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.
We love public and voluntary service bloggers. At their best, they capture the day-to-day reality of public services in a way that Westminster-commentators can’t – and they have the real expertise and insights we need to improve social policy. Here’s our selection of the best frontline blogs we’ve read this week. Do send us your suggestions for great posts we’ve missed – and those frontline bloggers we should follow in the future.
Posted 10th October 2012
“This week George Osborne outlined plans to slash housing benefit for people under the age of 25 in both his conference speech and a Daily Mail article. This is part of a wider £10bn cut to the welfare bill… I’m presuming the subtext here is that if you’ve never paid into the system, you shouldn’t be able to take anything out. This shows such a profound lack of insight into the lives of many young people in the UK.”
Dr Tim, a junior doctor working in Tower Hamlets, tells the story of three young people – Max (19), Bea (22), and Nelufa (19) – that he has worked with and who would lose out if proposals to reduce eligibility for housing benefit for those aged under 25 announced this week become reality. He argues that these reforms would leave vulnerable young people like these destitute, homeless and isolated.
From Same Difference
Posted 6th October 2012
“Exactly two weeks ago today, I heard and wrote about the case of Liam Barker. Eighteen years old, paralysed since birth, he breathes through a ventilator. His parents had just received a letter informing them that in order to receive Employment Support Allowance, he might have to prove he is unable to work by attending a Work Capability Assessment.”
In this post Same Difference describes the experiences of two disabled people with complex needs, Ruth Anim and Liam Barker, who have been subjected to the Atos-managed Work Capability Assessment (WCA). Liam has received a letter informing him that he will need to undergo a WCA, while Ruth’s mother has successfully appealed the findings of her daughters WCA which found that she was fit for work.
From Abetternhs’s blog
Posted 5th October 2012
“I have written this because like many, perhaps most GPs I feel very uneasy about power. I aspire to a partnership with my patients, teamwork with my fellow health professionals and a more equal society. I feel very strongly that power is a privilege and medicine is a vocation and a public service, or as Iona Heath recently described it, ‘a labour of love’. Usually medical power is viewed in negative terms, an unreasonable acquisition of privilege and abuse of patient trust and public respect for personal gain. Whilst I don’t deny that medical power is abused terribly in this way, I am concerned that power is shifting away from professionals and democratically accountable government, and I am not sure that this is in our patients’ best interests…”
GP Jonathon Tomlinson challenges the current orthodoxy in healthcare by considering the implications of the power that healthcare professionals hold. He argues that notions such as ‘patient independence’, ‘self-care’ as well as regulation and outsourcing, are reducing the autonomy of healthcare professionals and disempowering patients. He speculates about what this could mean for the future of healthcare.
From Mike Broad, on Hospital Dr’s Dr Blogs
Posted 9th October 2012
“Don’t get me wrong. I’m not blaming the private providers – indeed I’m not against the use of the private sector under certain circumstances. They’re not snatching these cherries, they’re being offered them by commissioners desperate to reduce costs.”
Mike Broad argues that the Government is rushing to privatise parts of the NHS to ensure that its reforms can’t be unpicked by any future incoming Labour administration. He outlines his concerns that the Government is not sufficiently addressing the risk that the private sector will cherry pick the most lucrative procedures under the policy of payment by results in health.
From PC Bloggs
Posted 5th October 2012
“Reading media reaction to Hillsborough, to Ian Tomlinson’s death, to all the other negative news stories, is galling at a time when we also feel let down by our own management and the Home Office. I am sure many police officers up and down the country have been wondering just what we are doing it for.”
PC Bloggs describes how the outpouring of grief in the wake of the untimely deaths of PCs Fiona Bone and Nicola Hughes has brought hope that the police service still commands public support in the wake of cuts and negative news stories. PC Bloggs argues that Big Society isn’t a replacement for public services, and that recent events point to a very different relationship where public professionals are valued and respected for the contribution they make.
From The Magistrates’ Blog
Posted 9th October
“Off to court yesterday morning. Standard kind of court list, three CPS trials listed, 2 in the morning, 1 in the afternoon. The subject of the charges also pretty usual, a couple of Assault by beatings (Common Assault) with domestic violence overtones and a Harassment without violence. In we go at 10 am all fired up having had some Case Management Training on Saturday…sadly it all went downhill from there.”
Bystander J, posting on the Magistrates’ Blog, describes three cases where the trials could not proceed because of bureaucratic barriers and lack of joined-up working between the courts and the Crown Prosecution Service.
