There is a subtle but important link between two of today’s depressing news headlines: the scandal at Mid Staffs Hospital and the confirmation by the IFS that economic sluggishness means the worst of public sector austerity is still to come.
When talking about the poor performance and low productivity of the UK economy there is a tendency to focus on high skill, high tech areas like life sciences and new materials. As I wrote the other day, R and D investment and commercialisation of these areas is stagnant at best and more likely in decline, but even if were they booming, these sectors – which will only ever account for a very modest proportion of the total workforce – would not be the answer to the biggest problems of our labour market. These lie in a low pay, low skill, low productivity service sector increasingly detached from the managerial and professional classes.
As a number of writers have argued, the most important challenge for the UK economy is improving the quality and productivity of service sector employment. And, by the way, improving the quality of services is also a more environmentally sustainable model of growth than producing and consuming more ‘stuff’.
But what’ the link to the Francis Report on Mid Staffs? Over the last twenty years a major trend in the public sector has been the development of a tier of poorly paid assistants (many of not most of whom would require tax credits to reach a living income) in jobs with a low skill requirement who are slotted in under the main service professions. In teaching for example the number of teaching assistants has risen from 79,000 in 2000 to over 220,000 in 2011. There has also been a steady rise in the number of health and social care assistants. And the category of police community support officers (PCSOs) which has only existed since 2002 has gone from 6,000 in 2005 to over 15,000 today.
The basic idea is that assistants don’t have highly developed skills and competencies as they will be overseen by professionals who do. But a number of processes undermine this model. Rising demands and multiplying bureaucratic processes, on the one hand, and the natural tendency of professionals to want to spend their time on the most rewarding and career enhancing activities, on the other, mean that assistants often end up performing vital task with limited supervision.
To the case study evidence of service failure by health care assistants provided by the Francis Report and a steady trickle of stories about PCSOs failing to manage difficult situations, can be added telling research from schools which shows that teaching assistants are among the least effective (and most expensive) ways of spending money to improve children’s attainment. Indeed, because teachers often ask assistants to work with the lowest performing children (leaving the professional to work with the more engaged pupils) they can end up worsening outcomes for this group.
Most teaching, health care assistants and PCSOs are hard-working and effective but the system is failing and the assumptions underlying it lie cruelly exposed. The idea of growing a low paid cadre to take the unrewarding, unpleasant, monotonous work off the hands of the better paid university qualified professionals seems like common sense but increasingly it looks like it is plain wrong; bad for staff, bad for service users, bad for the reputation of public services and bad for the economy.
Raising the skill threshold and performance expectations of the public service assistant cadre, while maintaining this as an entry point for non-graduates, should be a priority for public service reform. It is the key productivity challenge and it will require an integrated response starting in schools and FE colleges and reaching into the heart of management, work design and professional boundary setting. But if the public sector could grasp this challenge it could provide a vital lead to the rest of the service sector, which is characterised by very similar problems.
For while it may not be sexy, or offer politicians the photo opportunities they love in laboratories or science parks, it is change here at the bottom of the labour market that is most vital to public service improvement, economic dynamism and social justice.
At last week’s Scottish Renewables Conference, the question was raised whether Scotland could make the advances in cost effectiveness needed for technologies like wind and wave to compete, without subsidy, with other energy sources. An interesting response from the floor was to argue in the affirmative on the basis of the cluster of attitudes, skills and resources now benefiting the industry. All the major political parties in Scotland support investment in renewable energy, as does the public. The country also boasts more than half the world’s total research in wave and tidal power. The history of oil and gas provides confidence, experience and a stock of energy-related entrepreneurs and investors.
The answer got me thinking about clusters for public service innovation. They too would require buy-in not just from politicians and senior officials, but key stakeholder and user groups. Also needed would be input from university or think tank specialists in public service reform, and service designers would have a role to play. Vital too would be social entrepreneurs and potential investors (or at least people with expertise in how to lever in investment). And – an often overlooked resource – the cluster would also contain people with expertise in the organisational change process, which is a corollary of substantial innovation.
One approach would be to undertake an initial survey of whether theses aspects of a potential service-related cluster exist in a locality. The implication is that an important part of the full process of innovation is to identify missing elements and try to put them in place.
