The centre cannot hold

When, in what feels like another universe, Chris Grayling awarded a contract for Brexit-related Channel ferries to a firm with no experience, or ships, there was much amusement, as well as downright despairing fury. This followed his destructive privatisation of much of the probation service: an utterly inept, and pretty catastrophic, intervention, which, in May 2019, even the Tory government realised needed reversal.

Now, we find the government’s ‘test and trace’ project is run by an ex-head of a mobile phone and wi-fi company, (Lady) Dido Harding, supported by the deputy chief executive-in-waiting of a bank, Tony Prestedge.  Rupert Soames, the chief executive of Serco, as ever one of the firms involved in parts of the programme, was quoted recently in the press. 

From the Guardian on 4th June:

“In an email forwarded to staff, which was then immediately recalled, a message from Soames said: “There are a few, a noisy few, who would like to see us fail because we are private companies delivering a public service. I very much doubt that this is going to evolve smoothly, so they will have plenty of opportunity to say I told you so.”

It continued: “If it succeeds … it will go a long way in cementing the position of the private sector companies in the public sector supply chain. Some of the naysayers recognise this, which is why they will take every opportunity to undermine us.”

So, obviously, it’s just a matter of political prejudice, isn’t it?

Well, no.

I’ll have to start with an admission. As it happens, I do balk at the idea of profit-making, of prioritisation of ‘shareholder value’, imbuing the delivery of vital public services. I think every penny invested should go into providing those services.  I also feel deeply troubled that the safety and wellbeing of thousands of vulnerable people in care homes, or receiving domiciliary care, are undermined by the vagaries of the market. There have been many bankruptcies and closures in those sectors. These have been influenced, obviously, by the price a battered local government system can afford to pay, thanks, of course, to austerity, and successive central governments’ starvation of funding. But it is also a product of the marketisation of these sectors, with Boards making decisions about the viability of their companies, rather than focusing on need.

One result of the combination of the scandalously low level of public resources available and the competitive market is that many of the staff in these systems – and in the current test-and-trace programme staggering into being – are paid the minimum wage. This, of course, is partly driven by the ‘market price’ for these services: but the low-wage and gig economies are characteristic of much of the private sector.  This is not just a comment on the conditions for the workers, which can be inhuman and appalling: it means that required skill-levels in the services are underestimated and undervalued and, very frequently, end up lower than what is needed.

So yes, I have political views on this. But my main concern is about effectiveness.  The wellbeing of our communities, of vulnerable people, and of our services depends on stability, consistency, learning from experience, and genuine expertise.

An absolutely central priority in the provision of health, social care and welfare is integration.  Parts need to be able to operate locally, carrying out their specialist roles, but within a wider community wellbeing strategy, guided by granular understanding of local conditions, and with a genuine capacity to work together.  At times of crisis, they also need to be able to be organised and deployed at regional and national scales, framed by a strategy that is both nationwide, and responsive to local circumstances.

The ruthless destruction of local government capacity, and under-resourcing of healthcare means that the UK has no such dependable system in place. Of particular concern at present, Public Health services have suffered, despite the intelligence, skills, and commitment of many staff.  These services have an intimate knowledge of local communities, expertise and a place in the system which makes them best placed to implement much of the Covid 19 strategy. But no real attempt to deploy, learn from, or indeed strengthen, what we have got, seems to have been made. 

So now we are awarding contracts for an absolutely vital part of the Covid strategy to a fractured landscape of people and organisations with no track record in the field. They appear to be focused on delivering a ‘call-centre’, ‘gig-economy’, and let’s face it, amateur, and by all accounts frequently pretty incompetent, model of service. In his leaked memo, Serco’s Soames used the expression ‘supply chain’, as if they were delivering medicines, toilet rolls, or towels.  This says it all, really: he just doesn’t get it. ‘Test and trace’ is a vital part of the work of health and social care, a part that needs to be intimately embedded in local systems, and delivered with skill and understanding. During this pandemic, countries as varied as Germany and Cuba have been able to rely on an expert, integrated system organised at local and national levels. They have delivered positive results compared to the UK’s dismal performance. We really do need to get off our superior, and collapsing, high horse, and learn from others.

