Public Services 2.0
Essay and research project by Charles Leadbeater for Demos in the UK, concerning participative approaches to social care.
"With the think tank Demos I am launching a project in 2007 to explore the potential for public services to be designed to elicit user participation and contributions. Initially our work, funded by the Department of Health and the Improvement and Development Agency for local government will focus on highly participative models of social care, particularly those developed by In Control, a joint venture project between Mencap and the Department of Health. The project will explore how these highly participative models work and how they could be extended to cover all of social care and potentially over areas of public services such as health and education. We will also draw on international and city-based case studies. As well as a final report, which will be published in the Autumn, we plan a handbook for local authorities seeking to promote participative approaches in practice." (http://www.charlesleadbeater.net/orange-buttons/public-services-2.0.aspx)
From an article by Charles Leadbeater on the User Generated State:
"Five principles for Public Services 2.0
People are not consumers or users but participants
People will only become participants in creating service solutions if they play a much larger role in assessing their own needs, often through consultation with professionals and devising their own plans, for their care, education, re-entry into the workforce, long term condition management, local amenities.
In social care, for example, a large share of the system's resources are taken up with professionals assessing user need and then allocating services to them. Service users are largely passive in the process. The assessments use professional and bureaucratic language are beyond the grasp of most users. Filling out these forms is frustrating and time consuming for many carers: a Mori survey in Scotland found form filling was one of the most significant activities unpaid carers engaged in.
People will need simple to use tools to allow them to better self-assess and plan for their needs. In Bolton for example our design team developed a deck of cards for diabetics to use to self-assess they way they manage their condition and how it could be improved. In the Brazilian city of Curitiba, which has pioneered innovative approaches to participatory budgeting and service design, families in deprived neighbourhoods have been given comic books to guide them to self-assess their needs. Person centred planning techniques of the kind used in the In Control programme allow people to visualise the kind of life they would like to lead and how their care would have to be organised to make that possible. People make videos and draw pictures to explain what they need. All long term public service users whether in health, social care, education or welfare should be encouraged to self-assess and plan, using simple tools to help people visualise the support they currently get, the life they would like to lead and the kind of supports, formal and informal, that would require.
This process of self-assessment is often only possible with the advice and support of peers and professionals. At the moment professionals tend to assess people's eligibility in a formal, arms length process designed to ration eligibility to state services. A more personalised approach would require professionals to engage in a more informal but also more intimate conversation with clients, over a period of time to draw up and revise plans together, looking at solutions which lie beyond public services.
Giving users greater say will count for very little unless money and resources respond to these choices. The financial frameworks for public services will need to change to support greater participation. In social care, education and health that will mean taking a wider view of the total resources available for social care. If service users can be encouraged to become co-producers, with their carers, then they become part of the productive resources of the social care system not just consumers of those resources. The development of preventative and community-based care services, to relieve demand on professional and public services, will only be possible with long term growth in volunteering and scaling up the capacity of voluntary organisations. The unpaid and volunteer services, provided within families and the community, will be vital to the long run sustainability of the system as a whole. Helping to further develop that volunteer, collective, community infrastructure, should be a priority for social care investment.
Public sector budgets need to change as well with more joint commissioning of services and buildings. Councils commission many services - transport, care packages, meals - as block contracts to reap economies of scale that come from standardisation. External providers, including the voluntary sector, like such block contracts because they provide them with stability. Yet such block contracts can also mitigate against personalisation by locking resources into inflexible contracts. Councils would need much more flexible models of contracting that would allow people more choice over services.
But we also need something much more radical: give the money to the people and trust them to use it wisely. The experience of In Control is that users feel greater control when they can assess how budgets are being spent on their behalf. That also encourages them to take more responsibility for their care and to devote more of their time and effort to it. The key, however, is to find financial solutions that meet people's needs rather than following a rigid formula for disaggregating budgets. Direct payments and fully individualised budgets work for people when they have self-confidence to make choices, the information they need to compare options, advice and support from peers and professionals. However handling direct payments, including employing your own staff, also brings anxieties and responsibilities that many people do not want. Indeed some clients given an individualised budget may choose to spend it on the service they are already receiving. People should have a range of options for how budgets are distributed, with direct payments and individual budgets at one end of the spectrum and traditional services and top down budget allocations at the other.
Most public services are a public-private finance initiative at the micro level of the family, mixing private, family, voluntary and state resources. The same is true of care for people with long-term health conditions and investments in education. An effective public service would mobilise all these resources not just the state's portion.
