In part I, looked at one particular example of how local authority outsourcing has come under such pressure – both financial and managerial – that contracts are now simply undeliverable; there has developed, I contended, a distance between what ‘exists’ in contractual form and what happens in real life.
The ‘unreal’ contracts of this type tend to concentrated on delivery of support services to the most disadvantaged. The main reason for this is that those who receive (or don’t actually receive) these kind of services are less open to scrutiny and challenge than more universal services. If a contract for bin collection is let and bins only get collected on paper, not from houses, there’s a pretty good chance that service users will make the local authority aware, and that subsequently performance will be questioned in overview & scrutiny by councillors. If (to use another real world example) vulnerable carers of vulnerable people get a 3 minute phone assessment of their needs, thereby assumed to be insignificant (and cost-free), rather than the full in-person assessment they should have got and which should have resulted in a full support package, then it is unlikely that this will be picked up as part of a systematic but always inevitable non-delivery/gaming of the contract. The carers’ forum, established within the contract to make sure that this kind of thing doesn’t happen, is easy enough to skew, so that all that comes to it is a story of delivery success.
What, though, can be done about all this? How can we put the reality back in outsourcing, given continued and ever increasing pressure on public expenditure? How, in particular, can we ensure that the most vulnerable service users are not exploited in this way? This post seeks to explore some responses to this challenge, as well as seeking to locate these practical responses within a coherent framework for wider activism and empowerment. As this is a Labour party supporting blog, it also sets out these ideas in the context of the Labour party and movement’s current process of ‘renewal’ (if its current internal debate can be termed such).
Here’s the kind of response I’d like to see.
I’d like to see groups of public service workers coming together, ideally though not necessarily (see below) using the existing institutional legitimacy of local Trades Councils, to develop and implement a programme of scrutiny of outsourcing arrangements, existing and proposed. This Trades Council committee, strengthened but not dependent on service user input, should make it its principal job to assess the viability of contracts in terms of finances, likely quality of delivery and appropriateness of monitoring systems.
They should award themselves the authority – and that is the crucial concept to which I’ll return – to call before them commissioning managers, service directors/heads of department and where necessary Chief Executives to explain their decision making around how outsourcing contracts have been developed, and where necessary to justify their real world ‘deliverability’. In the end, the committee should take a view on whether or not the contract as set out by local authorities (and over time the NHS, as ‘devo max’ starts to be implemented) is acceptable to the Trades Council.
Of course, the key questions now arise of a) Why on earth local authority officers would subject themselves to such a process? b) Why would anyone in a position of local authority power take any notice of a decision by a Trades Council?
The short answer is that, initially at least, they may not. They may even laugh at the prospect. I’ll come on to how this might be changed, but first I want to look in somewhat wider terms at what an attempt to set up this alternative decision-making process, under the aegis of the Trades Council infrastructure (where it still exists) is really all about. Doing so – in the context of how power does and might work – may help in turn to determine what initial actions are appropriate in getting this kind of stuff off the ground.
We’re talking here about the establishment of a political institution which doesn’t have the sanction of the state and which, more importantly, contests the authority of the central state – via its sanctioned local decision-making process – to make decisions about how public money is best spent. As such, we’re talking about the kid of associative democracy championed by pre-war English pluralist socialists GDH Cole and JN Figgis, and later championed, in the context of the authoritarian bent of the Thatcherite state, by Paul Hirst (pdf) before his untimely death. In this vision of how society organises itself, the state has no a greater a priori legitimacy than any other form of social organisation, and by extension whenever the state seeks to impose itself as sole legitimate authority, it is open to valid challenge from any other grouping of people which chooses to assert its own legitimacy in deciding, say, how resources are allocated. Such groupings might include the church (whose legitimacy as an association on a level footing with the state is at the heart of theologian JN Figgis’ work), but also those whose particular function and expertise brings them together as a group – namely the professions (in their widest sense) and the unions .
In practice such a political standpoint could translate, in the circumstances we’re dealing with, into the following kind of assertion: “we are a properly constituted body of public service professionals and we have as much if not greater right to oversee and scrutinise the local authority’s commissioning of services in this area, and it is our view that the service as currently commissioned cannot be delivered effectively/safely.”
