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.
Education Secretary Michael Gove has unveiled “rigorous selection” tests for trainee teachers in a move he claims will improve the status of the profession and raise standards in the classroom. It’s a pity his own approach to policymaking doesn’t live up to the same standards he’s asking of teachers.
Announcing the policy, Michael Gove said: “The evidence from around the world is clear – rigorous selection of trainee teachers is key to raising the quality and standing of the teaching profession.” Despite an apparent inconsistency with previous announcements – in July Gove declared that, like their private counterparts and free schools, academies in England could employ people who are not working towards qualified teacher status (QTS) – at least this policy was based on evidence and developed by a review group of headteachers and education experts. For many of his other reforms, Michael Gove seems to make policy in secret, ignore what teachers and other experts think, and go against the best available evidence.
- Provoking two members of the expert panel recruited to redraft the English primary curriculum to resign; one of them, Andrew Pollard, criticized Gove’s plans for undermining teachers’ professional judgment;
- Repeatedly overruling another expert panel established to advise on selling off school playing fields;
- According to the Deputy Prime Minister, not even telling Number 10 of his plans to scrap GCSEs in favour of the so-called English baccalaureate (EBacc), which less than one in four teachers support, which has been developed without any meaningful input from teachers, parents or young people, and which is unlikely to be properly piloted before being introduced;
- Ignoring that, alongside its academic rigour, the main characteristic of the International Baccalaureate is its inclusion of practical and vocational elements – much like the GCSE dismissed by Gove as ‘dumbed down’;
- Dismissing concerns that a stronger emphasis on exams as opposed to coursework could exclude young people with learning difficulties such as dyslexia;
- Extending academies despite government data showing that local authority schools with a similar pupil intake perform better, without any evaluation of the possible impact on the already highly segregated education system, further divorcing schools from local democratic control and effectively centralising a major tranche of government spending with minimum parliamentary accountability;
- Scrapping the Building Schools of the Future programme because there is ‘no evidence’ that it helps to improve attainment – even though his department knows there is;
- Accepting the lack of transparency of academies and free schools, and awarding half a million pounds of public money to the Free Schools Network (which is not subject to freedom of information requests) to promote his £600 million untested flagship project;
- Abolishing the Educational Maintenance Allowance despite independent evaluations finding that it significantly increased staying-on rates and attainment for young people in education;
- Using secret emails to bypass even his own departmental officials (using the alias ‘Mrs Blurt’);
- Turning a blind eye to his department’s generally poor record on freedom of information and lack of transparency on who actually runs schools and what their status is.
Michael Gove’s colleagues have committed the Government to open policy making as well as open government. The Civil Service Reform White Paper published in June 2012 contained a commitment announced that: “Open policy making will become the default. Whitehall does not have a monopoly on policy making expertise. We will establish a clear model of open policy making.” Our project with The Democratic Society is currently examining how open policy making can be made a reality.
The Government has also promoted the evidence agenda, and is considering the case for new institutions that would perform an advisory role similar to the role that NICE plays for the NHS and the Early Intervention Foundation does for early years, to help ensure commissioners in central or local government do not waste time and money on programmes that are unlikely to be effective.
No-one seems to have told Michael Gove about either of these initiatives. No wonder teachers are starting to make their own education policy.
Open policy requires open research – the CBI’s report on outsourcing public services doesn’t meet this standardPosted: October 1, 2012
Last week the CBI published research that claimed that government could save billions by outsourcing more public services to private business. Ironically for a report titled ‘Open Access’, the main problem with the report is not its argument but its lack of transparency. For such an important issue as the future of public services and who delivers them, we aren’t given enough opportunities to judge for ourselves whether the report’s claims stand up to scrutiny. Open policy requires a much greater openness about the data and analysis used to support such conclusions – otherwise it’s just a press release.
The CBI’s Open Access report claims that “opening up public service delivery to independent providers” (that is, outsourcing public services) could achieve savings of £22.6 billion “or more”. For such a big claim, the research has a fairly simple methodology. The researchers (Oxford Economics) looked at 20 different service areas to determine the average cost savings from greater efficiency and productivity from outsourcing (a figure of at least 11 per cent, within a range of 10-20 per cent); applying the same calculations across the estimated £278 billion of public services which the CBI believes could be fully ‘opened up’ produces potential savings from outsourcing of £22.6 billion.
