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Monday 08 April 2024

Go long and go local: is this the future of public services?

By Craig Ryan

A growing army of academics and local leaders say thinking long-term and giving power to local people and staff is the key to saving the NHS and the UK’s other struggling public services. But are our national politicians listening?

Crowd at the launch of the Wigan Deal

In a gloomy end-of-year report for 2023, the Institute for Government (IfG) warned that UK public services are trapped in a “doom loop” where “perpetual crises” pile pressure on staff, undermine performance and focus ministers’ attention on survival and news management rather than solving problems. Government policy has become “erratic and unpredictable”, the influential think tank complained, making it impossible for public service leaders “to plan or implement performance-enhancing reforms”.

Nevertheless, both Rishi Sunak and shadow health secretary Wes Streeting insist that “reform” will “save” the NHS – although neither have been upfront about how. In the mouths of ministers, “reform” often sounds like a threat and adds up to little more than political stunts like ordering staff back to offices or cutting equality jobs. But Labour’s reform plans aren’t much clearer, and with little money to spend it’s hard to see how Labour ministers will break out of that doom loop.

Britain (or England at least) hasn’t had a public service reform strategy since the Lansley NHS reforms burned up on contact with reality a decade ago. Lansley now looks like the last gasp of New Public Management (NPM), which emphasised choice, competition and importing management practices from the private sector, and underpinned the reform efforts of the Blair, Brown and Cameron governments. According to Aveek Bhattacharya, chief economist at the pro-market Social Market Foundation, “there seems little appetite to continue down the same path”.

Ben Glover, head of social policy at independent think tank Demos agrees. “We’ve seen a retrenchment of marketisation, choice and competition in public services,” he says. “The scorecard is not good in the UK. It’s been very hard – maybe impossible – to build genuine competition in public services and it’s increasingly questionable whether choice is what people want.”

The 'New Localism'

With the prospect of a Labour government later this year, both Demos and the Institute of Public Policy Research (IPPR) recently published reports sketching out a new strategy for public services. They reach similar conclusions: the future of public services is local and long-termist. A sustainable recovery demands a transformation in the relationship between the state, citizens and local communities, and a complete shift in the way politicians operate – away from short-term, politically driven policies imposed from Whitehall towards long-term investment, workforce empowerment and local control.

These reports bring together clutch of related ideas that have gained currency recently, often as a grass-roots response to cuts in local services. Sometimes known ‘the New Localism’ or ‘the Community Paradigm’, these draw on thinking by the American Nobel-Prize-winning economist Elinor Ostram, who argued that local communities could resolve social problems better than central government or the market, and the British social entrepreneur and author Hilary Cottam.

Cottam’s influential 2018 book, Radical Help, set out a new model for welfare systems based on “deep participation”, “building capabilities” and “fostering human connections”. It is the thinking behind council programmes such as the Wigan Deal (pictured above) and East Ayrshire’s Vibrant Communities, and the work of the National Lottery Community Fund and New Local, a network of reform-minded UK councils.

"You have to give power away"

If NPM was driven by financial incentives, New Localism is all about relationships. Enthusiasts, like Demos chief executive Polly McKenzie, talk about replacing the “transactional model” of public services, focusing on “actions done to people”, with a “relational model” where services collaborate to build people’s capacity “to resolve their own problems in their own ways”. She quotes Sir Robert Peel’s original vision for the police: “the police are the people and the people are the police”. For the NHS that could mean a lot more community engagement, delivery partnerships, collaborative service design, supporting volunteers or “simply friendly outreach”, she writes.

The thinking behind Integrated Care Systems – focusing on collaboration, prevention and tackling the social causes of health – “is also part of this movement even if they’re not really working that way in practice,” Glover says.

The logic of ICSs is that devolution and integration go together. “It’s easier to join up services at local level”, says Chris Thomas, the IPPR’s head of health, because “you can get real political leverage” over how services are run. He cites “good results” in Greater Manchester, such as mayor Andy Burnham’s negotiation of NHS funds for homelessness initiatives. Thomas also points out that while the health secretary isn’t particularly powerful within the cabinet, “the NHS is very powerful at local level."

The IPPR also wants to see public service managers and staff empowered to make decisions based on local needs and circumstances. “You have to give power away”, says Thomas."A lack of ability to act on things they realise are going wrong and a lack of leadership capacity were probably, alongside pay, the biggest complaints when we researched with staff.“

This would mean ending national targets and frameworks that “dictate processes and take away autonomy, stifle innovation and redirect energy away from genuine leadership,” he explains. While there’s plenty of evidence from around the world that more “gold-standard modern management capacity” reduces mortality, he adds, “the NHS tends to insource capacity through management consultants, who are literally linked to declining efficiency.”

An approach like this would demand “a bigger contribution” from staff, adds Glover, who, rather than “just being told what to do”, would have more responsibility and scope “to experiment and be creative”. The lack of such freedoms “is one of the reasons why we have a workforce crisis in public services,” he says.

Short-termism is baked into the system

Where does all this leave central government? The key ask, and it’s a big one, is to shift what Thomas calls “the short-termism baked into the system”. The IPPR’s proposal to replace Whitehall targets with “national missions” is more than a rebranding, he insists. Missions are “wide, ambitious societal goals” which go beyond any one service, department or even government itself. “They’re challenges that we don’t know the answer to completely,” Thomas explains.

For the NHS, this could mean a single health mission – Thomas suggests “making the UK the world leader in healthy life expectancy over a 30-year period” – with mission goals “embedded across departments” so other services like social care, schools and housing play their part. Crucially, funding settlements would be long-term and based on the metrics set out in the missions, rather than the outcome of an annual hagglefest between the Treasury and spending ministers.

To overcome the short-termism inherent in five-year parliaments – and the even shorter shelf-life of most ministers – Thomas points to the way Britain’s net zero targets were enshrined in the 2008 Climate Change Act, with progress monitored by the independent Climate Change Committee.

“You’d need something similar for health,” Thomas says. "If you hold some accountability outside and make sure political capital is invested in it, I think you can sustain progress.” Proposals for cross-departmental “mission boards”, reportedly being considered by Labour leader Keir Starmer, look like a step in this direction.

"It's really hard to do!"

Does some of this have a familiar ring? The first politician I interviewed as a young-ish journalist was David Clarke, a Cabinet Office minister in the first Blair government. Clarke proudly showed me his ‘digital’ red box (a normal red box with a clunky laptop inside) and talked enthusiastically about “breaking down silos” and something called “joined-up government”. But more than twenty-five years later we’re still talking about it.

“That’s because it’s really hard to do!” says Glover. The Demos report argues that any serious attempt to devolve power and join up services needs cross-party consensus, which looks unlikely in today’s polarised political climate. But there are grounds for optimism, he insists. This agenda can appeal to both the centre-right, who like the localism and the emphasis on self-reliance and cutting bureaucracy, and the centre left, attracted by ending marketisation and the focus on respecting and empowering public service workers.

“If your vision for joined-up government is getting Whitehall departments to work together, you’ll probably fail,” Glover concludes. “You will only get joined-up public service working at place level, so you need to devolve. Once we’ve tried that for 15 years in England, you can come back and tell me this is impossible.”

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Photo: Wigan Council

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