Wednesday, 26 January 2011

NHS Reforms and 'Excellence in Policy-Making'

A few days after my last blog, government ministers felt the need to give a robust defence of their current plans for reforming the NHS. So I couldn't resist seeing how this contentious and admittedly radical policy matches up against the principles of excellent policy-making that I discussed last time. The question is, leaving aside political philosophy, how well-created is the policy itself?

I'll use the criteria of the DWP Model mentioned last time as a starting point (it's a different Department but the principles should still hold), with my comments against each:
Clear Objectives: OK here. The aim is to ensure that money follows demand hence improving responsiveness, and reduce overall costs in the process. The thinking has to be that reconstructing the system largely from the ground up should produce a much leaner (and hence cheaper) structure than the current one, even if GP consortia become quasi-PCTs with their own accountants and managers.
Outward Looking: Hmmm - unclear. How much stakeholder consultation went in to the development of this policy, and does any other nation have a similar health system?
Good Analysis: I'm sure the calculated savings work out, at least on paper, but less sure about the research that underpins them.
Well-Designed Proposals: A fairly broad criterion, but probably OK here.
Good Plans for Delivery: This is the criterion that comes closest to my point on Empathy - see below.
High-Quality Advice: Despite tight timescales, I'm sure DH can tick the boxes here.
Excellent Communications: They've done their best. It's the message rather than the medium that could be the problem.
Continuous Improvement: Yes in that piloting is going on, even if one suspects that decisions have already been taken.

OK, I'm sure this is unfair in that I've looked at these 'Excellence in Policy-Making' criteria only very briefly and subjectively, but it suggests a reasonable attainment against most of them.

But what about that extra factor of Empathy that I mentioned last time? What about the feelings and reactions of those affected by these proposed changes? Well:

  • GPs generally don't want it. Most GPs entered the profession to work with patients, not because they wanted to manage the NHS.

  • Managers and staff in PCTs and SHAs are largely against it, for obvious reasons.

  • Patients themselves probably don't care. They certainly want excellent service and treatment, but the systems and money that provide these are not 'visible'.

  • The General Public - if they understand it - are probably against anything they see as an attack on the NHS, even if they accept the need to reduce public expenditure.

In summary, a big FAIL here.

So will it work? Can the government drive through a policy that seems unpopular from every perspective? In practice, just because it fails this (modified) 'Policy-Making Excellence' test doesn't mean the government won't try to force it through. But they will need to brave the political unpopularity it will generate, and face the risk that the system will prove unworkable simply because no-one wants it to work.

I'm going to make a prediction: By sometime in 2013, when the current redundancy scheme has already reduced overall staff numbers, we will see the emergence of NHS Reforms Mk.2. These will present a compromise system, somewhere between what we have now and the coalition's current aspirations. Watch this space!


Check my web site at for more information and ideas.

Tuesday, 18 January 2011

Can We Evaluate Policy-Making?

This blog is part-inspired by a PMPA* session I attended last week, and partly because the subject has long fascinated me. The question is, can organisations evaluate and improve their policy-making functions, as distinct from the outcomes of the policies themselves?

It's all part of the cause-effect link articulated by many management models - and indeed by common sense. In order to achieve successful outcomes, we need to identify and improve the 'enabling factors' - what we do within the organisation which generates that success. For service delivery functions, these enablers are likely to include efficient processes, customer understanding, and skilled, motivated staff. But when considering the wider strategic picture, an organisation's (including government's) ability to develop effective policies also becomes a crucial factor. Doing the right things as well as doing thing right, you might say.

It is important here to distinguish between policy-making and the outcomes of that policy. These outcomes will become evident over time once the policy is implemented, assuming some realistic evaluation. But we need the evaluation of policy-making to be a predictor - if the policy fails it's too late then to ameliorate the process that created it. For such an evaluation to be meaningful we need some "proof of the pudding" before we come to the eating stage!

Poor policy decisions are not hard to find, the original Child Support Agency being a good (bad) example. In its original form, the system asked hugely complex questions of both the absent parent and 'parent with care', and relied on their cooperation in a system that benefitted neither of them. Little surprise that the system soon collapsed under its own bureaucracy, and has been extensively revised more than once since.