From this starting point, establishing the right to be taken seriously by the local authority’s decision makers is a matter of establishing legitimacy with a range of ‘players’ , both within and beyond the local authority. Clearly the use of the Trades Council institutional status may count for something, and it may be surprising what a forma letterhead and a ‘proper’ approach to the local authority can achieve, but there are a number of other ways, including through the Labour party structure (especially via councillors open to trade union persuasion ), through the voluntary, faith & community sector (VCFS) infrastructure and through local higher education links. If that sounds improbable, then it might be worth reflecting on the effectiveness of the 1971 Scottish TUC inquiry into the Tory government’s attempts to annihilate shipbuilding on the Upper Clyde, the success of which was all built on establishing the external legitimacy of the inquiry.
The key thing to note about all these examples of how local workers and service users might establish associative legitimacy on a par with that of the (local) state is, of course, that they are just examples. Every local area will have different circumstances, and different opportunities for building alliances focused on the establishment of ‘parallel legitimacy’. While I favour the Trades Council as the existing organisational form which might take a lead on such ‘parallel’ institutional development, not least as engagement in this relatively narrow area of public procurement might act as a bridgehead to wider re-orientation of the trade union movement , it may not be the most suitable one in many areas, especially those where Trades Councils simply no longer exist or where they have been adjusted to other purposes over the years which just aren;t amenable to this new area of activity .
In terms of which professional groups might play a key part in this kind of calculated associative democracy initiative, where the focus is largely on defence of quality services for/with the most vulnerable, there is no better candidate than that of social work. The social work profession is currently in a time of crisis , with its professional standards outsourced to a management consultancy firm, the College of Social Work (established in 2009 to develop professionalisation) forced to close in September, and a whole new training regime being swiftly imposed through the Frontline programme , with the intention that future social workers will wield a limited range of intervention tool to ‘sort out’ troubled families. The old concepts of social justice, and the need to see struggling families in context, are being brushed away as an irrelevance to the immediacies of modern social work, and the proponents of those old concepts as academics interested only in preserving their comfortably ‘ivory towers’ existence
In the face of this onslaught, social justice-oriented social workers face a choice: fight a no doubt heroic but almost certainly losing battle on the current accreditation and training terrain, or beat a deliberate retreat and take up the campaign for social justice social work on different terrain. The organic emergence of the Social Workers Assembly from the wreckage of the College of Social Work, with its intent to challenge the state’s intervention in their professional standards, could turn out to be a leading example, at national level, of the kind of parallel legitimacy organisation I advocate, but it is likely only to be able to do this by developing its legitimacy at local levels first; working with other parts of the labour movement, and with campaigning organisations like the Family Rights Group  in areas where it holds expertise, and in a way which demonstrates that it is able to (re)-establish social work as a profession which, like medicine, can and should be both self-governing.
In the end, whatever groups of public service workers, trade unionists come together around te establishment iof a new decision-making institution of the type proposed, I think there should be two wider aspiration, beyond establishing initial legitimacy.
First, as noted, it should be seen as a bridgehead to greater union/professional engagement in service design, in a way which takes the labour movement beyond the current narrow focus on terms and conditions, and (back) towards the ideal of trade unions as safeguarders and promoters of quality service provision in its own right (and with an ever expanding conception of what a public service is). I have written more about this here and here. In ideological terms this might be described as unions taking a Tawney turn, in their active attempt to take from the forces of managerialism the right to direct resources towards the best possible social function.
Second, and closely related to this, should be a conscious attempt to help public servants re-orientate their own working lives, so that – in the terms Michael Lipsky used and which the PCS used to seek to practice – they become advocates for those service users, rather than more or less alienated from those their profession used to serve.
