The Government is paying the political price for the lack of open policymaking in its reforms to the NHS

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
  • Unite
  • Unison.

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.


Best of the frontline bloggers (week ending 26th October 2012)

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.

Welfare

A4E? Who are they? What are they about?

From The Big Picture

Posted on 23rd October 2012

“What are A4E up to next? Well according to David Cameron they would make an ideal company, along with our old friends G4S, to become involved in the process of Rehabilitation… The scheme will see firms such as G4S and A4e, along with charities and voluntary groups, offered cash incentives to put offenders back on the straight and narrow. We already give these companies enough money, and now we’re going to give them more? Do they have a proven track record?”

Retired and Angry, retired from the Metropolitan Police Service, examines the recent history of A4E – and doesn’t much like what he finds.

Carers

If it works, break it

From Ned Ludd Carer

Posted on 24th October 2012

“Surely, if the carers and service users find these services valuable, that should count for a lot. But in the world of cuts, they don’t care what works, what’s valuable. They just want the overspend caused by their own unrealistically low budget reduced.”

Ned Ludd, carer, gets angry when ambushed by his local council’s plans to cut personally valuable “getting a life services”.

Social care

People with dementia need an independent voice

From The Age Page

Posted on 25th October 2012

“For a variety of reasons, most older people are unable to complain or express a view on the type and nature of care they need or want to receive. Worst of all perhaps, most are unable to influence the quality of service they have every right to expect or how or where to lodge complaints, if they have any.”

Sarah Reed reflects on the ambitions in the Government’s dementia strategy, and suggests this means we need to ensure that those who struggle to speak for themselves can be heard.

Education

This much I know about…an alternative to the English Baccalaureate Certificate

From John Tomsett

Posted on 21st October 2012

“If Jeremy Hunt announced a backward-looking reform to appendix operations which would be hugely invasive and leave patients in hospital for a fortnight (such as I experienced in 1977), the medical profession would deride him. Why aren’t we deriding Gove over his EBC proposals, which are the educational equivalent?”

Headteacher John Tomsett argues that educationalists need to begin an urgent campaign to provide an alternative to the Government’s proposals for an English Baccalaureate Certificate.

Things to know about ED Hirsch and the ‘Common Cultural Literacy’ idea

From Laura McInerney (@miss_mcinerney) writing on lkmco

Posted on 23rd October 2012

“ED Hirsch’s ‘Cultural Literacy’ has become quite popular in England this week due to him featuring on a Radio 4’s Analysis and also being the subject of a blog by Daisy Christodolou, Managing Director of The Curriculum Centre. Hirsch is the man who wrote the book ‘Cultural Literacy’ which he followed by creating ‘Core knowledge‘ an age-ordered curriculum with an emphasis on facts that, if taught correctly, he argues will give children the most important cultural knowledge. But to understand his work it helps to understand its American context, as the reason for his popularity in the States is really quite different to the way his ideas are being framed in the debate here in England.”

In this post Laura McInerny describes Hirsch’s model of ‘cultural literacy’ and its roots in the US – and questions how appropriate it is for the UK.

Policing

Re-offending – ‘Payment by results’ will not work

From Inspector Gadget

Posted on 22nd October 2012

“I have read the PM’s plans for ‘payment by results’ in terms of the re-offending rates of prison inmates with interest. This will not work. A bit like trying to use the wrong gate, ministers need to listen to police on this one. I’m sure it will be shown to have worked, but it won’t work for the simple reason that these days, criminals only go to prison in the first place if they are persistent offenders.” 

Inspector Gadget argues that the use of payment by results won’t work to reduce re-offending. He speculates that this idea probably came from a think tank who in turn have been sponsored by an organisation with an interest in securing ex-offender rehabilitation contracts. Inspector Gadget argues that the most effective way to deter ex-offenders from re-offending is a lengthy stay in a closed prison, preferably far away from home.

‘Re-inventing the wheel’ or just ‘Strapping two u-turns together’

From MinimumCover

Posted on 24th October 2012

“I want us to be bold and imaginative about transforming policing and the wider criminal justice system to save time and money and deliver a better service for the public. These are the words of our ‘beloved’ Home Secretary which she used to describe her latest improvement to the way Police investigate and prosecute offences. This bold and imaginative move introduces the power for Police to independently charge a number of offences that currently require consultation with the CPS.”

MinimumCover welcomes reforms to charging powers – but questions whether Theresa May can call these proposals ‘bold’ or ‘imaginative’ when they return powers that the police used to hold previously.

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: info@guerillapolicy.org or via Twitter @guerillapolicy and @guerrillapolicy


The West Coast fiasco points to the real problem with open public services

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.


Open policy requires open research – the CBI’s report on outsourcing public services doesn’t meet this standard

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.


Open Public Services – where are we after the reshuffle?

