding the resources to address it, and directing how the resources are used.  In 2020 PST language, services have grounded themselves on ‘social security’, where they should be supporting ‘social productivity’, and never more so than with disadvantaged individuals and communities.

Polly Vizard’s chapter in the report is persuasive in this context.  She proposes that the capability approach, pioneered by Amartya Sen, offers a better framework for analysis and action to reduce equality than those in which debate and practice has traditionally been cast – such as resourcism or negative liberties.  It evaluates the position of individuals and groups in terms of their real freedoms and opportunities – the central and valuable things in life that they can actually do and be.  Linked to a clearer and more accessible rights and human rights framework, Polly argues that the capability approach can deliver benefits not only in equity, but in efficiency.

Many communities, activists and professionals have worked hard to put equality concerns at the centre of public service policy and practice over recent years.  The challenge today is to make sure that they become part of a credible narrative of sustainable reform.

This is a tough budget. It adds another £40bn to the already stringent consolidation planned by Labour.  We won’t know its full impact for some time to come. The real test will be what happens to the economy and to jobs.  If growth continues and gathers pace next year, then the Government will feel vindicated, if not then people will question whether the scale and timing of deficit reduction was right.

At least now we know the numbers – what we don’t yet know is what will be the impact on public services.  That will be set out in the spending review, which now assumes even greater importance given the challenge of trying to maintain and even improve social outcomes in the context of huge spending cuts.

A large part of the story is about welfare cuts.  Child benefit will be frozen for the next three years and all other benefits, except pensions, will be uprated only in line with the Consumer Price Index, rather than with RPI.  Housing benefit will be capped at £400 a week.. The principles which are being applied to welfare cuts are conditionality and means testing, with the aim being to target expenditure on those who need it the most and to incentivise work.  But this clearly does not explain the decision to uprate the state pension, which is a political decision.

By far the biggest inconsistency in the coalition government’s position on public expenditure is on health.  The government’s argument is that we face a moment of unprecedented fiscal crisis and so everyone will have to share in the pain of cuts.  In so far as there is a glimmer of hope at the end of the tunnel, it lies in the belief that a crisis can be an opportunity to reform public services to get more for less.  Both these considerations ought to apply to health, it bears a huge share of public expenditure and no service area better represents the concentrated power of institutional and vested interest than the NHS.  Either public services need to be reformed or they don’t. It makes no sense to exclude the most expensive service of all from this process.  The exemption risks undermining reform elsewhere as well as forcing other spending areas to shoulder a disproportionate level of cuts.

It is a measure of just how big the other departmental cuts are that what looked a savage reduction in capital spending under Labour now looks likes an infrastructure reprieve under the new government – even though this still corresponds to a 17% cut in building projects.  The previous Budget’s projection of 10% cuts in non-ring fenced department spending now looks like the good old days, when compared with the 25% cuts which these departments will now face.

What the Budget lacked, and the Spending Review will have to provide, is a coherent public service reform narrative and strategy.  This points to a dissonance at the heart of the Coalition Government.  Whilst the Prime Minister has proclaimed the Big Society as the Government’s big idea, this is not mentioned anywhere in the 120 pages of the Budget statement.  Yet, if the Big Society is to have substance then surely it must be relevant to the fiscal challenge, otherwise it is just a nice to have decorative adornment to the age of austerity.

The spending review will need to develop a strategy for public service reform and transformation and not just for expenditure cuts. The challenge is even greater than that faced by countries like Canada, because the scale of potential cuts is greater and the expected level of economic growth is lower.  The question will be how can cuts on this scale be delivered without unsustainable public sector job losses, particularly in the north? And how can communities and neighbourhoods prosper and develop greater autonomy, when the support they will need to enable this will be under pressure as never before.  The spending review will need to put the emphasis on structural and institutional reforms and on building social productivity – focussing on neighbourhoods, service integration at local level,  more for less budgets for local areas and the social finance mechanisms which can enable scarce funding to be reprioritised on prevention and early intervention.  Without this, retrenchment will quickly turn into residualisation.

One of the most important points raised at this morning’s launch of 2020 Vision was the need to motivate citizens to engage with public services.  If we are to draw upon the broader, social resource that individuals and communities can bring to the table we need to paint a positive vision for public service transformation. As Rt Hon Stephen Dorrell (2020 Commissioner and Chair of the Parliamentary Health Committee) said, the prophets did not lead people out to the ‘wilderness’ but into the Promised Land.

2020 PST welcomes the public debate taking place on the need for public spending cuts.    However to inspire change in citizen attitudes and behaviours about the part they can play in achieving the outcomes we want from public services, we need to set out what our Promised Land looks like.  The public debate will eventually need to move from one of ‘fearful’ realisation of the ‘harsh realities’ of ‘tough choices’.  It will need to call upon language that speaks to a positive future, brought about by seizing the opportunities for change that the current ‘period of discontinuity’ (in fiscal, economic and political terms) presents.   Then we can encourage people to help create the service outcomes that we – as a society – want for ourselves and each other.

Timing is crucial though.  Last September only 24% of the public agreed that public services should be cut to address the level of national debt (Ipsos MORI/2020PST, 2009).  Seven months later, 54% agree (Ipsos MORI/Economist, 2010).  It is not uncontroversial to say that shift of political parties in framing the size of the problem and the available policy solutions has been critical in steering public attitudes.  The media also plays a part. 

And here, on the brink of an opportunity for reform into the Promised Land, we meet an age-old barrier; to paraphrase Alan Shearer after England’s 1-1 draw against the USA on Saturday – the British media is either in a state of abject despair or bursting elation.  Neither is particularly helpful when England puts in an ‘ok, but can do better’ performance. Similarly, the complexities of the UK’s fiscal challenges mean that a nuanced and genuinely ‘honest’ public debate is likely to be reduced to black and white headlines and soundbites.

1 cup new opportunities created by evolving technology, 1 cup long-term demand crisis driven by ageing population, ½ cup sense of urgency created by current fiscal crisis… This morning 2020 PST launched 2020 Vision: A far-sighted approach to transforming public services. The report draws on the work of the Commission to date which has developed a positive, long-term vision for the future of public services and analysed the shifts in culture, power and finance that need to take place to achieve that vision. 2020 Vision goes a step further by examining the implications of the Commission’s vision for setting the priorities for public action, redesigning services to create more public value and ensuring accountability. The report then discusses the barriers impeding transformation and steps that can be taken to increase the chances of success.

Working on this project has been very challenging. In many ways, it is not difficult to point to the shortcomings in our public services, or say things like, “Can’t they just ________ (provide good services everywhere, put that online, train people better)?” Even understanding the factors within the system that block change is relatively straightforward. But to find the right levers to unlock resistance to change – well, if it were easy someone would have done it before me. This report does not pretend to have all the answers – transforming public services is too complicated for one report to cover all the ground. I think the biggest contribution of 2020 Vision is to propose a framework for thinking about how to make change, by asking:

• What is our vision for the future? Where are we trying to go?
• What conditions need to be in place for that to happen?
• What are the barriers to those conditions?
• What are the actions that we could take, in the short, medium and long term, in society and at various levels of government, to remove those barriers and create the conditions needed for change?

As this morning’s discussion made clear, the time for transformation is now. A new coalition government and the fiscal crisis are creating the necessary momentum for major change. As respondent Stephen Dorrell argued, this is not just about deciding how much the public are willing to pay, this is about creating public services that meet the needs of citizens today. These are questions we should be asking ourselves even if we had all the money in the world to spend on public services. Now is the moment to take some risks, be innovative and transform public services so they can meet the challenges ahead.