The Government is paying the political price for the lack of open policymaking in its reforms to the NHSPosted: October 31, 2012
The NHS is facing significant financial pressure as a result of austerity with smaller increases in spending, which are not keeping pace with demand. This has meant that the NHS has to find £20 billion in efficiency savings by 2015. At the same time the health service is facing one of its biggest upheavals ever, which will result in a greater involvement of private companies in the health services. The reforms to the NHS have been introduced in the face of stiff opposition and in many ways represent the opposite to open policymaking – and the Government is now paying the political price.
The opposition to the Health and Social Care Bill was substantial and included the majority of the main health bodies, many of whom were not invited to attend the infamous Downing Street health summit to discuss the bill earlier in the year. Notable non-attendees included:
- British Medical Association
- Royal College of GPs
- Royal College of Midwives
- Royal College of Nursing
- Chartered Society of Physiotherapists
- Royal College of Pathologists
- Royal College of Radiologists
- Royal College of Psychiatrists
Opposition to the bill was widespread in the workforce of the health service. One survey found overwhelming opposition from hospital doctors, with 9 out of 10 professionals opposed to the bill. Strong opposition to the reforms was also apparent amongst the grassroots of the coalition parties. ConservativeHome came out in opposition to the reforms, arguing that it could cost the Conservatives the next election and would distract from important reforms to welfare and education, whilst Liberal Democrat party members opposed the reforms by 2 to 1.
Much of the opposition about the reforms has centred on how complex and fragmented the new health system will be. Clare Gerada, Chair of the Royal College of GPs, has argued that the move to a market-driven health care system will result in a culture of ‘my disease is more important than your disease’, with GPs at the centre of this trying to balance these competing voices. She has flagged her concerns about the lack of experience of GPs in managing relationships with the charities and lobbyists they will face when commissioning in future.
Andy Burnham, the Shadow Health Secretary, agrees on the point of fragmentation of health care, arguing that “my answer is simple: markets deliver fragmentation; the future demands integration.” He has called for a single system for health and social care which addresses the physical, mental and social needs of the nation. He has argued that central government should decide what health services should be delivered and local government how.
Despite the overwhelming opposition, ministers have been happy to write off the protests as ‘business as usual’ when it comes to NHS reform. Simon Burns, the then Health Minister, stated that the opposition from these ‘vested interests’ was to be expected and scare stories about ‘creeping privatization’ are par for the course. Andrew Lansley, the former Health Secretary and architect of the reforms, argued that the Royal College of Nursing only opposed the reforms because of pension changes, accusing them of being ‘a vested interest indulging in trade union -like behaviour’. The appointment of Jeremy Hunt as the new Health Secretary does not inspire hope about a change of policy course, given that he is seen as a proponent of greater involvement of the private sector in a market-driven health service.
The reforms have now received Royal Assent and the Government seems committed to accelerating the involvement of the private sector in the NHS. Research by the Labour Party using freedom of information requests to NHS primary care trusts found that contracts for almost 400 NHS services worth a quarter of billion pounds were signed in early October, representing the biggest act of privatization ever seen in the NHS. The research found that in a quarter of cases, the primary care trust had not been open about its intention to outsource, resulting in a considerable amount of privatisation by stealth.
The biggest privatisations so far have been in community services – those healthcare services offered outside of hospitals including musculoskeletal services for back pain, adult hearing services in the community, wheelchair services for children and primary care psychological therapies for adults. Children’s health care in Devon is now delivered by Virgin Care, as are GP services in Northampton and sexual health services in Teeside. This week’s Channel 4 Dispatches programme entitled ‘Getting Rich on the NHS’ uncovered poor quality services delivered by Virgin Care and concerns from local residents that their local services have been privatised often with little or no involvement from the community in this decision.
Paul Corrigan, the former Labour health adviser, argued in September that outsourcing of services should go further. He proposed that the private sector should be allowed a greater role in the NHS to ‘save’ failing hospitals. This argument is ironic given that this week it became apparent that the flagship outsourcing of Hinchingbrooke Hospital in Cambridgeshire to the Circle Partnership is not delivering on the initial expectations. The hospital, in private hands, has racked up losses of £4.1 million in the first six months of the contract – £2 million more than was expected. Given that the private sector was involved to save the hospital from financial ruin, the experience so far does not bode well.
