The quality of public services08 August 2012
The NHS is certainly focused on the idea that higher-quality service can deliver better value for money. David Dalton, CEO of Salford Royal NHS Foundation Trust, has demonstrated what can be done: speaking at a Reform conference earlier this year, he set out his analysis of the benefits of what he calls ‘harm-free care’. These include the elimination of hospital infections, of incorrect assessments of patient mobility (leading to needless falls), and of drug administration errors.
He explained that patients who suffer such errors face hospital stays that are roughly double the average. Were he able to reduce the occurrence of such events by 50%, he could reduce his number of beds by 78. Extrapolated across the NHS, about 10,000 fewer beds would be required (in a current total of 120,000 beds in acute care hospitals).
He also committed himself to the idea that the NHS should aspire to deliver the same standard of care at weekends or during holidays – ‘days off’ which account for a full 144 days of the NHS year. The poorer standard of weekend care means a much higher mortality rate and (again) a much longer hospital stay. Putting this right would save 52 lives per year and 36 beds. Extrapolated to the wider NHS, this would free another 5,000 beds. This kind of improvement in use of resources would greatly benefit the NHS at a time when hospital waiting times are starting to come under pressure.
Good quality – right first time
Something similar is also happening in criminal justice services. Just as David Dalton is trying to get health care “right first time” by eliminating errors, so criminal justice leaders are exploring different ways to catch offenders at an earlier stage in their criminal careers, rather than allow them to enter a cycle of reoffending which is both hard to break and extremely expensive. An example of this happening in practice: in January 2005, Strathclyde Police established the Violence Reduction Unit (VRU) to target all forms of violent behaviour, in particular knife crime and weapon-carrying among young men in and around Glasgow.
The Unit’s approach to crime-prevention looks at the causes of violent crime at four levels: the individual (including poor behavioural control and impulsiveness); the nature of the relationships involved (poor parenting skills or the prevalence of gang culture); community (such as a dependency culture) and society (for example, a lack of punishment for less serious offences such as knife carrying). The Unit then seeks to bring together policing, justice, health, parenting and education services because all of these have a bearing on the overall picture.
Among the nearly 500 gang members from eastern Glasgow who have engaged with any aspect of the Unit’s work since late 2008, violent offending has fallen by 46%; all other types of offending by 34%; and involvement in gang-related fighting by 73%.
Karyn McCluskey, co-director of the Unit, has pointed out that even the most straightforward murder inquiry costs £1.3 million, and a year in prison £50,000. As she says: “We don’t have to prevent many killings for this approach to become worthwhile.” Others agree: in April 2006, the Scottish Executive extended the Unit’s remit nationwide.
My hope would be to see the same analysis applied to education. Secondary schools clearly face tremendous costs when they inherit poorly educated children from primary schools. Around a quarter of 11-year-olds in England do not reach the required level for secondary school in English and maths (as measured by the annual national tests), and many of these children fail to reach that level throughout their secondary career. It can be also argued that progress needs to be made much earlier. Greg Martin, head of Durand Academy in south London, has suggested that a key aim should be that all six-year-olds are able to read, write and enjoy independent learning. Advocates of early intervention, such as Frank Field MP, are focusing on improving the parenting of very young children – even before birth. Field aims to establish a free school in Birkenhead to pioneer his approach.
If these improvements in quality were achieved, this should allow a wholesale reform of existing public services and their infrastructure. Such changes would inevitably raise questions and challenges, in particular for politicians. Would public sector workers and their representatives support extensive changes in the management of services under the banner of “zero tolerance” of poor quality? Eventually, would they lead arguments for radical redesign of services, with (for example) prisons playing a much less important role in criminal justice? Change is always a challenge, but for anyone interested in more productive public services, it is nevertheless an exciting prospect.