NHS at 60 – faltering progress on reform

The Economist has made content from its crystal ball gazing The World in 2008 available on the internet. It’s worth a look.

There is a fairly depressing prognosis for the NHS as it reaches the age of 60. The article notes that Gordon Brown lacks the enthusiasm for introducing the market forces of competition among health care providers. The article concludes:

It is hard for the public to feel confident about how Labour is handling the NHS when its staff are so dissatisfied. And one of their biggest gripes has been the threat of private health-care groups moving in on their territory. But there will be a long-term price to pay. For it is exactly that threat which has the potential to unleash real change in the NHS, as Mr Blair belatedly realised. His vision of turning the NHS into a publicly funded health-care market may have run into difficulties, but that reflected the resistance of the vested interests of its staff as well as ministerial incompetence. Under Mr Brown and his health secretary, Alan Johnson, genuine progress in transforming the NHS looks set to falter in 2008.

Charities: time for an inspector to call?

Last Wednesday’s Guardian carried a challenging article by Martin Brookes of New Philanthropy Capital. (A full version of the lecture is available too.) The article addressed what he sees as charities’ lack of accountability for the funds they receive:

This lack of scrutiny is not healthy, and is not fair to the taxpayer or donor either. A total of £1.3bn of subsidy on tax-efficient giving was provided to charities in the last financial year. This is money that could go into schools and hospitals. No one sits in judgment over the value for money provided by this. And private donors - that is you and I - give almost £9bn, the impact of which is not adequately recorded or monitored.

He could have added that increasingly third sector organisations are delivering public services rather than supplementing or critiquing them.

Martin Brookes believes that scrutiny would improve performance with better informed donors picking better charities and weak charities lose funding.

Its hard to argue with any of that. However, he recommends a new institution alongside the Charity Commission. This quango would be concerned with assessing and improving the performance of charities. It would be under the wing of the Cabinet Office and report to a House of Commons select committee.

I do like the idea of reports assessing how well charities are managed and governed, how they involve beneficiaries in shaping services, how they address issues of equality and diversity, etc. But I have some concerns.

Given the scale of red tape that small charities are wrapped in, like any other small business, I am wary of anything that adds to the regularity burden in the wider sense. Moreover, across the public sector there is so often a tick-box mentality where things are only done superficially and ritualistically in the expectation that an inspector will call.

Perhaps it would be better if the charities themselves stepped forward and took up the challenge of measuring and improving their own performance. Self-regulation is not always appropriate (as I’ve argued on this blog in connection with housing associations) but it would be a step forward for charities. They could help define the standards for the sector and design the framework for applying assessment.

Standard and Poor’s give social housing regulation a credit rating thumbs-up

Standard and Poor's have concluded in a new report that the planned re-organisation of social housing regulation in England will not lead to any weakening in the level of control over the sector. They do not expect any changes to credit ratings on U.K. housing associations as a result of the new regulatory regime with an independent Office of Tenants and Social Housing from 2009.

This is good news for housing associations and plans for more new social and affordable homes. We can only wonder whether or not the suggestions of self-regulation from the National Housing Federation would have led to a similarly benign result.

Wikis helping professionals to manage the risks of pandemic flu

Its that time of year again – when I start talking about the risk management issues around how the public and not-for-profit sectors are preparing (or not) for the contingency of pandemic influenza.

The technology of wikis has brought a useful website, Flu Wikie, for sharing information on pandemic flu and preparing for the worst.

I hope (and expect) the internet will create more such wiki sites of assistance to professionals in the public and not-for-profit sectors. If anyone has any other examples, please share them.

McKinsey on Government as a business

On the MacKinsey Quarterly website there is a new lecture worth looking at. Ian Davis, the Managing Director on McKinsey, reflects on Government as a business. (Both the transcript and the podcast are available although you'll have to register.) Hopefully the title will not turn people off.

The lecture reviews a range of issues facing the public sector internationally including globalisation and demography. But the most insightful section is on the “productivity imperative” – what is known as the “efficiency agenda” in the UK.

Davis starts by pointing out:

People often use the term "productivity" interchangeably with "savings"—seeing the word as synonymous with cost cutting and layoffs. But that is not productivity. Productivity achieves two goals at once: productivity simultaneously improves performance while decreasing costs. The magic is that productivity integrates both results and costs, conceptually and in terms of measurement.

