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.


Michael Gove’s approach to education reform is the opposite of open policymaking

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.

For example:

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.


Best of the frontline bloggers (week ending 21st September 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.

Health

A rare shaft of light

From The Jobbing Doctor

Posted on 15th September 2012

“Anna Soubry, the new junior minister at the Department [of Health], is reported to say that the Government screwed up by not engaging with the professions. She is right, although they never really intended to win hearts and minds: we are not idiots and could always see what was planned. This comment is a shaft of light in the murk of the plotting to break up the NHS.”

The Jobbing Doctor, a GP working in a large industrialised conurbation outside London, argues that the Government health reforms are not about empowering the professions but a detailed and planned assault on the service – supported by all the main political parties and a ‘tiny list of supporters’ to provide cover.

Education

A new summing-up

From Scenes from the Battleground

Posted on 16th September 2012

“The central contention of this blog is that our state school system is simply not good enough. It does not provide a decent quality of education for the vast majority, and most would avoid it if they could afford to. Too many people with power over education are content to provide a service that they would not think good enough for their own children.”

A dumbed-down curriculum and teaching methods, the ‘behaviour crisis’, and bureaucratic and incompetent management: the problems facing the education system as described by an ‘utterly dissatisfied’ secondary school teacher – and what the future holds.

Social care

Consulting on the CQC

From The Not So Big Society

Posted on 20th September 2012

“For a regulator to have public confidence, the public have to know what they do, what they are responsible for and what they are not responsible for. …Inspectors could have a greater visibility online and using broader social media to communicate with the public – not just through PR people. I want to know what inspectors do every day. I’d love to see a regular blog from an inspector (without needing to mention any specific services but just with broad themes – generally frontline blogs are more interesting than management blogs!)”

Ermintrude, a ‘social worker by trade but so much more’, reviews the new draft strategy for the health and adult social care services regulator the Care Quality Commission – and argues for a much more people-based approach.

Disability

Care is care. Let’s stand together for political and social change

From The Caregivers’ Living Room

Posted on 19th September 2012

“The thing is …we are all sitting around here talking about big ideas like nurturing leadership in our disabled youth population and whether we should lobby for more disability arts initiatives. What I think we should talk about is whether in ten years time, there will be anyone around to wipe our bums. I believe we are heading toward a time when giving care will be devalued and we will all end up being warehoused in institutions with lousy care and no one will notice.”

Donna Thomson, former actor, director and teacher, now parent to a disabled son and with a ‘second career’ as a disability activist, reflects on the challenge she once heard in a meeting of activists – and the need to think like a movement in order to achieve political and social change for the good of families and the future.

A perfect storm

From Welsh Wallace

Posted on 17th September 2012

“…according to the new test for the benefits I wasn’t disabled. I could pick up a pencil off the floor (regardless I had to feel around for it for a good five minutes first). I can walk (regardless I can only stand for about 5 minutes before my spine gives out) but enough in their words to walk from a taxi to an office. …So because I passed these “tests” I was refused on those grounds for disability benefit. Being blind was not an issue because I could still walk so with that logic walking a few steps enabled me to see where I was going, to read letters, to cross the roads without danger just as any sighted person could. It was a miracle! I was cured!”

A powerful post on what it’s like to ‘walk in the shoes’ of a blind man – and to undergo the disability test when you’re having a very bad week.

Welfare

Universal Credit – how is this simplification?

From DPAC (Disabled People Against Cuts)

Posted on 16th September 2012

“Overpayments under the new system will not be subject to the same rights of dispute which currently exist, so many claimants simply won’t be able to properly contest an unfair decision. When government is asked about the problems all of this creates they stick to script and tell us all how ‘work pays’. The emphasis on work is backed up by an assurance that simplifying the benefits system makes it more possible to transition from welfare to work; the new highway for making the transition is Universal Credit which we are all told is ‘on track’.”

Universal Credit is meant to merge all working age benefits into a ‘single streamlined payment.’ Not according to this detailed analysis it doesn’t, originally from the MyLegal forum.

Previous reads

Here are a few more great posts from the past few weeks.

Welfare

Problem?

From This is My Blog

Posted on 12th June 2012

“The big line being pushed by our beloved government this week is about “problem families” and the need to “crack down” on them. …So what makes a “problem family”? How do we define the country’s “worst scumbags”?

Mary, a 30-year-old knitter living with her husband, a robot vacuum cleaner – and ME – finds the Government’s definition of ‘problem families’ uncomfortably close to (her childhood) home.

Policing

The high price of cutting costs

From Minimum Cover

Posted on 5th July 2012

“…there is sometimes a huge chasm between the headline saving and the bottom line cost. Some officers, including me, have resorted to sorting these types of issue at their own cost on more than one occasion. It’s just what we do to keep things running smoothly.”