Of course, the idea of bringing people with different innovation-related skills together to solve a problem isn’t at all new. In fact there are many such processes and events, Social Innovation Camp being among the best known. But while SIC focuses on weekend events to develop and refine web based solutions, the innovation clusters I am describing would be just as interested in redesigning institutions and interactions.
More importantly, they would be more like industrial clusters in the sense of being a long term combination of people and organisations working both through formal processes and informal meetings and conversations.
Once the components of a local innovation cluster are in place, the challenge is to find platforms, processes and places so that there are plenty of opportunities for ideas and initiatives to bounce around the cluster. Using the kind of social network mapping tools being used and refined by RSA researchers, it would be possible to track the flow of information and ideas around the cluster.
Overall, public service productivity continues to flat-line. This is an important reason why the social aspiration gap (between people’s needs and expectations and what the state can provide) is widening. Innovation needs to be seen as a continuous imperative for public services. But do most localities have the resources and relationships which offer a fertile soil for innovation to be planted and grow? And, if not, how could public service innovation clusters be created and maintained? These are questions I’d be keen for the RSA to explore further.
Undeterred by the gradual drying up of comments, this is – for the time being – the penultimate of a series of posts on ‘the paradox of entitlement’. The most recent have explored two ways of reinforcing the reciprocal dimension of welfare and public service entitlements: conditionality and the contributory principle. Today I return to one of my recurrent themes over the years; how can public services be reimagined and redesigned to accentuate their reciprocal and relational core?
This is hardly novel and should be an easy argument to make. We know parental engagement is vital to the success of pupils and schools; lifestyles, attitudes and observance of treatment regimes are crucial to the prognosis of NHS patients, and the police find their job almost impossible if communities don’t exercise at least some level of responsibility and self- policing.
Public service outcomes are demonstrably the result of the collective efforts of service providers, service users and the wider community. Whether a basic public service entitlement turns into a life enhancing experience depends to a large degree on us and the ways we relate to those services. Yet still this truism remains marginal to the narrative, culture and day to day practice of public service management. So rather than making the case for relational public services again, I want to explore through concrete examples some reasons why the insight seems so hard to act upon.
The first is simply that change takes time and effort and can go wrong. The RSA itself offers an illustration. Following strategic guidance from Trustees, the RSA has over the last four years made a concerted effort to engage its Fellows more fully as partners in the delivery of the Society’s charitable mission. This has involved many changes including; the replacement of the former appointed, consultative Council with a new representative and more hands-on Fellowship Council; the creation of a team of dedicated network facilitators developing and supporting Fellows’ activities; encouraging Fellows to form networks at whatever geographical level and around whatever shared interest works best for them; supporting a wide variety of ways for Fellows to engage with each other on-line; the creation of the Catalyst Fund which regularly gives small grants to back Fellow’s initiatives; and a much greater emphasis on engaging Fellows in the Society’s research and development projects.
It is clear now that the faith of Trustees and the hard work of RSA staff is paying off: There are four or five times as many active Fellows’ groups as a few years ago (and that’s just the ones we know about), we have a good flow of bids to the Catalyst Fund and the quality of those bids continues to improve, RSA Fellows are playing a prominent part in key research projects (and this is being increasingly seen by our partners as part of the attraction of working with the Society), and the current Fellowship survey is showing both high levels of satisfaction and a growing enthusiasm for engagement.
Quite apart from all the good things generated by this engagement (many of which I have highlighted in blog posts), it has provided authenticity and distinctiveness to the Society’s mission; in arguing that the 21st century need a new more ambitious model of citizenship we are increasingly able to show how the Society’s Fellows are exemplifying that ideal.
Our pride at what has been achieved is exceeded only by our ambition for what could lie ahead. But, and here’s the rub, at times the process of engagement has been exhausting, dispiriting and even sometimes felt like it might all be a massive error. Among the mistakes we have made have been a lack of realism about how quickly culture can change, raising expectations without having the infrastructure to meet them and under-estimating the fierce resistance to change among those in the Fellowship who prefer a more traditional, hierarchical, model of engagement. Most of all, the process of working out how best – with limited resources – to support a group of busy volunteers to develop good ideas and act on them involves continuous trial and error, learning and self-criticism. If the Trustees and Executive had not seen Fellowship engagement as an essential part of the RSA strategy we may well have lost heart and momentum.
