NHS Reform Under the X-Ray

“The person I trust most for my health, number one, is my GP. And I’ve always seen him or her as a kind of a gateway to any other services. And it’s his judgment, ultimately, or her judgment, that I would back.”  That’s what Eric Pickles told The Telegraph last Saturday. There’s something bucolic about the government’s attempt to put commissioning power into the hands of local GPs, and take it away from “faceless bureaucrats”  in the Primary Care Trusts; it comes from the England of Cameron’s mother, the Berkshire Magistrate, from John Major’s England of “cricket grounds, warm beer, green suburbs, dog lovers, and old maids cycling to holy communion”.  But, the government are also, as Hague once put it, “Thatcher’s children”. Andrew Lansley wants to empower patients, and by empower them, he means increase their choices, and by increase their choices, he means create a market, and by create a market, he means promote efficiency and cut NHS costs, and by cut NHS costs he means offset the effect of the £20 billion of savings required by 2015.

The leaked account of the Strategic Risk Register, which lists the potential pitfalls of the reforms, suggests it challenges both horns of the government’s approach. GPs, it is alleged to say, may lack the experience and skills to manage funds efficiently. Equally, the introduction of a market may lead to private companies failing to do more with less, and simply siphoning away public funds in profit. Consequently, the NHS could eventually prove “unaffordable”.If this is an accurate report of the contents of the Strategic Risk Register – if it seriously moots the possibility of the reforms rendering the National Health Service prohibitively expensive – then it is not surprising that Andrew Lansley does not want to publish the report until after the Health and Social Care Bill is enacted.

The government is appealing an Information Commission order that they should release the full document. The Department of Health has pointed out that Risk Registers express the dangers of policies in “worst case” scenario terms and so can be open to misinterpretation if read out of context. It suggests that Risk Registers in their current form could not be produced if they were subject to FOI requests, for fear of giving the public the wrong impression.This is a version of the chilling effect argument, which Blair put like this:

“Governments, like any other organisations, need to be able to debate, discuss and decide issues with a reasonable level of confidentiality. This is not mildly important. It is of essence. Without the confidentiality, people are inhibited and the consideration of options is limited in a way that isn’t conducive to good decision-making. In every system that goes down this path [FOI] what happens is that people watch what they put in writing and talk without committing to paper…’

The Information Commissioner recognises the danger of FOI causing a chilling effect.  However, in this case it emphasised the fact that, whatever information is released vis-a-vis health reform, officials will still be required to be fully frank when they produce Risk Registers. The Commissioner felt that publishing information about NHS reform might make officials less forthright on that particular subject during the current process, but that there would not be a chilling effect on the record of risk across the policy spectrum.

The appeal will be heard by the Information Tribunal on 5 and 6 March, which may or may not be before the third reading of the Health Bill in the House of Lords – the last chance to substantially amend it. However, Labour propose to discuss the publication of the Risk Register  in an opposition day debate on 22 February. It is possible that this move will prove more effective than the Freedom of Information Act in getting the Strategic Risk Register into the public domain.

Open Data Consultation Launched

The government has launched a consultation today on Open Data and how to move forward the transparency agenda by encouraging ‘push’ (pro-active release) and ‘pull’ (stronger rights for access to data). The consultation covers a wide range of areas

  • Proactive: how to ensure ICTs systems can publish data easily and make pro-active publication a ‘default’ setting
  • Costs: possibly raising the cost ceiling for FOI requests (a ceiling of £1000, instead of £600 is suggested)
  • Changing mechanisms: giving the ICO more power, creating a new right to appeal for datasets and limiting internal review times

The paper also contains two interesting annexes on evidence of impact and draft principles.

For a brief summary see here and a discussion thread here. This appears to form part of a further push of the transparency agenda, alongside other initiatives. David Cameron recently said the reforms had now moved to ‘phase two’ from publishing core data to publishing more about public services and how they perform.

‘If our transparency focus over the past 12 months has been to open up core central government data in areas such as spending, our priority over the next year will be to release new data on the performance of public services. This revolution in government transparency will make it easier than ever before for the public to make informed choices between providers and hold government to account for the performance of key public services’.

Patience and Time? FOI and Trust

The issue of FOI and trust looks simple but isn’t. Politicians and others point out, quite rightly, that the more open you are the more you will be trusted.  This is true but it depends entirely on what information you are being open about.

The issue of if, why and how the public trust government is hotly debated. Trust may be based on experiences, emotions, gut instinct or all three. There is a question over whether trust is actually declining in the developed world. Many believe it has been falling since the mid-1960s blaming politicians, television, a more complex society, a lack of deference, the Vietnam War, the Beatles and Lyndon Johnson. Others have pointed out that, from what little we know, government has only ever been trusted by a few of the people a little of the time. Politics, they say, is not an occupation for the trustworthy.