But what of the bigger picture? A dog-eared jigsaw of health and social care services made up of fragmented provision, prioritising the delivery of contracts for split-off pieces of what should be more like a single picture, is not what we need.  Many attempts to create ‘integrated systems’ have been made over the last decade. Sadly, the fragmentation, and the very nature of the contracting process, means there has been little real success. 

If you’re beginning to find this dense and hard to follow, maybe nodding off, please bear with me.  Maybe take a break, a walk: that’s what I often had to do in the many years I grappled with this system!

Just imagine what it is like for a well-meaning committee to try to bring some coherence, common purpose and effective collaboration into being when there are so many providers to engage and organise together. Think about what will happen if they are each preoccupied with prioritising their own narrow performance targets and survival.  At the best of times, and particularly at a time of national emergency, managing such a complex and fragmented system as a whole, locally and nationally, would be nigh-on impossible.  On top of that, the central, national bodies that might have attempted to manage the system have themselves been broken up, and their capacity to lead and support undermined.  A thick curtain of out-sourcing, contracts and, yes, ideology stands between those diminished bodies and what needs managing.

A contracting culture depends on competitive tendering, with the issuing of specifications and standards, and processes of bidding and selection.  Inevitably, this leads to problems.  Those specifications can be of varying quality, often with little reflection of complexities of need, or the essential links between a particular service and the wider system.  The performance targets prioritised in a contract can lead to tunnel vision, to the neglect of the full picture of need, to the rigid delivery of specified, commodified services at the expense of responding to what is really required. Bidding organisations can make promises to deliver services to a quality and at a price that are unrealistic – sometimes knowingly, to get a foot in the ring, sometimes because they don’t really understand what is required.  At the other side of the table, intelligence, skill and subtlety in evaluating bids can be very varied.

Whatever else lies behind the questionable track record of companies such as Serco, G4S and Deloitte in delivering services, to the NHS, to the prison service, to the Department of Work and Pensions, etc, this culture has much to answer for.

Fundamentally, this marketised and over-complex system leads to instability and the erasure of learning from experience, as players win or lose contracts on the basis of short- term performance.  A simplified, stable system, involving long-term engagement with the community, within a coordinated network of services, is required. Such a system would be able to grapple with the challenges of delivering a quality service, build the relationships required, develop intelligence, identify problems, and take a sustained, strategic approach to improvement. Such a system would give us the best chance of managing challenging crises in the future.

Of course, in a ‘stable’ system, complacency can set in, but that can be dealt with far more easily than the problems of the current approach. Of course, too, public sector organisations can be dysfunctional, even corrupt; that, as we have argued elsewhere, requires attention – to the culture of performance management, regulation and leadership within our public services. And, without question, we need a variety of specialist voluntary sector organisations to contribute their expertise: but they need more stability, funding and support than the present system affords them. 

Private sector organisations, with genuine specialist capability in making and providing things for public services, will always have a role to play: but that is very different from breaking up what should be a publicly owned, coherently designed, integrated, stable and intelligently led system.  And their involvement needs not to be driven by idealisation – just look at the number of private companies that fail and collapse, let alone mis-serve their customers, as a matter of course, in a competitive system.  Track and trace, let alone our wider public services, should not be vulnerable to such a climate. We should all, including private sector bosses, listen to and learn from what happened under Mr Grayling’s watch.

John

7 thoughts on “The centre cannot hold

  1. What can I add John. Comprehensive analysis. I’m grateful to your spelling things out in this very complicated system. I would also like to add concerns particularly expressed by younger people, that they would in any event, not use any track and trace apps because there is so little trust that either Government or private bodies, would not use such systems as a wider surveillance of groups and communities to their own ends. I too would be wary. I believe that is exactly what has happened in China for example–that it was used for the benefit of preventing the spread of Covid 19, and that their Government decided to keep the app to spy on its people in general.

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  2. 👏👏👏 What a stunning critique of the ideologically-driven, deeply flawed policy of contracting out vital components of public services to private companies driven by shareholder value and short-term, bottom-line objectives and lamentably short of specialist or local knowledge. Thank you John for your post which so expertly identifies not just the patent political purposes of this policy (excuse the over-alliteration) but also the shortcomings of the processes involved and the managerial and operational shortcomings of the key players in the supply chain. Add to this the wilful neglect of local authorities and their partners in public health who have the local knowledge, networks and relationships to make things work on the ground And the charge sheet begins to fill up. No wonder the government struggles to keep its hand on the tiller and the various measures adopted to manage the impact of Covid-19 – e.g. test, trace and isolate – misfire.

