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The 2020 Public Services Trust Blog

Thursday, November 11, 2010

Longer term perspective

By Charlotte Alldritt

It’s been a busy week in UK politics: Prime Minister David Cameron defended top-up fees to the tune of 50,000 students rioting in central London; Secretary of State for Work and Pensions Ian Duncan Smith revealed new sanctions for claimants of unemployment benefit and, ahead of the G20 meeting in South Korea, Bank of England governor Mervyn King warned of the threat to our economy if chronic global imbalances persist.  Amidst all of this, the 2020 PST and RSA brought together scores of public, private and voluntary sector leaders at our Public Services Summit on Tuesday.

Sir Andrew Foster, Chair of the 2020 Commission, highlighted the timeliness of our focus: at this time of fiscal austerity, threats to our public services from cuts are at the top of the political agenda.  The ‘phoney war’ on budgets is set to launch a real offensive.  More than this (and despite genuine efforts from frontline professionals, managers and politicians) the ‘long tails’ of underperformance have left us falling short of what we want, expect and need from our public services.  Public services need to be redesigned so that they are fit for lives we lead and the society we want to create in the 21st Century.

In his keynote speech to the 2020PST/RSA Summit, Rt Hon Francis Maude MP set out the Government’s three-pronged approach to transforming public service delivery:

  1. Channel shift – moving more public services online (e.g. building on the success of the online DVLA vehicle tax renewal, initially to transactional services such as Student Loans and some welfare benefits);
  2. Mutuals – enabling service professionals and users to take a real stake in their public service organisations, unlocking the energy and innovation of ‘entrepreneurial frontline’ staff (e.g. Central Surrey Health); and,
  3. Payment by results – paying providers (of any and every type) for the outcomes they achieve, not pre-funding them so they have limited incentives to aspire to more efficient and effective social outcomes (e.g. Single Work Programme and rehabilitation of offenders).

The 2020 Public Services Trust has examined each of these throughout the course of our research programme.  Our Final Report, ‘From social security to social productivity’ calls for implementation of all three in some form.

But as always, the questions on my mind come back to accountability.  Francis Maude referred to the other big announcement of this busy political week – that of our ‘revolution’ in transparency and the relationship between citizen and the state.  But here the overwhelming consensus at the Summit, in Westminster, and beyond (for the need for change) starts to break down.  Lord Andrew Adonis said that recent announcements did not represent a redrawing of the lines between citizen and the state; “For as long as the State pays for services, Government will be held to account.  If the Government doesn’t set indicators/targets, the media will.”  Matthew Taylor quoted some of the more obscure passages from one of the departmental business plans (published on Monday), designed to enable citizens to monitor and scrutinise Government more closely.

Number 10’s Transparency website is a welcomed start to what will be one of the most interesting and important questions for our democratic society: how do we – the public – engage with our Government and public services?  It is a question that speaks to the availability of quality data; the provision and interpretation of information; mechanisms for citizen/user feedback and redress; public trust in politicians, and, the legitimacy and efficacy of our political system.   These challenges of governance and society have been with us since time immemorial; as was the aim of 2020 PST and our Commission, they give a single busy week a longer term perspective.

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Tuesday, October 19, 2010

Two missing links – accountability and information

By Charlotte Alldritt

Until this morning I had thought I’d understood the general gist of the Government’s White Paper, ‘Liberating the NHS’.  Even if, as Sir David Nicholson admitted, the Department is still “working on the detail” I thought I had a fairly firm idea of the direction of travel. 

But now – after four of the most senior managers of the NHS tried to explain it to the Health Select Committee inquiry on commissioning – I’m more confused than ever.  While the devil will indeed be in the detail, it is not clear how the whole system will align the incentives and levers of finance, clinical expertise and commissioning for quality care.  Add the need for £20 billion in productivity savings and a 30% cut in management costs, and it’s a significant mountain to climb.