In posts over the past few weeks we’ve looked at the Government’s ‘open public services’ agenda, in particular the outsourcing of public services, and how this threatens to undermine another Government initiative, for ‘open policy making.’ The Prime Minister has reshuffled his Government so that it is focused more on “delivery” for the rest of this parliament – but at the cost of undermining the open public debate that it should be having on the future of our public services.

The open public services agenda involves outsourcing public services to the private sector (and to a lesser extent the voluntary sector). Unprecedented levels of outsourcing are taking place across prisons, probation services, policing, schools, welfare to work and the health service. Virgin Care now run children’s health services in Devon for instance. The Economist magazine has predicted that £58 billion of public services will be outsourced by 2015 as part of this agenda, on top of the £82 billion already outsourced (according to Oxford Economics). And yet – as illustrated recently by the failure of G4S and increasing concerns over outsourcing police services – the Government doesn’t seem to want a public debate over its plans, despite its apparent commitment to open policymaking. Why not, if open public services are as popular as it claims?

The recent furore over the role of G4S and its £283 million contract to provide security staff to the Olympics has placed the outsourcing agenda firmly in the spotlight. G4S were forced to admit just weeks before the start of the Olympics that they would only be able to provide 7,800 of the required 10,400 guards, which resulted in the army being called in to the fill the gap. G4S has claimed that it will take a £50 million hit from their failure to meet the requirements of the contract – but we don’t know yet what its failure cost the taxpayer. Nick Buckles, G4S Chief Executive, is due to appear again before the Home Affairs Select Committee in the next couple of weeks as part of its inquiry into the scandal.

Philip Hammond admitted in an interview with the Independent that in light of the experience of G4S that we can’t always rely on the private sector. In particular he questioned the ‘lean model’ that G4S and other private providers such as Serco use, which has been adapted from manufacturing. Parts of the outsourcing industry uses a ‘just in time’ approach, which in the case of G4S meant that they planned to recruit, train and manage a new workforce that they would build from scratch weeks before the start of the Games. G4S didn’t bring existing capacity to the Olympics contract, rather they ‘sold’ their ability to recruit, train and manage a large workforce in an efficient way in a short space of time. The just in time approach is well established in the manufacturing sector, but there are legitimate questions about its suitability for parts of outsourced public services, something we will look at in a subsequent post.

Hammond and other ministers have acknowledged, at least when pressed in interviews, that the G4S debacle should  make us pause and consider the limits of outsourcing, but these statements have sounded like deflections rather than the start of a genuine and transparent debate about the role of outsourcing in public services. It seems that this debate has already been concluded – just without the public. Theresa May confirmed last week that police forces should press head with their plans to outsource more of their services into the hands of the private sector. Three police forces – in Bedfordshire, Cambridgeshire and Hertfordshire – are considering outsourcing more than 1,000 jobs in IT and human resources to G4S. May also ruled out a review of the £1billion contracts that G4S has with the public sector to run prisons, welfare to work and tagging of criminals arguing that the Olympics contract was ‘rather different’ from G4S’s ‘day in, day out’ public sector work.

This reluctance to engage in a public debate is also having a curious knock-on effect on some of the Government’s other initiatives to make public services more accountable. For example, most people in England and Wales will have the opportunity to go to the polls in November to elect a local Police and Crime Commissioner. The Economist reported last week that less than a fifth of voters are aware that there are elections for these roles or what the job of the commissioner involves. It is not surprising therefore to hear that the Electoral Reform Society’s prediction that only 18.5% of the electorate will actually make the journey to the polling station to vote, less than half the average turnout for local elections.

The quality of candidates for these posts has been criticized whilst the Government has also refused to fund an election address for candidates arguing that the internet, local and social media can fill the gap. The lack of public debate around these elections is a concern given the expected remit of these elected officials – Police and Crime Commissioners are clearly an idea that hasn’t caught on.

However, in the context of cuts and outsourcing, in many respects this lack of public engagement is in the Government’s interest – the main topics for debate will inevitably be the 20% cuts to policing budgets by 2015 and outsourcing more police services. Both of these are debates the Government would like to avoid given that the public remains unconvinced that cuts and outsourcing will lead to a more efficient and better quality police service, a view that is shared by many in the police force. Indeed, the outsourcing of public services has never been popular with the public. According to a recent YouGov survey for the Fabian Society, nearly two-thirds of people think that ‘services like health and education should not be run as businesses.’

Last week’s Cabinet reshuffle points to a ramping up of the open public services agenda with key proponents of this in Government bring promoted. The elevation of Chris Grayling to head up the Justice Ministry is a clear signal of the Government’s intention to expand the Work Programme model of outsourcing to revamp the much heralded ‘rehabilitation revolution’, whilst the promotion of Jeremy Hunt to Health Secretary points to an expansion of the private sector in the NHS. It seems like, whatever its promotion of open policy-making, there are some policy issues on which the Government is less interested in having an open debate.


