Saturday, September 29, 2007

NHS Foundation Trusts and accountability - some evidence

One of the legacies of Tony Blair will be foundation hospitals (FTs). They appear to be here to stay too.

A key characteristic of FTs is the governance structure which creates accountability to patients, staff and communities. The example of the co-operative movement served as a model. (Its worth adding that FTs remain not-for-profits and are not a form of privatisation - contrary to what their opponents say.)

Recent research suggests that these structures are working. (It’s a pity that my local FT appeared to lose my membership details for best part of a year. Hopefully I am isolated exception.)

The FT model (and the example of the co-operative movement) is worth applying elsewhere in public services.

Tuesday, September 18, 2007

The NCVOs on the Third Sector, public services and the efficiency agenda

Yesterday I went to an excellent conference run by Bristol University’s Centre for Market and Public Organisation on The Role of the Third Sector in Delivering Public Policies. As third sector organisations such as charities, mutuals and social enterprises are being considered as vehicles for both delivering public services and (to some extent) delivering public policies, the conference was timely.

The keynote speaker was Stuart Etherington, Chief Executive of the National Council for Voluntary Organisations. (I should declare an interest – Deed Consulting is a corporate affiliate of NCVO.) He outlined the main issues facing the Third Sector in its relations to ‘the state’ clearly and thoroughly – all without the use of Powerpoint.

Stuart Etherington raised concerns about key elements of the government’s agenda. On the subject of the ‘efficiency agenda’, he was concerned that interpretation by the public sector was often a narrow one concentrating on cost cutting with implications for project prices and, hence, the Third Sector. He also suspected that this agenda was driving a scaling up in procurement exercises like the recent letting of large regional contracts by the Department for Work and Pensions.

There was also an intelligent analysis of choice, ‘personalisation’ and localism for the Third Sector.

On the issue of potential conflicts of interest between designing policy as campaigners and delivering policy as contractors, Stuart Etherington suggested that there may be a split between Third Sector organisations concentrating on advocacy and campaigning and those focusing on delivery. There will need to be a response from the Third Sector to critics and cynics on these concerns when they are aired.

More doubts on efficiencies - MOD and Gershon

There is now more evidence to suggest that much of the Gershon "efficiencies" being claimed by the public sector are not entirely robust - as I have suggested here before.

Public Finance reports that the Public Accounts Committee's recent report on the MoD’s major project spending examined claimed savings of £781m on 20 of the ministry's largest projects. But the Committee found that only £242m of this represented genuine savings.

I fear that many of the savings in local government and social housing are (and will be) disguised cost-cutting and/or plain creative accounting.

Sunday, September 16, 2007

Between a Northern Rock and the NHS

The new report from Derek Wanless rings warning bells on the productivity problem in the NHS. There is an executive summary and an interview on the King’s Fund website. The report repeats some of the critique from think tanks like Reform although it does not go so far.

It is unfortunate that Wanless is a board member of Northern Rock. The NHS isn’t the only organisation a bit short of cash at the moment.

Friday, September 14, 2007

The NHS: gifts and markets - the need for both economies

Life has been busy so I have only just got round to reading last week's Society section of the Guardian. It carried an interesting article, Gift rap, by Paul Hodgkin about the role of gift economies in the health service.

I agreed with the main thrust of the article that altruistic and collaborative enterprises (such as support groups) have a vital role in NHS. Hodgkin is chief executive of Patient Opinion which is itself a good example of such gift enterprises. “Co-production” is likely to be a growing part of NHS activity in the future too.

What I disagreed with Hodgkin about was his casual rejection of "markets" in the NHS. He commented:

there are a number of reasons why the search for fully functioning markets in healthcare has little likelihood of success.

He went on:

First, markets within the public sector are zero sum - more hip replacements here means less chiropody there. Or put another way, the foundation trust's surplus tends to mirror my PCT's deficit.