So it is with the welfaer state. Indeed with growing needs, shrinking resources and the requirement of public accountability, the challenges are much greater. In attempts at the engagement of service users and citizens by public service managers and professionals there are invariably times when the whole process feels like more trouble than it’s worth. That’s when engagement is abandoned or more often scaled down to something less ambitious and more manageable. But it is almost better not to try than to enter into a process with a lack of conviction or realism.
Because engagement can be so difficult the public sector is prone to a self-fulfilling prophesy: a half-hearted commitment leads to a failed process which confirms the initial scepticism.
An important reason for that scepticism lies in the bureaucratic/professional culture of public services. To make this point simply (this post is already too long) I go back to an example I gave a few weeks ago: research by Anne Hook and Bernice Andrews found that a significant variable in the effectiveness of psychiatric treatment for depression was whether patients disclosed their true feelings to therapists. Those who hid their feelings – generally because of shame – were much less likely to get a good outcome.
The first lesson is that patients have to use the service responsibly (respecting the therapist’s need for openness) for it to succeed. But – and this is crucial – this lesson can only be learned alongside a second. Over to Dryden Badenoch, who wrote the blog post in which I read of the research:
By illustrating the effect of individual client decisions on therapeutic outcome, Hook and Andrews have furthered the argument for routinely considering the client’s contribution to the effectiveness of psychological therapies, rather than treating the client as a passive recipient of the ‘miracle therapy’ or the attentions of the ‘super-shrink’.
It is not easy for professionals and managers to accept that their success depends not just on their own methods and skills but on the engagement of services users and citizens, and also to accept that this engagement is only likely to work if they give up some of their own authority and power. The combination of professional resistance and the sheer difficulty and effort involved provides a high barrier to reconceiving public services as reciprocal and collaborative. Which is why people like me have been banging on about this for so long but making so little progress.
It is my great privilege and good fortune to have been able to test the theory out on the RSA and to see our amazing Fellows generating such exciting results. What organisations do is a more powerful influence than what they say. Hopefully, by sticking the course and showing how genuine engagement pays off, we can inspire others in the third and public sector to follow our lead.
Welfare reform exhibits a well-known ‘trilemma’: out of the three main goals of policy – helping the poorest, incentivising work and saving, and containing expenditure – it is possible to choose any two but never all three. This, in essence, is why the contributory principle, which was only ever partially embedded in the welfare state, has been consistently eroded by governments of all parties. As John Hills, perhaps the UK’s leading welfare expert, argued in a paper back in 2003:
‘ under governments of the Left, arguments in favour of inclusion have been predominant, non-contributory benefits expanded and contribution conditions softened; under those of the Right, the emphasis has been on focussing limited resources on the poorest through means-testing’
Those on the political right are particularly prone to criticise what they allege to be a ‘something for nothing’ welfare culture. The celebration of Margaret Thatcher’s reign occasioned by the release of a biopic may therefore be somewhat tempered by the recognition that reforms to pensions and benefits during her time in office were a major assault on the contributory principle. The current Government is making further inroads into what is left. The Employment and Support Allowance is in part a form of insurance against losing employment through ill health. Those who have paid into National Insurance were implicitly buying this protection, but now it is being cut back.
The idea that what you get out of the welfare state might in some way reflect what you put in is not, however, something which should be consigned to history. Reviving this idea might be part of addressing ‘the paradox of entitlement’, the subject of several of my recent posts.
Yesterday saw an alliance of organisations (including the RSA) representing a wide array of interests and views calling on the Government and opposition to work swiftly towards a new funding regime for social care. The Coalition appeared to knock the recommendations of the Dilnot Commission on Social Care funding into the long grass when they were published last July, but talks are forthcoming to try to develop a new cross party consensus on reform.
Social care is in crisis and – as I have suggested in past posts – it may now represent the first major area of welfare provision since the creation of the modern welfare state demonstrably to deteriorate. Many in the sector argue that a new funding regime is the essential prerequisite for creating a more stable system capable of providing decency to all in frail old age.
