{"id":13670,"date":"2021-07-09T13:37:03","date_gmt":"2021-07-09T13:37:03","guid":{"rendered":"https:\/\/sceptical.scot\/staging\/?p=13670"},"modified":"2021-09-09T10:34:13","modified_gmt":"2021-09-09T10:34:13","slug":"time-to-deliver","status":"publish","type":"post","link":"https:\/\/sceptical.scot\/staging\/2021\/07\/time-to-deliver\/","title":{"rendered":"Time to deliver"},"content":{"rendered":"\n

On becoming a Minister in the 1960s, Tony Benn reportedly had a map of Britain hung upside down in his Whitehall office.\u00a0<\/strong><\/p>\n

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.<\/p>\n

The same kind of thinking was evident in the Christie Report<\/a> on the future delivery of public services published a decade ago.\u00a0 No geographical inversion was proposed but upending thinking about policy making certainly was.<\/p>\n

\u00a0Too much thinking about policy formulation sees it as akin to a conveyor belt.\u00a0 In this view, Government announces policy that others deliver.\u00a0 The lever is pulled and the desired outcome emerges at the other end.\u00a0 And when this fails, the tendency is to pull more levers, seek more power to rectify matters.\u00a0 But power hoarding only makes matters worse.\u00a0 Many of the greatest challenges \u2013 the \u2018wicked problems\u2019<\/a> -\u2013 are not capable of being solved<\/em>\u00a0 but require to be re-solved<\/em>, with each problem addressed anew taking account of place, time and changing contexts.<\/p>\n

The policy process is more Heath Robinson than conveyor belt.\u00a0 There are lots of moving parts with machinery that has been cobbled together over time.\u00a0 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 \u2018shared endeavour\u2019.\u00a0 But sharing cannot involve central government dictating policy and others delivering.<\/p>\n

Christie did not call for Scottish central government to stand aside: it remained an important part of the policy making process.\u00a0 But an equivalent of Tony Benn\u2019s map was needed.\u00a0 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.\u00a0 None of this was new.\u00a0 Calls for such changes had long been made.<\/p>\n

But it would be wrong to suggest that there were no examples of good practice conforming with Christie.\u00a0 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.\u00a0 But these principles were secondary to improving outcomes.\u00a0 Achieving a fairer society was the objective.<\/p>\n

Christie was a distillation of existing good practice that led to better outcomes.\u00a0 It was not a roadmap in the sense of offering a detailed guide on how to get from A to B.\u00a0 Indeed, that would have been the very antithesis of Christie.\u00a0 Empowerment opens up decision-making, it does not close it down.<\/p>\n

Tools for change<\/h2>\n

There have been many examples of individuals and organisations using Christie as a tool to legitimise and facilitate change.\u00a0 But there have also been many instances when Christie has simply been paid lip service.\u00a0 And as often as not, much good work was quietly being done without any reference to Christie.\u00a0 There was always the danger that reform would focus on less challenging changes.\u00a0 And then there is the temptation to look to others to act or, worse, force others to deliver.<\/p>\n

CHRISTIE \u2018PILLARS\u2019<\/strong><\/p>\n

Reforms must aim to empower individuals and communities receiving public services by involving them in the design and delivery of the services they use.<\/em><\/p>\n

Public service providers must be required to work much more closely in partnership, to integrate service provision and thus improve the outcomes they achieve.<\/em><\/p>\n

We must prioritise expenditure on public services which prevent negative outcomes from arising.<\/em><\/p>\n

And our whole system of public services \u2013 public, third and private sectors \u2013 must become more efficient by reducing duplication and sharing services wherever possible<\/em><\/p>\n

\u00a0<\/p>\n

One of the central weaknesses \u2013 and one that has rarely been confronted \u2013 is that the four key pillars do not always operate in tandem.\u00a0 Empowered communities have often enough shown a preference for retaining acute services.\u00a0 When is integration or partnership relevant?\u00a0 Clearly not always.\u00a0 These are old questions that ultimately cannot be resolved in a Commission report.\u00a0 Appropriateness and proportionality must be taken into account and that means keeping outcomes uppermost in our thinking.\u00a0 All of this suggests that blueprints are to be avoided.<\/p>\n