M.C.’s blog – a “mixture of personal experience, factual accounts, [and] a modicum of fiction here and there to ease the literary process and protect the innocent” – reflects on how ‘cost-savings’ have turned replacing a 29 pence light bulb into a kerfuffle costing £100.

Standing outside the fire

From Cate Moore’s Blog

Posted on 12th June 2012

“I am telling you to play clever. And safe. You do not need to shy away from your ideals and the things that you care passionately about. Indeed you are letting the public down if you do. Speak truth, speak it fairly and speak it pleasantly.”

A retired policewoman encourages other officers to use social media to comment on government policy – but to do it carefully.

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


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.


How can trade bodies make greater use of social media to improve the impact of their policy and research work?

How can trade bodies make greater use of social media to improve the impact of their policy and research work? Chris Sherwood, Co-Founder of Guerilla Policy and Director of Innovation and Development at Scope, argues that public sector trade bodies could make much greater use of social media to improve the impact of their policy and research work.

The lifeblood of trade bodies is to represent the interests of their members effectively to Government. Generating impact from their policy and research work is critical to both maintain confidence of members but also to ensure that their organisations have a credible platform from which to lobby from. Social media can help to achieve this – especially if trade bodies wish to set the agenda not just respond to it.

Like many people in my position, I’m often invited to meetings held by trade bodies, which are intended to try to capture and reflect the views of their member organisations. I tend to take a lot away from them and, like many participants, I appreciate the opportunity to network at these events. I recently took part in a consultation event on one area of government policy, which involved drawing together 40-50 individuals from the leading organisations in the sector to discuss a series of policy recommendations to improve this area of policy. The event was summarized in a report that was submitted to the Government. It was a well-attended event and a good quality report emerged as a result. However, it also prompted me to think: how could social media have helped to achieve a better outcome?

At the moment, we’re thinking about the wider application of Guerilla Policy. Guerilla Policy is an experiment in how research and policy development can be opened up through the use of social media and the internet generally. Could this approach be applied to trade bodies in order to generate greater impact from their policy and research work? On this blog we’ve already discussed the potential benefits that could be gained from social media to the development of policy and research, especially by inviting collaboration from a wider group of people who use and provide public services. These lessons, we believe, also apply to trade bodies.

Social media can help trade bodies in the following ways:

  • Help them to work collaboratively with their members to set the policy agenda in an open and transparent way;
  • Reduce the costs of involvement such as travel and time costs;
  • Enable ongoing dialogue between members and trade bodies, which allows for greater time for reflection and consideration;
  • Provide greater transparency over what happens to the contributions that people make, so that they can see the connection between the ideas they offer up and the final product;
  • Engage more people, in particular frontline practitioners and service users who bring a different perspective on the issues to hand;
  • Strengthen relationships between trade bodies and their membership and in particular to deepen these by engaging more people in member organisations;
  • Hook the media early on in order to build interest, rather than relying on a press release at the end of a project.

Social media offers other possibilities for trade bodies. A dedicated social media community would also enable trade bodies to conduct quick trawls for case studies and evidence to enable them to respond to an increasingly fast media cycle or to collaborate more effectively with partners. Finding the right case study to articulate your ‘policy ask’ can often be critical in generating interest. Social media enables also trade bodies to expand their networks, and since many journalists already use Twitter as a main news source when researching articles, trade bodies need to increase their social media visibility if they are to continue to be heard.

There are obvious barriers to adopting such an approach, not least that this way of working could be quite different to the way that some of the organisational members of trade bodies work. Developing policy in an open and collaborative way might also be daunting – what happens if you arrive at a different conclusion to the one you expected? There are also concerns about accessibility of this kind of technology, since generally-speaking social media is more popular with younger workers.

Yet the benefits are likely to come in terms of the impact of trade bodies’ work. The Spartacus Report is a model to learn from – but also a warning. This report on welfare reform was developed by disabled activists using social media. The impact was significant with it trending no 1 on Twitter before hitting mainstream media including Newsnight. This example shows that in a crowded media agenda, it is important to think creatively in order to cut through on behalf of members and their issues. It also points to a potential risk for trade bodies in that they could face competition from groups who can claim to represent their members, as social media facilitates the formation of new common interest groups.

Social media offers up a range of possibilities for trade bodies to increase the impact of their policy and research work on behalf of their members. It allows them to strengthen their relationships with their members, gives them a better chance to cut through, represent their members and ultimately influence Government policy.


Put your name on policy – blog with Guerilla

We’ve got lots of plans for the next few months as we develop Guerilla Policy. Our ambition is to create a movement of people and organisations who use and provide public services, working together to create better social policy. This is just the start. One of the things we’d love to do is create a hub for frontline practitioners and service users to blog about their work, their experiences and how they think policy needs to change.