This closed approach to policymaking and reform is having a real and significant political impact on the Government. A recent survey by IpsosMORI on which party has the best policies on healthcare found that the Conservative’s ratings are at pre-Cameron levels. Only 16% of voters believe that the Conservatives have the best policies on healthcare and they seem to have lost the battle in convincing the public that the NHS is safe in Tory hands. A further recent poll by IpsosMORI points to a re-toxification of the Conservative brand, with a sharp increase in people who don’t like the Tories since they came into government, which the reforms to the NHS are clearly a part of. The Government is paying the political price for the lack of open policymaking in its reforms to the NHS.
The West Coast mainline franchising fiasco shows that the current approach to outsourcing public services has serious flaws that need to be addressed – the much too complicated and secretive nature of outsourcing is the problem, rather than the people handling the process.
Last week Patrick McLoughlin, the new Transport Secretary, cancelled the West Coast Mainline franchise deal. The Department for Transport has been on a damage limitation exercise ever since, with McLoughlin blaming the fiasco on officials at the DfT “because of deeply regrettable and completely unacceptable mistakes made by my department in the way it managed the process”. Philip Rutnam, the Permanent Secretary at DfT, has also joined in telling staff that they must accept that the reversal was the fault of officials. Meanwhile, Kate Mingay, one of the three officials suspended by DfT (an ex-Goldman Sachs employee parachuted into the civil service because of her private sector expertise) has hit out at the way her role in the procurement has been portrayed by the Department.
Blaming officials is an easy way to distract from the substantive story: whether the current approach to franchising used by the DfT is fundamentally flawed. The Department argues that mistakes were made from the way the level of risk in the bids was evaluated due to human error – in particular the way in which inflation and passenger numbers were taken into account, and how much money bidders were then asked to guarantee as a result. But the assumptions about inflation and passenger numbers are dependent on the state of the UK and global economy and the ability of the future franchisee to bring in new customers. Colin Cram, writing for the Public Leaders Network, argues that: “…this enters the realms of guesswork and slight changes in assumptions can lead to different outcomes for contracts that may be for only three or four years, let alone 13.” If the Government’s own Office for Budget Responsibility continues to get its predictions on economic growth significantly wrong, how can we expect the assumptions made in the rail franchising process to be watertight?
This is not the first time that assumptions about economic growth and customer numbers has gone wrong, for example the previous experiences with the East Coast mainline or in the commissioning of welfare to work services. The Work Programme was designed for a far more positive economic climate than we now find ourselves in. DWP’s estimates of the number of customers in receipt of Employment Support Allowance have proven to be wholly unrealistic, with serious consequences for the business models of prime contractors and charities.
The risks associated with complex procurement processes such as the rail franchise are compounded by the secretive nature by which they are often conducted, behind a veil of ‘commercial in confidence’. As we’ve argued before, this ‘closed shop’ approach leads to poor decisions and a profound lack of public engagement – until something goes horribly wrong. The complexity involved also means a significant diversion of resources into the process of franchising rather than actual delivery of services. Franchising might work however if the process was more transparent and the assumptions about passenger numbers (and any other projections) were open to rigorous scrutiny by others outside of the process – so why isn’t it?
The West Coast fiasco has much wider implications that the policy establishment probably doesn’t want the public to consider. Cheryl Gillan, the former Conservative Welsh Secretary, has argued that a root and branch re-examination of the High Speed 2 rail project is needed if the public is to have trust in such a significant investment of public resources. Instead, plans for competition and outsourcing are being accelerated in prisons, probation services and health. In this context, the secretive, complex and bureaucratic nature of outsourcing needs to be addressed as a matter of urgency. If the public is going to be on board, then a public debate is needed on the merits and risks of delivering services in this way – which surely is what the Government’s open policy should be all about.
Fundamentally, the political establishment doesn’t engage the public in a debate about the merits of rail franchising because the public doesn’t support the idea. This ‘outsourcing by stealth’ approach wins neither hearts nor minds. Various surveys continue to show a strong majority of public opinion in favour of re-nationalising the railways – one recent survey found that 70% of respondents supported such a move. Impossible? New Zealand provides an example of such a policy put into action. Its rail and ferry network was privatised in the 1990s and asset-stripped and run down by an Australian outfit. It re-nationalised both in 2009. Michael Cullen, the then Finance Minister said privatization had “been a painful lesson for New Zealand”. Kiwi Rail in public hands has been able to invest in its long-term future whilst also generating significant financial and economic benefits for taxpayers in New Zealand.