A first step will be in making clear the relationships between the Department, local authorities, GP consortia, the NHS National Commissioning Board, primary care inside and out of the remit of GP commissioners, social care, Health and Wellbeing Boards, individual patients, GPs disengaged or disinterested with the new system architecture, and the whole range of other stakeholders.  Without clarity on these relationships, as Rosie Cooper, Labour MP for West Lancashire asked repeatedly “Where is the accountability”?

Accountability is one of my two prime concerns for the new system of commissioning for healthcare.  How will providers be held to account for the quality of their outcomes for individual patients in the new system?  How will commissioners be held to account for the outcomes they achieve for their communities?  To what extent are local authorities to take the rap?   Where will discussions on competing ideas of ‘appropriate’ resource allocation take place? 

We know that the NHS National Commissioning Board will have ultimate authority.  But, as each of the four witnesses this morning (Sir David Nicholson, Dame Barbara Hakin, Dr. David Colin-Thome, and Ben Dyson) intimated, the local dynamics of the system will be key to delivering efficient and effective healthcare.  Appropriate accountability structures and incentives need to be in place to engage both clinicians and patients to achieve this.

The second of my prime concerns underpins the first; information and data quality.  For providers, commissioners and individual GPs to be held to account there needs to be a body of credible information on comparative outcomes, inputs and transaction costs.  ‘How much would the new Commissioning management system cost per head?’ asked Chris Skidmore, Conservative MP for Kingswood.  The Department does not know yet, but is determined to see it “significantly below 5%” of total costs.  Who will be monitoring those costs and outcome measurements?  David Nicholson says that the NHS Information Centre will – for the first time – be a hub collection point for Commissioning Boards to submit their standardized data.

However, it is not yet clear the extent to which the Information Centre will prescribe data standards or data requirements (e.g. and especially in primary care where it is almost entirely lacking).  As Dame Hakin and Dr Colin-Thome suggested, peer-based scrutiny and competition on outcomes can be a powerful lever for improving quality amongst clinicians.  But will this data be collected and made available for comparison?  Furthermore, in the new age of transparent government, will this data be openly available to the public?

The 2020 PST Information and Technology Group have submitted a formal response to the Health Select Committee on the role of information for commissioning.  We believe that that the White Paper does indeed hinge upon the ‘information revolution’ that the Secretary of State speaks of. 

The absence of accurate data on performance, spending and costs leaves commissioners and the public blind when crucial decisions have to be made about investment in, or closure of, services.   When the DH refers to high levels of patient satisfaction with their health professionals, to what extent do patients know how their GP compares with others?  Since patients and the public cannot get the answers to simple questions like, ‘How good or bad is my local GP?’ or ‘Which local provider organisations provide the best care?’ they can’t make informed choices about where to get care.  And they can’t make an informed contribution to local health discussions such as the merger or closure of services. 

We therefore recommend, for example:

  1. Standardised national data sets need to be developed urgently for episodes in primary care and community services, similar to the routine data set on episodes of hospital activity.  These should be done incrementally so that that striving for ‘perfect’ does not extend the existing delay of many years.
  2. It should become a legal duty of all providers who are funded by the NHS – including individual clinicians – to collect standardised, high quality data on their individual patient activity and outcomes to meet the national standards
  3. Commissioners should have the power to require addition local data access and suspend providers’ NHS funding or referral of patients for failure to comply.

 To be a truly devolved system as the Government envisages for the NHS, requires publicly available, high quality data across the full range of health services.  Only then will we be able to build a system which engages clinicians and citizens to work together, and so delivers quality care for patients at lower cost.

 

The 2020 Information and Technology Group submission has been lodged with the Health Select Committee, which will report later in the autumn.  For all enquiries on our recommendations and other work, please contact Charlotte Alldritt (charlotte@2020pst.org). 