That isn’t a big revelation. It is common sense. And its in all the UK government’s guidance on efficiency. Yet sadly in the UK the word “efficiency” is being abused in all sorts of ways. (One housing association that I know didn’t spend a large chunk of its training budget – it claimed that as an efficiency in its returns to its regulator.) The UK “efficiency agenda” really does have to get back to the key related issues of raising productivity and doing more for less

Davis advocates stretching ambitions for improving performance but reminds us:

This can't be achieved by pressure alone—you need support as well. And you need training. In government reform efforts we have seen around the world, pressure without support simply leads to demoralization, while support without pressure leads to complacency.

That sounds rather familiar?

In terms of means, he notes:

Virtually all countries could benefit from adopting more of the approaches that have helped drive the productivity gains in the private sector over the past two decades—better transparency, improved performance management, better alignment of incentives, stronger accountability, better incorporation of technology, and, crucially, better attraction, deployment, and development of talent.

I fear that in the UK we’re see more top-down approaches to improving performing – linked (or confused) with a more bracing financial environment for public services. Nevertheless, leaders and managers in the public and not-for-profit sectors can still raise to the challenge for raising productivity from the bottom-up.

Vision, Brown and the market for think tanks

Last month Prospect magazine gave the “left-leaning” Institute of Public Policy Research the accolade of Think Tank of the Year. I see this as significant given IPPR’s closeness to New Labour and power – plus a government in search of the “vision thing”.

It is note-worthy that the IPPR has been thinking and promoting reform ideas quite distinct form the Blairite agenda of choice and competition. Public Finance has carried an article by Carey Oppenheim and Lisa Harker setting out a Brownite “narrative” of collaboration between users and producers.

The two IPPR staffers identify behind “personalisation” and “co-production”, two guiding principles:

The first is that people should have more opportunity to shape their own public services and should be better involved and informed. The notion is that ‘how’ public services are delivered is as important as ‘what’ they deliver. The second principle is that a transformation of outcomes will only come about if users of services are jointly involved with professionals in achieving changes in behaviour. This might sound pretty unradical but it is likely to change fundamentally the experience of using public services as a patient or parent.

That all makes sense.

But I would suggest that public services still require incentives to change, innovate, improve quality and reduce costs – in other words, there is a need for the disciplines of markets. Think tanks like Reform and the Social Market Foundation continue to develop ideas around choice and competition.

Txt helping to cr8 better public services?

In media coverage of the billion texts now being sent every month there has been little mention of the emerging impact on public services.

Schools and colleges are starting to communicate by text on issues such as attendance. Social landlords are reminding tenants of visits by maintenance staff and gas checking staff. Prospective tenants are even bidding for flats and housing in choice based letting. Once tenants increasingly they can use their voice and contribute their views via text in resident involvement activities.

Personalising public services sounds like jargon. But text technology is connecting public services with customers. Its a good news story thats lacking the coverage that it deserves.

Enforcement, education and 16-18 years olds - does it add up?

While the proposed increase in “school-leaving age” (strictly speaking it isn’t that) to 18 does create opportunities for colleges and other providers of 16-18 education and training (partly offsetting the demographic trends of falling numbers), I am a bit of sceptic on this proposal.

The think tank Reform have published any interesting critique. Its worth reading. It quotes the economists of the Organisation for Economic Development and Cooperation on the proposal in its latest Economic Survey of the UK:

While raising education participation is an important goal, it is not clear that compulsion is necessarily the best way to achieve it. In the United States there is substantial evidence that higher student achievement leads students to stay in school longer voluntarily. For those students who have already performed poorly, and who are unmotivated, it is not clear what the returns to further education and training at ages 16 and 17 would be, particularly since the return on many existing vocational qualifications is low and the new diplomas are yet to be tested. It should also be kept in mind that education participation is a relatively poor proxy for skills, and that a focus on qualifications can hide problems of poor usage and over-qualification. Educational quality – measured by cognitive skills – is a much better measure of human capital than years of schooling, and care should be taken to ensure that greater quantity is not sought at the expense of quality.

Moore is less? NHS and Sicko

Although cinema is one of my enthusiasms, I don’t plan to turn this blog into me talking about my favourite films. However, I think I will comment on Michael Moore’s new film Sicko as it touches on public services here.

Sicko movie is Moore’s polemic against the lack of free universal healthcare in the USA. It makes a strong case against what many Europeans would see as indefensible. When Moore leaves American shores, the film is more ropey.

Moore shows the NHS as idyllic. No reference to MRSA, Clostridium Difficile, the neglect of mental health, the way the NHS has sucked in huge additional resources without a proportionate improvement, etc.

When Moore visits France, its not just the social insurance based healthcare that is wonderful – it is everything. I am no expert on French healthcare but I am aware that there is racism, social exclusion, youth unemployment, etc – and that is just the suburbs of Paris.

I did like Moore’s trip to Cuba. Viva Fidel!