Andrew Lansley is gone, but his closed approach to policy-making is likely to continue

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.


Why outsourcing policy is only open to insiders

In posts over the past few weeks we’ve looked at the Government’s ‘open public services’ agenda, in particular the outsourcing of public services, and how this threatens to undermine another Government initiative, for ‘open policy making.’ Open policy also involves outsourcing policy – but this risks repeating some of the problems with outsourcing public services, especially reducing accountability.

We like open policy. We think that policy development has been too closed, to a too narrow set of participants, for too long. We agree with the Government that Whitehall hasn’t got a monopoly on policy expertise, and we support its recent announcement of a “presumption in favour of open policy making, with policy developed on the basis of the widest possible engagement with external experts and those who will have the task of delivering the policy.” In earlier posts we’ve suggested ways in which Government can make open policy a reality.

However, we’re less sure about that part of the plan to “Pilot contestable policy making by establishing a centrally-held match fund which can be used by Ministers to commission external policy development (for example, by academics and think tanks).” If this marks a significant change in how policy is developed (which we have to presume it does), then like outsourcing in public services it raises important issues of transparency, accountability and trust. Just as outsourcing has in some instances undermined the publicness of public services (for example, their accountability to the public), so it could threaten the publicness of public policy by undermining the extent to which it is made in the public interest.

Given our recent focus here on outsourcing, consider this: policy on public services could now be outsourced to organisations that favour more outsourcing of public services. This is more than likely given that so many think tanks are part of the ‘Whitehall consensus‘ in favour of outsourcing. Will think tanks that consistently argue for more outsourcing  be commissioned to develop policy that leads to more outsourcing – or will they be automatically disqualified from conducting such work? How about think tanks whose sources of funding are less than transparent – wouldn’t it undermine trust in policy if they were commissioned by government without the public knowing what other interests might influence their research? How would this increase the accountability and transparency of policy-making, at a time when the public’s faith in political institutions is in such marked decline?

We noted in the previous post how some think tanks have argued that lobbies that benefit from increases in government spending should be ignored because of their (self-) interest. The same think tanks have also argued that government should stop funding charities to lobby it for more public spending on their ‘pet issues.’ Logically, the same should hold true for open policy – that government should avoid the risk of underwriting the mutually beneficial relationship between outsourcing companies and those think tanks that take sponsorship from them.

In apparent recognition of these issues, the Government’s plan includes the commitment to “clear contracts – setting out criteria to ensure that the policy being developed is done so in the best public interest, and that it does not favour any bias of the provider.” This appears to accept that some providers will be biased, but that a contract will ensure that this bias doesn’t inform their work – something which is either surely naive or disingenuous. If government wants to ‘build on evidence of what works’ in social policy (another of the themes in its reform plan), wouldn’t it better to commission researchers who don’t have such a tendency to bias, and who instead have a track record of neutral, evidence-based analysis?

Moreover, how does commissioning Westminster and Whitehall-centric think tanks – which are by definition already insiders – help to bring more ‘external expertise’ to policy? If government wants to hear ideas from think tanks, then it already can, and without spending a single additional penny of public money (an efficiency of which Francis Maude would surely approve). For the moment however, this part of the open policy agenda risks policy being developed by the same old insiders, only with less transparency and accountability than it is at present.

It is perhaps indicative then that the first commission under open policy risks further politicising policy development, and that it is being conducted in the traditional closed way. The Cabinet Office is commissioning research into changing the balance between the permanent (and in principle, neutral) civil service and introducing a larger politically appointed element, as in France and the US. Likely candidates for the research have been reported to include usual suspects such as Reform and the Institute for Government, but both have now apparently turned down the chance to bid for the work due to a desire to maintain their “independence.” To some, this might demonstrate that the system is self-correcting – that think tanks recognise the need to maintain their integrity as well – but it also suggests that the concerns expressed here are real ones.

The problem isn’t so much that government has a “virtual monopoly on policy development” (to quote from the Government’s civil service reform plan) – in one sense that’s the definition of government, and anyway it isn’t true. Think tanks, academics, charities and campaigners all develop and propose new policy, and in this sense there’s more than enough ‘contestability’ in policymaking already. The problem is conscious or unconscious collusion among insiders about contentious aspects of public policy without the public also being allowed to participate.

What’s really missing, to quote from the Government’s own proposals, is how to “enable policy to reflect the real-world experiences of citizens and harness public engagement with the policy making process.” That’s not something you’re going to get from Reform or the Institute for Government, or in all likelihood whatever organisation does get commissioned by the Government. It requires a different way of thinking about policy, who can participate in it, and how – something we’re considering in our ‘manifesto’ project, and we’d welcome your thoughts.