Of course, none of this insitutional legitimacy, and the acceptance of a trade council’s right to veto or adjust an outsourcing contract, creates more money for councils to do tender properly. Tha’s the brutal reality of a Tory government. What it does do, though, is highlight the way in which many councils are having to/choosing to squeeze contracts focused on services to the most vulnerable, less than other areas of expenditure, precisely because the poor and vulnerable have had, to date, less capacity to resist (and because they vote less). This in turn creates some space for trades councils etc to push local authorities towards more innovative social financing arrangements of the type advocated here, and in many other thinktank forums, but so far massively underdeveloped because of a political risk aversion to the kind of complexity that such ‘downstream savings’ require (see my post here for more on this).
Finally, where does the Labour party – in its current soul searching/holding out for a hero mode – fit with all this. In terms of the leadership debate, Jeremy Corbyn has not yet engaged with this area at all – hence the lingering doubts about whether his is a solely state-oriented socialism. If he does win, it is to be hoped that the process of re-orienting the Labour party’s resources towards the kind of community organisation advocated by Stella Creasy – though she too needs to reflects on the contradictions inherent to her (and Liz Kendall’s) view of power – will be near the top of the to-do list. In practical terms, this might mean enabling/encouraging CLPs to work with and resource emergent or re-emergent trade councils (remembering of course that trades councils cannot constitutionally affiliate to Labour), or with other institutional developments. This kind of grassroots resourcing, funded through an extended NEC CLP Improvement Fund, should take precedence over the proposed Diversity Fund, which is a distraction from the real job in hand, and which simply fuels the Westminster-centricity of the party.
More likely, of course, is that whoever leads or deputy leads the party will prove to be a disappointment when it comes to internal party and movement development. That goes with the territory. In reality, local parties – along with any local bodies and people they can develop alliances with – are going to have to do it for themselves.
 The legalistic principles (Laski, esp. chapter 1), and the historical reality of state formation by violence (Tilly) that underpin the doctrine of associative democracy are my preferred underpinning to my proposals for the development of institutions with parallel legitimacy of the state, not least as they coalesce with a more explicitly Marxian analysis of the state as an agent of capital, and therefore one which needs to be undermined through these ‘parallel legitimacy’ means or more directly.
However, it is also worth pointing out – perhaps in the interests of strategic alliance building between the left and (more intelligent) Conservatism – that associative democracy is also consistent with the basic tenets of communitarianism, and even with the kind of reformed ‘Big Society’ programme now advocated by people like Danny Kruger. From this perspective, it might be argued that the kind of parallel democratic structure advocated here acts as a corrective to the current ‘rights v responsibilities’ imbalance. The old Big Society programme, now rubbished by the left and earlier advocates alike, can be seen as massively imbalanced towards the responsibilities side of the bargain, with local communities and organisations getting all the crap that goes with coping with the cuts, but none of the rights that could have gone with that. (We”ll leave aside here that a key failure in both communitarian and Red Tory/Big Society thought is the essentialist assumption that positive communities are just ‘there’ – an assumption arugably even less valid than it was when it was first dreamed up, or emerged from faith-based discourses such as Catholic Social Teaching)
 See my earlier post on strategic action fields and the development of links to organisations with ‘mutually realisable interests.
 Trades Councils’ constitutions do not allow for official affiliation with the Labour party.
 In my own area, South West Lancashire Trades Council changed its remit over the years so that it runs to all intents and purposes like a small charity, focused on debt advice. This is not a criticism of the people who have taken it in that direction in response to an identified and unmet need, and it is quite possible with appropriate support from the TUC that many could re-emerge with new purpose and energy.
 For evidence of the hostility between the ‘new young Turks’ at Frontline and other social work educators, see its CEO’s “get out of the way” attack in Progress magazine, and the response. The choice of Porgress magazine as a place for the initial attack is not a coincidence, since it was Progress, and in particular its head honcho Andrew Adonis, who were responsible for making Frontline happen, via a compliant IPPR (which hot-housed Frontline) and a Coalition government delighted at the managerial, anti social work ‘blob’ approach being promoted by Frontline. The coup has been, to date, astonishingly effective.
 Declaration of interest: I sit on the advisory panel of the Family Rights Group’s Your Family, Your Voice project, which is seeking to drive its work to more local level, though it is early days.
