Memorandum from Sophia Parker
To expand any of the ideas in this note, please
see S Parker and J Heapy, The Journey to the Interface: how
public service design can connect users to reform (Demos,
2006). It can be downloaded for free at http://www.demos.co.uk/publications/thejourneytotheinterface.
Before exploring some of the specific questions
posed by the Committee I want to pause and reflect on why this
agenda is so important. There are five main reasons that explain
the importance of user engagement and involvement in public services:
i) People feel more satisfied when they see
a way to shape outcomes
Recent research, noted in the Local Government
White Paper, indicates that there is a correlation between people's
perception that it is possible to get involved in local
service provision, and levels of satisfaction—at a time
when only one in five people are satisfied with opportunities
for such involvement. In a recent poll, 73% of people supported
the idea of neighbourhoods having more control over the provision
and budgets of services. [49]And
91% of people with long-term conditions want more involvement.
[50]
ii) Involving users can decrease failure demand
(i.e. the cost of getting it wrong first time)
Users are able to see losses in productivity
that are not always identified through system monitoring. For
example, someone entering a prison is assessed seven times in
the first three days—for level of risk, for health, for
learning and development and so on. Each of those assessments
could be perfectly designed; however that prisoner is still providing
the same information over and over again. Similarly, one government
department calculated last year that they were spending £18
million on telling people they had called the wrong number—a
strong hint that significantly more could be done to improve signposting.
iii) To achieve today's ambitious outcomes,
people need to get involved
Increasingly the kinds of problems that governments
are expected to solve require people's participation. As Peter
Wanless argued in his 2002 review of the health service, `the
key differentiator for success over the next 20 years is not how
the health service responds, but how the public and patients do'.
For example, diabetes accounts for 9% of the NHS's budget today,
but on projected figures that is set to increase to 25% by 2020.
In health and indeed many of the other most pressing issues—energy
supply, climate change, community cohesion—it is clear that
outcomes simply cannot be achieved through applying greater pressure
to existing models of services, or trying to squeeze yet more
productivity out of them: improvement alone is not enough. We
need radically new models of service where people are creators
of value rather than passive recipients of pre-defined services.
iv) Involving people is a catalyst for innovation
and learning
These new models of public services will only
emerge from government working more closely with citizens, investing
time and resources into developing capacity for collaboration
and finding new ways of tapping into the energies and motivations
of people, encouraging them to participate in the common enterprise
of positive outcomes.
Innovation literature emphasises repeatedly
the need for user involvement and customer insight in driving
change. More needs to be done to balance out the heavy emphasis
on top-down reform that characterised the early years of New Labour
with a greater ability to encourage and channel `bottom up' pressure.
There needs to be a perspective shift: the whole field of public
services needs to be seen as a site of potential innovations,
rather than innovation being something that is brought about through
grafting practices from other sectors on to existing models of
public service.
v) Tough decisions about using limited resources
should be made by all of us
It is crucial that this agenda does not simply
become another management or public policy fad. Forging deeper
connections between public services and citizens is not simply
about delivering better outcomes and improved services, important
though those aspirations are. There is also a political and moral
case to be made for greater participation. Through getting more
involved, people can open up the possibility of playing a more
active role in shaping their own lives. Participation is a way
of helping people to make connections between the decisions they
make, and the quality of the public realm as it is experienced
by others around them.
Taken together, these reasons create a compelling
case for why this area needs further investigation. I welcome
the decision for PASC to undertake this piece of work.
1. LEARNING FROM
ELSEWHERE
— Can public services learn from the
way that either non public sector organisations or overseas governments
make use of user experience in service delivery and design?
There is a great deal that can be learnt from
elsewhere. The challenges public service organisations face in
terms of connecting people's experiences with strategies for change
and improvement are challenges that every large organisation
faces, whatever sector it is in.
Despite a shift to a service economy, the UK
has not seen a service revolution. Many of our interactions with
service organisations are characterised by profound frustration,
hanging on the end of a phone, arguing over our consumer rights,
feeling ignored and misunderstood, worrying about the working
conditions of those who are serving us.
The pressure on large organisations to deliver
more for less has never been stronger. But too often this comes
at a price: those organisations find people difficult to accommodate
and they seek to `design people out' of systems and processes
in order to maximise efficiency. As one interviewee described:
"You get the feeling that they don't want you
there, that they think you're the problem...they seem to be saying
`my life running this hospital would be so much easier if you
weren't here'... when I find myself in this system I feel helpless."
