This month, the think tank Reform have published a report criticising public sector commissioning. The title certainly doesn’t mince its words: Faulty by Design.
Long-term readers of this blog will know I’m generally pretty sceptical of these kinds of reports, and specifically the work of Reform. Some of this is natural defensiveness. When I read sentences that state ‘commissioners … do not possess the necessary skills’ (p.11) I feel attacked personally. But what I want to suggest here is that part of my frustration at these sorts of reports is about something more fundamental.
(Before I move onto the fundamentals, though, I can’t resist highlighting out the oddity of some points in the paper – for example where they disapprovingly note that 72% of local authorities are planning to cut substance misuse treatment budgets [p.23]. I’d love to know what the other 28% are planning to do, when public health budgets are being cut by central government by 20% up to 2020, at which point funding will reduce to zero. Or when they note that services to address homelessness are ‘commissioned by a plethora of providers’, when a provider is someone who is commissioned, not someone who commissions.)
One of the recurring themes on this blog is that while straightforward and honest thinking and writing – thinking to some purpose – should be the aspiration of all those involved in politics and policy, humans are complex, as is the world they make around them, and so we shouldn’t imagine there are neat, perfect solutions that don’t require compromise.
Without wishing to violate the first of those principles – that I should be straightforward in my thinking and writing – I’d suggest that the ontological model of the Reform writers is naïve.
There is a section entitled ‘Not knowing what works’, which is to misrepresent and simplify the mechanics not just of commissioning but public policy more generally. Public policy is not as simple as identifying a problem and then implementing a solution. Any issue will be fused with others, and any ‘solution’ will affect not only that one issue but those others too.
And in any case, it’s not that commissioners don’t know what works; it’s that this can’t be represented as an ‘intervention’, or even a set of interventions, that can be managed as part of contracts. This model of ‘commissioning for outcomes’ imagines a world of unilinear causality (if that’s a phrase): somewhere we you can pull a lever somewhere in the machine that is society, and then monitor and note the effects. But society isn’t a machine, and policies and interventions aren’t levers.
What ‘works’ in addressing substance misuse, for example, is a complex mixture of housing, employment, relationships, education, and any number of other factors that most people would simply refer to as ‘life’. No one organisation, no one ‘policy intervention’ can produce the relevant ‘social outcome’, to use the language of the report.
To be fair to the authors, they acknowledge that part of the problem is that the social world is ‘extremely complex’. But they still conclude the section by suggesting that there is a solution to this, and that it is ‘greater development of the knowledge base and better dissemination of existing expertise’, with the development of ‘what works’ centres seen as ‘a positive step’ (p.14).
That is, the problem is framed as one of ‘knowledge’: if only we did more research, we could develop the magic lever.
Instead, I’d suggest, we’d have better public policy if we realised that striving for perfect knowledge is futile as there are no magic levers, and the question we should be asking cannot be as simple as ‘what works’.
As such, the approach of this report and others can feel like a lament about the fact that the world doesn’t fit into boxes or categories, or that people don’t behave in easily modelled ways. When the report complains of the reality of STPs (p.35), this isn’t the fault of the idea of STPs, and it’s not something that a policy or structure can address; it’s simply poor management and people not doing their jobs terribly well. When, on the same page, the authors describe the tension between ‘what works’ and what the voting public want, we’ve got to the heart of the matter. Policy isn’t, can’t be, and shouldn’t be, simply about ‘what works’.
And just as there no magic ‘intervention’ that ‘works’, there is no ideal structure for public services. The report laments ‘the cost of fragmentation’ (p.20), but the fact is that the idea of seamless integration, or a definitive structure, is a chimera. The cake has to be cut somewhere, and there are pros and cons associated with every option. Anyone who has observed health policy for more than four years or so will notice the incessant back and forth of the size of administrative units. The grass may always seem greener, but it’s as if people are actually hankering after flowers that even the greenest of grass won’t produce.
A case in point is public health. The report complains that locating public health departments in local authorities ‘has stood in the way of integration elsewhere in the NHS’, but equally locally its ‘prevention’ function in the NHS would hamper its ability to shape key influences on health that sit within local authorities, like transport, housing, planning, licensing, schools, and so on.
There is simply no ideal policy on this, and yet the report uses the word ‘integrated’ as if it simply means ‘good’ when there will inevitably be choices of what and how to ‘integrate’, and there will be pros and cons to any approach. Setting aside the fact that ‘the NHS’ doesn’t really exist as an institution for a department to integrate with, we’d have to acknowledge that public health departments can either be ‘integrated’ with local authorities or ‘the NHS’ – unless of course you’re planning ‘integration’ of the whole set of public services. But rather than cutting the Gordian knot, this would create one, with different strands of complexity inextricably linked to one another. And even in that extreme example there would be a dividing line: we’d still have to decide what elements of life are ‘public’ and what ‘private’.
But at points in the document it really does seem that the authors imagine a world without boundaries or departments – of otherworldly ‘integration’. In fact the language is oddly spiritual, suggesting public services should ‘transcend’ current service boundaries (p.25). I can only assume they are imagining an all-encompassing ‘service’ (or ‘intervention’?), ‘commissioned’ presumably by some overarching ‘public commissioner’ – a leviathan of the police, community safety, social care, healthcare, transport, and so on ad infinitum.
To go back to a cake metaphor, it might seem like I’m having my cake and eating it – that I’m asking the impossible of the report’s authors as I criticise them for failing to provide a solution to a problem I think is intractable by definition. But that isn’t quite what I mean. I’m criticising them for noting the complexity of the world, and criticising commissioners for simplifying it, before they go on to simplify it in their own way, which is no more intellectually or practically justifiable.
Life is complex, and can be understood and arranged in an infinite number of ways. None of these ways is perfect, and the reality is simply hard work on the ground, not a magical policy or structure being delivered by government, policymakers or a think tank.
The report presents the idea of integrating health and social care (which is already an article of faith of STPs and the Better Care Fund) as if it is groundbreaking or will make all the difference, rather than focusing on the fact that this kind of development is simply difficult and requires hard work. There is no structure or approach that makes it easy.
And this is where my real unease with these think tank reports lies. They always feel like they are written by ‘policymakers’ or ‘wonks’, rather than people who actually have to commission, design or deliver these services.
There can be ‘integration’, but it won’t come from breaking down departmental boundaries or fiddling with commissioning budgets. There will never be a single department or budget where savings across every social policy field can be identified and pooled.
Instead, integration must come from the inevitable ‘plethora’ of commissioners and providers sitting together around a table and talking about the multiple needs of individual people, or groups of people, at a range of geographical levels. The levels and groups of people around a table will never be perfect, but there’s no need for a report explaining this. There’s just a need for people to talk to each other and get on with the work.