Introduction to part 2
In part 1 of this critical engagement Professor Alexis Jay’s report on Child Sexual Exploitation (CSE) in Rotherham, the focus was mainly on the factors which drove the upsurge in CSE in the late 1990s and 2000s, rather than the council’s and other agencies’ response to that upsurge. Clearly, though, the way in which those ‘external’ factors took effect during the period had an effect on the appropriateness, or otherwise, of the response by those agencies.
In part 1, I made two main points in particular about the weaknesses in the Jay report in respect of these factors. Here in part 2, I’ll expand somewhat on the implications of these, and of how the reports interprets them, before moving on to the ‘internal’ institutional dynamics of the agencies response to CSE, and will again suggest that the analysis by Jay is inadequate, and indeed potentially counterproductive at a national level, given her new role as adviser to the public inquiry into Child Sexual Abuse announced in July.
In part 3, I’ll move on to what I think is the biggest conceptual flaw in the Jay report – the failure to grasp what community development actually is – and I’ll finish with an assessment of what does actually need to be done to stop and prevent the growth of CSE (and child abuse more generally), and offer some suggestions on how we might move in that direction. Needless to say, these suggestions won’t involve manadatory reporting, which is at best a distraction, or fabricating evidence so that staff can be disciplined, as the MP for Rotherham is now apparently suggesting. Sadly, Labour has been utterly useless in its response so far, and this is my attempt to help it respond better, before it is too late.
Ethnicity and political correctness
In part 1 I suggested that the report lacked the courage of some of its convictions about the “issue of ethnicity” (as one of the report chapters is entitled), with Jay going to lengths to say that ethnicity cannot possibly be seen as a predictor of child abuse perpetration, before backtracking and accepting that future work to combat CSE may have to confront ‘cultural issues’. I then set out an alternative way of approaching the matter, in a way that not only allows for a ‘race-blind’ approach to tackling CSE, but which is actually more effective because it is race-blind i.e. it is not caught up by extraneous issues of ethnicity, but focuses on the actual material circumstances which are predictive of CSE .
This is important stuff because, if we accept that race-blind intervention to stop and then prevent CSE is not only possible but more effective than ethnicity-focused intervention , much of the criticism, itself based in the report on little more than hearsay, that police, council staff and councillors betrayed children because they weren’t courageous enough to ‘take on political correctness’ – becomes an irrelevance.
Maybe, just maybe, the managers and councillors were correct in their approach. Maybe, just maybe, being politically correct can be correct in terms of lived outcomes as well as votes.
That’s not to say that sending the Home Office researcher off on diversity training course for using the word ‘Asian’ in a report was the correct thing to do; this does sound cack-handed, as it is pretty well impossible to imagine a Home Office researcher into CSE having anything other than a good understanding of diversity issues, and therefore open to a reasonable debate, based on the kind of evidence I produced in part one about circumstance being the overriding predictor, about whether her approach was reasonable. Her mistreatment, though, may have more to do with the dominant masculine managerialism referred to in the Jay report (and which I analyse below) than with the fact that she was right and they were wrong about the fundamentals of the best way to tackle the CSE epidemic.
Maybe it was the other way round. Maybe the managers were right. Maybe she was wrong.
Let”s be blunt, then. Even though the report hedges it is bets – “Recommendation 14 reads: The issue of race should be tackled as an absolute priority if it is a significant factor in the criminal activity of organised child sexual abuse in the Borough)” – this very hedging means that the media and popular reaction to the report has focused on the need to overcome political correctness and focus on ethnicity a way to prevent further abuse.
The Jay report may therefore end up doing children currently being exploited and at risk of exploitation more harm than good.
The perfect storm: external meets internal
Also in part 1, suggested that a key weakness in the Jay report – though this may have more to do with the terms of reference and timescales than Jay and her team’s own capacities – is the failure to assess why the incidence of CSE has risen. My own answer to this question is linked to the argument above about circumstance over ethnicity, and argues that the rise of mobile and social media technology, plus the easy availability of internet porn as a progressively misogynsing factors [link to Us article], creates both the ‘motivation’ and opportunity to develop exploitative techniques. Jay’s relative failure to assess the surge in incidence feeds into the over-emphasis on ethnicity. It also incidentally allows her a route out of commenting properly on the horribly inequitable funding of the council as a whole; while she notes the 33% loss of spending power in Rotherham in comparison with 4.8% in Buckinghamshire (para 12.14) , there is no recommendation as to what might be done about such clear inequity.
