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The 2020 Public Services Trust Blog

Thursday, April 9, 2009

Scandalous social care

By Charlotte Alldritt

Tonight, BBC’s Panorama broadcasts a scathing attack on the UK’s social care services for elderly people. The programme depicts a picture of chaos and neglect, as staff are overworked and some haven’t even received any formal training. Research for the BBC found that private companies are delivering care for as low as £12 an hour, £10 less than what it costs local councils. This is an example of public services going to the lowest cost bidder with serious implications for quality.

Yet contracting out of public services is not necessarily a recipe for disaster. And its a good job, given that competition, diversity of providers and choice are the building blocks of a cross-party consensus on public service delivery. This move away from public sector monopoly was designed to ramp up quality and enable ‘citizen-consumers’ to receive personalised care, cost-effective for the taxpayer. Scandalous examples of where this has failed are unforgivable, but do not necessarily call into question the model of contestability and competition in public services itself. Rather, it beckons serious concerns over the quality of monitoring and inspection. It also causes us to ask about the role of central targets, minimum standards, and the benefits of a principle (as opposed to risk-) based regulation system.

The design and reform of public services over the last few decades has seen moves backwards and forwards on policy instruments and the appropriate role of government (both central and local). What remains critical, however, is the need for quality to be at the heart of the system and the needs of the citizen to be paramount. Both parties have acknowledged this in their rhetoric. The NHS Darzi Review has seemingly embraced it in practice. Unfortunately, even then difficult questions remain, not least – as Ben Lucas reminds us (see Is fairness back in fashion? 8 April 2009) – in the face of a serious funding crisis.

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Posted by Charlotte Alldritt at 2:08 pm
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Tuesday, January 27, 2009

From individual consumption to social contribution…

By Ben Lucas

The times are changing and the era of individualism, which stretches back to the 1980s in the Anglo-American world, looks like it is drawing to a close. President Obama’s inaugural speech last week contained a strong call for society to embrace a much stronger ethic of responsibility. This responsibility stretches from big corporates, whose perceived greed, especially in the banking sector, has precipitated the global recession to individuals who will be expected to pull together to get through these difficult times.

As Obama said: “What is required of us now is a new era of responsibility — a recognition on the part of every American that we have duties to ourselves, our nation and the world; duties that we do not grudgingly accept, but rather seize gladly, firm in the knowledge that there is nothing so satisfying to the spirit, so defining of our character than giving our all to a difficult task. This is the price and the promise of citizenship”

What is striking about the new emphasis on responsibility is that it not only introduces a new expectation of social responsibility to the business world but it also calls into question the language of consumerism which has been used to drive reform in public services. If, as Obama has said, we are going through difficult times which require a more mature conversation about how these challenges can be met, then we have to think about the relationship between citizens and the state as being a more active one than consumerism implies.

In Britain, politicians are still playing catch up with this new world. Last week saw two interesting developments which could suggest a new direction. The Government published its long awaited NHS Constitution and David Cameron set out his thinking about the key elements of progressive Conservatism. Both of these put an emphasis on responsibility as well as choice and consumer rights. But both need more development. Last week also saw the publication of a sobering report by the New Economics Foundation, which shows just how far Britain will have to go if it is to move from unhappy individualism to become a more socially responsible society.

The aim of the NHS Constitution is to entrench the NHS in the British political settlement and to entrench citizens’ rights in the health service. It sets out a collection of legal rights, pledges and responsibilities for both patients and NHS staff. These include a right to make choices about healthcare and to information to help exercise that choice, as well as new rights in relation to vaccinations and drug treatments. The Constitution continues the process of rebalancing the power relationship between doctor and patient, so that patients are able to have greater choice.
The problem is that it is stronger on ideas associated with consumerism than in relation to individual and collective responsibility for health. When the constitution talks about responsibilities for the public it does so in the context of their being patients, rather than in the wider circumstances of preventative health care.

Likewise, whilst David Cameron’s speech sets out an interesting new framework for progressive conservatism and embraces the idea of responsibility, there are still some significant shortcomings in this approach. Cameron defined four progressive ends which he says progressives across all three parties share: fair society; equal opportunity society; green society; and a safer society. He said that what distinguished progressive Conservatives was the means which they want to use to achieve these ends, these include devolving power and responsibility to individuals and communities based on ‘nudging’ rather than regulating, the family, economic growth and fiscal responsibility. He also set three tests for deciding the appropriate policy response to future problems which reflect these means. Leaving aside the question of how these tests would have helped a Cameron government to respond to the credit crunch, there is also a wider question about what this framework has to say about the hard choices which will have to be made on public services in the future. To live up to the tag of ‘Progressive Conservatives’, the Cameron Conservatives will need to initiate a more honest discussion with the electorate about what shared responsibility will mean in the context of rising demand for public services, just when the money will have run out to pay for improvements.

The reality is that our public services face growing demand pressures, including ones which fall outside traditional institutions such as schools, hospitals and prisons. Many of these are behavioural challenges, from combating obesity to spurring ambition and social mobility through to encouraging greater civility. These are in addition to the growing cost of caring for an increasingly ageing society and the, as yet unquantifiable, social costs of the recession. Yet we know that even on the Government’s optimistic PBR forecasts public spending will need to be cut by at least £37billion in the next spending round. What we need from British politicians is a more open conversation with the public about how we are going to square the circle between society’s growing expectations of public services and the fast diminishing resources to pay for these.

Part of the answer will have to lie in accelerating public service reform, through once in a generation innovation and productivity gains. But this is also going to have to lead to a much greater emphasis on how and what individuals and society can contribute to public services. We need to move from an ethos of individual consumption to an ethic of social contribution. More personal responsibility in relation to self-regarding behaviour (health, ambition etc), greater social responsibility in relation to working together to get better outcomes from public services, and a willingness to pay for better outcomes either directly or indirectly through taxes and charges. This will build on some of the existing, but so far marginal, work on ‘co-production’, ‘co-creation’ and ‘co-payment’, but needs to be expressed in a more compelling and accessible language. The challenge for politicians is to re-frame the public debate, so that it is better aligned with economic and social reality.

The scale of this challenge is underlined in National Accounts of Well Being, a new report published by the New Economics Foundation. This found that Britain ranks lower than any other European country amongst 16-24 year olds when it comes to trust in each other and in social institutions – a reflection of just how individualistic Britain has become. But a social model built on individualism will not deliver the well being that Britain’s will want for themselves in the future. David Cameron is right to talk about responsibility and Gordon Brown would do well to start to do the same. But British politicians will have to go much further than this if they are really to help facilitate the development of a new social model based on responsibility and contribution rather than passivity and consumption.

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