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 4^th 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