But this is just one part the ‘perfect storm’ that hit those principally and statutorily responsible for protecting children – frontline social workers. The other factors which hit children’s social care staff in the crucial period were understaffing – I’m not sure how any council department might be expected to operate with a vacancy rate of 43% (para 12.2) – and the rampant managerialism which took hold of public services delivery in the 1990s and 2000s.
I should be clear what I mean by managerialism, a term not used in the Jay report itself but which I use here to reflect the kind of events she describes (but doe not fully analyse) in her report.. I mean the ideologically-motivated assumption that if public services (indeed services of any kind) are subject to improved management targets and controls, then the quality of that services is bound to improve. This assumption, as Chris Dillow has set out on his blog and in his fine book New Labour and the folly of managerialism is wrong, not least because what may be gained through ‘efficiencies’ is lost through diminished professional/worker autonomy.
This we can see from the Jay report, is precisely what happened in Rotherham in the 2000s. The account at paras 6.21-6.24 about how social worker time was remorselessly squeezed away from both preventative and vital followup work is not just an account of understaffing. When I asked frontline social workers in my area about this section, they actually burst out laughing at the idea that there might not have been downward pressure to increase “throughput” (the beautifully managerial term used by Jay at para. 6.23); of course frontline professionals would deny that they had submitted to such pressures, they told me, as that would make them look unprofessional in the eyes of Jay’s team (and therefore open to disciplinary measures for loss of professional standards), but of course they will have submitted to pressures – how, if there were no such pressures, would have the question of such pressure have arisen in the first place?
Perhaps even more revealingly, Jay covers the role played by Barnardo’s in the removal of professional autonomy, through the introduction of a “numeric scoring system” (para 6.38). Jay detiails how, while managers may claim otherwise in their interviews (again, understandably in the view of possible sanctions), frontline social workers make it quite clear that there was little room for them to exercise professional judgment and override the scoring system where they felt the scoring was underplaying the actual risk at which children found themselves.
Again, I asked experienced children’s social workers, with whom I come into contact for me work, what they thought of these paragraphs in the Jay report (they had not read the report at that stage, so I paraphrased Jay but referred specifically to the Barnardo’s scoring system, which is well-known and in widespread use. These colleagues answered to the effect that the Barnardo’s scoring model is deficient not just because it doesn’t, of itself, allow for professional judgment alongside the scoring, but that professional judgment is actively excluded by the insistence on the need, within the scoring process, for concrete evidence.
The (recent) example I was given of a teenage girl who had been found by police (involved in other crime detection work) on an edge-of-town caravan park, miles from home, and in a place unfamiliar to her family. There was no evidence that she was on that night subject to sexual exploitation and so, despite the putting of two and two together by social workers, the risk assessment as scored downplayed a risk obvious to pretty well everybody involved in the case.
It is not always thus. One of the local authorities that my work connects with had looked at the Barnardo’s mode in the mid-2000s and, because they remained open to some real frontline social worker interaction, had chosen not to go with the ‘best practice’ Barnardo’s model, but instead asked frontline social workers to develop their own model for standardised assessment.
What to make of all this? Well, the first thing to mention is the level of control that Barnado’s, a voluntary sector organisation dominated by a controversial Chief Executive, appear to have had not only over Rotherham but across a swathe of local authorities in England. While a voluntary organisation in legal definition, Barnardo’s size and capacity to undercut smaller organisations and in-house provision, combined with its clever marketing means that it has become something of an untouchable. Even here, where the finger has been pointed at Barnardo’s for the introduction of a scoring model which is demonstrably not ‘best practice’, or even good practice, the (otherwise very good) Rotherham Council response to the Jay report continues to refer to it in these hallowed terms, and to make clear that it use will continue. Here is not the place to delve in detail into the relationship between Barnardo’s (and its arc-rival NCH) and the state, but it is worth stressing that if you are going to act effectively as an arm of the state, then you really need to be held to the same standards as the state. On this occasion, at least, this hasn’t happened.
