The Reform of Social Services: The Reform of Social Services: Problems, Pitfalls – and Prizes , Julian Le Grand London School of London School of Economics New Zealand 2014
Central Problem of Social Service Delivery • How to improve the effectiveness of social services (school education, higher education, ( g health care, social care, etc). • Do poor providers (hospitals schools • Do poor providers (hospitals, schools, children’s homes, social work offices) need incentives to improve? Or is the provision of h f incentives irrelevant – or actually damaging?
SOCIAL SERVICES: DIMENSIONS OF EFFECTIVENESS • Quality • Efficiency Efficiency • Responsiveness • Equity • Accountability? Accountability?
Motivation: Knaves and Knights Motivation: Knaves and Knights ’ In contriving any system of government, and fixing the several checks and controls of the constitution, every man ought to be supposed a knave and to have no other end, in all his actions, than private interest. By this interest, we must govern him and, by means of it, notwithstanding his insatiable avarice and ambition, co-operate to the public good ’ David Hume
MODELS OF SOCIAL SERVICE DELIVERY • TRUST • MISTRUST MISTRUST – Targets and Performance Management – Regulation • VOICE VOICE • CHOICE – Reputation Competition – Public Service Mutual Public Service Mutual
% patients waiting for hospital admission > 12 months % patients waiting for hospital admission > 12 months 30% 25% onths aiting > 12 mo 20% England 15% Northern Ireland Northern Ireland % patients wa 10% % 5% 0% 0% 2000 2001 2002 2003 2004 2005 Source: Are improvements in targeted performance in the English NHS undermined by gaming: A case for new kinds of audit of performance data? Gwyn Bevan and Christopher Hood, British Medical Journal (forthcoming)
% patients waiting for hospital admission > 12 months % patients waiting for hospital admission > 12 months 30% 25% onths aiting > 12 mo 20% England Northern Ireland 15% Scotland Scotland % patients wa Wales 10% % 5% 0% 0% 2000 2001 2002 2003 2004 2005 Source: Are improvements in targeted performance in the English NHS undermined by gaming: A case for new kinds of audit of performance data? Gwyn Bevan and Christopher Hood, British Medical Journal (forthcoming)
% patients waiting for hospital admission > 12 months % patients waiting for hospital admission > 12 months 30% 25% onths aiting > 12 mo 20% England Northern Ireland 15% Scotland Scotland % patients wa Wales 10% % 5% 0% 0% 2000 2001 2002 2003 2004 2005 Source: Are improvements in targeted performance in the English NHS undermined by gaming: A case for new kinds of audit of performance data? Gwyn Bevan and Christopher Hood, British Medical Journal (forthcoming)
% patients waiting for hospital admission > 12 months % patients waiting for hospital admission > 12 months 30% 25% nths ting > 12 mon 20% England Northern Ireland 15% 15% % patients wai Scotland Wales 10% % 5% 0% 2000 2001 2002 2003 2004 2005 Source: Are improvements in targeted performance in the English NHS undermined by gaming: A case for new kinds of audit of performance data? Gwyn Bevan and Christopher Hood, British Medical Journal (forthcoming)
% Patients spending less than 4 hours in A +E % Patients spending less than 4 hours in A +E 100 80 60 % 40 20 0 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 2002/03 2003/04 2004/05 2005/06 + 24% increase in A+E admittances 24% i i A E d itt Source: Chief Executive's Report on the NHS - Statistical Supplement (December 2005)
Competition in health care: Evidence from UK. • Following roll out of choice in UK, AMI mortality dropped faster in more competitive y pp p areas (Zack Cooper, Carol Propper). • Introduction of ISTCs (Independent Sector • Introduction of ISTCs (Independent Sector specialist treatment centres) led to technical efficiency improvements in NHS competitors ff (Cooper) • Expansion of market since 2008 to include any willing provider: no further improvement? willing provider: no further improvement?