In a sense the Dilnot package includes a modern form of the contributory principle. The Commission proposed a state guarantee to pick up all social care costs above a fixed limit (£35,000 was suggested by the Commission). As well as addressing the perceived unfairness of older people giving up lifetime’s assets to pay for care, through capping the total an individual can be asked to pay this proposal seeks to create the basis for a market in social care insurance. Dilnot also proposed that the means test limit below which people are not required to pay for any care should be significantly increased.
Some on the left criticised Dilnot on the grounds that his package was more geared to helping the middle class than the poor. But any attempt to create a financially sustainable system in which all have a stake involves combining a universal safety net with a partnership between the state and those who can afford to meet some of their care costs.
Another response to an ageing society is the auto-enrolment pensions system designed by Labour but from later this year being gradually rolled out by the Coalition. Indeed in combining individual contributions, employer contributions and a Government contribution (through a tax break) the new system echoes one of the first manifestations of the modern welfare state: Lloyd George’s famous ‘Ninepence for Fourpence’ health insurance scheme unveiled in 1911.
The student loan system too is a form of contributory welfare. Students’ courses are funded by a combination of direct funding and underwriting of loans by the state and income contingent student contributions.
It is well understood that the classic Beveridge model contributory system has largely withered away. It is less often noted that new models and proposals for state-individual contributory partnerships are emerging. Squeezed budgets and rising costs mean that new contributory arrangements are necessary – indeed inevitable - if universal entitlements (including core public services) are to be protected.
An important task for politicians and thought leaders is to explore the rationale, values and expectations necessary to underpin a new contributory principle.
Yesterday I sat in on a conversation about social care involving about twenty people, mainly practitioners from Leicester. They were an impressive group; committed, thoughtful, optimistic about what could be achieved but very aware of the limitations of existing provision.
Personalisation was a recurrent theme of the conversation. Speaker after speaker described the importance of fully understanding someone’s needs. A typical story involved a person with severe learning difficulties who started continually hitting his head against a wall. The behaviour was treated as a regrettable but inexplicable symptom of mental incapacity until a nurse noticed that the person always hit the same side of his head. It was only then that a quick examination revealed a severe but treatable ear infection.
Government strategy on personalisation has for several years revolved around the development of individual budgets. Currently, about a third of eligible social care clients have taken up individualised funding (either through direct payments or managed personal budgets) but take-up has been by far highest amongst those with physical disabilities. Extending individual budgets to people with learning difficulties, mental illness or dementia is much more challenging, though it will often be the carer who is the budget holder. Evaluation of individual budgets is limited but positive. But just because more people have individual budgets doesn’t mean services will necessarily be better, even from the perspective of the service user. The quality of care will depend enormously on the amount of money allocated and what services are available to be purchased.
A key question is how individual budgets might develop to facilitate a reframing of social care. As I listened to the conversation I could distinguish four levels of ambition for publicly funded interventions. Level one – the traditional system – simply involves the bureaucratic allocation of available services to the identified client group. Level two is what is conventionally meant by personalisation: allowing individuals to use allocated resources to choose their own care packages. This is fine for individuals, but many clients need support in making choices, and unless clients and carers come together to commission services, their choices may be very limited. So level three involves working with clients and carers to identify a set of interventions, which in the context of people’s wider personal resources and needs, will offer them the greatest empowerment and wellbeing. An example here is a group of people with physical disabilities and learning difficulties who collectively commissioned fitness classes which are not only tailored to their needs but also offer the opportunity for sociability for both clients and carers.
Level four is the most challenging but arguably the most necessary. This involves exploring the latent resources of care, altruism and ingenuity which exist within a client’s family, friends and wider community and then asking what interventions might best release these resources. This is the kind of thing being explored by a variety of RSA projects ranging from work on social networks and wellbeing to a whole person recovery approach to people in rehabilitation from drug and alcohol dependency.
There is no inherent reason why this social asset approach can’t be pursued within the context of individual budgets. The fact that individuals have to buy into services is a useful discipline to ensure those services are effective and relevant. But without co-ordination and collaboration the danger is that individual budgets end up buying tiny parcels of care from large impersonal providers while local public agencies retreat into a focus on resource allocation and risk management.
As resources are squeezed and needs grow the ambition should be that individual budgets are seen not simply as a way of paying for services but as a means to leveraging collective action and civic commitment. A new deal for social care rests on reframing the relationship at its core from professional and client to community and citizen.