David Boyle is the author of the new CentreForum report Turbo-charging Volunteering, and was the government’s independent reviewer for the Barriers to Choice Review (2013).
Why did costs rise so fast in public services, especially during the Blair and Brown years?
It is taken for granted that they will go up in the NHS as the population ages and treatments get more sophisticated. But why everywhere else?
There are various available explanations. The costs of targets, making organisations less flexible and less able to deal with variety is one. The way that poor outsourcing has allowed contractors to shift costs elsewhere in the system. There is also undoubtedly a way that the system, as currently organised, encourages a multiplicity of overlapping agencies, seeking out appropriate need.
But there is one explanation – let’s call it here the ‘co-production critique’ – which has had less debate on this side of the Atlantic. It suggests that costs rise when service users are encouraged to be passive recipients rather than actively involved in helping to deliver care.
The term co-production was coined by the Nobel prizewinner Elinor Ostrom. She was asked by the Chicago police to find out why, when they took their police off the beat and into patrol cars – and gave them a whole range of hi-tech equipment that can help them cover a larger area more effectively – did the crime rate go up?
This isn’t just a question confined to the police. It lies at the heart of why public services become less effective on the ground as they become less personal and more centralised. Elinor Ostrom’s team decided that the reason was because that all-important link with the public was broken.
When the police were in their cars, the public seemed to feel that their intelligence, support, and help were no longer needed. She called this joint endeavour that lies at the heart of all professional work co–production.
It explains that doctors also need patients, and teachers need pupils, and politicians need the public if they are going to succeed.
The critique was refined and radicalised in the USA by the civil rights lawyer Edgar Cahn. The big agencies pay lip service to the idea – the NHS is formally committed to co-production, without really understanding it.
It means that services are wasting all that knowledge, energy, experience and the ability to support each other. And the willingness to do so, not among everyone, but many people who feel there is a reciprocal element missing to our services. It is a version of the Big Society, but with some intellectual roots and depth.
It suggests that the reason our current services are so badly equipped to respond to a changing society is that they have largely overlooked the underlying operating system they depend on: the social economy of family and neighbourhood.
The mechanism that can unleash people’s willingness to play a wider, active role in the services they use is beginning to emerge, whether it is in community justice panels or time banks in health services, or co-operative nurseries. Or in a slightly different way of approaching professional support in social care, based on more informal solutions, like those used so successfully the Local Area Co-ordinators of Middlesborough and Derby.
But this is still on a tiny scale compared to what is necessary if we are going to humanise and re-energise services, so that they work more effectively. So here is the question: how can we roll out this kind of infrastructure in every public service on a huge scale?
Where do you start? My report, published today, suggests that all service contractors, public and private, need to be asked the following questions: How do you plan to rebuild social networks? How do you plan to encourage mutual support among users? And how do you plan to reduce the level of need for your service year by year?