However, there are some exceptions to this pattern
of large, distant organisations. In The Journey to the Interface
we examined a number of large organisations, across all sectors,
which appeared to have learnt how to design people in, rather
than out. The organisations we met had high levels of customer
or user satisfaction, a highly motivated workforce, and a sustainable
business model. We were looking for the characteristics of these
organisations, to reflect on what this might mean for public services.
What we found is that all the places we visited shared one thing:
a relentless focus on user or customer experience that was reflected
in every aspect of the organisations, from job specifications
to business planning processes. Coupled with this we noted the
inordinate amount of time senior staff in the organisations we
visited spent in trying to get into the mindset of their users.
In other words, for some of the most successful
large organisations of today, engaging with people, understanding
their experiences of services, is not an add-on activity, or a
feel-good exercise. It is instead the way in which strategies
are developed, resources are allocated, staff are measured and
so on.
Our research was just the tip of the iceberg.
There remains enormous value in understanding in practice what
effective large organisations do to bring user experience into
the heart of their business. Particular lessons that can be learnt
(we cover some examples in the book) include:
— How to create more sophisticated
forms of user segmentation—exploring attitudinal and behavioural
segmentation as well as demographics—to drive service provision
— How to map user journeys across channels
and over time
— How to understand the interaction
between people's experiences, different spaces and a range of
channels
— How to empower and motivate staff
as the key interface between the user and the organisation
— How to measure and assess customer
experiences
— How to make best use of real-time
data and feedback in many different formats
The organisations we spoke to have a real, deep
understanding of the value people attach to services. Far from
seeing them as commodities to be produced at the lowest cost by
automaton workers, people value services for their less tangible
qualities—a sense of being supported and understood, a belief
that the service has your best interests at heart.
One important caveat: this is not an argument
that the private sector is better at understanding people than
the public sector. The evidence suggests that our commercial service
experiences are not much better, and often worse, than public
service experience. According to research by the National Consumer
Council, 81% of people had a bad experience purchasing services
in 2005. Words that came up frequently in relation to commercial
service transactions included "distant", "clinincal",
and "uncaring".[51]
In other words, there is a common challenge of great service
provision: how to create more intimate relationships with people.
2. MINIMUM STANDARDS
— Is it possible to set minimum standards
for public services? If so how is this best done?
— What role do measures of customer
satisfaction have in assessing the standards of public services?
How should user views be monitored? How can the cost effectiveness
of user surveys and feedback mechanisms be assessed?
Standards—what is a `good' public service?
The target regime that characterised the first
two terms of the New Labour government relied heavily on the creation
of a series of proxies for good services—waiting lists being
the most obvious example.
In seeking to build user influence into the
design as well as the delivery of public services, there might
be value in exploring some more process-led (rather than output-led)
targets based on some of the findings of the research outlined
above. Effective, responsive and user-oriented organisations carry
out a series of activities that could be replicated in all organisations.
For example, what would happen if all public service organisations
had to put their senior management teams alongside a handful of
users for two days every quarter to map the user journey, as BUPA
do? What would happen if all public service organisations had
to work with users (and indeed non-users) to develop a set of
metrics by which to monitor effectiveness (as a particularly innovative
school federation in Kent does)?
This is not a zero-sum game; it is not an argument
for replacing one set of targets wholesale with another set. More,
there is a strong case for diversifying and broadening the mix
of `evidence' used when setting minimum standards for a service.
Too often, there is a gap between system measures and people's
experiences of a service. For example, as one local authority
official put it, `you might get the three-star CPA ratings but
the residents may not think the service is three star'. More needs
to be done to create a single view of public service effectiveness—and
what standards matter. This single view needs to be recognisable
and intelligible to citizens as much as it is to government officials.
Satisfaction
Satisfaction has risen up the agenda in recent
months, not least due to the previous work of PASC. Inasmuch as
this reflects a desire to enrich measures of system effectiveness
through a firmer emphasis on user perspectives, it is a positive
shift. However, satisfaction as a proxy for better public services
needs to be treated with real caution, for three principal reasons:
First, it is very individualistic as a measure.
The strong emphasis on `choice' belies a tendency by some politicians
and policy makers to treat public services as commodities to be
purchased by consumers. Demos research over the last three years
demonstrates that this is at odds with how people see services.
