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.
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.
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.
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.