But there will always be a choice between hip replacements and chiropody - unless resources are unlimited. Love it or loathe it, but the National Institute for Clinical Excellence is a way of making those decisions by setting entitlements. The market (or call it choice for patients and competition among providers) is a tool for resolving whether those treatments are at hospital A or hospital B or polyclinic C.

Hodgkin continued:

Second, the "goods" the market is trying to allocate are usually not desirable - unlike a holiday in the Maldives. No one aspires to go to hospital for a mastectomy. As consumers, patients can call some shots in a market. But their fears and anxieties are easy to exploit by suppliers (read doctors) inducing demand for ever "better" care.

I think that medical treatment is very desirable when you need it - even major surgery. The point about professionals over-treating is valid although incentive structures can be developed that address that risk. So doctors and/or hospitals are rewarded for healthy outcomes rather than simple throughput of treatments.

One of the biggest obstacles for markets is the imperfect information that patients have about alternative doctors, hospitals, etc. But Patient Opinion and similar initiatives are tackling that.

I believe that Hodgkin's article reflects are cultural weariness of "markets". We hear the word and imagine Del Boy selling three legged tights or City traders yelling "Sell, sell, sell" into their mobile phones. Perhaps there would be less prejudice against "markets" (and associated hostility to reform) if we spoke about decentralised decision making by patients (or parents or service users or whoever) rather centralised decision-making by planners and politicians.

Wednesday, September 12, 2007

Road signs - lessons for regulation

There is sometimes a case for regulation. For example, oversight of the governance and finances of housing associations means that lenders reduce the interest of loans as the HAs are seen as lower risk. But regulation and regulators tend to grow beyond what is strictly necessary.

Government politicians and civil servants cling to regulation as a safety blanket. Opposition politicians promote regulation ask why regulation didn’t stop each and every unfortunate incident. The auditors thrive on regulation. The regulators can justify every lengthening of red tape. There is always a case for doing and regulating more – without little time to consider the compliance costs, let alone the unforeseen and unintended consequences.

So it was great to learn today that a town in Germany is abolishing road signs. So often denigrated as lovers of regimentation, the Germans are showing that the way with this – allowing pedestrians and motorists to self-organise, take responsibility and negotiate amongst themselves. It’s a theory of “shared space” already being tried elsewhere in Europe and supported by Eurocrats of all people. There is even a variant in Kensington involving the decluttering of streets.

(If you don’t think it will work think about car parks. They don’t generally need traffic lights and the rest.)

Let us hope the lessons of Bohmte – with its bonfire of road signs – are learned elsewhere – not least in the UK’s public services. We need a bit less regulation and more anarchy.

Police, customers and targets

Its not news that target-driven policing doesn’t work. But it is good news that the government has admitted this.

We might even see the police service adopting an ethos of customer service. My local police station might even open at the stated time. When shut, the buzzer to the duty station may even work.

Perhaps not given uncertainty over the 101 pilots – where citizens could report non-emergency incidents without clogging up 999 lines and without being trapped in labyrinth-like never-ending call-waiting. These lines are showing customer satisfaction of 90%!

Wednesday, September 05, 2007

House prices from £10: supporting Shelter

It’s not often that people can buy a house for £10. Shelter is building a city in cyberspace. By buying a house, a shop, a skyscraper or whatever, you can help support Shelter’s campaigning for those suffering most from the shortage in affordable housing.

Deed Consulting has a shop in Shelter’s city. (Although the logo doesn’t seem to show.)

Monday, September 03, 2007

"Mass fatalities" - planning for the risk of pandemic flu

It is never very jolly to get back from holiday. It was particularly depressing to see that the Mass Fatalities Unit of the Home Office (I never even knew that they had one) had issued draft guidance on Planning for a Possible Influenza Pandemic (pdf available).

The report includes interesting planning assumptions. It also gives scenarios such as:

The reasonable worse case scenario could produce around 650,000 additional deaths across England and Wales, based on a clinical attack rate of 50% and a case fatality rate of 2.5%.

Nevertheless we should be cheered that central government is taking the risk of a flu pandemic seriously. Are other providers of public services doing likewise.