The Reform of Social Services: The Reform of Social Services: - - PowerPoint PPT Presentation

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The Reform of Social Services: The Reform of Social Services: - - PowerPoint PPT Presentation

May 04, 2023 104 likes •359 views

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

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SLIDE 1

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

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SLIDE 2

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 h f incentives to improve? Or is the provision of incentives irrelevant – or actually damaging?

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SLIDE 3

SOCIAL SERVICES: DIMENSIONS OF EFFECTIVENESS

  • Quality
  • Efficiency

Efficiency

  • Responsiveness
  • Equity
  • Accountability?

Accountability?

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SLIDE 4

Motivation: Knaves and Knights Motivation: Knaves and Knights

’In contriving any system of government, and fixing the several checks and controls

  • f 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

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SLIDE 5

MODELS OF SOCIAL SERVICE DELIVERY

  • TRUST
  • MISTRUST

MISTRUST –Targets and Performance Management –Regulation

  • VOICE

VOICE

  • CHOICE

–Reputation Competition Public Service Mutual –Public Service Mutual

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SLIDE 6

% patients waiting for hospital admission > 12 months % patients waiting for hospital admission > 12 months

30% 25%

  • nths

15% 20%

aiting > 12 mo

England Northern Ireland 10%

% patients wa

Northern Ireland 0% 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)

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SLIDE 7

% patients waiting for hospital admission > 12 months % patients waiting for hospital admission > 12 months

30% 25%

  • nths

15% 20%

aiting > 12 mo

England Northern Ireland Scotland 10%

% patients wa

Scotland Wales 0% 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)

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SLIDE 8

% patients waiting for hospital admission > 12 months % patients waiting for hospital admission > 12 months

30% 25%

  • nths

15% 20%

aiting > 12 mo

England Northern Ireland Scotland 10%

% patients wa

Scotland Wales 0% 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)

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SLIDE 9

% patients waiting for hospital admission > 12 months % patients waiting for hospital admission > 12 months

30% 25%

nths

15% 20%

ting > 12 mon

England Northern Ireland 10% 15%

% patients wai

Scotland Wales 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)

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SLIDE 10

% Patients spending less than 4 hours in A +E % Patients spending less than 4 hours in A +E

100 80 40 60

%

20 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 2002/03 2003/04 2004/05 2005/06 24% i i A E d itt

Source: Chief Executive's Report on the NHS - Statistical Supplement (December 2005)

+ 24% increase in A+E admittances

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SLIDE 11

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 ff efficiency improvements in NHS competitors (Cooper)

  • Expansion of market since 2008 to include any

willing provider: no further improvement? willing provider: no further improvement?

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SLIDE 12

Waiting times: an equity problem Waiting times: an equity problem

195 200 180 185 190

The poor waited up The poor waited up to to 30 30-

  • days

days longer longer

170 175

than the wealthy than the wealthy

155 160 165 145 150 I II III IV V I II III IV V

Level of Deprivation ( V = Most Deprived Quintile)

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Hip replacement broken down by deprivation: Impact of targets and deprivation: Impact of targets and choice

300 200 250 I 150 II III IV 50 100 V 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Year

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Parental Choice in New Zealand Parental Choice in New Zealand

96% f t i di t d th ld lik t l t

  • 96% of parents indicated they would like to select

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
  • f $30,000 or less strongly agreed with the

t t t th t ith l i f statement than parents with an annual income of

  • ver $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

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SLIDE 15

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 t f bl k t d 26 35 d

  • 87 per cent of black parents aged 26‐35 and

66.4 per cent of blacks aged 18‐25 supported vouchers.

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Who wants choice UK: Gender Who wants choice UK: Gender

100% 69% 80% 100% 56% 69% 60% % saying people should have a great d l it l t f 40% deal or quite a lot of say over which hospital to go to if they need treatment 20% treatment 0% Men Women

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h h l l

M i l

Who wants choice UK: Social Class

59%

Managerial and professional

64%

Self Intermediate

  • ccupations

class % saying people

64%

Lower i Self- employed social c y g should have a great deal or quite a lot of say over which hospital to go to if they need

62% 67%

semi routine supervisory & technical treatment

67%

55% 60% 65% 70%

and routine

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SLIDE 18

h h Who wants choice UK: Income

70%

£10 000 < £10,000

% saying people should have a great deal or quite

65%

£32 000 £10,000 - £32,000

income

great deal or quite a lot of say over which hospital to go to if they need

57%

£32,000 - £50,000

i

g y treatment

59%

0% 20% 40% 60% 80% 100%

>£50,000

0% 20% 40% 60% 80% 100%

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SLIDE 19

h h d l h Who wants choice UK: Educational Achievement

69% None

  • n

67% GCSE/O Level

al qualificatio

% saying people h ld h t

59% A Level

t educationa

should have a great deal or quite a lot of say over which hospital to go to if

56% Higher

Highes

they need treatment

56% 0% 20% 40% 60% 80% 100% education 0% 20% 40% 60% 80% 100%

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SLIDE 20

London Choice Pilot: % opting for an alternative hospital

100% 69% 65% 65% 67% 68% 67% 66% 67% 63% 73% 60% 80% 40% 20% 0% Female Male Basic Higher Below verage Above verage n-white White Not ployed ployed F H B av A av Non N emp Emp Sex Educational status Household income Ethnic Group Employment Status

Source: Evaluation of the London Patient Choice Scheme, Picker Institute (July 2005)

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SLIDE 21

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

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SLIDE 22

Reputation Competition: % Ambulance response times to life threatening emergencies response times to life‐threatening emergencies < 8 minutes

8 5

Star ratings published

7 5 8 5

Target 

5 5 6 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)

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SLIDE 23

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)

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SLIDE 24

So So…

For social service providers to improve, need external pressure. This could come from: p

  • Government (mistrust)

R l ( i )

  • Regulators (mistrust)
  • Peers (reputation competition)

( p p )

  • Users (voice or choice)

Need form of pressure least damaging to knightly motivation. Competition plus PSM?

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SLIDE 25

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

l h bl solution to the problem.

  • Prize: A system of social service provision that

Prize: A system of social service provision that is….. Th l t t

  • The least worst.