Public services – still not getting real
What with the recession and Northern Ireland, not to mention Jade Goody and Julie Myerson, not much attention will be paid to what will seem to many people as yet another Government paper on public service reform (by the way, has anyone yet written the inevitable Goody-Myerson comparison: on the one hand the ignorant untalented, lumpen Goody who is enduring media intrusion in her dying hours in order to provide financial security for her children, on the other, the fragrant, highly intelligent, middle-class Myerson who seems to be encouraging media intrusion into her family in order that she can sell more books, sorry that should read ‘expose the scourge of skunk’).
There’s nothing wrong with the announcements Brown will be making today. A greater reliance on user satisfaction is a good way of balancing the need for accountability with the scope for local discretion. But it is hard to avoid the impression of superficiality. Public service reform is facing some major system challenges and I sense a question mark hanging over the fundamental trajectory of reform. There are more Academies but more of them also complain that they are losing the autonomy that makes them different. In the NHS the Darzi recommendation for integrated care trusts is hard to reconcile with the internal market. It could be that this represents a carefully calibrated middle way between contestability and cohesion, between autonomy and accountability, but if so I haven’t yet heard any minister describe it that way or explore the kinds of challenges such a strategy involves.
On the other hand, and here I am a cracked record, there is no sign that ministers have even begun to face up to the spending problems that will kick in just after the next General Election. Indeed there appears to be a conspiracy of silence between the two major parties. Labour doesn’t want to talk about public debt or add to the bad news, the Conservatives don’t want to look as though they are planning cuts. So both parties will shy away from addressing the scale of the problem while secretly planning for the big squeeze.
For the Conservatives too are in la la land when it comes to public spending. Their highest profile public service reform – based on the Swedish model – is to allow parents to draw down what is essentially a voucher to use to set up their own schools. The problem with this policy is that while supporting new entrants the Conservative Government will also have to support existing schools so they can fight back or at least manage decline. So, as with all policies that seek to increase diversity and contestability in a quasi-market, extra capacity will need to be funded (this is what New Labour controversially had to do when it was encouraging the private sector into NHS treatment).
Generally it is assumed that you need the market to have about 20% extra capacity in order to allow new entrants in while supporting existing providers. But the Conservative policy is supposed to be enacted in the middle of a huge public spending squeeze. As public service jobs and services are being cut back left, right and centre can we really imagine a Tory spokesman defending spending an extra 20% on surplus school places just to invigorate the market, especially when the system already contains such diversity and where there are other cheaper routes to bring in new providers?
The clumsy progress of the NHS
People often ask me (OK, someone once asked me), ‘do you have any examples of clumsy solutions?’ A clumsy solution, as you will recall, is one which engages the active paradigms (egalitarianism, individualism and hierarchism) of cultural theory (as well as being aware of the ubiquity of the fourth paradigm, fatalism). In his book ‘Organising and Disorganising’ Michael Thompson offers the example of the successful relocation of Arsenal football club, involving as it did an alliance of the hierarchical actor (Islington Council), the egalitarian (the local community) and the individualist (the Club itself).
I will offer a much bigger, and more controversial, example: the NHS. Benefiting as it has done from several years of growing revenue and capital budgets the NHS is in pretty good shape. Long waits – for decades the public‘s greatest complaint – have been abolished, outcomes are improving in key treatment areas such as cancer and heart disease, and patient satisfaction levels are at an all time high. Despite the flu, the weather and the norovirus, another winter is passing without the kind of crisis we used to think inevitable. The test will be when the flow of cash starts to slow down next year but there are reasons to believe the NHS has developed broadly the right balance of change levers.
Of course, there is no shortage of hierarchical levers in the form of targets, regulation and expert frameworks. But the individualist devices of competition and patient choice are also embedded with, for example, more and more patients being aware of, and taking up, choice. The possibility of individual budgets for those with long term chronic conditions could bring another individualist driver into the system. And the recent Darzi review, with its recognition of the need for local discretion in developing health strategies and closer local collaboration between the NHS and local authorities, provides an avenue for benign forms of egalitarianism, focussed, in particular, on addressing public health.
More evidence that the balance of drivers may be broadly right can be found in the modest tone of the Conservative critique; a long way this from the hyperbole of Labour 1997 pledge to save the NHS and its subsequent disastrous dismantling of the internal market (only for it to be rebuilt five years later).
In a huge enterprise like the NHS clumsiness is a framework, not a solution. The inevitable dilemmas of the health service – national accountability versus responsiveness, integration versus competition, public health versus the medical model, and (the most difficult of all in years to come) universalism versus patient empowerment, will continue to create challenges for policy makers, managers and clinicians. These dilemmas will never be resolved but if the NHS continues to be a clumsy system they can be the context for, and not a barrier to, further progress for patients.
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