House of Commons - Public Administration

Select Committee on Public Administration Fourth Report

5 MAKING USERS' VOICES HEARD?

168. The prospect of more choice, which may bring with it the complex and serious policy implications we considered in the previous chapter, increases the need for users to have an effective say in public services. In this chapter we examine central government initiatives and policy on voice, as well as local schemes which have produced positive results for local services and communities.

Individual choice and collective goods

169. It is clear that individual choices can sometimes conflict with wider public priorities, and that choices can conflict with each other (for example, to pay low taxes and to have quality services). There are policy areas (transport is an obvious example) where the public interest is clearly not to be found simply in the aggregation of individual choices. Present choices can conflict with future choices (as with environmental policy) and the interests of current users can conflict with the interests of non-users and future users. In these cases there is a need for wide-ranging and well-informed debate about the way forward. As Camden London Borough Council told us "political choice, and choice made through democratic representatives, need to feature in this debate as well. Governance of public services means reconciling many interests, and diverse and potentially conflicting individual choices".[133] On the other hand, the Government is emphatic about the value of choice in strengthening the hand of those for whom 'voice' is not effective. There is an obvious need for a coherent collective voice for users and citizens. Adjudicating on such issues must be a matter for collective deliberation rather than individual choices.

170. Individual choice or the cultural norms of a particular group may conflict with decisions reached collectively, in ways that may need to be resolved, in the end, by the courts. The issues are illustrated by the recent case of the Muslim schoolgirl who won the right to wear clothes which were not in line with her school's overall policy on uniform. Similarly, a choice to have faith-based education may conflict with a choice to have an integrated school system.

171. We found during our visit to Birmingham that many people also have long-standing attachments to their locality and its institutions, and that simple references to the importance of listening to the choices of individual 'service users' fail to capture the strength of feeling about community position. Asked why Birmingham's Council tenants had voted in large numbers against a transfer of their homes to an outside provider (despite the prospect of substantial repairs if provision transferred to an outside body), Carolyn Palmer-Fagan, District Housing Manager, Hodge Hill, Birmingham City Council, told us that:

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172. Loyalty to local institutions often appears to play a part when people express doubts about choice in healthcare. The NAO reported that a number of people considered that if they used a hospital in a distant town (perhaps prompted to do so by poor standards or long waits at their local hospital) their local health facilities would decline further. This motivated them to choose their local hospital, whatever its shortcomings.[135]

173. Thus a complex mixture of interests and motivations is at play in the debate about public services. While there are millions of individual needs and preferences, expressed in choices of various kinds, collective interests—local and national—also need to be taken into account. We discuss below the mechanisms that are needed to bring the diverse threads of choice and voice together.

Constraints on the effectiveness of collective voice

174. We are aware that, just as there can be constraints on the effectiveness as choice as a mechanism for responsive public services and for giving more power and control to communities, there are also constraints on voice, which policy design will have to overcome. The National Consumer Council listed a number of problems with voice, including the fact that the extension of voice was dictated and managed by providers. It might therefore, according to the NCC, fail to offer the same degree of power and control that is produced by greater user choice. Other potential shortcomings of voice included:

"Consultation processes can conflict with efficiency if the desired ends are not clear or if they are unrealistic.

Stakeholder processes are subject to capture by unrepresentative groups if not carefully managed.

Involvement and consultation that doesn't affect outcomes can increase cynicism and contribute to 'consultation fatigue'.

User involvement in governance needs to be matched by a mature understanding of risk sharing if individuals are to take on a greater responsibility for decisions that directly affect others.

Processes involving the public need to develop in sophistication and appropriate use if they are to build public confidence. Experience in this remains limited, particularly in the area of governance".[136]

175. These points demonstrate the difficulty of establishing credible and robust mechanisms for making the voice of the user heard through representative bodies. There is also some evidence that the Government is beginning to doubt the value of certain of its own policies on voice in public services, after initial enthusiasm about the prospect of greater public involvement through representative bodies. Two cases illustrate the point.