    Integration of services is a laudable aim but very hard to achieve for reasons that are probably worth a post from somebody more experienced in these matters than I. The Blair snd Brown governments recognised that joined up problems need joined up solutions and exhorted services to combine. It was a struggle. Sectoral interests can be hard to reconcile, resources are jealously guarded and reluctantly shared, cultures not easily amenable to change. It did not need the pandemic to reveal the imperative for integrating health and social care and the recognition that it needs more than a change in name of a Whitehall department.

    The NHS is something of a leviathan so integration with social care could make it more so. What is important is to retain a local perspective on service design and delivery because it is at this level that people should be able to avail themselves of what is provided. It is also at this level that any blockages, leakages or other malfunctions need remedy. And more holistic approaches need to be applied. So let’s have a few trailblazers, pathfinders or some other metaphor for innovation, change and development which can be set up, tested and learned from. Something tells me that Manchester might not be a bad place to start.

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    1. Thanks Bryan. Helpful points – and I agree about the challenges of integration. For me, it’s less about structure (though that needs some attention). I think what’s more important is, if I dare use a much misused term, ‘whole system thinking’, based on genuine understanding of local communities, their resources, cultures and needs. And within that, determined building of joint vision, with the expectation of, and fostering of, collaboration, and relationships, supported by a far less commodified and industrialised approach to ‘specifying’ duties, roles and tasks. I agree that Manchester has much to teach us. The ‘Preston Model’: https://www.preston.gov.uk/article/1339/What-is-Preston-Model- also helps us build a picture of a way forward.

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  3. |Hi John. I am afraid you have lost me in the details of your systems analysis and I don’t have the time to take up your helpful suggestion of a walk at the moment. However, here is my immediate concern about about track and trace.

    There is a personal decision with regard to track and trace that any of us may have to face with very little time to reflect and I am wondering what your thoughts would be. I was taken aback recently to receive an answerphone message stating, “We are a Midlands Response Company undertaking trace and access. We have been given your details and need to make arrangements to come to your address.” My first thought was that someone I know has Covid and had passed on my details…..or perhaps unbeknown to me I have Covid. (It took some minutes to realise the company in question had been referred by my house insurers to investigate a problem with our drains. No interpretations please!) The point is it was a moment of visceral shock. And any of us might receive such a call in future months. How would we respond to knowing our personal details had been been handed over or to being asked to hand over details of people with whom we have been in contact?

    My thinking at the moment is that I would decline to give out contact details of anyone I had met. Instead, I would undertake to personally speak with anyone with whom I had been in contact and inform them myself of any health risk.(If I had seen a therapy client I would definitely not pass on details.) As I understand it, contacts are “advised” to self-isolate for 14 days but this is not mandatory. Presumably it would make no difference if someone were to hear from me rather than a Serco agent.

    I am alarmed by how much information we are being required to hand over “for the communal good” and the creeping power of the state. I am also concerned that track and trace is partly outsourced to Serco who have an appalling record for mismanaging information. Even before the track and trace system was properly up and running Serco had leaked the details of 300 of its own contact tracers. (Guardian 20th May)

    The problem we have around the handling of this pandemic is one of trust – or rather mistrust. And I am simply not prepared to trust Serco with personal details – mine or anyone else’s. What do other people think?

    P.S. “More or Less” on Radio 4 is doing some brilliant analysis of Government statistics – otherwise know as lies.

    Carol Baker.

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    1. I can well empathise with the shock of that call. And, though I’m sure there are many sensitive people signing up to work on the track and trace project, with the crude training they’re likely to have received, I wouldn’t be surprised if many people contacted would find it difficult to immediately distinguish the language of a real T&T communicator from a sewage firm representative, or, indeed some scammer. I absolutely share your concerns about privacy, and indeed professional confidentiality. I’d be less ambivalent if it were not outsourced – especially to a business like Serco – but the dilemma would still be there. If T&T was being carried out through, say, GP surgeries (properly resourced and supported by Public Health) I’d have a lot more confidence.

      Sorry you found the post so indigestible – and I hope the drain problem is rapidly fixed!

      John

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