The Palace of Westminster has apparently long been sinking into the mud of the Thames. In its current paralysed and floundering condition, it seems to be sinking faster.
The delivery of public services can never be divorced from the overall political context. Given the political crisis we are currently experiencing, it is actually no small wonder that Ministers were able to sanction and release the NHS Long Term Plan in January. Of course, the necessary accompanying long-term strategy for social care, without which the NHS Plan is unlikely to succeed remains bogged down and delayed in the morass of government distraction and some have argued a Brexit inspired general dereliction of duty.
At least, in Health, we have something to start with. But do we have the political means to bring people together in the way to achieve the changes required?
An understandable conclusion is that politics at the national UK level has plummeted to a nadir of widespread contempt, anger and glaring division. Brexit has revealed a nation at odds with itself, with little self-confidence and diminishing respect on the world scene. A simplistic binary referendum and an over-optimistic belief in the power of a narrow majority have thrown into question much of what we might have come to treasure as a democracy. The Hansard Society, in its annual audit of political engagement published this last week, found that opinions of the system of governing are at the lowest point they have been in the 15 years they have been doing this audit and even lower than in the aftermath of the MPs’ expenses scandal. They found people pessimistic about the country’s problems with a sizeable number willing to entertain radical political changes. Perhaps worryingly, 54% of those interviewed thought “Britain needs a strong leader willing to break the rules” (only 23% disagreed) raising the spectre of more autocratic governance. The audit noted that feelings of powerlessness and disengagement are intensifying.
Our political system has proved incapable of dealing with the EU crisis, and yet we need a robust democratic system more than ever to deal with all the other the issues we face. Whatever the actual Brexit outcome, the political consequences are likely to be profound if difficult to predict. Maybe it’s not too late to sell off Westminster to a hotel and theme park developer who will pay the £3.5 bn to stop it sinking any further and instead start to use the proceeds on something slightly different?
What might a democratic system that can start to address the real issues that pervade the 21st century look like? How might it provide a way to deal with the issues of rapidly, relentlessly rising demand and the need to make prevention as effective as possible? These are challenges not just for health but for social care as well, to say nothing of economic and environmental sustainability. The NHS Plan with its ambition of stopping 85,000 premature deaths each year makes key points about public health and anticipatory and preventive action. How might a political system evolve to truly support and enable this?
In February 2019, the New Local Government Network published a key paper by Adam Lent and Jessica Studdert entitled “The Community Paradigm – why public services need radical change and how it can be achieved” which for me helped to begin framing the challenge ahead.
Lent and Studdert start with the premise that for prevention to be successful it requires citizens and their communities to take greater responsibility for their lives but this will only work if people are given the power to exercise responsibility. Paradigms of public service are historically characterised by a hoarding of power in hierarchies that have been quite resistant to change. They trace the development of public sector services in the UK over three successive paradigms, all of which I would argue, are connected to prevailing political thinking:
- The Civic paradigm from 16th C to mid-20th C in which independent bodies provided services funded by voluntary contribution and latterly some taxation
- The State paradigm dating from the 1940s and the inception of the NHS through to the 1980s
- A Market paradigm which has tried to improve cost and efficiency and increased choices through competition and the infiltration of the private sector.
In the State paradigm, the hierarchies of the Civic paradigm were reinforced with service users and communities seen as passive recipients. The Market paradigm did not dismantle the hierarchies in developing a more transactional relationship between provider and user. This was sufficient for the times which weren’t faced with the relentlessly rising demand that we are now experiencing and that they are incapable of dealing with this. Because the State paradigm sees users as passive recipients, it is unable to realise the assets that citizens and their communities bring. The Market paradigm with its underlying emphasis on competition has led to endless efficiency drives through which it insists on breaking down public service interactions into easily definable and costed units encouraging providers to take a narrow view of their role and what constitutes success and payment. To be fair, there has been recognition of this in the Five Year Forward View and NHS Plan in the move toward integrated partnerships although commissioner and provider struggle with this and the avowed shift from the private sector is not happening quickly as the Churchill PET issue has shown.
Lent and Studdert see the opportunity for a different paradigm in what they interpret as the growing expectation of the public for more influence and through the widespread adoption of digital technology enabling people to connect and operate in previously unthinkable ways (again not out of step with the NHS Plan). They make a direct link for this desire for influence to the sentiments that have been unveiled in the Brexit referendum and aftermath – the concept of taking back control, the anger that decisions are being made by others, the perceived distancing of people from the Westminster, elitist or metropolitan bubbles and presumably that infamous message on the side of the red bus. They argue that it is possible to turn the expectation and desire for influence into something more positive and relevant to the challenge of rising demand. However, transforming the growing desire for influence into actual participation will only happen if public services are willing to transfer power and funds to the citizens and communities they need to work with. Hence the need for a new Community paradigm built on the principles of:
- Moving decision-making power out of public service institutions
- Resourcing communities by placing control of resources in the hands of local communities
- Sharing the powers of commissioning between public service provider and the communities they serve.