Muted voice: two case studies

FOUNDATION HOSPITAL BOARDS

176. There is one recent innovation intended to strengthen the representative voice of the community where progress can be examined in some detail: the establishment in 2004 of the governing bodies of foundation hospital trusts, the product of Mr Milburn's work as Secretary of State for Health. These are directly elected by local people, including patients and staff, and work with the boards of directors to help set the overall direction of the organisation.

177. The evidence on which to assess the potential of foundation trusts to improve services and engage the public is still very limited. It remains to be seen whether such bodies, only a tiny minority of Britain's hospital boards, will in the long term achieve the Government's aim of bringing "far greater local ownership and involvement of patients, the public and staff".[137] It is also difficult to see how patient representation on the boards of particular local provider units fits with a developing world of extended patient choice of provider.

178. On the broader policy front, the omens for foundation hospital boards look even more uncertain. When we asked the Health Minister, Mr Hutton, about the origins and significance of foundation hospital boards (introduced during the passage of the Health and Social Care Act 2003) he told us "It probably would be true to say that we made that concession as the Bill progressed in Parliament because that is essentially what many of our colleagues asked us to do. They wanted to have that as part of the Bill. There was a history to that argument which I will not go into but I can understand why some people would make that observation".[138] Given the tone of this statement, it seems unlikely that the future of foundation hospital boards will be bright.

SURE START BOARDS

180. For example, the chairman of the Bellingham Sure Start board, responsible for the scheme in an area of south London, was critical of the Government's proposed changes. He feared that the quality of consultation would diminish "we're going from a board that is one third parents or carers, a third community people and a third service providers to just an involvement panel". He was concerned that parents would become "disillusioned and cynical" about the scheme as control slipped away to the distant town hall, and, significantly, that services would suffer.[139]

181. There are arguments to be made for both the "neighbourhood" and "traditional local government" approaches to representation. Whereas neighbourhood bodies may be more responsive to specific needs and may have a good understanding of the precise environment in which services are delivered, larger local authorities can offer a broader perspective, access to a wider range of professional expertise and greater democratic legitimacy.

182. Indeed there may be questions about the legitimacy of any new body for giving people a "voice" which is not grounded in recognised democratic institutions. Concern might be especially strong in cases where the new body is responsible for important functions such as the delivery of services or decisions regarding finance. Such a new body may well be, and seen to be, legitimate if its 'constituency' covers only those who are directly and self-evidently affected (for example, the tenants of a housing estate). But legitimacy may be more open to question in cases where the constituency cannot be so easily identified (for example, in the case of 'patients', who are urged to play their parts in the election of foundation hospital trusts).

183. We believe that there is a strong case for a programme of pilots of various approaches, followed by proper assessment of the benefits and disadvantages of different types of representative body. There is now a range of models available, and we would encourage further innovation. But the process has to be properly managed, integrated and evaluated.

184. The Government needs a more coherent approach to the question of what is the most effective method of providing a representative voice for the user of public services. The uncertainties over Sure Start and foundation hospital boards raise questions about the voice of service users. The Government has welcomed innovation in the field of 'choice'; it should equally welcome innovation in 'voice', initiating a programme of pilots to test and assess the merits of various models.

Voice and voting

185. Despite the Government's positive words about the merits of local participation there are signs of a more fundamental Government scepticism about the practical usefulness of voice.

186. There are two ways of expressing voice through the ballot box: voting on a single issue referendum and voting for representatives, whether for foundation trust boards, parent governors, local councils, directly elected local mayors or national elections. Turnout at both local and national elections has decreased substantially over the last ten years. In its memorandum for this inquiry, the Government appears extremely sceptical about the value of democratically-elected representative bodies in improving standards in the public service, accusing them of being:

"often poor at dealing with under-performance. Voters are rarely faced with the costs of meeting their service requirements. When they are not faced with those costs, they can simply vote to increase or maintain services at other people's expense. Indeed, this often happens when school or hospital closure proposals are put to a vote; the voters concerned usually do not have to bear the costs of keeping the institutions concerned open and in consequence usually vote the closure proposals down … Whatever activists' hopes and aspirations may be, in fact far fewer people are involved in expressing their views through formal mechanisms of 'voice', than through using services. And those that do tell us that there is much more to be done to make such mechanisms satisfying and effective".[

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187. Mr Nick Raynsford, ODPM Minister, also told us that "voice alone is probably not sufficient if you want to achieve really responsive public services".[142]

188. The debate over tenant ballots on social housing options has raised some important questions about the value of voting in decisions on the future of public services, and Government and local authority attitudes to it. If the option being considered is transfer of the housing stock to a registered social landlord, then there is a requirement to ballot tenants. If the option is either to introduce an ALMO or PFI, there is no requirement for a ballot. In many local authorities, the consultation process has taken the form of ballots regardless of the options, and there have been some high profile examples, such as Camden and Birmingham, where tenants have voted against the option put to them. In Camden the tenants voted against an ALMO, and in Birmingham a 75% turnout voted two to one against stock transfer. Effectively, tenants appeared to be voting against improvements being made to their homes.

189. Elsewhere, such as in the London Borough of Newham, tenants have not been given a vote on stock transfer, but have been consulted by means of public meetings and a MORI survey. In Birmingham, after a ballot returned a 'no' vote, the Council is now consulting within individual neighbourhoods on smaller transfer agreements. Mr Wood, Newham's Director of Housing, explained to the Committee his view that:

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190. Thus at several levels of government there is dispute about the value of voting and of representative bodies on local service issues. The collective voice sounds uncertain.

The role of complaints in making services responsive

191. If the situation of collective bodies is unsatisfactory, there are also shortcomings with the machinery for dealing with individual complaints. Large parts of the system for putting things right in public services need reform, but there is little early prospect of it. The Government notes in its evidence to the Committee that:

"Individual voice mechanisms such as complaints procedures also have their problems. They require energy and commitment to activate; they take a good deal of time to operate; and they create defensiveness and distress amongst those complained against. They favour the educated and articulate. Users who complain are not necessarily those who have the most to complain about; and adversarial relations between professionals and users, especially tied to a threat of lawsuits as they often are, can lead to expensive and inefficient defensive reactions on behalf of providers".[

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192. There are serious difficulties affecting the mechanism for handling NHS complaints. Ann Abraham, the Parliamentary and Health Service Ombudsman, told us of her serious concerns about the state of the system. She said that planned reforms were not being examined properly and that they contained significant flaws. Draft regulations covering the reforms "Focused on process and timescales rather than outcome, leadership and staff competence; failed to address the issue of redress for justified complaints; and included time targets which were not achievable for all complaints and so would result in disappointment and dissatisfaction". She continued:

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193. The Ombudsman also told us of her anxiety that the Healthcare Commission, which is charged with handling many complaints under the new system, might be "overwhelmed" by the number of cases referred to it.[146] As with expanding choice, it is clear that providing more effective voice can be expensive in terms of both money and time.

194. More widely, the ability of Ombudsman systems to improve services is hampered by the relatively small number of cases that are dealt with by that route. It is difficult, although not impossible, to make suggestions for service reform based on such a limited evidence base. Ms Abraham said, however, that she would welcome a wider role in making the voice of the user heard:

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195. We are encouraged that the present Ombudsman is using the evidence she has received about the variations in funding for continuing adult care to make recommendations (now accepted) for a consistent national approach.[148] But this is a rare opportunity, offered by the exceptionally large number of relevant cases (600) that have made their way to the Ombudsman's office.