From The World of Mentalists
Posted 11th October 2012
“This idea that claiming benefits is a lifestyle choice is as hilariously preposterous as it is bullshit. Who would even entertain the notion of choosing this ‘lifestyle’? It’s a horrid way to go through everyday existence, as I can wholeheartedly assure naysayers. …Are there scroungers out there? Yes. Do they need weeded out of the system? Yes. Of course they do. But not at the expense of the vast majority that claim due to genuine illness. And it is a majority.”
To mark the passing of the Welfare Reform Bill by the Northern Ireland Assembly, The World of Mentalists spends the day listening to David Cameron’s speech day “in a state of raw terror [and] guzzling diazepam” – but at least it produces a good rant.
If you’re a frontline blogger, do send us your latest blogs on policy issues or posts from the past that you’re particularly proud of, and they could be included in next week’s round-up. Get in touch with us at: email@example.com or via Twitter @guerillapolicy and @guerrillapolicy
We have a new secretary of state for health – but not apparently a new policy for health, or a change in the way that health policy is made. The way to improve the NHS is apparently the same as it was before Andrew Lansley was sacked – more outsourcing and competition. Jeremy Hunt has been appointed to implement this policy by being a ‘better communicator.’ But the Government’s reforms are unpopular not because of how they have been presented, but because of how the policy was developed – including the fact that no-one voted for them.
Under Any Qualified Provider, private health providers are likely to profit because, in contrast to existing NHS services, they can offer worse terms and conditions for staff, they will not be subject to the same regulations of transparency and accountability as NHS providers or bound by the same financial regime. AQP is a not about establishing a ‘level playing field’, or even about extending proper choice (since patients will not be told who owns providers including whether they are profit-making). Rather, it’s a programme to turn the NHS into a ‘trojan brand’ for private health provision, paid for by the public, while NHS providers lose income and some will have to close – so making the NHS as a whole less sustainable.
Whether you think these are the right reforms or not, they are not a popular because the public has never voted for them and haven’t been involved in developing them. These policies are not completely new of course – many of these ideas are shared across the main political parties, and this particular policy has already been applied in elective care. But this only reinforces the point. AQP is a classic example of the ‘Whitehall consensus’ – the shared view about the obvious rightness of outsourcing held by the policy establishment in the political parties, most Westminster-centric commentators and think tanks – that ignores what the majority of people who use and provide public services including the NHS actually think and want.
Andrew Lansley’s real problem was that he epitomized this approach to policy-making. The issue wasn’t his personal style or language, more that as a member of the Whitehall consensus he assumed that outsourcing is obviously better than ‘monopoly provision.’ It’s this that explains one of his most famous quotes, to nurses at a Royal College of Nursing conference, that: “I am sorry if what I’m setting out to do hasn’t communicated itself.” He thought the case for outsourcing was so obvious that he didn’t really understand why it had to be made at all.
As befits a former senior civil servant and head of the Conservative Research Department, Lansley’s approach reflected the way that policy wonks often approach public services. They seem to assume that institutions such as the NHS can be re-engineered according to blueprints, rather than respecting them as collective institutions with complex cultural as well as organisational histories. Hiring the like-minded (and self-interested) from management consultants such as McKinsey to sketch out massive structural changes reinforces this blinkered thinking, at the expense of any real world, practical engagement with improving how the health service operates, how patients are treated, and how resources are spent and saved.
In the name of greater efficiency, Lansley’s reforms have already wasted hundreds of millions of pounds and distracted health staff from the day-to-day business of improving services. But the point of hiring McKinsey is that they ‘get it’ – they share the view that the (lack of) evidence for outsourcing doesn’t need to be put before the people because they too assume that private provision must be better than public. This outsourcing of policy to the like-minded, even though they are likely to benefit from the policies they help to develop, is the same reason that parts of public health policy under Lansley were effectively outsourced to fast food companies.
This closed and cosy approach will continue as long as the political class is largely drawn from the same old PPE-think tank-commentator axis which pays the greatest respect to an elegant argument and a nicely designed slide deck, but which lacks any real experience of public services, or indeed any broader experience of life outside the Whitehall consensus. The lack of public engagement, and public mandate, for the Government’s health reforms further erodes public confidence and trust in policy-making. The greatest irony of all is that the reforms were supposed to be about devolving power and enabling shared decision-making between GPs and patients. At the heart of these policies, however, is a fundamental lack of accountability – at the level of some (privately-provided) individual services but also for the reforms as a whole.
