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The 2020 Public Services Trust Blog

Thursday, January 20, 2011

COPD: Cautiously Optimistic about Payment on Delivery

By Lauren Cumming

About 15% of people my age have a long term condition. A little over two years ago I developed COPD: Cautiously Optimistic about Payment on Delivery, and have been unable to rid myself of the affliction. Thus having published Better Outcomes, a report exploring the what, where and why of payment-by-outcome, I and several colleagues have spent the last six months dedicating our minds to understanding how to make it work well. Despite intense criticism and even dismissal from eminent thinkers like Aaron Wildavsky and Allen Schick, paying service providers based on what they actually achieve rather than on the effort they put in has persisted as an idea with merit and is one of the flagship policies of the current UK government. I hardly need to list the advantages here as they are so obvious. But the criticism, coming from such reputed quarters, needs to be taken seriously.

Through case studies on welfare to work, offender management and long-term condition management and drawing on examples including pharmaceutical pricing, foster care, foreign aid and streetscene management, my colleagues and I have tried to extract lessons from past experience using payment-by-outcome. These lessons form the backbone of the toolkit we have produced.

We have spent countless hours grappling with the complex problems associated with measuring outcomes, designing incentives that encourage providers to do what commissioners really want them to do and not something else, and dividing a population of diverse service users so they all receive a high quality service tailored to their needs, among other things. After all this we have a host of lessons to offer the debate, and I feel cautiously optimistic that others will be able to use our report to develop concrete solutions to make payment-by-outcome a driver of better public service outcomes in their particular sectors.

Payment by Outcome: A Commissioner’s Toolkit is a document for implementors, those who have to roll up their sleeves and deliver on policy promises. But it is also for politicians and policymakers who want to understand where payment-by-outcome can apply, what the pitfalls are and how they can ensure they are part of the solution rather than adding to the problem. This is a policy with enormous potential to improve public services, but only if it is implemented well. Let’s make sure we do just that.

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Posted by Lauren Cumming at 12:55 pm
Wednesday, January 5, 2011

the condition of conditionality

By Henry Kippin

Interesting contrast in a couple of news stories coming from the states in the last few days.  On the one hand, portents in the Guardian of a difficult 2 years for President Obama in the face of a Republican controlled Congress.  On the other, a piece in the New York Times on falling inequality in Brazil.  The articles are interesting in themselves.  But something else seems striking.  For many new Republicans (some Tea Party affiliated), the idea of government spending people’s money – in the form of social security, socialized healthcare, sheer government profligacy etc – is abhorrent.  On one level, this is protest against conditionality – that the public is free to earn, on the condition that some of their cash is held back to spend on the ‘public good’.

The NYT article is about the Bosa Familia initiative in Brazil – which aims to reduce poverty through direct cash transfers to the poor:

“The idea is to give regular payments to poor families, in the form of cash or electronic transfers into their bank accounts, if they meet certain requirements.  The requirements vary, but many countries employ those used by Mexico: families must keep their children in school and go for regular medical checkups, and mom must attend workshops on subjects like nutrition or disease prevention.  The payments almost always go to women, as they are the most likely to spend the money on their families.  The elegant idea behind conditional cash transfers is to combat poverty today while breaking the cycle of poverty for tomorrow.”

Plenty has been written in the international development field on the pluses and minuses of this approach (see here for example), but it seems to be working in Brazil. Similar schemes are up and running in Mexico and Tanzania.  As the article says, ‘if current trends continue, the United States may soon be more unequal than Brazil.’

So what is the relationship between the two articles?  On the one hand, they both show the politics of conditionality in different lights.  The public seems far more willing to impose conditions on the poor, or those who would ‘squander’ the resources given to them (cf perpetual benefit cheats exposes in the UK), than accept conditions on high earnings (wrangling over bankers pay, for example?).  The public are more than willing to impose conditionalities on the behavior of government.  This is a good thing.  But those affiliated to the Tea Party seem less willing to contemplate much conditionality in their own behavior and spending.  Sometimes this is a good thing, too.  But as Matthew Taylor alluded to recently, (and an Economist piece supports), citizens seeing themselves as the ‘passive victims of leadership’ without a sense of its responsibility and compromise is a pretty unsustainable mix.

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Posted by Henry Kippin at 10:33 am
Thursday, November 25, 2010

Local Identity – the photographic evidence?

By Henry Kippin


Last night I was speaking at the mining institute in Newcastle at a roundtable discussing themes from LOCAL – a book my Dad and I published recently.  The book is a mix of photography (based on an artist-in-residence period at Cumbria County Council), and text (an essay on local politics & identity), and the roundtable reflected a mix of interests in the photographic process, the politics of creating a piece of work like this, and its relevance to the current national and local political context.

Lots of discussion centred on the potential impact of spending cuts on the North East – impacts that no-one can really prejudge, but that most people felt would be socially damaging.  Those asking “where is the growth strategy to get places like Sunderland out of the other side?” are asking the right question.  This is where concepts like the big society and the 2020 Commission’s idea of social productivity must have practical impact.  And it is precisely because the public sector is such a shaper of economic trajectory (the University in Sunderland, for example) that social productivity – which suggests a more active role for the state – is more likely to help people think through what happens next.

Back around the table, one participant commented on the ‘pace’ of the photographic content of the book – “feels almost rhythmic, like its own council logic of movement but inertia, meetings, decisions, problems, meetings, solutions, meetings…et cetera.”  What he was getting at was that the pictures carry a sense of the banal, a sense that nothing changes in the machine of (local) government.  Our book was created in 2009, before the current politics took shape.  But I wonder if this is true now. Bradford council was reported to have sent every employee a letter warning that ‘their jobs are at risk of reduncancy’.  This is hardly everyday – and we should be worried if it is the start of a new politics that considers jobs and people as collateral damage as budgets are quickly balanced.

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Posted by Henry Kippin at 4:36 pm
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 ( 

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