196. Another constraint on the capacity of the Ombudsman system to strengthen the voice of the user is the fact that the office's jurisdiction is restricted by the list of bodies that is laid before Parliament pursuant to the 1967 Act that governs her activities. This can have serious consequences, as was demonstrated when the Ombudsman was unable to investigate the activities of the Government Actuary's Department in the case of Equitable Life. Ms Abraham told us that she would welcome a legislative change which would make it the presumption that central government bodies were within her jurisdiction, but she saw little chance of such a change being made in the near future.[149] We also support her call for the removal of the MP "filter" for Ombudsman cases, a proposal now supported by a clear majority of MPs in a recent survey undertaken jointly by the Ombudsman and by the Committee

197. We repeat our earlier recommendation that the Government should move promptly to introduce legislation to remove the 'MP filter' on cases which are sent to the Parliamentary Ombudsman. There should be early action to modernise the system by which the Ombudsman's jurisdiction is determined, so that it should become the presumption that her jurisdiction includes any central government body.

User surveys

198. There are a variety of ways in which those who provide services can discover the detailed views of service users. These can include: customer surveys, focus groups; and suggestion boxes or forms. Although there is no doubt that effective examples of all these exist in the public sector, they seem to have been neglected in the current debate on the public services.

199. It is true that, in recent speeches, the Mr Alan Milburn has suggested that there are benefits in asking users directly for their opinions on services. He told the Social Market Foundation "Satisfaction levels with policing in the North West, for example, rose only after services in both Blackburn and Liverpool began to elicit public views on how performance could be improved. Many health and local authorities are finding the same. There are enormous gains to be made from bringing the public inside the decision-making tent".[150]

200. Mr Milburn's view was echoed by Ms Palmer-Fagan, Birmingham City Council, who told us that "As a district housing manager, I would not like to make any decisions in my district about changing that service without engaging and involving the people who I provider those services for".[151] The South Birmingham Primary Care Trust also carries out "regular satisfaction surveys, focus groups, and patient forums with our service users" and felt that they "have made quite a lot of significant improvements in the services as a direct result of people saying 'we would like things to be done this way, rather than this way". [152]

201. Whilst in Birmingham we also heard from Vic Smith, a tenants' representative, that the transfer ballot appears to have prompted the Council to redouble its efforts to bring tenants into the decision-making process. Mr Smith told us that "we have been involved more since [the stock transfer ballot] than we ever were before … The tenants have the chance to come and say what they want".[153]

202. Schools operate a variety of "voice" mechanisms. Parents have a say through representatives on governing bodies and complaints systems. Parents are also often surveyed on proposed changes to schools such as the introduction of uniforms, and as part of OFSTED inspections. Pupils may have a voice through school councils. Martin Ward of the Secondary Head Teachers Association suggested to the Committee that an extension of pupil voice might be appropriate:

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203. When we considered the Ombudsman's concerns about the new arrangements for the NHS complaints system last session, Sir Ian Kennedy, chair of the Healthcare Commission, told us:

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204. In a subsequent memorandum, Sarah Mullally, the then Chief Nursing Officer, explained that

"NHS complaints reform—Making things right".

"Making things right"

… we have worked … to develop a model comment card and supporting guidelines.

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205. We commend comment cards as a straightforward but effective means for establishing user experiences from which the providers can learn and improve their service.

206. The value of regular consultation of service users about their experiences and expectations of service delivery is clearly shown in Canada, where a biennial survey of 9,000 users across the provinces and territories is carried out by the Institute for Citizen-Centred Service (ICCS). The survey examines key "drivers" of satisfaction with services: timeliness; knowledgeable staff who go the extra mile to help clients, fair treatment; and a successful outcome. The 2002 survey found that timeliness, by a slight margin, was the lowest scoring in terms of satisfaction, but that it had the strongest impact on satisfaction, which suggests that in Canada improving timeliness presents the single biggest opportunity for service improvement. The same survey also examined the link between good services and confidence in government institutions, finding that "Good service not only makes citizens happy, it strengthens the institutions of government".[157]