What’s worrying about the appointment of Jeremy Hunt is not his lack of knowledge of health services – after all, Andrew Lansley held the health brief for many years, and look what happened. It’s that in his time at the Department for Culture, Media and Sport he adopted a similar behind-the-scenes, and way-too-close, relationship with corporate interests against a loved and largely respected but inevitably imperfect public institution (in this case, the BBC). The NHS is still – just about – a public institution. Its future should be deliberated, developed and determined publicly.
Ten reasons why we need a new approach to developing social policy – 8. Policy would be more innovativePosted: May 16, 2012
This is the eighth in a series of posts on why social policy should be developed by and with the people who use and provide public and voluntary services. We’re publishing the rest of the series over the next week, and we welcome your comments.
With less money and, in the case of ‘rising tide’ issues such as an ageing society, less time as well, we need plenty of new ideas in social policy – but where they come from matters. Steve Jobs said that: “A lot of times, people don’t know what they want until you show it to them.” True, but a lot of innovation is sparked by seeing people’s needs close-up and figuring out better ways to meet them. This is why practitioners have created many of the best new approaches, and why we should distinguish between two types of innovation – those that seem like a good idea on paper but should stay there, and those that are good in practice because that’s where they’ve come from.
- new solutions are mostly developed in Whitehall departments and R&D labs in large technology firms (and indeed sometimes in think tanks);
- innovation grows out of major hardware solutions implemented at scale and business process re-engineering;
- process innovation (or ‘lean systems’) is the most effective way of improving efficiency;
- innovation is driven only by market or quasi-market competition; and
- the primary job of public servants and frontline practitioners is to implement what emerges from this pipeline.
The current Government would claim to have moved decisively away from this kind of thinking with its emphasis on ‘open public services‘, in which decentralisation, localism, choice and outcomes-based payments will create many more opportunities for grassroots-led innovation. But it continues to push ‘solutions’ such as lean and shared services, adheres even more than its predecessors to the importance of competition, and can’t restrain itself from introducing big ‘top-down’ reforms such as universal benefits and the Work Programme, Academies and free schools, Police Commissioners and the NHS reforms – many in the name of greater localism, it says, but with the obvious irony that they all are being pushed (imposed) from the centre.
Innovations dreamt up by civil servants and think tanks can be whizzy but can also lack groundedness, practicality, a proper analysis of possible bad outcomes, and a constituency of support necessary for successful implementation (pace the NHS reforms in particular). It would be tragic as a result if ‘innovation’ became a dirty word amongst practitioners – something that’s largely ‘done to’ them rather than ‘done by’ them. Fortunately however, there is a better way.
Secondly, then, practical innovation. Many of the most exciting ideas in public services over the past few years have come from practitioners and service users – personalisation and direct payments, family friendly policies, user voice (from the disability rights movement in particular), Nurse Family Partnerships, the Expert Patients Programme, The Swindon LIFE programme (developed by Participle with 15 local families), Keyring and Shared Lives in social care, the Richmond Fellowship’s RETAIN programme and Star Wards in mental health.
This isn’t surprising. Practitioners and users are much closer to problems, and they can see for themselves the ways in which existing services aren’t working (especially ‘failure demand‘ and where this stems from). Unlike most policy wonks, practitioners find it difficult to insulate themselves from the frustrations of services users, their families and local communities. Consequently, practitioners’ intelligence is akin to what W. Edwards Deming called ‘profound knowledge‘, rather than the partisanship and prejudice that often characterises policy debate in the Westminster bubble. Practitioners can also test out for themselves the viability of alternative approaches (though they often do it surreptitiously, which tells you something about how far we still have to go to create a system that supports frontline innovation).
This has important implications for policy. Practitioners and service users experience policy – they see firsthand how the approaches designed at the centre, from funding and commissioning to regulation and performance measurement, actually operates at the frontline. They are better positioned to anticipate how it will be interpreted and implemented, not according to the perfect blueprints of its creators but based on what happened when previous policy encountered reality. This includes the likely unintended consequences, for example, how measurement and targets can be ‘gamed’. From this, practitioners are also better placed than policy wonks to identify ways that policies act as barriers to better provision (whether the policy in question derives from central government or their own service or organisation), and so how policy could be reformed to create a more suitable and supportive environment for services including innovative approaches.
Think tanks can and have supported some of the practitioner-developed innovations mentioned above, and this has been important. But more often than not think tanks neglect others’ ideas in favour of their own (as part of the ‘battle of ideas‘ they cling to), and don’t do enough to build alliances with charities and campaigners. We might also wonder why it is that receiving a ‘seal of approval’ from think tanks matters so much, given their typical remove from the reality of life on the frontline.
