Big Society: big break or big bore?

Few of us who work in the public engagement world could fail to have been intrigued by the new government’s apparent enthusiasm to involve The People in its decision-making.  Intrigued, and in most cases I suspect, more than a little sceptical.  Do they really know what they are letting themselves in for? And do they really mean it?  Is public consultation finally going to earn its place in the sun or is it going to be trampled underfoot in the rush for the exit?

Consultations – A Thousand and One Commitments (not quite)

So it was off to the Consultation Institute to find out more about the new government’s plans for public engagement.  It was a lively session aimed mainly at professionals in the public sector who are responsible for running consultations with a few private sector consultants thrown in for good measure.  The Institute has analysed the government’s plans and has managed to find 31 commitments to review, 11 to consider, 10 to investigate, 6 to explore, 4 to examine and a whole raft of policy areas which programme director Rhion Jones described as “consultation significant”.  Regular readers may be interested (and unsurprised) to note that top of the list are communities, environment, energy, health, schools and transport as well as government transparency and political reform.  So is it an exciting new dawn for public engagement for those of us working in the field?

Where Are the Bodies Buried?

Working on the premise that it is good to start as you mean to go on, let’s take a look at the government’s first big discussion with the public:  Spending, or rather the Ending of Spending.  Clearly there is no time to waste on this one and government has wasted none in writing a couple of weeks ago to six million public servants to thank them for all their hard work and ask them to go online and tell them where the bodies are buried – or at least grass-up their colleagues for wasting money on new coffee machines, buying overpriced staples or taking up space with their presence in a town hall backroom.  A fine example of the benefits of mass engagement through new technologies.  Maybe this should operate like the Public Disclosure Act and people should be required to tell their managers of their unvoiced concerns before rushing off to tell Messrs Cameron and Clegg, but then again, that would slow down this very speedy consultation process.  We at MAC always encourage our clients to provide attractive incentives and rewards to consultees.  A two year pay freeze and the chance of a place near the front of the dole queue (for yourself or a friend) was not exactly what we had in mind.

Semtex Shake Up

Time is understandably of the essence for the new government and evidence to date would suggest that there won’t be much pussy-footing about with 12 week consultation periods. Just remember how much consultation has taken place around the launch of Free Schools all set to kick off next term. Precisely none.  Not much respect for the old adage that consultations should probably wait til everyone gets back from their holidays either.  Most of the big decisions about spending will have been made by the end of August.  But perhaps this is no bad thing.  As Rhion Jones said, if the last fifteen years had shown that institutions had perfected the art of good consultation and engagement we might be seriously worried, but perhaps this whole consultation business needs a bit of Semtex under it.  MAC partners have often had to deal with raised eyebrows when we suggest “quick and dirty” consultations.  They  are often just what is needed and work well as long as you talk to the right people and ask them the right questions.  (Perhaps something a little more revealing than Yougov’s recent  question about getting rid of “unnecessary” bureaucracy which produced a stonking 97% approval rating).  Of course the real answer is to create an ongoing dialogue in which a consultation is just a part of the relationship not an expensive one-off event – but that more mature approach may have to wait a bit.  MORI provides some very useful practical advice on how to get the public on board in these discussion in its post budget Tough Decisions setting out its top ten tips on priority setting with the public.

Big Decisions Little People

With the public sector being cut so fast and so ruthlessly from above is anyone going to have time or the will to stop and listen to what ordinary people have to say?  And will they know what questions to ask them?  It looks pretty much like the big decisions have already been made at government level and they are being made right now in town halls and primary care trusts as I write.   Even if some “real” people do manage to make their voices heard above the storm, it will probably be the ones who shout loudest and the ones we have heard before.  The voices that will be drowned out will be those of the most vulnerable and the those most likely to be adversely affected.

A Third Want In

There may be little room for the sort of consultation we all want to see over the next few months.  I guess I am not the only one who fancies a holiday.  But we need to take some heart from the fact that the government is still making noises about wanting to move decision-making closer to the people.  Big Society may not have gone down so well with the press but there is some evidence that real people are attracted to the idea.  According to MORI, about a third of the population wants is involved or wants to get more involved with a further  third wanting to be kept properly informed.  Several delegates at the event highlighted the importance of getting councillors, health board non-execs and other key local “public” players to champion this work within their organisations.  The challenge for all of us may well be to find new and better ways of “doing” engagement and consultation and, yes, spend less time and money on it.    High value engagement is what we need – engagement that asks the right people the right questions at the right time and which leads to real change and real improvements.  So no more empty halls, stewed tea and uneaten biscuits please!

The painful truth

“Text cloud” for this post below, created by www.wordle.net

US scaremongering is a distraction

“The painful truth about the NHS” as Marjorie Ellis Thompson said in a thoughtful Guardian comment piece recently,  is that scaremongers in the US are distracting us from the real debate about British healthcare:  “What is important is that we acknowledge the need for adaptation and change without sacrificing the central principle of equal access to healthcare, an argument that apparently terrifies those who are lucky enough to be insured in the US.” Quite so, but how to do it?

This is a stiff challenge for citizens to get to grips with because it has got harder recently to have a serious discussion about the NHS without tripping over some politician or other trying to shout louder than the rest.  If it isn’t a maverick MEP hurling vitriol about the NHS being a “60 year mistake”, then it is the Health Secretary’s sanctimonious rebuttal to such talk as “unpatriotic”. Did no one forewarn Mr Burnham of Dr Johnson’s pungent observation “patriotism is the last refuge of a scoundrel”?

Caught in the crossfire

All in all, this is not a pleasant crossfire to be caught in. The big guns are out for points and the sniping isn’t likely to die down much between now and upcoming election.  Most people will keep their heads down.

Donning my tin hat and venturing above the parapet nonetheless, I too see a painful truth about the NHS -  in the form of the shackles that bind it to party politics of all persuasions.  There will be no resolution to what passes for “the debate on the NHS” as long as political parties still have breath in them.  To have a proper debate, we need to separate “health” from “health systems” which are about delivery.

Health is not delivery

“The NHS” is just a delivery system, albeit one that has assumed the position of a surrogate national religion.  It was created out of a now-vanished post-war context to address issues like communicable disease (think TB and diphtheria, not swine flu) and the debilitating effects of grinding poverty on large sections of the population.

To be fair, it has delivered quite a lot in its 60 years – far more in fact than Beveridge, Bevan and the other founding fathers could have foreseen. But continuing to tinker with its basic design has little impact on the underlying factors - economic, educational and behavioural - largely determining the health of individuals and communities.

Outcomes matter for health

What we really need to be debating is not another ratchet of system reform, but something which is more fundamental: what do we really want in terms of health outcomes? Once that is clear, and no one should pretend it is an easy question to answer, then the job is to build new systems to encourage, incentivise and deliver those goals. Politicians should be facilitating that conversation rather than indulging in quasi-patriotic sloganising – or worse “twittering” – about who is better at loving the good old NHS.

Sadly, the 1948 model however much we flash it up in contemporary livery and lavish love on it is never going to deliver enough of what is needed. Other models in other countries have feet of clay too, so this isn’t a paean of praise for any one of them.

Thinking about ends is hard work

As informed citizens we should be addressing three questions: “what is a health system for?”; “who should be its owners?”; and only when there is a consensus on the first two, “how should it be paid for?” These are mainly questions about ends not means. It is our almost universal preoccupation with “means” that keeps the real issues in the background. Until they come centre stage, expect confusion and frustration to be the main outputs from the current “debate”.   And expect the politicians to shout even louder.  Ear defenders anyyone?