Here, despite the strong public preference for a nationalised rail network, none of the three main political parties are committed to such a policy. At last week’s Labour Party conference, Ed Miliband and Maria Eagle made positive noises in this direction but no firm commitments. So we are left with an unpopular, risk-laden, fragmented rail network – and the policy establishment searching around for scapegoats when they should be looking somewhat closer to home.
Olympics over (at least until the Paralympics start), we can get back to where we were – wondering how G4S cocked up so badly providing security for the Games, and what it might mean for outsourcing and social policy. The Olympics have provided a stark contrast between the performance of companies like G4S and the thousands of volunteers and public sector workers who made the Games happen – something to remember when it comes to who we trust to deliver public services.
The biggest cheer at the closing ceremony was undoubtedly for the volunteers. An astonishing four million people applied to be volunteer ‘Games Makers‘, and 70,000 were chosen. Spectators’ and tourists’ experience of their help and hospitality seems to have been almost universally positive (volunteers’ own stories seem to have been equally good).
Then there’s the behind-the-scenes public sector workers – the planners, highways staff, events and civil emergency teams, social workers and others who supported the Games, often on top of their regular responsibilities. Comments on the Daily Telegraph’s site might regularly refer to public sector workers as “parasites” and “scum”, but when it comes to delivering for the nation it seems that the public sector still has its uses and some forms of ‘public investment’ are okay.
This is not private sector-bashing; many businesses and sponsors also made the Games happen. The National Lottery also played a crucial role in the Games’ success, through its investment into hosting the Games themselves, as well as into the success of Team GB’s athletes. But the G4S experience shouldn’t be forgotten. It points to at least three important issues in outsourcing.
The first is about trust. On our behalf, the Government trusted G4S to deliver and the company failed. Thankfully there were no major security incidents, thanks to the thousands of public sector workers in the form of the police and army who stepped into the breach at the last minute. What we need to know now is whether this failure relates specifically to G4S or not. If G4S is a particularly poorly managed company that can’t be trusted, its performance in delivering so many other contracts also needs to be reviewed. Alternatively, if as G4S and others have seemed to suggest, the Government made major mistakes in how it commissioned and oversaw its contract, then the issue is much broader – it’s about whether outsourcing at this scale can ever be trusted.
The second is about openness. G4S’s clumsy and surely counter-productive ‘donation’ of £2.5 million to the armed forces shouldn’t succeed in obscuring these issues, rather it raises more questions. We will only find out the answers if we can see the contract that G4S was given, and in particular how the company will ever be held accountable. How many security staff did G4S (2011 revenues of £7.52 billion) actually deliver? What penalty clauses are there for its non-delivery? How much will it paid for what it did manage to do – and how much will it (properly) recompense the public sector for the additional costs that it (we) had to cover?
The third is about what we value and what motivates us. Some commentators (and ministers) have claimed that the Games reflected the Big Society. The Games Makers in particular demonstrated that people are prepared to volunteer in huge numbers. This doesn’t mean we can deliver public services on the backs of volunteers, but it does suggest there is a vast and often neglected commitment that could be harnessed to improve society. Even The Economist magazine (a consistent advocate of outsourcing) noted last week that volunteering has gone up during the recession – not because of the Big Society but because people care about their local services and communities and so are more motivated to ‘save’ them when their budgets are being cut. Danny Boyle’s opening ceremony (also largely a volunteer army) might have been “multicultural crap” to reactionary misanthropes, but the reason it moved the rest of us is that it reminded us of social achievements driven by a commitment to collective good rather than private benefit.
How many of the Games Makers would have turned up if their job was to save G4S’s neck? The latter might not have offered much pay, but the former weren’t offered anything – beyond the opportunity to be part of something that matters, to make a contribution to a national moment. The Big Society (by whatever name you want to call it) won’t happen if people feel they are being asked to take the place of public services that they’ve already paid for, especially if large outsourcing companies are getting paid at the same time. Perhaps it wasn’t coincidence that while we were distracted by the Olympics, it was ‘leaked’ that the Government is set to give the contract to manage the National Citizen Service to Serco (2011 revenues of £4.64 billion). Put to one side the question of why volunteering – something that charities do all the time – requires a for-profit outsourcing company to manage it. The G4S fiasco suggests we should make sure the penalty clause is so strong – and so transparent – that we won’t have to rely on Serco’s sense of ‘charity’ if and when it fails to deliver.