Good policy decisions can be harder to identify, but are generally recognised by those policies left unchallenged by successive political administrations. The use of community groups and volunteers to supplement, and sometimes replace, the role of social services might be an example. Despite the issues raised by current budget cuts, few would argue that such partnerships deliver benefits both in cost and service terms.

Between the two of course there are many grey areas inextricably linked to political belief. The coalition government's current 'Big Society' theme is based on the philosophy that the balance between public sector and third sector delivery needs to be shifted towards the latter. In such a situation there will be winners and losers, and hence many who fundamentally disagree with the strategy. But the policy development function - government's and others' ability to turn that strategy into successful outcomes - can still be evaluated separately from the philosophy itself.

So how do we do this? Essentially by learning from those previous experiences (good and bad), identifying the key components of good policy-making, and ensuring that we do these well. This is the basis of a model developed and now used by DWP, which in turn draws on Cabinet Office and National School of Government work in this area. Factors such as clear objectives, outward-looking, good analysis and excellent communications are amongst those considered, the principle being that these can be assessed either internally or via feedback from other stakeholders. And by understanding current capabilities in these areas, improvements can be identified and policy-making functions strengthened.

These models are generally good stuff, with many sound ideas embedded. But I have a caveat, something I think is missing from them, and the word I would use is Empathy. Understanding what it's like to be there, or to have this policy done to you. It's precisely why the original Child Support Agency system failed, and why poor policy decisions continue to be made. Essentially, those making or advising on policy are too remote from those on the receiving end, and don't sufficiently understand how people will react to their policies on the ground. Central government in particular has often been good at systems, less good at people.

Ultimately, this could be the make-or-break for Big Society. Assuming we understand its broad intentions, the practical policies we have seen so far are relatively small steps around encouraging more volunteers and central government "getting out of the way" in order to promote community ownership and empowerment. But so what? Society, big or otherwise, is made up of the population within that society, and can only be changed by changing 'hearts and minds' - attitudes and the way people behave every day.

Are the government's policy-makers good enough to deliver this? I leave the question for you to ponder.

Check my web site at for more information and ideas.

*Performance Management and Policy Association, linked to CIPFA

Wednesday, 12 January 2011

Value for Money: Do the Maths!

In these financially constrained times, can there be any public service organisation that isn't seeking better value for money? To deliver more for less? It's a theme beset with problems, partly around the difficulty and pain of any type of change, but also because the concept is such a nebulous one anyway.

To understand why, it's sometimes helps to break down Value for Money (VfM) into the 3 E's: Economy, Efficiency and Effectiveness. The following formulae show the definitions and the "maths" associated with these three terms:

In simple terms, we buy input (materials, staff time, other resources), which then use processes to deliver outputs, and it's the value of these outputs that matter, not just the quantity of them. So the net result is that Value for Money is the value of output (normally referred to as outcomes), divided by the cost of input.

But herein lies the problem: value and money are not measured in the same currency. Money is pounds and pence (or some other coinage), whereas value in the public service arena is something very different. This not the case in the private sector, where despite some increase in social responsibility, the bottom line still rules and hence value generally means more money.

Value in public services is the difference we make, how we change or improve people's lives. It's something akin to what David Cameron talks about when he wants to measure happiness. But these are intangible things; we don't have any standard units of happiness, let alone any conversion formula between these and money.

Value by definition is subjective. Like beauty, it lies in the eye of the beholder. Value for one individual or group may be very different from value as perceived by another. A public park may be hugely valued by some, ignored by others, and regarded as a nuisance by yet others (e.g. because of noise or dog fouling). So any measure of value must recognise the context, and who is judging that value.

There's a lot more to say on this (watch this blog for continued discussion), but the starting point for any evaluation - notice the word Valu(e) in there - of public services or social impact has to be an understanding of stakeholder perspectives. How do different individuals and groups perceive value, and what changes for them? And how do we balance the positive and negatives to determine the overall impact of our services? Robert Burns wasn't a manager, but he put it well in his famous lines:
“O would some power the giftie gie us
To see ourselves as others see us”

Check my web site at for more information and ideas.