What’s out-of-date then – what should be our priority for innovation – is the way we innovate in policy, including challenging the largely closed ‘innovation industry’ that inadvertently reinforces the idea that innovation is a specialised ‘elite activity’ beyond the reach of the rest of us. Instead, to get more fresh new ideas we need to go beyond the same old suspects. Focusing more on practitioner-led innovations will mean a greater practicality in new ideas. It will also – if we chose to listen – mean policy that’s better suited to frontline innovation. After all, if government can ask practitioners for suggestions of where to save money, there’s no reason it can’t ask them for their ideas to improve policy – which is also what this project is about.
Ten reasons why we need a new approach to developing social policy – 2. Policy would stand a better chance of achieving its objectivesPosted: May 2, 2012
This is the second in a series of posts on why social policy should be developed by and with the people who use and provide public and voluntary services. We’ll publish the whole series over the next two weeks, and we welcome your comments.
In the policy world we sometimes appear to forget that ‘policy’ doesn’t stop at writing a pamphlet or publishing a bill. Whether policy ‘lives’ and fulfills the objectives set for it depends in part how easy it is to implement and operationalise, and whether a community of stakeholders who want it to succeed has been recruited to champion it. The best way for both of these to happen is to open-up policy research and development to a much broader range of participants.
On making policy easier to implement, the expertise and experience of those who work at the frontline in public and voluntary services – as well as those who use and rely on them – is largely neglected in current policy research and development. This expertise could help to design policy that stands a better chance of being implemented effectively. This doesn’t just apply to those at the frontline of course, but to anyone at any level of ‘the system’ who is responsible for taking policy from pamphlet to pavement.
Part of the reason for this neglect is that, for all the talk of performance improvement and ‘deliverology‘ over the past couple of decades (or ‘Mickey Mouse command and control’ if you’re John Seddon), there’s often still a gulf between those who develop policy and those who are responsible for making it real. Few people in the policy world (by which I mean senior civil servants, special advisers, think tankers and the politicians drawn increasingly from this narrow ‘political class’) have much practical experience beyond ‘thinking’, and they especially tend to lack any ‘doing’ experience in the sense of managing the delivery of programmes and services at scale.
The day-to-day demands of delivery might not be as glamorous as writing and publishing policy papers (on the policy wonk measure of desirability at least), but it’s equally if not more important to policy success. Despite this, delivery remains largely a mystery to most people in policy – something that ‘someone else does’. A civil servant who contacted us described the problem in the following way: while there is at least some public visibility when it comes to policy development (with consultations and so on), there is little transparency and political ownership of the implementation phase. The result, they suggest, is that when promised outcomes or savings are not achieved, it is the policy rather than the implementation that gets the blame. This sets off another hunt for ‘new ideas’ – what David Walker calls a restless ‘neophilia‘ – rather than the collective learning which might focus on how implementation, delivery and administration could be improved.
The most obvious way to capture this kind of learning would be to open-up policy research and development to more ‘doers’ – those nearer to and at the frontline. After all, implementation is necessarily a shared endeavour; it’s not about a single organisation winning the contest of ideas (or ‘think tank of the year’). Collective development of policy could also help to reduce the amount of policy that currently gets ‘lost in translation’ between the centre and local implementation.
This is why the Government missed an opportunity by not releasing at a much earlier stage a version of its NHS risk register (I recognise that they don’t see it this way). It’s likely that the quality of the risk analysis would have been greatly improved if it was conducted publicly and openly, by inviting medical professionals, managers, patients and other interested parties to use their experience and expertise to identify potential implementation problems and propose solutions – and remember, this is to help implement a policy (GP-led commissioning) that most practitioners agree with.
This brings us, briefly, to the second reason to open-up policy research and development – building a community of stakeholders to support successful policy implementation. If policy was developed more collaboratively, it would in all likelihood have many more champions amongst the frontline practitioners and the public (including service users) that had played a role in shaping it. This might be thought of as ‘naive’ by McKinseyites, but it’s been identified as one of the factors in policy success by an Institute for Government report published earlier this year, and illustrated by examples such as the ban on smoking in public places, the Climate Change Act, Scottish devolution and the introduction of the national minimum wage. Ironically, open and collaborative development might even be a hidden success factor in policies that the ‘deliverologists’ point to as proof for their ‘blueprint’ approach – see for example this review of Michael Barber’s book on education reform. Participation and collaboration is also how we want to develop this project – so let us know your thoughts.