From the closure of 400 Sure Start centres to the NHS “Bill with no friends” opposed by the BMA, the Kings Fund and even an ex-GP Conservative MP, the Conservative-led Government is making a hash of public service reform. If they’re not slashing services because of an ideologically driven desire to shrink the state, they’re imposing radical structural reform which is wanted neither by the public or practitioners.
The forthcoming White Paper on Public Services – one of several delayed white papers – will set out the Government’s approach to public service reform. Desperate to portray their reforms as a natural extension of Blair’s reforms, the Coalition wants to change the public perception that Labour is the party which looks after public services. Labour cannot afford to let that happen. The election of a new leader and the policy review process have meant that we have not yet said much about public services. Soon, we must. This essay examines how we should approach the issues.
1. Talking about public service reform: values first, the policies will follow
Current debate about public services raises critical policy questions: how should we best fund public services? How should public services be accountable to the public they serve? Who should provide public services? What role should the private and voluntary sectors play? What’s the best balance of decision making between national and local government? How should public services join up at local level to offer the best experience possible? How should government ensure best value for money in public services?
This essay does not seek to answer these important questions. However, we should not let the Conservatives set the agenda and dive straight into a debate of the finer points of whether mutuals are a better mechanism than co-operatives for delivering public services. If we do, we miss a crucial opportunity to explain why public services are so important to Labour, the values that would underpin our approach, and why we should be trusted to safeguard them for the next generation.
Devoid of a driving set of values, the Conservatives talk of diversity of provision, accountability structures and payment by results. They make public services sound like a series of transactions between people needing a benefits payment or a prescription with the state. But they are much more than this: they are institutions built over time, which embody the values we hold dear.
Our public services are the envy of the rest of the world, not just because of their quality but also because of these values of fairness and community they represent. Witness any British person explaining with pride the NHS principle of “free at the point of need” to a foreign visitor: everyone pays into the NHS through taxation and then everyone can use it when they need to. This principle is not just at the heart of the NHS, it’s a core British value: fairness. That’s one of the reasons we are so proud of the NHS, and one of the reasons we should protect it.
2. Protecting public services for those who play by the rules
There is nothing that offends our sense of fairness more than someone who breaks the rules the rest of us play by. It’s a common doorstep conversation: why should I pay my taxes and work hard when others milk the system? It’s unfair.
It’s the little things. Even though there are five million people on waiting lists for social housing, some people still rent out their council homes. That’s not fair. The NHS only has so many doctors, can only see so many patients. So those responsible for the 12.6 million missed GP appointments and the 4.3 million missed nurse appointments are not just wasting millions of pounds, they’re preventing people who really need healthcare from getting it. That’s not fair.
The public was frustrated with Labour’s perceived inactivity or inability to protect their system – the one they paid into, the one they value as a core part of their country – from being abused. They started to lose faith that services were protected for people like them. The more often principles of fairness are undermined, the weaker public support for public services becomes.
Labour should foster shared ownership of public services and encourage people to use them responsibly. This will both safeguard the system – and the principles that underpin them – for those who play by the rules.
3. Recognising we only get the right to spend taxpayers’ money if we spend it wisely
During 2010, Labour sometimes sounded like we thought all that mattered in public services was increased investment. To any question raised about quality or poor service, every Labour minister and activist had been taught to trot out the real terms increase in spending on key public services since 1997. We resorted to cheap political point scoring by deploying “Tory cuts vs Labour spending” dividing lines. In fact, they were more damaging to us than our opponents.
We must be wary of such political opportunism now too. Everyone knows it is disingenuous: if we had won the election, we would be cutting. Not as much, not as quickly, and in a different way, but we would be cutting. Further, the Conservatives have effectively won the argument that public service reform is not just about how much money you put in; it is at least as much about what you do with it. No evidence suggests that that the solution to cutting crime is to increase the number of police, or to improve health is to hire more nurses: it isn’t as simple as that. The public knows it is more complicated. To go on talking as if it is not, suggests either we think the public are stupid, or we are. Worse, it stokes the suspicion that we are cavalier with taxpayers’ money.
Public services are paid for by the public through taxation. We should respect how hard they worked to earn it and be as careful with their money as they would be themselves. This recognition – not a think tank-born obsession with diversity of provision – should provide the backdrop for everything we do to improve services and increase value for money.
4. Taking difficult decisions: fairness, responsibility and contribution
Projections suggest that in the next 20 years, we will need to spend an additional 4-6 per cent of GDP on public services just to keep up with the ageing population let alone increased expectations. The answer cannot be simply to plough ever more money in. The state can’t pay for everything. As demands on public services increase and people expect better service, government must make more and more choices about priorities. Again, principles matter as much as policies. We do not just vote for governments because of what they will do, but how they will do it. I can’t know what decisions will have to be taken in the next 5 years, but I do know that I want whoever is taking them to care about the same values as I do.
When the economy was growing it was easier to duck the issues: increased need was met with increased investment. Not anymore. Yet for all the talk of “painful decisions”, the coalition has said very little about how they are being taken. Instead, the Conservatives talk about who should take them. The ‘Big Society’ devolves these decisions to the lowest possible level but it is silent on the principles which should govern them. In reality, far from empowering local people, government is abdicating all its responsibility. It hardly seems right: we elect politicians to govern the country, but then they tell us it is actually not their problem, it’s ours.
Government should not take decisions in individual cases – that’s for professionals – but it must provide a framework. After all, if it was straightforward, it wouldn’t be political. How should GPs choose between giving drugs to a cancer patient and giving a child physiotherapy? How should a job centre worker choose who to give access to a training course? How should a local authority choose between services to fund? Labour should take the opportunity to initiate an open, principled, grown up conversation about how.
Of course need matters. Of course cost matters. But in addition, Labour’s guiding principle in taking these tough decisions must be fairness. From this point of view, responsibility and contribution should matter more than they currently do too.
In some areas of public service, we are already very clear about how and why we limit provision: for example, welfare recipients have to look for work; it’s only fair that if you’re claiming benefits, you should be prepared to take a job if one comes up. Responsibility-based funding and care decisions already happen at the margins in the NHS: for example, alcoholics prone to relapse are deprioritised for new livers.
But it simply isn’t fair that people who drink, smoke and do not exercise get free diabetes drugs whilst others who are born with chronic asthma have to pay for their prescriptions. It simply isn’t fair that people who have offended repeatedly get the same access to help as people who are first time offenders. Labour should make the case to extend responsibilities-based prioritisation across health, criminal justice and social housing. Forced to choose, guided by fairness, a Labour government should choose to prioritise those who are taking responsibility for their own lives if they can.
The contributory principle chimes with our sense of fairness too. It simply isn’t fair that someone who has worked all his life and has fallen on tough times gets the same dole money as someone who has never worked. The poverty trap – where the tax system disincentivises low paid workers to increase their working hours because such a large proportion of their extra earning are taken away by the taxman – is hated at least as much because it actually penalises people for contributing to the economy as it is about the money.
So Labour should make the case – again based on fairness – that in more areas of public services, contribution should matter more than it currently does.
Of course, as with any public service reform, the devil will be in the detail of our policies, and we will need to get it right. But people are drawn to political parties based on their vision and values. The current government has a weakness here, ripe for exploitation. Though to get to the end point will require detailed policy wonkery, the start has to be our values. After all, governments are elected to take difficult decisions. If Labour wants to look like the Government-in-waiting, we need to start setting out how we would make them.
Article image by Castaway in Scotland