When things go wrong in public services, we blame individuals and rush for structural reorganisation. It’s better to focus on systemic change at a local level
The way in which we deliver our public services means that the most vulnerable and those with complex problems inevitably get a raw deal. And yet we seem incapable of changing.
For a start, when services are deemed to be unsatisfactory we still see structural, rather than systemic, reform as the only response. That is what Andrew Lansley’s reforms of the health service were about, as well as Michael Gove’s education reforms. Much the same criticism could be made of most of Tony Blair’s public service reform agenda.
None of this is surprising, because structural reorganisations give both officials and politicians the impression of having done something and short-term action is attractive to those who are building careers or reputations.
The problem is that reorganisations hardly ever deliver better services to clients, citizens, users or patients. This is because they rarely address the systemic reasons why they have been receiving poor services. Often, too, reorganisation is accompanied by yet more intense regulation and performance management, as those responsible for delivery become ever more desperate to demonstrate that things are improving.
In fact, all that the attention achieves is to identify failure more efficiently.
If you think this is an exaggeration, then look at the way in which we have responded to the death or serious abuse of children and vulnerable adults over the past 30 years, with the systemic failures exposed by serious case reviews rarely being effectively addressed. Contrast that to the way in which, for example, the aviation industry responds to accidents or near misses.
While that industry seeks methodically to identify and rectify system failures, we in public services are obsessed with blaming the pilot. As a result, the aviation industry improves training, ensures that pilots are better prepared to react to problems as they arise, and ensures that systems and equipment are redesigned to minimise future risk.
Whereas in public services we continue to blame individuals and then respond with surprise as the same systemic failures recur again and again.
None of this is to suggest you never need to reorganise public services or indeed manage performance or hold people to account. It is to suggest that structural reorganisation is not the place to start. The place to start is with the clients or users and, in particular, the clients with the most complex problems.
In spite of two decades of rhetoric, we still have services that are, more often than not, designed for the convenience of providers rather than to meet the needs of clients and users.
Sadly, when public service reform is discussed it fails to engage the public or the most senior policymakers because it seems to be about dry theories of bureaucratic administration. But the consequences of the way in which we have mismanaged public services are waste and personal suffering.
Recently, I heard of an elderly lady who was in hospital when told she was reaching the end of her life. Like most people she wanted to die at home and the hospital staff wanted to help her fulfil that simple wish. It took the involvement of 25 different teams, 23 separate assessments and the convening of two funding panels before she was able to leave hospital three months later, only to die at home within a fortnight.
That is but one example of the human cost of fragmented governance, an obsession with structures and a lack of service design capacity. Five years ago, I was tasked to look at how our public services could best respond to the expected period of austerity. One of my recommendations was to develop the Total Place programme to encourage agencies to work together at a local level, to rethink the way they meet local needs and to deliver better services at lower cost.
Total Place was an attempt to improve services without further reorganisations and proved immensely popular. However, because it was associated with the then Labour government it did not survive the 2010 election, although it did provide the inspiration for community budgets, the Troubled Families programme and City Deals.
Total Place, for me, demonstrated several other important points relevant to this discussion. First, it showed that the more effective integration of services around clients requires genuine devolution of power.
Second, Total Place demonstrated that Whitehall’s determination to work in silos and centralise has often stood in the way of developing effective local collaboration.
And, third, it showed the importance of civil society in improving the quality of people’s lives. Very often, government – local and central – has thought solely in terms of delivering services, whereas the primary aim should be to help citizens lead better lives – and that is not the sole preserve of the public sector.
Many of our problems derive from a, doubtless well-intentioned, belief that the public sector can alone solve the problems faced by the most disadvantaged members of society. As a result, many people feel disempowered and sometimes at the mercy of insensitive bureaucracies.
Although we have long spoken about the importance of consultation and participation, there has been much less said, let alone done, about co-production or co-design. These, of course, require a shift of power from professionals and policymakers to citizens and therein may lie the reasons why they have so rarely been achieved. They do, however, offer the chance of policies and services that make sense to clients. They might also result in clients feeling able to use their own resources and initiative to better effect to improve the quality of their lives.
That kind of approach is a long way from relying on bureaucratic reorganisations and inspections but it might just stand a better chance of improving the quality of living for the most disadvantaged and vulnerable.
Lord (Michael) Bichard has been a cross-bench peer since 2010. A former permanent secretary, he was a chief executive in both central and local government, and the first director of the Institute for Government. A version of this article appeared in a Fabian Society pamphlet on multiple service needs
This opinion piece was first published in the May edition of Public Finance magazine