In this recent series of posts we’ve been exploring the tensions between two competing Government agendas – for so-called ‘open public services’ and ‘open policy-making’. The former is supposed to improve public services by widening the choice of providers, while the latter is meant to improve policy by widening the range of voices that influence policy. These ‘tensions’ aren’t necessarily undesirable for policymakers – outsourcing can be a useful way for Government to ignore the views of those on the frontline when these views conflict with its policy agenda.
Last week Atos was appointed to carry out assessments for the new Personal Independence Payment (PIP) securing two contracts worth over £400 million. PIP is the new benefit to replace Disability Living Allowance from April 2013 for new claimants (with existing claimants migrating onto this benefit by 2016). This decision has proved to be highly controversial because of Atos’ £100 million a year role in the Work Capability Assessment (WCA). The WCA is the main assessment for Employment Support Allowance (ESA) claims.
The WCA has been a public policy fiasco, which has caused real anxiety and fear for people who have been forced to go through this process, as highlighted in recent documentaries by Panorama and Channel 4’s Dispatches. The media has been littered with examples of people who clearly should not have been found fit for work. According to an Early Day Motion last year, 1,100 claimants died while under compulsory work-related activity for benefits and a number of those found ‘fit for work’ and left without income have committed or attempted suicide.
As a result, there is considerable fear, distrust and anger amongst disabled people towards Atos, and the company has faced serious criticism from campaigners, charities and the media for its role in the policy. However, the concerns of disabled people have clearly not featured in the decision to commission Atos to deliver PIP – indeed, they have been dismissed.
Perhaps this is because the problem is the policy, not necessarily the provider. Charities and commentators have argued that the process is flawed, the tests are too impersonal, take little or no account of the wider circumstances and motivation of a person, and that the fluctuating nature of some conditions is not sufficiently taken into account (charities have instead called for a ‘Real-Life’ Assessment rather than a one-sized fits all approach). GPs at their annual conference in May called for the WCA to be scrapped because the assessments are “inadequate” and “have little regard to the nature or complexity of the needs of long-term sick and disabled persons”. They called for the tests to be replaced with a more “rigorous and safe system”. Of the 390,000-plus appeals that have been lodged against decisions not to grant the benefit, just under 40% have been successful. By some estimates the appeals process has actually cost more than the value of the Atos contract to deliver WCA.
Helpfully from the Government’s point of view, criticism of the role of Atos has often obscured concerns about the policy itself, in spite of the fact that the design of the assessment itself is the problem. Professor Harrington was appointed to review the process and recently announced that he is quitting after his third review is completed. Paul Farmer of MIND also stepped down from the Harrington Scrutiny Panel, highlighting a variety of concerns about the WCA. The WCA contract was a poisoned chalice and any provider delivering this contract would have faced similar criticisms.
The policy has also had serious implications for another initiative, the Work Programme (discussed in previous posts), with the flow of customers in receipt of ESA significantly below the estimates provided by DWP to bidders when commissioning the Work Programme. The scale of appeals against WCA decisions has created this logjam in the system, which was not anticipated. The effect of this has been that many charities in the Work Programme who expected to work with ESA customers have seen little or no referrals, whilst the financial models of primes have been affected given that this customer group attracted the biggest financial payments.
Work Programme providers are also required to recommend customers for benefit sanctions – this is an integral part of the design of the programme and providers face consequences if they don’t carry out this aspect. As with WCA however, it is providers who have faced criticism (in this case for their role in sanctioning customers) when the design of this sits with the Department for Work and Pensions. Sanctions are a policy decision and they can only be implemented by DWP – they are not a provider decision.
The outsourcing of both PIP and WCA are examples of the Government’s open public services agenda in practice, whereby public services are opened up to greater competition from the private (and to a lesser extent voluntary) sector. Previously both the WCA and PIP could and would have been delivered ‘in-house’ by Jobcentre Plus. But with outsourced provision, badly designed policies such as WCA and the Work Programme can lumber on while the media and others focus on what’s ‘gone wrong’ with a particular provider. What price open policy then, when providers are effectively being paid to cover for poor policies – at least for a while?