Of the many previous efforts to reform public services, the 2005 Kerr health review<\/a> is notable.\u00a0 Professor David Kerr\u2019s terms of reference were informed by a set of values that were little different from those Christie would outline.\u00a0 Kerr\u2019s proposals were more focused and bolder.<\/p>\n

KERR VALUES<\/strong><\/p>\n

providing services in a consistent and equitable manner across the whole of Scotland<\/em><\/p>\n

ensuring that the patient is at the centre of change, so that they get the treatment they require, when and where they need it<\/em><\/p>\n

removing barriers from the patient’s pathway of care, and<\/em><\/p>\n

working in partnership with patients, staff and other stakeholders<\/em><\/p>\n

\u00a0<\/p>\n

Prevention and progress<\/h2>\n

But Kerr\u2019s reforms faced considerable impediments.\u00a0 As he noted in the report:<\/p>\n

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 \u201chospital closure\u201d or \u201cdown grading\u201d. 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 \u201ctouch paper\u201d issue of centralisation.<\/em><\/p>\n

But are the Christie Pillars always mutually compatible?\u00a0 One of the greatest challenges is shifting resources to prevention but what happens when the public do not want to shift resources to prevention?\u00a0 Christie acknowledged that \u2018achieving a radical shift towards preventative public spending is likely to be controversial, but we consider it to be essential\u2019.\u00a0\u00a0 But the status quo wins when a necessary radical shift confronts populist reactions and weak political leadership.<\/p>\n

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.\u00a0 Or that it becomes platitudinous.\u00a0 The fundamental aim was delivering better outcomes.\u00a0 But outcomes have deteriorated across a range of public services.\u00a0 Christie had noted that public services were \u2018facing their most serious challenges since the inception of the welfare state\u2019 as demand for services increased due to demographic changes and the failure to tackle the \u2018causes of disadvantage and vulnerability\u2019.\u00a0 But this was precisely why Christie called for a \u2018thorough transformation of our public services\u2019.\u00a0 That has simply not come close to happening.<\/p>\n

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.\u00a0 This has had many consequences.\u00a0 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.\u00a0 We need to spend more on prevention to save on acute services.\u00a0 But we also need to do this to prevent the despair and misery that flows from failure demand.\u00a0 And this is all before we take account of the impact of the pandemic.<\/p>\n

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<\/a>).\u00a0 More than a quarter (27%) of deaths in 2019 were avoidable.\u00a0 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<\/a>.\u00a0 We have a long way to go to address such gross inequalities.\u00a0 The longer that is evaded, the more difficult and painful is the transition.<\/p>\n

Featured image: Scottish cabinet meeting of May 21 courtesy of Scottish Government\/flickr<\/a> CC BY 2.0<\/em><\/p>\n

James Mitchell was a member of the Commission on the Future Delivery of Public Services that reported in 2011.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

“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.\u00a0 This has had many consequences.\u00a0 Money required for acute services means less for other services.” A member of the Christie Commission on delivering public services in Scotland looks back\/forward in sorrow<\/p>\n","protected":false},"author":101,"featured_media":13676,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[13],"tags":[168,228],"class_list":["post-13670","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-culture","tag-nhs-scotland","tag-scottish-local-government"],"_links":{"self":[{"href":"https:\/\/sceptical.scot\/staging\/wp-json\/wp\/v2\/posts\/13670","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/sceptical.scot\/staging\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/sceptical.scot\/staging\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/sceptical.scot\/staging\/wp-json\/wp\/v2\/users\/101"}],"replies":[{"embeddable":true,"href":"https:\/\/sceptical.scot\/staging\/wp-json\/wp\/v2\/comments?post=13670"}],"version-history":[{"count":0,"href":"https:\/\/sceptical.scot\/staging\/wp-json\/wp\/v2\/posts\/13670\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/sceptical.scot\/staging\/wp-json\/wp\/v2\/media\/13676"}],"wp:attachment":[{"href":"https:\/\/sceptical.scot\/staging\/wp-json\/wp\/v2\/media?parent=13670"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/sceptical.scot\/staging\/wp-json\/wp\/v2\/categories?post=13670"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/sceptical.scot\/staging\/wp-json\/wp\/v2\/tags?post=13670"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}