6 June 2006
Changes in health and education are difficult and challenging but essential to deliver 21st century services to the public, Tony Blair has said.
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The most superficial way in which to conduct this debate about public services is to debate whether public servants are "to blame" or politicians are "to blame" for its challenges. The vast bulk of public servants do a great job, often in trying circumstances, which is why we are paying frontline workers more, employing more and safeguarding their pensions. The truth is we all have a common desire:to improve the service we offer.
But that’s not really the issue. The issue is: how do we do it? And the reason I am passionate about changing public services, making changes that are difficult and challenging, including learning from business and the voluntary sector where it is sensible, is because I believe in public services, believe in their ethos of fairness, believe in their purpose of serving the public so that patients whatever their wealth, pupils whatever their background, citizens whatever part of town they live in, get a decent service, delivered in the way the 21st century expects.
There is a basic deal here. Investment for results. I know that if having put in this extra money, we can’t show clearly, demonstrably that the service has got radically better, then the consent from the public for investment is in jeopardy. That is why change is not about attacking public services but saving and inspiring them. All the progress made from the transformation of results in primary schools to the lowest waiting lists in the NHS since records were kept - have been through change and reform. That’s why it must continue to be extended. And the services have got better. There is no doubt about that. You heard just now some stories from people out in the field about how their services have improved. But so have expectations risen.
Today, people want the service to be organized around them, not them around it. They want high quality service, tailored to their specific needs and at a tune and place convenient for them. One way or another virtually every modern Government round the world is struggling with this agenda of Reinventing Government and public service reform.
In the business world, adjustment to change comes through the market. You adapt or you go out of business. In the public services, the profit and loss accountability does not exist, at least in anything like the same way.
The purpose of public services is therefore to serve the public; and to do so equitably. So the value system - the ethos - of public services is different from that of business. Without public services like schools, hospitals, transport and police, only the wealthy could afford to get by. But in stating this - which is obvious - there is then a great pitfall, which, if we are not vigorous, we tumble into. It is true that the purpose and ethos of public services are different from those of business. However, how those public services are delivered, has many attributes in common with business. A service can be delivered effectively for the consumer or not. Cost effectively or not.
Resources spent effectively or not. People employed productively or not. In other words, the danger is that we use the obvious truth that the purpose and ethos of public services are not the same as business, to ignore the fact that, in many respects they do indeed operate like businesses; and in doing so, we confuse the ethos of public service, with the vested interest of keeping things as they are, failing to adapt to necessary change. Because the market doesn’t force such change, Governments look for alternative ways of replicating that pressure for change.
For us in Britain, we have embarked on a journey with several stages to it. We increased investment in the public realm. Per pupil spending will have doubled by 2008. The Health budget will have been trebled over the same period. And funding of the police is up 33% since we came to government. We set challenging targets for improvement, to ensure a return on this investment.
But recently we have moved increasingly from a centrally driven approach - necessary to address the worst of the problems we inherited - to try to make change self-sustaining by the use of incentives, user choice and contestability of service. Instead of Government having continually, and usually tardily, to catch up with the latest developments, the system itself should have in-built flexibility and capacity to push forward.
The idea is to put the user first, for example, the patient at the centre of the NHS; the parent and pupil at the heart of schooling. That is why market mechanisms choice, the encouragement of a range of different providers of a service, incentives, partnerships with private and voluntary sectors - have a key role to play. They are not contradicting the values of public service. They are actually helping make them real, retain their relevance, improve their implementation.
We have fashioned four central principles of reform. First, we focus on certain minimum standards of output, set centrally and driven across the system. Central targets met with a lot of opposition. But look at the results. Compared to 1998 84,000 more pupils leaving primary school this year can read and writebetter and 96,000 more pupils can do basic maths. In London, as a result of the London Challenge, no borough now has fewer than 44% of its pupils achieving five good GCSEs, whereas in 1997 nearly two thirds were achieving below this level.
Hospital waiting times have fallen drastically; maximum waiting times for operations have been cut from 18 months in 1997 to 6 months in December 2005, and 19 out of 20 people are seen in A&E within four hours.
It is hard to imagine this could have happened without the discipline exerted by targets. And where there is serious failure or consistently poor performance, for example in tracking foreign national prisoners, we have to be able to say so and drive change on behalf of the public. We have not been slow to intervene directly when that is required. Over 1,400 failing schools, for example, have been turned around and a further 200 closed since 1997 as a result of interventions following poor performance assessments from OFSTED. Second, we are creating mechanisms of user choice and power in health; in extending choice in schools; in direct voice in community policing. Third, providers must be allowed to contest provision and commission from different sources where they believe it to be in the interests of the user. The independent treatment centres; diagnostic centres; trust schools and academies; the expertise of both the voluntary sector and the private sector. Then, the money needs to follow these choices. This is the spur for improvement. The service responds to the demand of citizens and the payment follows the demand. It is not the state directing the resources, it is the citizen.
In all cases the funding remains invisible. The payment stands behind the transaction, progressively collected and distributed. And, fourth, the traditional patterns of working and demarcation between professions need to be broken down. Nurses are capable of prescribing. Since May 1 this year this has been massively expanded. GPs can take on functions like minor surgery and diagnostics that used to go to hospitals, landing on the desk of the consultant. Teachers now have the help of 152,000 teaching assistants. The traditional police force has been supplemented by 6,300 CSOs, rising to 24,000. Throughout the process of reform, there are certain maxims I have learnt. Put the consumer not the producer first. Learn from those at the frontline actually doing it. Question the system as well as just work it. Back public servants who take risks and tough decisions. Experiment and innovate. Money matters but it is never about money alone. Break down barriers between public, independent and voluntary sectors - they are often more about history than service. Let me put this another way: public services are not a monument, to be erected and then admired. They are living organisms, planted in the soil around them.
The institutions of 1945 were a deliberate and inspiring response to the challenges of their day. They were built on barren land, for a people whose immediate folk-memory included deep economic depression and the threat of invasion. They were created for a country that was hierarchical, stratified by class, ordered and deferential. Women tended to stay at home and half the workforce was employed in manufacturing. Government provided comparatively little in the way of services and people were grateful for what that got. The past, in the old saying, is a foreign country. The number of households in Britain increased by 30 per cent between 1971 and 2005. The number of couples divorcing has more than quadrupled since the 1950s. Pensions is a topic of crucial importance where people are living longer and with fewer in work to support them. The economy has changed shape - services now provide over two thirds of GDP.
This, along with better education - 42% now go on to higher education, compared to just 5% until the 1960s - has shrunk the old industrial working class. The middle class has bulged. Law and order and migration are being managed in a context revolutionised by globalisation and cultural change.
At the same time, the possibilities of the modern world would read like science fiction to any radical of 1945 vintage. Sometimes politics seems like it works to an accelerated clock. But its change is glacial next to the way in which everyday technologies have moved. The computing power of a microchip now doubles roughly every 18 months. Steam technology took a century to have its full impact. Electricity took 40 years. The impact of the information revolution has been almost immediate. This changes what is possible in public service. The range of treatments in health care is greater than it has ever been. There are new drugs, novel procedures. People have access to greater information. It is now common for a patient to arrive at the GP’s surgery armed with a small library of research on their condition. Nanotechnology will soon allow us to fit the computing power of today’s world into a unit the size of a sugar cube. This will allow us to tackle medical problems at the molecular level.
All of this means change in public services, and in government, to meet the challenges of change in the world, must be continual and, as far as possible, selfsustaining. And we need this because one thing has not changed: the need for public services.
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