The bland lexicon of public service reform – targets, choice, contestability – certainly doesn’t feel like the territory over which the 2015 general election will be slugged out. Health and education are relatively safe territory for Labour in the polls. It might be tempting to think all the opposition need do is mount a defence of schools and hospitals in the face of cuts in the next two years. Perhaps little wonder, then, that these issues are getting less opposition airtime than the economy.
Of course, a detailed public service reform plan will not win Labour the next election. Yet there is a more important reason it must be developed. What happens if Labour wins? Nobody is predicting a 1997-style majority with the longevity that implies. That means that a Labour government may have no more than five years to make a difference, and barely any cash to do it. Redistribution on any scale will be out of the question, and while it’s all very well to talk about ‘predistribution’, the truth is it is a long term project that not even economists really know how to achieve.
Which leaves public services. Radically improving our public services within five years could be transformative: imagine if four in five schools and childcare services were outstanding, instead of the current figures of one in five and one in ten. The multibillion-pound public service reform question that looms over this, though, is: how? This has to be one of the most important questions facing the centre-left. But current debates are still too stuck in the what: trying to describe the magic ingredient that makes a particular service great. The most popular narrative is that the Labour government was too stuck in top-down, centralised reform and we should focus on more ‘relational’, personalised public services.
This hand-wringing risks becoming an unhelpful diversion. If you look at any outstanding school, GP surgery, or childcare setting, of course they have excellent relationships between skilled practitioners and service users at their heart. Any public service reform agenda worth its salt recognises that what makes a great public service is great people, trained, supported and developed in the right way. The simple truth is if you take a school and fill it with the top 10 per cent of teachers it doesn’t matter what initiatives are coming out of Whitehall, or how the curriculum is tweaked, or how much paperwork teachers have to do: it will be a fantastic school.
Moreover, condemning top-downism isn’t necessarily an electoral win. How many parents or patients who’ve had bad experiences share the analysis that it’s down to government interference with professional autonomy? They rightly blame the government for badly managed, unresponsive services. But does that really extend into a critique of New Public Management, even if this is what is dominating our current political discourse?
Politicians love to point to examples of great schools and hospitals, and there’s a lot to learn from them about what excellent public services look like. But it’s less useful for the how: looking at the brilliant outliers doesn’t tell us a great deal about what type of system will lead to those outliers becoming the norm. That’s partly because of the truism that the best professionals tend to be found in the best services. But also because turning a service around in a system where there is a lot of variance in quality is a different enterprise to turning it around in a system where there are lots more very good performers. For example, one of the quickest ways for new leadership to turn around a failing school is to push the poorest performing teachers out to other schools. That works in a system where almost one in three schools are not providing an adequate standard of education. It doesn’t work in a system where those types of schools are all but eliminated.
Improving standards across the board requires two things. First, improving average standards in the profession and cutting out the very poor-performing tail. One strategy for this would be what might be called the #McKinsey approach#: focusing on recruiting the crème de la crème into teaching, nursing, or childcare. This is effectively what the top international school systems do: Finland recruits its teachers from its top 10 per cent of graduates. But it would take a very long time to work its way through the system, and it has its limitations.
We therefore need to focus on improving the quality of existing professionals in the system. There are interesting insights from specific interventions proven to work in improving outcomes across education, family and health service, like Family Functional Therapy and Nurse Family Partnership. These interventions don’t make much difference to the outcomes achieved by the highest- and lowest-performing professionals. Where they do make a big difference is in the middle to lower end of the spectrum, through initial high-quality training; continuing professional development; sticking to a specified, evidenced delivery model that acts as a framework for practitioners whilst still allowing them to use professional autonomy to individually tailor services; monitoring performance using real-time data linked to continuous quality improvement; and proper management and reflective supervision. When this combination works, the result is a fantastic, relational service like Family Nurse Partnership, proven to work in improving long-term outcomes for disadvantaged children through intensive parenting support.
Second, where adjustments to systems are found to produce better results, providers should be incentivised to replicate them across the board. For example, moving to telephone-first GP consultations, where all patients initially get a call from their own GP to determine if they need to go in, results in more surgery capacity, improved patient satisfaction and up to 20 per cent fewer A&E attendances. Yet only a tiny minority of practices have adopted this practice.
All of this starts to sound like the unfashionable managerialism most politicians are eager to condemn. But smart managerialism has long been recognised in the private sector as vital to achieving results, for example the ‘Kaizen’ philosophy pioneered by Toyota, which empowers employees to achieve continuous improvement in production and customer service through a system of employee alerts to management and collective problem-solving.
Whitehall obviously cannot nor should not impose this sort of managerialism top down. It is not the job of central or local government to insist on one way of doing things. But ministers have a duty to foster a ‘Kaizen’ culture by ensuring there is muscular accountability for service providers, whether they hail from the private, public or voluntary sectors. Depending on the circumstance, this might be centrally-set targets or outcomes-based payments written into central or local government contracts, to ensure service providers from local authorities to academy chains manage those services so we get more outstanding schools. Or it might be ensuring there is enough user power so that patients and parents can quickly raise the red flag when things are going wrong, for example via patient user forums or school governing bodies. These are very simple insights that were at the heart of the much-maligned New Public Management. Yet there remains a long way to go, for example in ensuring there are simple performance data available on schools and GP surgeries (why don’t schools have to publish annually which quintile they fall in on contextual value-added data, for example?)
The most common critique of targets is they impose a top-down, centralist view of what a better world looks like. Of course, bad targets can be set, and of course it’s sometimes more appropriate for targets to be about user satisfaction. But surely it’s not beyond our wits to come up with collective and measurable objectives for our public services – ensuring young people leave school with the skills they need, or reducing the amount of Type II diabetes through public health prevention, for example – and have a robust system of accountability that blends top-down with bottom-up. If we don’t, we risk having expensive public services that are ineffective at achieving what we want.
There are lessons for Labour from both Blairite and Cameroon public service reform. Blair’s reforms were too easily distracted with trying to impose a top down model on public services. No matter how robust the evidence that something works on a small scale, trying to impose it system-wide is unlikely to be productive.
The coalition’s health and education reforms suffer from two devastating flaws: conflicts of interest abound (for example, academies are directly accountable to education ministers; yet one chain is being run by a minister) and a lack of clarity about what happens when a service is failing, regardless of who runs it. On the other hand, there is a positive lesson to draw about the benefits of getting ready in opposition: compare the smooth passage of the academies act (written before the 2010 election) with that of the health and social care act (which certainly wasn’t).
Ed Miliband is not in the game for the sake of winning, but to change the country for the better. That means Labour’s task over the next two years has to be about more than coming up with a winning manifesto formula. Public service reform is not election-winning territory, which is why this is the stuff of a quietly-developed programme for government rather than flashy manifesto pledges. But if it is to make a difference in government, Labour somehow has to re-learn to love Blairite statecraft.
Sonia Sodha is a former policy adviser to Ed Miliband and writes in a personal capacity
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