Queen’s Speech

Lord Bichard Excerpts

Wednesday 3rd June 2015 Lords Chamber

[Lord Bichard (CB)]

My Lords, a new Government and a first gracious Speech provide an opportunity for us to revisit some of the most intractable of our problems. My particular hope is that the Government think long and hard now about how better to reform our public services, especially those which we are debating today.

Few people do not believe that reform is still needed. Successive Governments have tried, but what really matters is that, from the citizen’s perspective, the user’s perspective and the patient’s perspective, the results have been disappointing. It is true that, recently, the lack of resources has made the task even more difficult, but the problem is not primarily one of resources. Too many of the services that we provide are unnecessarily complex and therefore very difficult to access—we have heard many examples of that already today. Too many make more sense to the providers than they do to the users, too many provide poor value for money and some just do not work very well. If that sounds too pessimistic, your Lordships should take an honest look at the availability and quality of much social care, take a look at the extent to which the NHS is truly patient centred, and ask themselves whether improvements in educational attainment have kept pace with our international competitors.

So why have we not been more successful, in spite of all the effort and good intentions? Perhaps we continue to place too much emphasis on changing the structures of our institutions. Few people now would deny that the Health and Social Care Act 2012 was a classic example of that. As the noble Baroness, Lady Morris, pointed out, quite rightly, all the evidence suggests that structural change does not make that much difference to quality; in fact, it often demotivates the staff who can make the difference. At the end of the day, it is the quality of teaching in the classroom and the quality of nurses and clinicians that make the difference.

Perhaps we have continued to place too much reliance on regulation and inspection, which can only ever describe services, never improve them. Perhaps, in spite of all the protestations, we are still too fond of centralisation, prescription and intervention when things just do not go according to plan. Perhaps the many targets we have set from the centre have served to confuse rather than to clarify priorities. It may be that creating ever more specialist agencies has made it more difficult for teams to work effectively together at a time when few, if any, of our social problems can be resolved by one department or agency working in isolation.

What I am sure of is that if all we do is to continue with these same approaches, then we will get the same disappointing results. Is there a better way, a way we could do things differently? I think that there is, and that some of the things that we can do are really quite simple. For example, instead of constantly beginning any process of reform by thinking about how departments, agencies and authorities should change, we might start by looking more closely at the experience of users and what they really need. Having spent more time understanding that better, we might try and design services and policies around users’ needs rather than around our bureaucratic boundaries. We might try and make those services more accessible, seamless and reliable.

We could certainly do much more to involve users in the design of services and the development of policy at an early stage, instead of leaving it to belated and sometimes meaningless consultations after decisions have already been taken. We could, in other words, seek to achieve a genuine process of co-production. In doing all that, as the noble Lord, Lord Giddens, suggested, we could do a lot more to integrate technology into the design of our public services, building on the excellent work of the Government Digital Service: using technology as a way of giving people more power but also as a way of giving them greater personal independence and improving the quality of our services. We could and should be much more imaginative in drawing on and supporting the potential which I believe exists in every place and community, so that people become less dependent on the state and more able to provide together for their own needs.

Am I optimistic? There is some hope. The Care Act, which came into force only on 1 April, does seek to build around the needs of clients, not the convenience of providers. It talks about building on users’ strengths, not just assessing their weaknesses, and points towards the need for co-production. It needs more resources, and I for one cannot understand why we always talk about protecting the health resource, but never the health and social care resource, which is what we actually need to do. This is a piece of legislation which I hope the new Minister will give real priority to, because it will not only bring benefit to the users of these services but could offer a new model for our public services.

However, in ending, I contrast the ambitions of the Care Act with the way in which we provide financial support for those in need of care. They, or more usually their dependants, have to struggle still with a complex, confusing maze of bureaucracy, involving: the Department for Work and Pensions, which provides lower and higher-rate attendance allowance; local authorities, which provide or commission domiciliary or residential care; and the NHS, which provides continuing healthcare. This is a system full of perverse incentives and different assessment arrangements, some means-tested and some not. It is a system designed by bureaucrats for bureaucrats and makes no sense at all to users. If you look on the internet, you can see that the system has spawned an industry of companies that are offering paid-for advice to vulnerable people on how to obtain the best deal from those bureaucracies. On top of all that, it wastes taxpayers’ money. If we really did design services with users around the needs of users, we would never end up with such an unsatisfactory set of arrangements. Beacons of light are all very well, but we need user-led services to be the norm.