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Wednesday, June 16, 2010

A recipe for transformation

By Lauren Cumming

1 cup new opportunities created by evolving technology, 1 cup long-term demand crisis driven by ageing population, ½ cup sense of urgency created by current fiscal crisis… This morning 2020 PST launched 2020 Vision: A far-sighted approach to transforming public services. The report draws on the work of the Commission to date which has developed a positive, long-term vision for the future of public services and analysed the shifts in culture, power and finance that need to take place to achieve that vision. 2020 Vision goes a step further by examining the implications of the Commission’s vision for setting the priorities for public action, redesigning services to create more public value and ensuring accountability. The report then discusses the barriers impeding transformation and steps that can be taken to increase the chances of success.

Working on this project has been very challenging. In many ways, it is not difficult to point to the shortcomings in our public services, or say things like, “Can’t they just ________ (provide good services everywhere, put that online, train people better)?” Even understanding the factors within the system that block change is relatively straightforward. But to find the right levers to unlock resistance to change – well, if it were easy someone would have done it before me. This report does not pretend to have all the answers – transforming public services is too complicated for one report to cover all the ground. I think the biggest contribution of 2020 Vision is to propose a framework for thinking about how to make change, by asking:

  • What is our vision for the future? Where are we trying to go?
  • What conditions need to be in place for that to happen?
  • What are the barriers to those conditions?
  • What are the actions that we could take, in the short, medium and long term, in society and at various levels of government, to remove those barriers and create the conditions needed for change?

As this morning’s discussion made clear, the time for transformation is now. A new coalition government and the fiscal crisis are creating the necessary momentum for major change. As respondent Stephen Dorrell argued, this is not just about deciding how much the public are willing to pay, this is about creating public services that meet the needs of citizens today. These are questions we should be asking ourselves even if we had all the money in the world to spend on public services. Now is the moment to take some risks, be innovative and transform public services so they can meet the challenges ahead.

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Friday, June 4, 2010

Four obstacles in the face of the final frontier

By Charlotte Alldritt

The sheer breadth and complexity of information and technology policy became all too clear at 2020PST’s roundtable yesterday morning.  Leading officials and activists met to discuss the next stage of open government and online self-services.  This brought us into the territory of – amongst other things – the Coalition’s ‘new politics’ of transparency and accountability; cost efficiencies and cuts; social and digital inequalities and the prospect for more personalised, responsive, citizen-focussed public services. 

 Many, many important points were raised, but four in particular stood out for me:

  •  Culture in government, Whitehall and public services - lack of awareness/understanding of the power of online ‘self services’ to deliver high quality for less is the primary barrier.  There is often a presumption that many public services can only be provided face-to-face and alternatives are ‘too cheap’ to deliver quality outcomes and too risky to implement.  Similar arguments apply with regards to open data.  Determined leadership is vital, but the business case for online service delivery and open government needs to be made.  Only then can we expect to see ingrained cultural attitudes and practices begin to change.
  • Provider capture and vested interests – often there are strong incentives acting against the diversion of citizens to lower cost channels.  While models of funding which ‘follow the user’ can help to support choice and competition in public service delivery (in theory generating cost savings and increased quality), they encourage default face-to-face interaction when alternative channels might be more appropriate and cost efficient.
  • Scale – the issue of scale often brings to mind the age-old debates of local vs central procurement of IT systems, software and shared services (for example) and delivery/administration (e.g. housing benefit).  But it also demands we consider the level at which we are trying to engage users and achieve certain outcomes.  For instance, are we trying to enable communities – whether for a locality or other common cause – to work together more effectively via social networking?  Or transform national public service institutions and systems?  Do we need to employ different tactics and strategy to achieve both of these aims? 
  • Public voice – how can the public voice demanding online access to information and services be rallied to push government and providers?  How do we ensure (and reassure the public) that it is as easy and secure to log on to public services as it is to access internet banking? 