The second, broader, point to make about this section of the Jay report is that, while Jay set out well the way frontline social worker were subject to managerialist influences to the detriment of their professional judgement , she probably fails to reach the correct conclusions on the basis of these findings. Instead of pointing out how the managerialism which spread across local authorities in the 1990s and 2000s at the expense of professional autonomy – some of this because of contracting out to bodies like Barnardo’s – may have caused the practice failures she uncovers, Jay instead opts for another broad explanatory factor: the aggressive. ‘macho’ culture which dominated the council in the same period. Yet no direct link is apparent between this macho culture and poor practice outcomes for children.
It seems to me that a more indirect explanation is brought forward while an indirect one is ignored, either because it is inconvenient or – I suspect more likely – the idea that managerialism night be a problem lies beyond Professor Jay’s conceptual paradigm of how a local authority should operate. This is not to say that councillor and senior officer misogyny and aggression did played no part in what happened, but it is also possible that this cultural aspect of the council’s failure was fed and watered by the ideological and institutional factors which came into local government from Thatcher onwards, whereby management efficiencies become more important than professional relationships in a way which then fostered ‘black box’-style – I don’t care how the target is met, just meet the target – approaches to management .
Again, this is not just esoteric wondering about the background causes to the Rotherham failures; establishing why the failures happened is essential to ensuring that they don’t happen in future. If the public eqnuiry on which Professor Jay will act as a key adviser and is chaired by a key proponent of privatization, accepts her analysis that macho, male-dominated councils are at the heart of the problem, then the solution will lie in human resources practice to ensure that more women are in top positions and /or that macho practice is trained and developed out of people. If, as I contend we should, the key problem is actually that professional autonomy has been stripped away from professionals (and from professional training), then the answers lie elsewhere. This will be a key battleground in the inquiry process, but at the moment the managerialists hold the higher ground.
That’s enough for part 2. Part 3, covering the key conceptual failure of the Jay report, and recommendations for action on the part of those willing to think and act in the interests of children, as opposed to the need to be seen to be angry, will follow soon.
 There is a straight analogy with the application of English law here. The basic principle is that an offender is prosecuted for an offence, not for the type of offender s/he is, although when assessing the level of offence it is leigtimate to take into account other offences committed to establing an offending pattern. It seems odd therefore, for people interested in ‘British values’ to be arguing that there should be a focus on offender profiling rather than offence profiling when it comes to CSE.
 Another question arises here about the ‘issue of ethnicity”: if CSE were in fact ethnic culture-driven, rather than circumstance-driven, what would we actually do about it? Is Jay actually suggesting that priority should be given to changing culture in some way, over and above measures to intervene tactically in the circumstances which we know actually create CSE opportunities? If so, this would seem to be anti-PC gone maaaad, a desperate attempt to paficy the Islam-correlates-with-rape crowd at the expense of children’s futures?
 It occurs to me that this may seem like too strong a defence of frontline social workers. After all, whatever managerialist influences they were subject to, they are still professionals, with professional standards, so should n’t we have expected them to stand up better to their bosses. The answer to this question is yes, we should, but my argument here (as elsewhere) is that moral condemnation of staff – and their sacking – does nothing about professional competence in the long term; we need to establish why and how professional didn’t feel able to act up to professional standards, and a failure to do so will be a like act of gross political failure (as well as failure in social work training, which i’ll cover in part 3)
Here is not the place to go into loss of professional ethics and standards in detail, other than to say that there is a rich seam of ressearch literature on the subject, for those politically professional enough to engage with it. It’s called, broadly, Implementation Studies, and starts with the seminal work of Michael Lipsky (1980), which details how frontline professionals move, in certain circumstances, from autonomy and advocacy towards alienation and disregard for their clients as whole human beings. It ends, for me at least for now, with this detailed qualitiative study of how even Finnish welfare professionals are subject to managerialism and see their work get worse as a result.