207. The ICCS also provides measures by which public satisfaction with individual services can be assessed. It is the custodian of a series of Common Measurement Tools which services can adapt and use in order to carry out individual surveys. The evidence from Canada is also becoming more widely known. When we visited that country in 2003 we were impressed by the commitment at both federal and provincial level to asking consumers what they needed and wanted from public services—and to making sure lessons were learnt to make sure they were improved (including targets for improved satisfaction levels over time). Writing in 2004 Mary Tetlow, principal adviser at the Office for Public Service Reform in this country, said that "The OPSR is now considering whether we should develop some aspects of the Canadian model here" as, although public service customer surveys are carried out in the UK, the UK lacks a common measurement tool. Ms Tetlow continued:

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208. The National Council for Voluntary Organisations (NCVO), representing the voluntary and not-for-profit sector, made a valuable point when it told us that "consultation should be about those things that the individual or the community really can have a say over. And it should include a feedback process to ensure that those consulted know the outcome of the consultation and the reasons for decisions".[159] There is a great deal of scope for innovation in the area of feedback about user preferences and levels of satisfaction with public services, and the Government should do more to encourage such innovation.

209. We believe that there should be a more concerted approach to the measurement of public satisfaction with public services. The Canadian experience has shown that such an approach can be very useful in ensuring that lessons are learned and services improved along the lines that consumers require. Consideration should therefore be given to the development of a Public Satisfaction Index (PSI) which would be used to measure satisfaction with individual services. This should play a part in performance assessment and should be rigorously audited by an independent body such as the National Audit Office or Audit Commission.

210. The machinery to allow service users to contact government departments and to communicate what they require is itself complex and variable in quality. It was found in March 2005 that there were no fewer than 198 call centres for central government alone.[160] As The Guardian commented "Does the DWP really believe that the public's best interests are served by having 10 different contact centres for pension matters? Surely one would suffice?" In this area, choice does not seem likely to be what the public want of their public services. In France, there is a move to introduce a single access gateway, called 'Allo Service Public'. The scheme aims to answer citizen's administrative queries, satisfying 70% of requests straight away so users do not have to go elsewhere. The objective is to give a human and friendly service, as well as a modern image to public services. The development of a similar access gateway in the UK could help to make it easier for users to negotiate an increasingly complex world of public service delivery. Building on the success of NHS Direct, we believe the trial of a Public Services Direct would be a valuable addition to the voice mechanisms available to users.

A FAILURE TO LISTEN TO THE VOICES OF USERS

211. We have identified shortcomings in the design and operation of the mechanisms which are supposed to give users a say in the direction of services. Neither complaints systems, representative bodies nor user surveys are sufficiently well developed or sensitive to the needs of the people who use services. One of the concerns raised by the Government about voice mechanisms is one which can also be levelled against choice-based systems—that they favour the "educated and articulate".[161] It is ironic, and significant, that those who might be most disadvantaged by provider choice—the poor and the inarticulate—are often those who are also least able to take advantage of the "voice" they are given through the (often ineffective) representative bodies that currently exist. Their voices are rarely being heard.

212. It is therefore disappointing that the Government memorandum to the Committee, while acknowledging these difficulties, fails to offer any proposals for overcoming them. It appears that, within Government, policy development on choice has been given priority over policy development on voice, and that some important issues have been neglected. We hope that the recent initiatives from ODPM might help to overcome this deficit, but there is clearly much work still to do.

213. We recognise that, just as there are constraints on choice, there are constraints on voice, whether expressed in representative bodies or through complaints systems and user surveys. More careful and imaginative consideration needs to be given to making voice mechanisms effective. The problems being encountered by the Parliamentary Ombudsman in gaining active and practical Government support for modernisation is one example of the current difficulties. Together, choice and voice can contribute to making public services responsive and giving more power and control to those that use them, but they must be treated with equal seriousness by the Government.

133 CVP 14 Back

134 Q 293 Back

135 CVP 12, para 86.2 Back

136 CVP 04 Back

137 CVP 24a, para 25 Back

138 Q 474 Back

139 Guardian Society, 19 January 2005 Back

140 CVP 24, para 3.3.6 Back

141 CVP 24, para 3.3.7 Back

142 Q 479 Back

143 Q 125 Back

144 CVP 24, para 3.3.9 Back