In this recent series of posts we’ve been exploring the tensions between two competing Government agendas – open public services and open policy making. In this post we examine these tensions in more detail, using a flagship Government policy – the Work Programme to tackle long-term worklessness.
The Work Programme is regarded by Government and others as a model of outsourcing that should be replicated in other areas of public services. The Economist magazine has predicted that £58 billion of public services will be outsourced by 2015 as part of the Government’s agenda for ‘open public services’, on top of the £82 billion already outsourced (according to Oxford Economics). Much of the comment surrounding the Work Programme has focused on what it means for the future of outsourcing – but what does it also suggest about the potential for open policymaking?
The Work Programme is a £5 billion initiative that has been heralded as the most radical attempt by UK government to address long-term worklessness. It is based on the principle that government will get out-of-the-way and will financially reward providers who perform. The Government has argued that delivery of this programme should be outsourced rather than delivered in-house, because this will drive innovation and significantly improve performance compared to previous programmes such as Flexible New Deal. Responsibility for both delivery and risk has been transferred to large generally private prime contractors who are largely paid on results, that is the number of people entering into work and keeping their job for up to two years.
However, one of the striking things about the Work Programme, given its size and remit, is the lack of publicly available performance data. This seems to run counter to what the Government has said about the importance of open data, transparency and now open policy. For example, the Government’s Open Public Services White Paper states that ‘Provides of public services from all sectors will need to publish information on performance and user satisfaction’ – yet the same emphasis isn’t always apparent when it comes to this flagship Government programme.
Effective transparent scrutiny of the Work Programme is difficult because providers are not able to share data about what is working and what isn’t. They are required to sign comprehensive contracts, which prevent them from sharing performance data unless it is already in the public domain. Provides face serious consequences if they flout these rules especially if they generate ‘adverse publicity’ for the programme. Nonetheless, some data have trickled out, and the first analysis of performance was released by the Department for Work and Pensions earlier in the summer. This followed a data set released by trade body ERSA in May. ERSA and the Department estimate that one in four people are going into work after being attached to the programme for six months.
The Government has argued that there are complications in releasing timely data about the Work Programme, both because it is new and because there are customers coming onto the programme all of the time, which can distort the overall impression regarding its performance. The Minister responsible, Chris Graying, in evidence to the Work and Pensions Select Committee in March this year argued that his Department is publishing data about the Work Programme in accordance with Office of National Statistics guidelines covering both what, when and how statistics are published. However, a careful reading of his evidence might suggest that the ONS rules don’t actually prevent DWP from releasing Work Programme performance data – in other words, that the Department has more room for maneuver than the Minister appears to suggest. We’d be happy to be corrected on this interpretation – if someone from DWP or indeed ONS wants or is allowed to get in touch.
What is certainly true is that it is still very difficult, a year into the Work Programme, to build an accurate picture of whether the policy is in any way on course to deliver against its original objectives. This vacuum of information is creating a lot of unease about the policy. It has been left to the likes of the National Audit Office and the Social Market Foundation to fill the gap – much to the chagrin of the Government. A report from the NAO earlier this year stated that the Government’s assumptions about the Work Programme were over-ambitious, and that only 26% of job seekers would secure work compared to the Department’s target of 40%.
Given the scale of investment in this programme, both political and financial, it is unsurprising that there is so much interest in this policy – and so many demands for more openness and transparency. There are legitimate questions to be answered as to whether the Work Programme is working in the way it was intended. A number of charities have pulled out of the programme whilst others have gone bust because of the financial constraints of the payment by results model used in the programme. St Mungo’s, a well-respected charity is the latest example to pull out after failing to receive any referrals. The NCVO has also raised a number of concerns from their members about how the programme is being implemented. Given this level of public interest and concern, lack of transparency becomes counter-productive – rather than reducing possibly inaccurate comment and analysis, it only serves to increase it.
The Work Programme points to a real tension between the Government’s open policy and open public services agendas. The Government wants to create a vibrant and efficient market of providers for outsourced public services. It also says it wants the performance of providers to be transparent and open to public scrutiny. But if other, equally important areas of provision such as reducing re-offending, public health, skills, and drug and alcohol recovery employ the Work Programme model, this suggests that open policy in public services will be severely limited, and that the public will know less than they should about what their money is funding and what the results are.