 The best read I know on this post-Thatcher trend, other than Chris Dillow’s book, is Gerry Stoker’s (2004) Transforming Local Governance: From Thatcherism to New Labour. Here’s how he summaries managerialism:
Managerialism……..began in the 1980s and 1990s to take an increasingly strong hold in local government. This ideology saw political leadership as important in setting direction but beyond that a potential source of inefficiency. Politicians should set goals but not dictate the means to achieve them. The key to managerialism is its emphasis on the right of managers to mange against inappropriate interference from politicians or, for that matter, the special pleading of professional groups (p.13, my italics)
The NHS is dying, pretty well exactly as I said it would some two years ago now:
Some scandals may emerge in time over ‘backhanders’ paid by the private hospitals to the private commissioners, and in some circumstances it will turn out that the people doing the commissioning are simply commissioning themselves in another name – the whole inefficiency of which the provider-purchaser split was supposed to stop – but it will all be a bit esoteric and complicated for people to understand, and there won’t be much of a fuss.
In fairly short order, we may get these new commissioners creating two tiers of provision from within GP surgeries, with one level of care for those not paying, and those who just happen to have signed the relevant insurance policy forms, which just happen to be in the GP surgery.
Insurance-based healthcare, and the exclusions that this brings, will come not through a government announcement, but by the surgery backdoor……
The consortia [now called CCGs] will end up being led by two or three ‘movers and shakers’ in each area, whose job will be simply to negotiate a decent deal for their colleagues and let the private commissioners get on with the rest. There will be no revolt in primary care, and in secondary care no-one will actually notice till it’s too late.
Two years on, it’s being more widely recognised that, as of 1st April, the NHS privatisation will being quietly but in earnest, as the section 75 regulations kick into gear, Clinical Commissioning Groups with often overwhelming direct financial interests in private providers put services out to the market, public provision withers on the vine or simply goes bust, and private insurance arrangements start to become the norm, initially for (the more profitable) elective healthcare, and then for the rest. As Lucy Reynolds from the London School for Hygiene & Tropical Medicine rightly notes, what comes next in this wildly ‘imperfect’ market is market abuse and health cost inflation. This inflation around the ‘cherry-picked’ services, Lucy might also have noted, will lead to the stripping of resources from the less profitable services – no health budget ring-fencing will protect that.
So what is to be done? By 2015, if and when Labour regains power, the promise of a repeal of the Health & Social Care Act (and the accompanying Section 75 regulations) may be a welcome statement of principle, but it will not significantly change the way in which services have already been privatised, seemingly irrevocably. In many cases, there simply won’t be the public services to transfer them back to, and the incoming government is likely to consider the full-scale implementation of NHS II a little too much of a fiscal challenge, even if the recreation of the cumbersome institutions of 1948 were desirable.*
What Labour can do, though – and needs to start thinking through now – is to tackle the local institutional architecture, in a way which creates the platform both for the establishment of local democratic control of both the type and quality of provision. If it gets this right, this might actually lead, in the medium term, to a better health service than we currently enjoy – as I’ve noted before, it does not become Labour to gloss over the very clear health and social care failings caused by the managerialist ideology that has held sway for the last thirty years.
More specifically in terms of local institutions, the Labour government-in-waiting should first consider retaining the Clinical Commissioning Groups. but diluting the power of GP practices within them by making theirs a minority voting position, through the introduction of members of Foundation Trust governing councils (increasingly focused on quality standards if the Francis Inquiry recommendations are carried through) along with elected councillor representation in keeping with Councils’ new public health function. The immediate impact of this is likely to be presumption against private sector provision where other options still exist (they won’t in many places).
Second, the Labour government in waiting should commit to ensuring that these new-style CCGs adhere both to the letter and spirit of the Public Service (Social Value) Act 2012 under which all CCGs (and the NHS Commissioning Board), have a duty to consider:
(a) how what is proposed to be procured might improve the economic, social and environmental well-being of the relevant area, and
(b) how, in conducting the process of procurement, it might act with a view to securing that improvement.
(Oddly, this is Tory legislation, aimed primarily at breaking the perceived monopoly power of local authorities, but can be used to the same effect against private sector dominance in healthcare provision. That will really piss off the Tories….)
