On becoming a Minister in the 1960s, Tony Benn reportedly had a map of Britain hung upside down in his Whitehall office.
It was his reminder that there were different ways of looking at the world and a prod, so the story goes, to challenge thinking about the gravitational pull of power and wealth.
The same kind of thinking was evident in the Christie Report on the future delivery of public services published a decade ago. No geographical inversion was proposed but upending thinking about policy making certainly was.
Too much thinking about policy formulation sees it as akin to a conveyor belt. In this view, Government announces policy that others deliver. The lever is pulled and the desired outcome emerges at the other end. And when this fails, the tendency is to pull more levers, seek more power to rectify matters. But power hoarding only makes matters worse. Many of the greatest challenges – the ‘wicked problems’ -– are not capable of being solved but require to be re-solved, with each problem addressed anew taking account of place, time and changing contexts.
The policy process is more Heath Robinson than conveyor belt. There are lots of moving parts with machinery that has been cobbled together over time. Central government may play a leading role but, as the First Minister herself once said in a lecture on closing the educational attainment gap, it must be a ‘shared endeavour’. But sharing cannot involve central government dictating policy and others delivering.
Christie did not call for Scottish central government to stand aside: it remained an important part of the policy making process. But an equivalent of Tony Benn’s map was needed. Hence the call for empowering citizens and communities, for a radical shift to prevention instead of the traditional focus on tackling problems after they become acute, for partnership and integration, and removing duplication. None of this was new. Calls for such changes had long been made.
But it would be wrong to suggest that there were no examples of good practice conforming with Christie. It was never difficult to find remarkable achievements in improving outcomes by adopting these principles but there was just too little policy making informed by these principles. But these principles were secondary to improving outcomes. Achieving a fairer society was the objective.
Christie was a distillation of existing good practice that led to better outcomes. It was not a roadmap in the sense of offering a detailed guide on how to get from A to B. Indeed, that would have been the very antithesis of Christie. Empowerment opens up decision-making, it does not close it down.
Tools for change
There have been many examples of individuals and organisations using Christie as a tool to legitimise and facilitate change. But there have also been many instances when Christie has simply been paid lip service. And as often as not, much good work was quietly being done without any reference to Christie. There was always the danger that reform would focus on less challenging changes. And then there is the temptation to look to others to act or, worse, force others to deliver.
Reforms must aim to empower individuals and communities receiving public services by involving them in the design and delivery of the services they use.
Public service providers must be required to work much more closely in partnership, to integrate service provision and thus improve the outcomes they achieve.
We must prioritise expenditure on public services which prevent negative outcomes from arising.
And our whole system of public services – public, third and private sectors – must become more efficient by reducing duplication and sharing services wherever possible
One of the central weaknesses – and one that has rarely been confronted – is that the four key pillars do not always operate in tandem. Empowered communities have often enough shown a preference for retaining acute services. When is integration or partnership relevant? Clearly not always. These are old questions that ultimately cannot be resolved in a Commission report. Appropriateness and proportionality must be taken into account and that means keeping outcomes uppermost in our thinking. All of this suggests that blueprints are to be avoided.
Of the many previous efforts to reform public services, the 2005 Kerr health review is notable. Professor David Kerr’s terms of reference were informed by a set of values that were little different from those Christie would outline. Kerr’s proposals were more focused and bolder.
providing services in a consistent and equitable manner across the whole of Scotland
ensuring that the patient is at the centre of change, so that they get the treatment they require, when and where they need it
removing barriers from the patient’s pathway of care, and
working in partnership with patients, staff and other stakeholders
Prevention and progress
But Kerr’s reforms faced considerable impediments. As he noted in the report:
One of the most vexing issues in the recent Scottish health debate is centralisation of services. It has polarised communities, caused confusion within front line professions and has often been portrayed as “hospital closure” or “down grading”. Health Boards felt, reasonably, that they were doing their best to deliver modern responsive hospitals given their financial and service constraints, but somehow the debate, often fanned by local media, ignited around the “touch paper” issue of centralisation.
But are the Christie Pillars always mutually compatible? One of the greatest challenges is shifting resources to prevention but what happens when the public do not want to shift resources to prevention? Christie acknowledged that ‘achieving a radical shift towards preventative public spending is likely to be controversial, but we consider it to be essential’. But the status quo wins when a necessary radical shift confronts populist reactions and weak political leadership.
While Christie can be read as a call for upending our thinking, we should be careful that its precepts do not become another scoresheet to be ticked off each month. Or that it becomes platitudinous. The fundamental aim was delivering better outcomes. But outcomes have deteriorated across a range of public services. Christie had noted that public services were ‘facing their most serious challenges since the inception of the welfare state’ as demand for services increased due to demographic changes and the failure to tackle the ‘causes of disadvantage and vulnerability’. But this was precisely why Christie called for a ‘thorough transformation of our public services’. That has simply not come close to happening.
The failure to reduce demand in acute services through prevention is evident in the increasing proportion of Scottish budget spend on the National Health Service. This has had many consequences. Money required for acute services means less for other services. Failure demand occurs when demands for services arise because action has not been taken earlier and when this is not addressed it becomes adds to costs and makes reform even more challenging. We need to spend more on prevention to save on acute services. But we also need to do this to prevent the despair and misery that flows from failure demand. And this is all before we take account of the impact of the pandemic.
As Professor Kerr noted a couple of months ago, there had been improvements in outcomes for chronic diseases but progress in reducing avoidable mortality had plateaued since 2014 (Herald). More than a quarter (27%) of deaths in 2019 were avoidable. The health gap between the richest and poorest is widening, with the 10% most deprived Scots nearly five times as likely to die from an avoidable death as someone in the top 10%. The pandemic has widened health inequalities. We have a long way to go to address such gross inequalities. The longer that is evaded, the more difficult and painful is the transition.
Featured image: Scottish cabinet meeting of May 21 courtesy of Scottish Government/flickr CC BY 2.0
James Mitchell was a member of the Commission on the Future Delivery of Public Services that reported in 2011.