Much is already happening in response to many of these four points.  The progress of data.gov.uk and the Coalition’s commitment to publishing  data online is a good start.  But the withdrawal of funding Professor Nigel Shadbolt and Sir Tim Berners-Lee’s web science institute is a major blow.  More than ever – at a time of cuts and cost savings – technology should not be thought about as an expensive ‘bolt-on’ in the hope of making bad services slightly better.  Not least because in practice this (by lack of coherent integration and design) often makes matters worse.  Instead, it’s about using existing and emerging (typically low-cost) communication technologies to enable citizens to work with public services in a way which enables better outcomes at lower cost. 

But I’m at risk of sounding too tech-evangelical.  What is needed is to build the evidence base and let the argument speak largely (and loudly) for itself.

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Friday, April 23, 2010

A vision for 2020 information and technology: Part 2 – Criminal Justice

By Charlotte Alldritt

The year is 2020.  Over the past decade, simple online technologies have transformed the way we access data and information, hold public services to account and engage with government.  Transparency is the watchword of the day.  The ultimate prize? Renewed political legitimacy and public services finally fit for purpose.  In the second installment in this series, I look at how technology and information can inform the public about the real risks of crime they face  in their local area, and allow active dialogue between citizens and their criminal justice service. 

David Johnson is an elderly resident in a large town in the South West.  David has lived here for many years, but he has recently found it more difficult to get out and about to nearby shops and community facilities for fear of being victim to anti-social behaviour.  Unfortunately, low-level crime is increasing in David’s part of town and he is spending more and more time confined to his home. 

Crime Mapping has been around for over a decade, but now data from a range of sources can be mashed up 

David’s family have persuaded him to relocate closer to them.  One of the first steps in the search for a new home is to look up comparative crime rates in the local area. By accessing the local authority webpage, the Johnson family is linked to a local crime mapping site.  This site integrates data on reported crime, appeals to witnesses (building on the pioneering work of Viscero), criminal sentences and A&E data (which captures injuries caused through (typically violent) crime – as shown in BBC’s ‘The Truth About Crime’ in 2009).  It also hosts a forum for residents on anti-social behaviour (ASB).  The web forum allows citizens to talk to each other and to their Neighbourhood Policing Team about how safe they feel in their local area, ideas for how to tackle low-level crime and what measures they feel are working to tackle ASB.  This local crime mapping website is linked to the national CrimeMapper service, and features similar easy-to-read graphs showing detailed crime rates over time at street level.  This kind of information is reassuring to David and his family, who are able to search for properties within a safe area close to the shops and community activity centres.

Active dialogue between residents and their Neighbourhood Policing team without breaching citizen anonymity

The Neighbourhood Policing Team is active in cross-checking local residents’ concerns with reported anti-social behaviour.  They are keen to build a complete picture of where local residents feel most at risk of crime, why and how they might improve the situation.  This commitment encourages citizens to report ASB online using the Report It system (accessible via the same, single local authority website).  This system can be accessed and updated by the Neighbourhood Policing team and local police force so that patterns of repeat ASB can be identified and steps taken to protect victims.

In developing these systems for better information and active dialogue between citizens and police service, concerns about anonymity were taken very seriously.  The online residents’ forum on ASB is allows users to choose whether or not to share their identity.  All data is protected as stipulated by the Data Protection Act.  In order to avoid false or inadequate reports, there is an online video guide on the website that describes what constitutes anti-social behaviour, what kind of evidence must be gathered and presented, and what information on witness protection available.

Citizens can hold their local police service to account better through a simple online comparative performance tool

Finally, the local authority portal links to a single, national police service comparison website.  This has a dashboard for relative performance of all police forces across the country and, by enabling users to post their feedback and engage in discussion with HMIC, it builds on the beta version, MyPolice launched in March 2010.  Technology and information are helping to inform citizens, strengthens their relationship with the criminal justice system and gives them a greater sense of ownership within their local communities.  Once again, technology and information serve to enhance transparency, accountability and the quality of our public services.

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