The progressive case for public service reform [by Tony Blair] - 4 comments

Reproduced with permission from the original article published as part of the Euston Manifesto Group's Social Democratic Futures thread.

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The progressive case for public service reform

There is always a progressive case for reform. What progressive case is there for the status quo, except in utopia?

One of the original aspirations for universal public services was that they would help to equalise British society. Education would make for fair life chances. The NHS would equalise life expectancy. We still have a long way to travel.

It is not just that the results are unfair. Access to services is not yet fair either. There is a wealth of evidence that lower-income, less educated and unemployed people do not use health services as much relative to need as their richer, better educated peers.

And remember: there has been a progressive dividend in the very fact that public services today are so healthy. A decade ago it was seriously being debated whether or not tax-funded public services could survive. The long period of under-investment had taken its toll. People had become fatalistic about the mortality of their services. Now, the argument is no longer about whether there should be public services provided publicly at all. It is about how they might best be managed.

Society has changed and its demands along with it. Universal public services were established in something like their current form in the 1940s. They offered a service to a society that was ethnically homogeneous, socially patriarchal, economically industrial and recovering from the experience of large-scale unemployment and rationing at a time of war.

We are a much older people than we were. Our lifestyles have changed. The tides of global markets wash up on our shores. Migration is now more extensive than ever before. The competition from other nations is more intense. The ways in which we deliver services are changing all the time, powered by new technologies.

Perhaps more important than anything else, the expectations of the public have risen. In the early days of universal services the standard of service provision, in all aspects of our lives, was poor. This is not any longer true. The standard of goods is vastly superior to what it once was. It would be naïve to suppose that these rising expectations have not been extended to public services. They have. People are now accustomed to a level of service and convenience that is new.

All of these changes have meant that services have to change too.

The pattern of provision is changing quickly. Take the NHS — about 60 percent of cases were day cases in 1997, now it is 70 percent, an increase of 1.5 million. There will be 2.4m more people over 65 in 2017 than in 2007. That changes the nature of care the NHS has to offer. Chronic disease will be the biggest policy area of the future. Already, chronic care costs 80 percent of the budget of the NHS. People are eating more and exercising less — one in five adults in the UK is thought to be obese.

Advances in biotechnology and medical practice mean that infectious diseases can be tackled but the more we can do the more we face difficult funding and rationing decisions. It is now a common experience for patients to go to their GP armed with extensive knowledge of their condition.

Technological change means that we can design lessons for children more personally than ever before. Manufacturing industry has declined, meaning that the training required has changed beyond recognition in a generation. The low fertility rate means that the pressure on the working to fund pensions is greater. We need to change the pattern of housing: the number of households in Britain increased by 30 percent between 1971 and 2005 and is still rising.

So, the argument will be not whether we can resist these changes but whether we can shape them to progressive ends. The alternative to reform according to our values is not no reform at all. It is reform according to the values of another political creed.

Our strategy for public services has been through three phases. The first phase was a zero tolerance approach to failure, with strong central direction and public targets, to ensure that under-investment could not be used as an excuse for endemic failure. This was then followed by a correction of the long period of under-investment. We are now into the third phase: progressive reform.

The driving idea behind reform is to transfer power from providers to citizens. To give power to the people — it is as traditional a left-of-centre slogan as there is.

Aneurin Bevan once said that the purpose of power is to be able to give it away. That idea is our guide too. We want to put citizens in charge because it is both right in itself and it is a way of ensuring that services are tailored to their needs and that services constantly change and innovate as required. So, power to the people is both the means by which the vision will be achieved and is a progressive end in itself. It is no coincidence that the least well-off, the people with least power, consistently tell the polls that they want choices the most.

If the citizen has a choice they have a power. The service is likely to be more responsive to their needs. Their voice is a lot more likely to be heard and acted on. The service has a stimulus to improve.

It is also important sometimes that people are supported in making their choices. Expert intermediaries can be employed to act on behalf of the citizen. Sometimes the choice will in fact be made by an expert individual or body. Sometimes the choice will be made collectively. All of these things are just ways of transferring power to the citizen, to be judged on their merits in each case.

These reforms will make services more efficient. This is necessary but not sufficient. Public services have to be equitable too. We have preserved equity in three ways: the prevention of selection, collective funding and effective regulation.

First, it must be the citizen doing the choosing not the school or hospital doing the selecting. In countries that have allowed selection in schools, like New Zealand, for example, they have found that the gap between the rich and the poor grew. In countries such as Sweden, which did not allow selection but which did give the power of choice to parents, they found that the gap closed.

Second, it is important that the funding is organised progressively. We protect equity by ensuring that we defend the principle of progressive funding. Services should be free at the point of use. Essential services should not be rationed because an individual cannot pay.

Third, a service can and must be designed to ensure that access is equitable. The content of what is provided, the ways that staff work, the outcomes expected for citizens: all these are subject to stringent regulation. These regulations apply to all sectors and the claims that the reforms lead to two-tier services are quite wrong.

In the end, the best argument for reform is that it works. Waiting lists have fallen by almost 400,000; maximum waiting times for operations have been halved from 18 months in 1997 to 9 months in April 2004 and now virtually no one waits longer than 6 months, with the average much lower; there are now 5,800 more good or excellent primary and secondary schools today than in 1997. Exam results are at record levels; more young people are going to university. The biggest ever NHS hospital building programme is underway; record numbers of doctors and nurses are treating record numbers of NHS patients; deaths from cancer and heart disease are falling.

All of these objectives require intelligent government. The progressive left's belief that government can be a force for good is a major advantage. David Cameron has understood that he needs to be seen as a centrist. He is doing his level best to sound reasonable, although his various policy reviews keep giving us an unfortunate glimpse of the contradictions he falls into whenever he is actually forced to confront tough questions rather than simply pose them.

This will be critical when he is finally forced to make decisions about policy. It is all very well to talk about some of the questions thttp://www.blogger.com/img/gl.link.gifhat government faces. But if you put yourself in a position where you can't determine the solution, then sooner or later this will become clear to the British public. In the meantime, the serious reform, to match the profound changes to our country, goes on.

Tony Blair

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