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No novel solutions to the problems of public services


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Friday, 9 July 2010

No novel solutions to the problems of public services

It is difficult to write about public services without sounding preachy.

Few subjects expose the writer’s point of view as clearly or as quickly.

A new report* from the 2020 Public Services Trust, begins with a quote from the essayist Edward Abbey: “If the end does not justify the means, what can?”

The point of the quote is not to introduce a moral polemic – the report is mercifully free from that – but to make two practical points.

The first is that the authors found it very difficult to agree on the question of means. The Health Working Group does not pretend to be a collection of like-minded individuals, which may well be a strength.

In his introduction, Greg Parston writes: “Some members favour more market-oriented reforms to the UK’s systems of health and social care; others are inclined to accept more state directed interventions.” If you review the list of members, you will see that Dr Parston has a gift for understatement.

The second reason for focusing on ends is that the means are subject to frequent change – a point that needs no embellishing in the week before the white paper. The 2020 part of the trust’s name reflects its long-view of public service reform. By contrast, the current focus of the public sector is necessarily short-term: it’s about cuts and savings.

Some of this is familiar territory – the passive welfare culture designed around the needs of institutions, not individuals; a nod to the progress made in past decades, followed by a warning that the level of investment that enabled it cannot be sustained; the need to start the design of a 21st century model of welfare “from the citizen up”.

The report describes three systemic shifts – in culture, power and finance – that are needed to transform the citizen-centred vision from rhetoric to reality. In places the language blends traditional left and right of centre concepts so smoothly that you almost long for a quick, clarifying blast of ideology.

It talks, too, about “an inclusive relationship between citizens and professionals”. What this means is greater contact for clinicians and managers with citizens during their training and working lives; more exposure to the consequences of their actions; and fewer excuses for losing the plot.

The report does not deal in trite conclusions. It recognises the possibilities of opening up commissioning via personal budgets, integrated commissioning functions and wider patient choice, but also that these things may come at a price – increased pressure on certain local services, the loss of others and changing patterns of work which would have losers as well as winners.

In avoiding a prescriptive approach, the authors also find it difficult to reach conclusions. They attempt instead to describe a set of measures that transcend the politics and economics of the moment and will be as useful in 2015 or 2020 as they are today.

The seven “instruments of change” identified at the end of the document add up to a useful checklist for policy makers, the NHS, local authorities and others. The lack of novelty will disappoint some readers and please others.

Don’t bother reading the report if you want to know what to do next, but if it does nothing else this thoughtful and thorough piece of work reminds us not to wait for someone else to come up with the answers.

*Improving Health Outcomes: A Guide for Action