Professionals and workforce reform
Participative public services will only work with the support of staff as well as clients. Professional opposition to ceding control to clients or pupils who "cannot be trusted" will be one of the major obstacles. In many settings people will still want a professional solution. Someone going into hospital with a hernia does not want to be an active participant in the operation. They want to be well served by well-trained professionals. But often we need professional support to find our own solutions rather than a professional service upon which we come to depend. Indeed more participative approaches which relieve some of the management burdens from the shoulders of professionals may allow them to get back to their original professional vocation rather than acting as risk assessors and gate keepers.
Professionals would still play a critical role within a participative system but they would have to give up some of their power in exchange for a better quality of work. They would have to share assessment, planning and risk assessment with clients. They might have to accept working alongside para professionals.
Professionals would play several roles as :
- Advisers, helping clients to self-assess their needs and forge plans for their future care.
- Navigators, helping clients find their way to the services they want.
- Brokers, helping clients to assemble the right ingredients of their service package from different sources.
- Service providers, deploying their professional skills directly with clients.
- Risk assessors and auditors, especially in complex cases involving vulnerable people who might be a risk to themselves or other people.
Take social work as an example. Social work could be made more attractive and satisfying as a profession if social workers had less management responsibility, paperwork and bureaucracy. Yet that would mean social workers ceding management control to others. The development of para-professionals, such as social work assistants and expanding the role of care workers, would relieve some of the burden on social workers who sometimes seem to do jobs they are over-qualified for. The re-design of the role of social workers would need to trigger a re-design of the skills, responsibilities and roles of the wider social work workforce, including managers, para-professionals and unpaid carers.
Creating a wider market for services
There is no point giving users greater say over the services they want and even the budgets to commission services if supply is unable to respond to shifting demand. Participation in planning public service provision will mean nothing if services are trapped in rigid blocks, as in the case of Wigan's taxi service to take Joe to school.
The following principles should guide how services are organised to support participation:
- Flexibility, so that provision can be reconfigured easily to meet shifting needs. If service resources are tied up in inflexible contracts or in building based services, they will not have the flexibility needed to meeting changing demands.
- Integration, so that different services - housing, social care, health and education - can be combined, to create a joined-up experience for service users. That will require more joint commissioning of services, more joint planning of provision and more work in partnership between different services. People with complex needs rarely find the services they want within a single department or even within a single local authority. They need support from several different sources. Those supports need to be integrated to be effective.
- Variety, to provide people with real choice over the style of provision. Choice between two standardised services is no choice at all. People should be offered a variety of modes of provision, which might for example, demand more or less of them as participants.
- Innovation, so that they social care system develops new service options for people. A prime example is exploring the role digital technologies might play in more personalised, home-based care support, by allowing more remote monitoring of the health of frail and elderly people to allow more timely interventions to prevent crises or respond to them more effectively.
Participative and personalised public services will require far more flexible use of resources to give users more say over the services they get so that differing needs can be met in differing ways.
New measures of success
Too often public service users and staff report that the measures of success reflect macro performance targets and budgets that pay too little attention to user experience of services. Feedback loops in public services are very extended. Service improvement is not driven by direct user choices or complaints but by external regulation and reviews of services, acting at one remove, often after the event.
More participative approaches to planning services would only work if the participants also define more of the standards and outcomes. We need more person centric measures of success in education, health and social care, to complement the top down and macro measures of targets and standards. User panels should be more directly involved in the formal regulation and inspection of services. Users also need more effective direct triggers to force a change in services when they fail to meet agreed standards. Some public service users feel they have no option but to accept the service that is available, no matter how bad it is. Users need to be given a right to options, such as direct payments or individualised budgets, to be able to commission alternative provision if the public services they are getting do not come up to scratch. Imagine the eBay rating system applied to public service provision, or a service like TripAdvisor, the travel site where people rate and comment on hotels they have stayed in. Public services users need similar sites and services
These five themes should be at the heart of more participative approaches to public services:
- Tools to give users more choice and voice, to encourage them to become participants in shaping the services they get and so to take more responsibility for them, investing their own resources and ideas in better outcomes.
- A new financial frameworks to encourage investment in community-based prevention, allow integration of different public service budgets around shared social goals and devolve more spending directly to users so services are commissioned around their plans. At a micro level of the family all care, welfare, health and education is a public-private finance initiative.
- A new division of labour within public service workforces, with the growth of para-professional assistants, support workers and managers, that will in turn allow a revival in professional vocational roles. social work based around the roles of adviser, navigator, advocate, broker, counsellor, risk assessor and designer. - Continued development of a mixed economy provision so that user choices can be translated into service provision. That will require services that are more flexible, integrated, diverse, innovative and cost-effective.