Trade unions have criticised the report for a ‘lack of evidence’ (for example, Unison) and for not taking into account any of the transactional costs associated with outsourcing including procurement, tendering and contract management, let alone when private providers fail to deliver. The Local Government Association called the report’s calculations “ludicrous” for effectively double-counting savings from services which have already been outsourced. Other commentators have identified specific flaws in the research (for example, for fundamentally misunderstanding who already provides what in the housing sector).
Beyond this, it’s also important to note that efficiency is not the same as effectiveness, which is to say, cheaper does not always represent real value for money. This is especially the case when it comes to public services where there are often broader considerations to be made regarding ‘public value‘ – encompassing not only benefit to the individual service users but also to communities and society as a whole.
For example, it’s unfortunate that the CBI’s report promotes the Work Programme as a model of good practice, both because of the identified risk of fraud in the programme, but also because of the significant concerns about the programme’s impact on charities. As the NCVO has argued: “The Work Programme continues to pose major issues for charities particularly around managing cash flow and taking on risk and very large contracts prevent smaller and more specialist organisations from playing their full part. More seriously it’s clear that the payment structures used continue to threaten the viability of contracts.” However ‘efficiently’ it achieves its objectives, if a programme undermines the diversity of provision including from smaller charities, can it really be regarded as generating better ‘value’ for society?
Further, while the report recognises the widely shared public concerns about outsourcing public services, it also effectively makes these problems that government needs to solve – as if government is to blame for them: “The Government must take important steps to ensure the public retains confidence in the opening up of public services by becoming a more effective market manager and ensuring that the best, most effective providers from all sectors have the opportunity to manage our public services. Providers too must work with the government to address the public’s concerns about value for money, accountability and service failure.” Certainly government has the ultimate responsibility to ensure that public money is spent responsibly, for example that providers are properly audited. But if they are to be given millions or billions of pounds of public money, private providers also need to do more to prove their worth and reliability, such that they can be trusted to provide public services (something not helped by last week’s further revelations about the G4S Olympics debacle). Of course, one way to avoid such problems would be not to outsource more public services – but this is a view that the CBI regards as “dogmatic”.
However, the main problem with the CBI’s report is that we can’t properly determine the accuracy or veracity of the research for ourselves. It seems particularly questionable to assume that the same level of savings can be achieved uniformly across different areas of public services, and yet to quote from the research: “If an average 11% of productivity improvements is achievable across just £24.5bn out of the £666bn annual public sector expenditure on services in the UK, then similar levels of savings must be possible: not just in the un-open proportion of the markets researched but in the unopened proportion of the estimated £278bn of public services spending which could practicably be more opened up to independent provision.” [emphasis added]
Unfortunately, it’s not possible for us to investigate this much further. The problem is the methodology – or rather its lack of openness. As acknowledged in the report: “There is as yet little published information on the scope and performance of services delivered by independent providers.” The average saving figure used in the report is based on “existing research, and information from public bodies and providers” – including crucially from a survey of CBI members. The CBI has produced a nicely presented summary of the analysis by Oxford Economics; the actual analysis (which is a bit more difficult to find) is pretty opaque, especially when it comes to this survey of CBI members. One phrase that keeps popping up in the original Oxford Economics analysis is: “The degree of potential cost savings that could be achieved through outsourcing these services is estimated from responses to the CBI member survey.” In other words, the most critical figure in the research, the basis of the argument made in the report, comes from what the CBI’s own members claim – a claim we are unable to judge for ourselves because we are provided with no further information about it (for example, how many of the CBI’s members responded, what size were these providers, what specific types of services they provide, etc). For an argument in favour of open public services, this represents a remarkably closed approach to evidence.
As the CBI’s report notes, we are in the middle of the biggest wave of government outsourcing since the 1980s, with more than £4 billion in tenders being negotiated in 2012 alone in services ranging from prisons and police to defence and health. Given this, we need much more robust and reliable research about the benefits and the problems that outsourcing more public services would produce – before we outsource these services (perhaps irreversibly). The research commissioned by the CBI may or may not be a useful contribution to this analysis; the problem is that because of the report’s own lack of transparency, it’s very difficult for us to know.