So where does FOI fit? It is hoped that the more open you are the more the public will trust you. This is because they will understand more about what you do and also because, quite simply, you will be less secretive.

Our projects have all looked into this. Our central government project concluded that FOI did not increase trust. This was because most people find out about FOI through stories which rightly (see MPs’ expenses said journalists) or wrongly (just open a newspaper said politicians) are about government failure. But it isn’t fair to blame FOI. This never ending battle is much bigger than FOI, which just gets caught up in it. The government spins, the media attacks. The more interesting point is that both requesters and officials felt their own requests were in some senses ‘motivated by mistrust’. But again this isn’t FOI’s fault.

Our local project has found different results. Local government is, generally more trusted than central government anyway. Here it can be very variable. In some areas the local press use FOI often, in others never. It is also used to find out about lots of non-local government issues that don’t necessarily reflect on the council such as violence in public libraries (more than you think in answer to your unspoken question) and dirty restaurants. Requesters are also divided-some say it has increased their trust, others say it has not. Local politicians have pointed out that they can do things that central government can’t to build ‘local trust’. They can improve their services (taking bins out, repairing roads) and try to be more ‘visible’ in the community. Opening fetes and judging vegetables may have more effect than any FOI.

This last point highlights the difficulty. How you measure trust depends, as ever, on what you ask and how you ask it. Some recent studies about E-government point to the fact that people trust more if they see their actions make a difference. It also may dependent on what attitudes and ideas they bring with them (here some members of the public were disappointed by the messiness of how politics really worked).

There is probably no definitive way of answering this. The real answer to ‘does FOI improve trust?’ is ‘it depends’.  It is unrealistic and naïve to hope FOI on its own, caught between a spinning government and a hostile press, could improve things. It may also be early days. For openness to make a difference it could take time, a whole lot of precious time, patience and time, the two things politicians don’t have.

FOI and the politically empowered

Here at the Unit we’re wrapping up a project on FOI and Parliament which looked at the use of FOI by MPs and peers. We’ve been asking:

  • Is FOI another tool in MPs’ arsenal?
  • Is it useful, and has it become part of the cut and thrust of politics?
  • Or, is it not being used?

After all, MPs already have great research tools, like Parliamentary Questions, access to the House of Commons Library and many NGOs working in the field who can provide them with information. Plus they are likely to get a more robust reply from ministerial letters than an ordinary member of the public (a reason their work for constituents is so valuable).

So why do any MPs make FOI requests? Examples from different parliamentarians provide us with some answers:

A key role of the parliamentarian is to hold public institutions to account, and our previous research finds that FOI helps increase accountability of institutions. Time will tell if FOI grows in popularity as an accountability tool among the elites who know how to manipulate and publicise information more than most. Our study finds that overcoming structural resourcing shortages may be the key to this.  The time and resource issues of FOI, compared with ‘instant’ PQs, cannot be easily overcome. FOI requests and their subsequent analysis takes much time, something that heavily effects FOI’s use by peers in the less professional and less well resourced House of Lords in particular. In New Zealand, it was the switch to a proportional voting system and a parliament with at least five political parties represented that saw FOI use increase as parliamentary competition did. Maybe an elected House of Lords could at least provide the competitive impetuous for wider use by peers. Though a cynic may say any increase in use by MPs will coincide when the tally of requests becomes another feature of They WorkForYou statistics…

Coalition Works! The Independent View

Article from Liberal Democrat Voice

The coalition is working well, but the Lib Dems could do better, is the overall message from the Constitution Unit’s first report on how the coalition works in Whitehall and Westminster. We are conducting a 12 month study, funded by the Nuffield Foundation, with a research team of five, including two former senior civil servants, and one senior broadcaster. David Cameron and Nick Clegg have authorised access to all the key figures in Whitehall, and so far we have interviewed 90 ministers, special advisers, officials, parliamentarians, and external interest groups.

Everyone we interviewed in Whitehall says how much more harmonious the coalition is compared with the rivalries and infighting of the Blair/Brown years. After widespread fears that coalition government would be weak, quarrelsome and divided, in the first year the coalition has proved remarkably stable and united. Cabinet government has been revived; but coalition issues are mainly resolved in informal forums, with weekly meetings between Clegg and Cameron, and regular get togethers between Danny Alexander and Oliver Letwin. The mutual trust and close working relations developed not just between Clegg and Cameron, but amongst all their top advisers, should help the government as it faces tougher times ahead.