- New measures of performance which give users greater say over service quality and new rights for users to switch services when quality falls below an agreed threshold." (http://www.charlesleadbeater.net/archive/public-services-20.aspx)
"We need a new way to create public goods that take their lead from the culture of self-organisation and participation emerging from the Web that forms a central part of modern culture, especially for young consumers and future citizens. Increasingly the state cannot deliver collective solutions from on high: it is too cumbersome and distant. The state can help to create public goods - like better education and health - by encouraging them to emerge from within society. The tax system increasingly depends on mass involvement in self-assessment and reporting. Welfare to work and active labour market programmes depend on the user as a participant, who takes responsibility for building up their skills and contacts. Neighbourhood renewal has to come from within localities, it cannot be delivered top down from the state. Public goods are rarely created by the state alone but by cumulative changes in private behaviour.
The chief challenge facing government in a liberal and open society is how to help create public goods - like a well educated population, with a appetite to learn - in a society with a democratic ethos, which prizes individual freedom and wants to be self-organising and "bottom-up". Government cannot decide on its definition of the public good and impose it from above, at least not continually. But nor can it stand back and accept whatever emerges from self organising systems. Government's role is to shape freedom: getting people to exercise choice in a collectively responsible way and so participate in creating public goods.
Productivity should rise because highly participative services can mobilise users as co-developers and co-producers, multiplying the resources available. Participation allows solutions to be tailored more readily to individual needs and aspirations; people have to share responsibility for outcomes and devote some of their own inputs. Participation is the best anti-dote to dependency if they equip people with tools so they can self-provide and self-manage rather than relying on professional solutions and services. Participative approaches are not only vital to create more personalised versions of existing services - like health and education - but also to address emerging needs and issues - such as waste and recycling, community safety and long term conditions - where public outcomes depend on motivating widespread changes to individual behaviour. Participative public services connect the individual and the collective in new and far more powerful ways than seeing people as taxpayers, occasional consumers and even more infrequent voters.
The triumph of the modern industrial public sector is is the creation of institutions on a vast scale, which provide services such as education, health and policing, that were might have once been limited to just a few. These universal systems aspire to deliver services that are fair and reliable. Yet that in turn requires codes, protocols and procedures, which often make them dehumanising. After Ivan Illich trained as a priest he went to work in a poor Puerto Rican neighbourhood in New York and he was struck by how many other institutions seemed to be modelled on the church and how many professions seemed to take their cue from the priesthood.These institutions and the resources they control become the power base for the new priesthoods: the public service professionals.
The dominance of professions, creates two big problems, according to Illich: counter-productivity and dependency culture.
As people become more dependent on the expert knowledge of professionals so they lose faith in their own capacity to act. The rise of professional power is mirrored by a loss of individual responsibility. We become cases to be processed by the system. Education and health come to be commodities to be acquired rather than capabilities we develop in ourselves to live better lives. We now identify services delivered by professionals with the ultimate goods we want as a society: health, learning, safety, order, justice.
First, public institutions and professional should educate us towards self-help and self-reliance as much as possible. As Ivan he Illich put it in Deschooling Society in 1972: "Good institutions encourage self-assembly, re-use and repair. They do not just serve people but create capabilities in people, support initiative rather than supplant it." Almost thirty years later the Wanless Review of health spending reached exactly the same conclusion. We will only become a healthy society if we restore the proper balance between professional service and self-help. The golden rule must be that instruction by professionals must never outweigh opportunities for independent learning; any service must be designed to motivate and enable self-help.
We need much greater emphasis on intelligent self-assessment and self-evaluation. That is already the lynchpin of the tax system and should play a greater role in education and health. The education system schools us to think of assessments as exams, something we do at the end of the pipeline, checked by a professional. We need an education system that builds up capacity for intelligent self-evaluation, so that we are better equipped to assess and solve problems under our own steam, with the help of our peers and professionals if needed. An education system for the 21st century would have constant self-evaluation, much of it through peer to peer criticism and support, at its core.
In Limits to Medicine Illich described goal of making health as a personal task, which people must take responsibility for for this way: "Success in this personal task is in large part the result of the self-awareness, self-discipline, and inner resources by which each person regulates his own daily rhythm and actions, his diet and sexual activity...The level of public health corresponds to the degree to which the means and responsibility for coping with illness are distributed among the total population."
These ideas are not appropriate to every aspect of public services. People in need of urgent and acute surgery do not generally want to be participants in the process: they want a good service, delivered by professionals. Too often the ethic of self-help can be used to get us, the users, to do more of the work ourselves. Self-service is not the same as participation.
Yet the range of ways we can create public goods is expanding. In energy, for example, nuclear power might provide part of the solution to global warming but so too could highly distributed, domestic micro-generation. Schools and hospitals will continue to exist but in an environment where more learning and health care can be delivered, informally and at home. People will want to be consumers some of time, participants at other times, when it makes sense for them. (http://www.charlesleadbeater.net/archive/public-services-20.aspx)
Government 2.0: research project by Don Tapscott