Is consultation broken – or is it our political system? Consultation seems to have become the lightening rod for general discontents about politics and policymaking. Let’s improve consultation – but let’s also rethink how we do policy and politics at the same time.
In the Open Policy project with the Democratic Society in association with the Cabinet Office, we’re exploring what ‘open policymaking’ means in practice, and how we make it effective and democratic. But we’re starting the project in consultation – what works, what doesn’t, and how it can be improved.
A widely held view of consultation is that it is a sop – an exercise that governments are legally required to undertake but which rarely changes policies that have already been decided. This might be both broadly true and largely unfair. Consultation is only one mechanism, one particular stage in the policy process; it was never intended as the sole mechanism for engaging ‘the public’, let alone to ensure that policies have a democratic mandate that other parts of the political process have failed to invest in them.
In our previous post for this project we suggested how open policy represents a challenge to consultation. For us, taken to its logical conclusion (to its greatest openness), ‘open policy’ means we need to develop a radically different approach to policy and research. In terms of social policy, this means developing approaches that enable public service practitioners and services users to conduct and engage in research and policy analysis directly. These groups are at the frontline of public services and social issues, and as a result they have practical expertise and experience that could be used to improve social policy, especially to make policy more credible and pragmatic.
Where does this leave today’s approach to consultation? Consultations are often about what government intends to do. It hardly makes sense to complain when government does what it said it intended to (indeed, we commonly criticize government for the opposite). In the case of particularly contentious policies or those that haven’t been sufficiently publicly debated, consultation will never be able to resolve the perceived lack of a public mandate.
As a thought experiment, just imagine a consultation process that was much more ‘open’ – one whereby policy did change dramatically compared to what was originally proposed. The problem immediately becomes apparent: government could in theory find itself in an endless ‘consultation loop’, with each new stage of consultation radically changing the policy in question, to the extent that a new round of consultation would be required to accompany it. Government would never get anything done, and quite rightly this would generate accusations of endless ‘dithering’ and ‘u-turns’ – of being in office but not in power.
In recognition of the devalued nature of consultations and possibly the ‘one-size-fits-all’ manner in which too many consultations are approached, the Government has announced it is moving to a more “proportionate and targeted approach” (this announcement produced what is perhaps the least thrilling headline ever on the BBC News website). The new guidelines recognise the need to “avoid creating unrealistic expectations” by making it clear where policy has been finalised and will not be subject to change as a result of the consultation. This makes sense – much of the criticism directed at consultations stems from unrealistic or inaccurate expectations among respondents. The guidance recommends instead that the objectives of any consultation should be clear, and depend to a great extent on the type of issue and the stage in the policy-making process.
However, the new guidance also risks replicating the current confusion about consultation by advising that: “Engagement should begin early in policy development when the policy is still under consideration and views can genuinely be taken into account.” From a democratic point of view this is unarguable – but the problem is that consultation can’t hope to meet these aspirations. ‘Public consultations’ in most cases aren’t – they don’t reach the public or garner many responses from them. They also aren’t really a form of deliberation; they’re not about policy formulation, rather they are more commonly about policy adjustment. Why be cynical about what should be obvious? Government sometimes makes the mistake of trying to appear as if it is engaged in open policy formulation when it isn’t, but we don’t have to collude in this and then blame government when this turns out not to be the case.
We need new forms of participation for early policy development, and for research, evidence-gathering and analysis. This isn’t and can never be the job of consultation. Unless we create a much clearer distinction between consulting on policies that government intends to enact, and developing new policy agendas where government isn’t sure what should be done, we will see much more of what we call ‘guerilla policy’ – grassroots policy research and development that people and organisations do for themselves without being given ‘permission’ by the policy establishment. There have always been campaigns and protests of course; what’s different now is that people can mobilise, coordinate and share information so much more quickly – including to overturn official policy (or at least severely undermine its credibility). We happen to think that we need more guerilla policy – but we recognise that government might not.
What’s important about this project is that it encompasses how we can improve consultations today, but also how we can develop radical new forms of engagement in policy tomorrow. The extent of the crisis in democratic legitimacy suggests we need to do both. Sorting out which is which will be crucial to our work. So in the spirit of the exercise, let us know your view – are there aspects of consultation we should retain, or does ‘open policy’ require us to start again with a blank sheet of paper? Comment on this site or on the Open Policy forum for open policymaking and better consultation.