And how could the Lib Dems do better? Read the full article at:


The Inside Story: How Coalition Government Works–A Summary

The Coalition in Whitehall

  • Finding a balance between unity and distinctiveness is the key problem for coalition government. The current coalition has successfully ensured unity, and stability; but struggles to allow the two parties to express their distinctiveness.
  • Formal cabinet government has been revived: Cabinet and cabinet committees now meet regularly, but these are mostly forums for dealing with interdepartmental issues rather than specifically coalition issues.
  • The main forums for reaching agreement between coalition partners are informal. Coalition issues are often dealt with before they reach the formal machinery of government.
  • This informality of coalition decision making is based on high levels of trust between the leadership of the two parties. Trust, and the importance of compatible personalities, are essential for coalition government.
  • However, this informality has one drawback: it means that the Lib Dems are often unable to demonstrate their influence in government.
  • Some machinery has surprisingly not been effective in coalition brokerage—in particular, the Deputy Prime Minister’s Office, special advisers, and Liberal Democrat junior ministers.

The Coalition in Westminster

  • Flexibility within the executive is not always matched by flexibility in parliament. Compromise hammered out in government has led to excessive rigidity when policies are introduced into Parliament.
  • The informality and relatively close relationships in the executive are not matched by similar relationships within Parliament. In both houses, the coalition is tolerated rather than embraced.
  • Coalition governments often lead to a divide between the frontbench and backbench. Rebellions in this parliament are historically at record highs.
  • The parliamentary parties have begun to modify their backbench committees to prevent the divide between frontbench and backbench widening.

The Dilemmas for the Junior Partner

  • The Lib Dems are still reeling from the loss of their state funding, given only to opposition parties. This has led to the loss of many of their staff. It may help explain their under powered performance, particularly with the media.
  • By going for breadth over depth, the Lib Dems have spread themselves too thinly. They need to prioritise. Given the numbers they have, what can they realistically do which will have an impact with the public?
  • In a future coalition, the junior partner might seek to specify the support to be made available to them, in terms of special advisers, expanded Private Offices, and additional support for the parliamentary party.

Press Release: Coalition Works! The inside story from the Constitution Unit

What works, and what doesn’t in the new coalition? A first year report – full version pdf

Despite the political strains which have affected the coalition in recent months, the Constitution Unit’s research on how the coalition works shows that it has functioned very well in its first year. Viewed from inside, the ructions which have dominated the headlines have not destroyed the coalition’s effectiveness.

The Unit’s first year report, Inside Story: How coalition government works, is based upon 90 interviews with senior people in Whitehall and Westminster. The mutual trust and close working relations developed inside the government should help as it faces tougher times ahead.

“People feared that coalition government would be weak, quarrelsome and divided” said the Unit’s director Prof Robert Hazell. “But in the first year the coalition has been remarkably stable and united. Everyone we interviewed in Whitehall says how much more harmonious the coalition is compared with the rivalries and infighting of the Blair/Brown years”.

“Maintaining that unity in government while demonstrating the distinctiveness of the two parties is the key challenge going forward” Prof Hazell added. “This is particularly difficult for the Lib Dems as the junior partner. Instead of spreading themselves thinly across the whole of government, they need to prioritise their effort on areas where they can clearly have an impact”.

“An interesting development is the Lib Dems’ backbench committees” said the project’s lead researcher Dr Ben Yong. “It is a sign of how stretched the Lib Dems are for resources that these have been created. But it is also a way of preserving their distinct identity, and gives backbenchers regular contact with the frontbench. Conservatives we interviewed have been rather envious, and they have now started their own backbench policy committees”.

The report’s findings and recommendations include:

  • The Lib Dems did well in the coalition negotiations, with 75% of their manifesto items going into the coalition agreement compared with 60% of the Conservative manifesto. But in any future coalition, they should focus as much on the division of office as the division of policy. It is through ministerial leadership that coalition partners have visible impact.
  • By going for breadth over depth in their selection of ministerial posts, the Lib Dems risk spreading themselves too thinly. They may have achieved hundreds of small policy wins, but their influence is invisible to the public
  • Cabinet committees deal mainly with interdepartmental issues. Coalition issues are resolved in half a dozen informal forums, and are dealt with before they reach the formal machinery of government.

Notes for Editors

  • This is an initial report from a 12 month study of how the coalition works, funded by the Nuffield Foundation. The project runs until December.
  • Access to Whitehall interviewees has been authorised by the Prime Minister, Deputy Prime Minister and Sir Gus O’Donnell. So far the project team have interviewed 90 officials, ministers, special advisers, parliamentarians and outside groups.
  • Robert Hazell is available for interview this weekend, tel 020 7679 4977 (Friday), 020 7267 4881 (Sat and Sunday).
  • Browse the coalition government project pages