We see public services as something deeper than consumer goods;
their value rests in the less tangible sense that a service is
supportive, empathetic, responsive. Recent debates about the provision
of breast cancer drugs highlights the perils of this consumer-based,
individualistic mental model of service. Resources are finite;
people cannot view their usage of public services as if it were
purely an individual choice. The decision made by one person potentially
has an impact on the options available to another. Satisfaction
is part of a consumer way of thinking about public services and
therefore needs to be treated with caution.
Second, as a measure, satisfaction does not
give due weight to non-users. For some services, for example social
care, effective services are as much about work with non-users
as it is about working with users. For any public services where
prevention is a goal, satisfaction may be a useful indicator but
it does not provide the full picture.
Third, it is entirely subjective. Satisfaction
measures the extent to which people's expectations are aligned
with their service experience. Therefore those people with low
expectations might be highly satisfied with a very average experience.
This is significant as there is a correlation between low expectations
and social exclusion. Therefore satisfaction measures may fail
to identify inequalities in provision.
`My-metrics'
All of these are cautions, rather than arguments
against satisfaction. In The Journey to the Interface we
explored some emerging methods for measuring user experiences
themselves, rather than satisfaction. What defines all of these
methods is their participative nature: service providers
sought to involve people in determining what matters most as part
of the process of assessing standards. Three examples illustrate
this point.
Dignity team at the Department of Health
The dignity team have been working extensively
with users and running an extended consultation exercise with
older people about their experiences of services. Over the course
of this work they discovered that when people were asked `were
you treated with dignity?' invariably people said that they were.
The team then worked with users to explore in more depth what
`dignity' meant for older hospital patients, and developed some
more specific questions to ask. When users were subsequently asked
things like `were you given time to finish your meal' a clearer
picture emerged—one where it was not always the case that
people were treated with dignity.
CSCI's measurement and assessment framework
In collaboration with Bradford University, CSCI
has developed a number of innovative initiatives in measuring
effectiveness through including approaches that take account of
service users' experiences of social care services. I would strongly
recommend that PASC explores these models further.
Birmingham OwnHealth
This is a phone-based initiative to support
people with long-term health conditions, jointly funded and run
by two PCTs, NHS Direct and Pfizer Health Solutions. A full case
study is included in The Journey to the Interface, but
one notable dimension of the programme is its approach to assessment
and target setting. In the first conversation between the care
manager and the person, they will discuss some simple questions—about
diet, exercise, and so on—and the digital platform that
underpins the system will then highlight areas where the patient
needs to do some work. Together, the care manager and the patient
will talk in order to understand which issues are relatively straightforward
to tackle, and those where the patient feels they need more support
to tackle. They then set some targets—not based on system
performance but instead on the goals that the patient feels they
can achieve through the conversations and coaching offered by
the nurses. Over time, as the patient grows in confidence and
knowledge and feels more able to self-manage their condition,
the care manager works with them to develop their `graduation
criteria'—which are focused on the capacity to self-manage,
rather than a pre-defined set of outcomes that may mean different
things to different individuals.
Ultimately, satisfaction is one element in what
needs to be a much richer picture. Very few services can be properly
evaluated through quantitative measures alone: services have to
be run at a more complex level than that of KPIs. Minimum standards
need to be developed in participation with citizens, rather than
being seen as a set of indicators based on a detached analysis
of what matters most. However operating in this way requires a
more open dialogue between politicians, senior officials and the
public; a dialogue that recognises the complexity of the task
in hand, and a dialogue that encourages and challenges people
to engage in the difficult trade-offs that are inevitably part
of public management.
3. MAKING COMPLAINTS
— What constitutes best practice in
responding to complaints about public services?
— Is information about complaining
easy to find and accessible?
In the organisations that participated in our
research project, what we noted was the dynamic exchange
of information between users, staff and organisations. Feedback
loops featured strongly in the ways that people described their
strategy processes—in other words, information was rarely
one way, and much more dialogic models were in play.
On that basis, complaints and avenues for redress
are a crucial part of the picture. Service innovators are hungry
for knowledge and insight, and they are as interested and willing
to work with negative feedback as they are positive feedback:
in fact they embrace it. For example, one health organisation
we visited works with a small group of people on the four elements
of the service that they least like. Participants were asked to
work with staff to think about how each of these elements might
be improved; in the following months, some of the ideas generated
are tested and monitored, before the group reconvenes for feedback
and reflection. The success of this approach rests with an emphasis
on learning, rather getting things right: something that
is a very real challenge for public service organisations under
intense media scrutiny.
Of course, every service needs to ensure it
has accessible and fair avenues for redress. But the goal should
be to ensure that these avenues are used as little as possible.