Policies that would take forward the Community paradigm include:
- A new approach to devolution – the starting point of transition to prevention as a priority
- Focusing on the cultural change rather than any new structures
- A new approach to financing – through place-based budgets and fiscal devolution
- Locating decision-making as much a possible with citizens in their communities using different deliberative approaches and ways of participation (the opposite of a binary one-off approach of a referendum). Deliberation aims to build empathy and consensus but exploring ways of avoiding the dominance of any vocal minority or excluding those less able or inclined to participate
- New more dynamic roles more clearly defined for elective representatives away from the cycles of engagement around elections
- Pursuing the place-based budgets rather than single service budget (in effect much of what the NHS Plan is suggesting).
Their discussion is well-founded and provides case studies and examples from across the UK and elsewhere. In developing the case and a way forward, they refer to ideas that are emerging from public sector practice, for example in Wigan and Cambridgeshire and in health care through some of the new care models program.
As I have said, for me, this paper provides a helpful framework and springboard for thinking. It links with considerable work and development of ideas that is going on already in terms of asset-based community development which I will turn to in future blogs. Although elements of the changes required might be found within the NHS Long Term Plan there are aspects which clearly jar with it. The Primary Care Networks that need to be defined in the next few weeks are more likely to be imposed either by the GPs themselves or by CCGs where GPs find it difficult to come together. Are PCNs primarily instruments simply for developing service at scale rather than vehicles for developing the kind of community interaction that the new paradigm suggests? There are examples where PCNs have been formed without any reference or consultation with other services including the community services with which they must closely interlink. In urban areas in particular, the PCNs may have little bearing as meaningful geographies to the people on the ground. How they relate to actual communities may be difficult to see. And what do we really mean by a community in this day and age? Lent and Studdert define community as “any network of individuals collaborating more or less formally to achieve a shared socially beneficial goal”. This will include geographical neighbourhoods but also condition-specific collectives and groups pursuing particular social goals. Quite a difficult concept to facilitate through local political change.
Paradigms cannot be imposed – they develop and evolve – sometimes the evolution is very rapid and it may appear historically as a major shift. Internal forces cannot be underestimated. With health it is not just the political system that encourages the hoarding of power. There is the added complexity of the professional tribes all vying for their own positions, their own indispensability, their own undoubted need for resources.
In reality, paradigms may, even in times of intellectual and other upheaval, come about through numerous shifts at different scales, degrees and speeds across the board. In this respect change may be a catalyst for broader political change, or the broader politics may foster or hinder the overall approach. It will be a complex interaction and the final product may never be predictable. This process of evolution means that paradigms may not be watertight or purist and compromises are made. Aneurin Bevan, the great socialist, achieved the creation of the NHS through (his words allegedly) “stuffing hospital consultants’ mouths with gold” and getting GPs on board by allowing them to operate as independent contractors in a protected and constrained market that enabled regular profits and mitigated most normal business risks – hardly a Marxist paradise.
Paradigms arise out of environments of struggle but also of growing consensus. The transition to a State paradigm (although aspects were politically opposed by some) actually met the mood of post war Britain and, it is often forgotten, followed on from the Conservative Rab Butler’s 1944 Education Act which raised the school leaving age to 15 and removed all state sector school fees, laying the foundation for our current education system. Although Thatcher was bitterly opposed by many, the Market paradigm that her regime and successor nurtured received a boost in the expanding public sector of New Labour. It may remain to be seen to what extent the general feeling for greater participation is universal, given the Hansard Society’s finding about autocratic desires. Most certainly it will be variable and in a divided nation may have differing results depending on where one is.
And that brings us back to the quagmire of the Thames and the sinking feeling that I don’t think I have been alone in experiencing. There is a chance to rise up. In the post-Brexit aftermath, political change will be required, and it may turn out to be unavoidable. At the same time, something different is needed in the way we approach public services and how we build on the assets and partnerships of citizens and the groups they form. Maybe the two go together and initiatives in community participation will help inspire a change to our political expectations, behaviours and system of representation that in turn can foster the necessary environment for addressing the key challenges we face.
Adam Lent and Jessica Studdert “The Community Paradigm – why public services need radical change and how it can be achieved” New Local Government Network