Just leave it alone

We don’t hear much about the welfare state these days. A decade
ago, the phrase was much in use in political circles. The
government of the day wanted to “roll back the state” and was
routinely accused of undermining the post-war settlement with a
mixture of marketisation and negligence.

Now we have a government committed to defending, expanding and
improving what we used to call the welfare state. The language has
changed – rightly perhaps, as “welfare” is redolent of hand-outs
and “state” of nannying, and both are buttons to be pressed at
one’s peril. Most often, we hear about education and health
services. We know they are a top priority for government, subject
to heavy investment. We often hear that they are under-performing.
Much effort goes into modernising them. This involves not only
targets, performance indicators, inspections and league tables, but
also – somewhat contradictorily – devolution of spending power to
those in charge of services at local level and more choice for
parents and patients.

The overriding sense we get, though, is one of obsessive anxiety on
the government’s part. Will health and education services improve
its performance ratings soon enough to validate the latest reforms?
Should something else be changed – just in case? The poor public
sector is picked at, over and over again. Its chances of
improvement diminish with each stab of the fingernail.

The more preoccupied the government, the media and, indeed, all of
us become with how well or badly public services are performing,
the less we can stand back and consider the big picture. Why do we
want schools and hospitals anyway? Isn’t it because of the value we
attach, as a nation, to health and education? The services, surely,
are a means to an end, not an end in themselves.

If the primary aim of government were to ensure that everyone was
as healthy and well-educated as possible, and if that aim inspired
and shaped all its dealings with the public sector, we should have
very different health services, schools and colleges. We’d hear
less about waiting times, more about measures to tackle the causes
of ill-health; less about exam results, more about what it takes to
develop in young people a desire and capacity to learn. We might
give more weight to preventing dementia, rather than simply
focusing on providing services for people who suffer from it. We
might give a higher priority to ensuring that children in care are
willing and able to learn – and have the opportunities and support
they need to do so.

A new Treasury discussion paper comes tantalisingly close to
acknowledging the problem. It criticises “past approaches” to
measuring productivity for concentrating on resource inputs and
overlooking “the primary concern of government and citizens alike
which is that public services should achieve certain specified
results”.¹ What’s needed, it says, is a focus on
outcomes, “such as levels of health and literacy within society”.
Sadly, this theme is not developed. It calls for “clear long-term
goals, expressed as desired outcomes”, but then retreats to safe
old territory – how to improve the services we already have. It
does not address how to design the functions of the public realm to
achieve the goals of a just society.

Why do governments become fixated with services? It is easier to
tinker with practical operations than to design and implement
complex strategies. Services are immediate and tangible. They make
better stories for the media. Around them are built up professions,
which then develop a strong interest in defending “their” services.
Political conventions demand that every problem is met with a
solution that can be measured and judged within a short time span.
It is easier to measure the outputs of services than to evaluate
complex strategies with long-term implications.

So on they go, pick, pick, picking. No wonder it doesn’t get any
better. They should leave it alone. We should all remind ourselves
of what we really want. Then we should think hard about how to
achieve it. Finally, we should have the courage to be radical. The
end may not always justify the means. But nor should the means be
allowed to justify themselves.

¹ The Treasury, Public Services: Meeting the
Productivity Challenge, Stationery Office, April 2003. Available
at
www.hm-treasury.gov.uk

Anna Coote is director of public health, The King’s
Fund.