We’ve written before here about our love of public and voluntary service bloggers, and how we’d almost always rather read a dispatch from the frontline than (largely) warmed-over opinion from a Westminster-centric commentator. At their best, frontline bloggers capture the day-to-day reality of public services in a way that no-one else can, including the dirty, difficult, and sometimes dangerous experiences that form the basis of real expertise and so the insights we need to improve social policy. For example, read BendyGirl‘s writing on the reality of welfare reform at Benefit Scrounging Scum (shortlisted for the 2012 Orwell Prize). These blogs are often highly informative, contentious, challenging, and sometimes as dull as real life – which after all is the reality of life at the frontline.

These bloggers often engage directly in policy issues, but from a practical, pragmatic and informed perspective that could surely be incorporated into policymaking before we’ve wasted millions of pounds (and harmed people’s lives) introducing policies that are destined to fail. So much ‘professional’ commentary is dominated by that week’s ‘inside baseball’ nonsense, to the exclusion of how policy effects real lives and how it could be improved. Frontline bloggers make policy real, sometimes uncomfortably so from the perspective of policy wonks – which is probably why their views aren’t usually invited into national policy debates (Guardian Professional Networks is a notable exception, along with parts of the trade press).

We want to put the real insiders where they belong – at the centre of policy. What we’re looking for are practitioners and services users who can provide a real-life perspective on policy – just as BendyGirl does on the reality of welfare. It doesn’t matter if you don’t consider yourself an expert – in fact, we’d prefer it if you didn’t (self-proclaimed ‘expertise’ often denoting an arrogance and insularity from other viewpoints).  It doesn’t matter if you don’t know the ‘right’ words, because writing that’s worth reading doesn’t depend on anything other than your proximity to the reality of public and voluntary services. And it doesn’t matter if you can’t write for us every week (you have a life to live and a job to do, after all) – we’d prefer it if you posted when you have something to say and a bit of time to reflect.

If you already blog, we’d love to syndicate you here and hopefully add to you readership. And if you’ve never blogged before, why not give it a go – your voice deserves to be heard as much as anyone else’s. If you’re interested or have any questions, just fill out the form below and we’ll get back to you asap. We can’t pay you – but we can help you to put your name on policy.


Reflections on New Think Tank – 1. Phillippa Rose

This is a new series of posts in which we’ve invited people to give us their reactions to the New Think Tank project. First up: Phillippa Rose from Redfront. Thanks to Phillippa for contributing this post, and we welcome your comments.

Last month I was invited to contribute to a branding workshop for the currently described ‘New Think Tank’ – an experiment to develop new ways of making, and influencing public policy, from the ground up.

The notion of a bottom up think tank is in itself a bit of anomaly. People associate think tanks with ivory towers, white cubes, sometimes intimidating, and organisations steeped in high-level thinking, in all senses. Think tanks are associated with thorough research practice, sometimes publishing insights or data which influence policy, and challenging the status quo. They are rarely associated with people actually delivering public services, testing assumptions in the policies of the day. New Think Tank however advocates that “the people who experience the effects of social policy should have the opportunity to help shape it.”

At the branding workshop we looked at driving forces behind the initiative, role play, future scenario setting etc, to get a sense of the driving forces behind New Think Tank, perceptions in the room, and where this thing is going. It was a fascinating afternoon, with 20-30 people with varied views on the subjects raised. The room was made up of people working at the forefront of policy, business, charities, social enterprises. For me there was only one missing link – front line practitioners and service users. I think there was only one person there who worked in social services.

As a service designer, I have found it refreshing to see the New Think Tank testing assumptions online, consistently iterating and revising its approach in response to contributions and feedback in such an open and transparent way. I believe in Minimal Viable Product and Agile Development – trial and error, learning by doing, and involving user input from the very start. For the New Think Tank to be meaningful and make lasting impacts on policy, it needs to move to the next level, to specifically target service users and practitioners, and involve them on key areas to focus on, and practical action.

The concept and the thinking behind New Think Tank is new, exciting, fresh and has the potential to make a significant impact on policymakers, practitioners, and end users, experiencing these services. The messages are strong, the communications channels are established. With the official launch date June 1st, fast approaching now is the time to focus, perhaps one policy area at a time, or one locality at a time, who knows. It’s time to ask the people working with, and using public services.

Phillippa Rose from Redfront has enjoyed over ten years developing strategies, services and projects in the public and private sector. She has special interests in the following areas: innovation, co-creation, talent development and enterprise. At Redfront, Phillippa specialises in user-engagement, strategic partnerships, service innovation and networks.

http://www.redfront.co.uk/

https://twitter.com/#!/phillirose