Waiting times: an equity problem Waiting times: an equity problem 200 195 190 The poor waited up The poor waited up 185 to to 30 30- -days days longer longer 180 than the wealthy than the wealthy 175 170 165 160 155 150 145 I I II II III III IV IV V V Level of Deprivation ( V = Most Deprived Quintile)
Hip replacement broken down by deprivation: Impact of targets and deprivation: Impact of targets and choice 300 250 200 I II 150 III IV 100 V 50 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Year
Parental Choice in New Zealand Parental Choice in New Zealand • 96% of parents indicated they would like to select 96% f t i di t d th ld lik t l t the school their child goes to • 80% of parents agreed that education should be • 80% of parents agreed that education should be funded such that parents can afford to send their children to the school of their choice. • A higher proportion of parents with annual income of $30,000 or less strongly agreed with the statement than parents with an annual income of t t t th t ith l i f over $30,000. • Source: Steven Thomas and Ruth Oates The Parent • Source: Steven Thomas and Ruth Oates The Parent Factor Report Four: Access to Education. Auckland: the Maxim Institute, 2005
Minorities and Choice in the US Minorities and Choice in the US • 52 per cent of parents, and 59 per cent of public school parents, supported school p p pp choice. • 60 per cent of minorities supported vouchers. • 87 per cent of black parents aged 26 ‐ 35 and 87 t f bl k t d 26 35 d 66.4 per cent of blacks aged 18 ‐ 25 supported vouchers.
Who wants choice UK: Gender Who wants choice UK: Gender 100% 100% 80% 69% 69% % saying people 56% 60% should have a great deal or quite a lot of d l it l t f say over which hospital 40% to go to if they need treatment treatment 20% 0% Men Women
Who wants choice UK: Social Class h h l l M Managerial i l and 59% professional Intermediate 64% occupations class % saying people y g Self- Self social c should have a great 64% employed deal or quite a lot of say over which hospital Lower to go to if they need supervisory i 62% treatment & technical semi routine 67% 67% and routine 55% 60% 65% 70%
Who wants choice UK: Income h h 70% < £10,000 % saying people should have a great deal or quite great deal or quite £10,000 - £10 000 65% income £32,000 a lot of say over which hospital to go to if they need g y £32,000 - £32 000 i 57% treatment £50,000 59% >£50,000 0% 0% 20% 20% 40% 40% 60% 60% 80% 80% 100% 100%
Who wants choice UK: Educational Achievement h h d l h None 69% on al qualificatio GCSE/O 67% Level % saying people t educationa should have a great h ld h t deal or quite a lot of say over which A Level 59% hospital to go to if Highes they need treatment Higher 56% 56% education 0% 0% 20% 20% 40% 40% 60% 60% 80% 80% 100% 100%
London Choice Pilot: % opting for an alternative hospital 100% 80% 73% 69% 68% 67% 67% 67% 66% 65% 65% 63% 60% 40% 20% 0% n-white Higher ployed ployed Female Male verage verage White Basic Above Below Not H N emp Emp Non B av av A F Sex Educational Household Ethnic Group Employment status income Status Source : Evaluation of the London Patient Choice Scheme, Picker Institute (July 2005)
Reputation Competition: % pupils achieving > 5 good Grades GCSE A* to C Wales stops publication league tables Note: data are missing for 1998, 2001 & 2005 & these have been estimated as the mean values from adjacent years
Reputation Competition: % Ambulance response times to life threatening emergencies response times to life ‐ threatening emergencies < 8 minutes Star ratings published 8 5 8 5 Target 7 5 6 5 5 5 4 5 1 9 9 9 2 0 0 1 2 0 0 3 2 0 0 5 2 0 0 7 England Wales Source: Bevan & Hamblin (2009)
The Public Service Mutual The Public Service Mutual • The Public Service Mutual (PSM) is an employee ‐ led (and owned) organisation, often p y ( ) g spun out of the public sector, delivering a public service public service. • Mutuals across sectors and countries deliver: • High user satisfaction • Greater productivity • Greater productivity • High employee morale (especially professionals)
So So… For social service providers to improve, need external pressure. This could come from: p • Government (mistrust) • Regulators (mistrust) R l ( i ) • Peers (reputation competition) ( p p ) • Users (voice or choice) Need form of pressure least damaging to knightly motivation. Competition plus PSM?
Problems, Pitfalls and Prizes Problems Pitfalls and Prizes • Problem: how to exert external pressure on social service providers, that does not damage p g knightly motivation and that is politically and socially acceptable socially acceptable. • Pitfall: Thinking that there is a perfect solution to the problem. l h bl • Prize: A system of social service provision that Prize: A system of social service provision that is….. • The least worst. Th l t t
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