These two relatively simply steps will set the direction of travel back against wholesale privatisation, although of course attempts to terminate contracts are likely to result in lengthy and quite likely unsuccessful legal battles, so early progress is likely to be quite slow.
Nevertheless, institutional change at local level by government, especially if accompanied by moves within the Labour party and the broader movement to re-energise Trade Councils, in a move away from the vapid Tory ‘consumer localism’ and towards a quality-oriented ‘worker localism’**, could provide early impetus for the creation of a properly socialist health and social care system – a system fit for the 21st century (whether or not this is tax-based or progressive social insurance based doesn’t really matter as long as it provides for equitable provision) , with private operators increasingly steadily cleared out in favour not just of direct NHS Trust delivery, but also a new surge of worker co-operatives (although charities and social enterprises may also play a valid part).
* It is always worth remembering, in the context of the fetishisation of the 1948-style NHS, that until very late in the day a radically different – and I would argue preferable – NHS structure was being argued for. This was a much more decentralised and locally accountable system, rather than the monolith we grew to love despite it tendencies to managerialism (and I would argue that this is why service standards have declined in the NHS faster than in local authorities, say). See Rudolf Klein’s seminal The Politics of the NHS for more (the later edition is called The New Politics of the NHS but the early chapters are the same).
** This is not to argue for the introduction/retention of localised terms and conditions. Trade unions should of course be encouraged to negotiate at national level, and a properly brave/strategic Labour government would use the need to ‘renationalise’ the NHS, and to invest quality in the hands of its staff (as opposed to its bosses) as a rationale for the relatively painless (in terms of reactionary public opinion) repeal of restrictive trade union legislation. Frankly, I’m not holding my breath on this one.
The online social enterprise community – of which I may now well be an honorary member – has had some debate about the importance or otherwise of the Secretary of State for Health’s recent definition, for the first time in English law, of what it is to be a social enterprise, which I covered here, and originally here.
David at Beanbags and Bullshit gives links and a good overview of the debate, which boils down to different views on whether the definition set out in the new Healthwatch regulations will come to act as precedent, replicated in other legislation and in broader NHS (and other departmental) policy, or whether it’s strictly focused on the very narrow, and relatively unimportant issue (given their lack of real power) of who will get to run Local Healthwatches.
To date, my own position on this has been simply “I don’t know”. On the one hand, it has been difficult to work out how exactly this new definition might be used as a lever for privatisation of NHS services. On the other, it’s a puzzle as to why the Department of Health would go to so much trouble expanding the usual conception of social enterprise to include private firms as long as they don’t take out more than 50% from profits in any one financial year, unless there was some kind of plan to expand its use beyond the financially unimportant Healthwatch scheme.
However, the news emerging about Monitor’s Fair playing Field recommendation, that private health firms should become exempt from corporation tax on their NHS profits, has me leaning a little towards the latter interpretation, namely that the Healthwatch regulations form part of some devilishly clever scheme.
I find it difficult to believe that Osborne will find it politically feasible to stand up at the next budget and announce this new tax break in the face of a popular swell against tax avoidance, however much it might be sold on the grounds that Any Qualified Provider private firms currently suffer from unfavourable cost terms when compared with the NHS itself. That would surely be too risky as a confirmation of whose side the Tories are on.
But if the tax break is dressed up as an incentive for social enterprise, tapping into the government fairly well developed narrative on the virtues of mutualism and pointing to existing ex-NHS staff mutuals as an example, but conveniently leaving out the detail of how social enteprises are legally defined nowadays, Osborne, Hunt and the private health lobbyists may well feel its worth a go as part of the pre-election scorched earth strategy.
Or maybe that’s a conspiracy theory too far. I still don’t know.
If I’m right, you heard it here first. If I’m not, then it’s simply the usual omnishambles, ok?
ps. I ‘m thinking of doing a Freedom of Information request on the consultation responses and meetings which fed into the Healthwatch regulations, to try to ascertain to what extent the private health lobbyists were at work. Has anyone else reading this done one, or are they interested in doing so?