A central part of Labour’s appeal in 1997 was the party’s assertion that public services should be of high quality for everyone and not just a safety net for the poor. Today, however, voters are not only pessimistic about the prospects for improvement in health, education and law and order, they also marginally prefer Conservative to Labour policies in every single one of these areas.
This is an extraordinary situation for the government to find itself in. Labour has bet the house on public services, and devoted to them its best brains, most valuable political capital and massive financial resources. How has the government reached this point, and how can it redeem the situation? This second question – where now for the public services – is the subject of a major forthcoming ippr report called Public Services at the Crossroads.
When asked about public services, many people appear to think primarily about the NHS. The chart below shows how views about prospects for improvement in the public services as a whole closely mirror views about the health service specifically. The public has more faith in the government’s approach to education, and despite last year’s foreign prisoner debacle is only marginally negative about law and order.
Three current controversies capture the difficulty of making political capital out of the health service, despite huge injections of public money and some important successes such as the reduction in waiting lists. The first is the ongoing dispute over the availability of high cost treatments such as Herceptin. The second is the rash of local disputes over hospital reconfigurations where changes to the pattern of hospital services involve closures at some locations and re-provision on other sites. The third is the degree of resistance within the health workforce to the government’s current programme of change. Together they provide lessons that can be applied more generally across the public services.
The appearance of Herceptin, with its potentially life-saving health benefits for women with breast cancer, prompted a campaign for its availability that forced the health secretary, Patricia Hewitt, to intervene personally. Yet it is immediately apparent that, regardless of the merits of the particular drug, it cannot be right to make decisions about resource allocation in the health service one at a time and by ministerial dictat. It is not just a matter of an independent body such as NICE evaluating the cost effectiveness of drugs and treatments. At bottom the problem is that the public resists the very idea that such decisions should be taken by weighing up costs alongside benefits. Recent ippr research showed that only one in four accepted this idea in relation to the availability of drugs and treatments.
Every single person working in the health service understands that some form of rationing takes place every day, at every level of the NHS. Yet it has proven irresistible for politicians to trumpet the massive investments rather than engage the public in the difficult decisions that will always need to be made, regardless of how much resource is available at any one time. If the health service is to be sustainable in the long term, this must change. This is partly a matter of sheer political leadership and long-term vision, but it is also partly a matter of having the right structures in place to allow meaningful public ownership of the choices that have to be made at national and local levels.
The secretary of state for education is not called on to resign when a single school fails – it is understood that there is a more local form of accountability, and we urgently need an analogue of this for both health and law and order.
Hospital closures are one of the issues that every politician fears. Yet there are good health reasons for changing the pattern of hospital provision in this country. Certain activities such as serious trauma surgery or treatment for heart attacks are far safer when carried out at specialist centres, while long-term care would often be more appropriately delivered outside hospitals in smaller clinics. However, such changes will involve the closure of some existing facilities which enjoy strong emotional attachment, and thus the political impasse.
In the current atmosphere of financial stress in the NHS, it is difficult to persuade people that changes are genuinely motivated by health concerns rather than by short-term monetary pressures. However, even well informed local people generally do not know whether or not their hospital is in fact relatively safe and effective – the information is simply not readily available. Most hospital protesters are thus unaware of whether the services they are fighting for deserve their protection, or whether they would be safer and healthier being treated somewhere else with a better record of success. More information of this kind across the public services would make a big difference to their accountability.
Obesity is just one of the more obvious examples of the impact of personal behaviour on the cost and effectiveness of public services. There is now a rich field for a new progressive approach to the relationship between citizens, users and services. Rather than simply insisting on personal or community responsibility and drawing the boundary of the state accordingly, a progressive approach will be one that seeks to empower communities and individuals, develop services which are responsive but transparently fair, and where democratic accountability is devolved within a context of secure national standards and high quality public information about performance.
Finally, it has become increasingly clear that the health workforce is deeply disenchanted with their current circumstances, despite very significant recent improvements in pay and conditions. Again, the health service provides lessons for the wider public services. The pace of change in the health service has been ferocious since 1997. This is challenging enough in itself, but more importantly the direction of reform has been inconsistent, with the Labour government halting the Conservatives’ market-based reforms in its first term, leaning heavily on target-driven regulation as it poured in resources in its second term, and now racing towards a radically ambitious quasi-market in elective care in its third term. The reforms lack legitimacy among the workforce that is required to carry them out.
There is a new deal to be struck between the public service workforce and the government. On the government’s side, this requires a more realistic pace and scale of structural reform, consistency of direction, recognition of the need for appropriate professional autonomy, and a shift away from pervasive centralised performance management. On the side of the workforce, this requires a genuine embrace of local accountability, transparency about performance, and an embrace of the ambition for ever higher standards.
The progressive future for public services thus consists in a new set of relationships between citizens and the state, services and their users, the government and the workforce, and central and local government. Success requires central government action but also change on the part of citizens, service users, managers and professionals and local politicians. All the political parties are starting to talk this language. The challenge for progressives is to translate it into action.