In the organisations we visited, they made use of every possible
channel for feedback in order to identify problems and failures
as soon as they possibly could.
Two channels in particular that are often under-used
in public service organisations are staff and technology.
Staff
For organisations like John Lewis Partnership,
insights about people's experiences and frustrations are a valuable
by-product of the interactions between staff and customers. JLP
see their staff as the `eyes and ears' of their organisation.
Staff are encouraged to share what they learn about customers
and their responses with colleagues locally, and their views are
fed back to product development teams. Our case study of the Luton
and Dunstable head and neck cancer unit demonstrates the power
of creating improvement teams that include staff and patients
working together.
Technology
Paul Hodgkin is a practicing GP who has a sideline
in an exciting new social enterprise. In 2005 he founded the websitewww.patientopinion.org.uk.
It is a powerful example of how service innovators are creating
new channels at the interface that bring together feedback, service
measurement and user information simultaneously. The website invites
people who have recently experienced hospital treatment to swap
stories. Other people preparing to go to hospital can use the
site to help them make decisions about where to go for their treatment;
the information is far more accessible and immediate than any
star rating or performance report.
Paul also sells full access to the information
on the site to PCTs, to enable them to get a better feel for system
performance from a different perspective. In effect, looking at
the website gives the Trusts continuous access to collective wisdom
across the system.
For the most innovative service organisations,
it is not possible to separate out insight, measurement, feedback
and information; and for these organisations, this data is not
just gathered: it is offered back to the users of services. Requesting
and sharing information in this way, on a regular basis, offers
an effective new channel of honest dialogue that can benefit service
organisations and users in equal measure. Presenting system information
and measurement back to users in accessible and usable ways as
an important element of building trust and putting people in control.
With the proper focus, advances in technology should help service
organisations to develop better `real time' and `very local' information.
4. VOICE
— Should users be more directly involved
in service delivery? If so, how can this be achieved?
— Are there certain types of decision
which are more suited to consultation than others?
— Do official consultations typically
manage to capture the views of the right people? What kinds of
consultation are most effective in engaging with the appropriate
people?
— How valuable are advisory panels
in the design and delivery of public services?
Consultation
We know that the many and frequent consultations
since 1997 have not resulted in greater satisfaction with public
services. Consultation might ask what people think but it does
not disrupt the traditional model of the `doers' and the `done-to'.
In other words, most consultations review existing provision,
or ask how to improve the work of functionally defined services,
rather than developing new provision or questioning the `fundamentals'.
This limits the scope of their effectiveness.
Furthermore, the capacity of consultations to
give feedback to respondents and the general public seems limited.
This is a very real problem: it breeds cynicism and a sense that
taking time to respond is pointless because it is never clear
how it has changed things.
Indeed this cynicism may be well-founded. Audit
Commission research has found that three quarters of `best practice'
local councils fail to link the results of consultation to their
decision-making processes. This kind of evidence points to the
fact that consultation is too often undertaken as a `box ticking'
exercise, rather than being seen as a genuine tool for decision-making
and policy development. Similarly, a European-wide survey found
that there was a gap between the commitment to involve people,
and its implementation.
One of the biggest challenges with this agenda
is that whilst most people are in agreement about the need to
involve and engage users, there are many different understandings
of what this looks like in practice. Such approaches have a long
and varied history, from international development to community
planning. A major priority for government over coming months is
to do some further thinking and research about particular approaches
to user involvement, what works, where and with whom.
A number of academics have developed their own
version of a `ladder of participation' which begins to unpack
the many different ways in which users can get involved in service
design, delivery and governance. One version of the ladder is
this:
This diagram is not intended to preference one
form of engagement over another, but more to help people assess
what approaches are fit for the task in hand.
Involvement across service design, delivery and
governance
Seeking to enhance opportunities for citizen
involvement across the `design, delivery and governance' of public
services brings a range of challenges to public servants and politicians.
For example:
Participation through governance
Recent Demos research found that whilst roughly
a quarter of us say we would like to participate in our local
communities and service provision, a mere 1 or 2 percent of us
actually do. Demos identified a `rich get richer' effect with
those participating in governance structures—in other words,
becoming a member of a board makes it more likely that you will
become a member of multiple boards. In these terms, the challenge
is twofold: how to ensure that the widest possible range of people
end up in the 1% who are participating; and how to ensure that
the connections between that 1% and the rest of the population
remain strong and positive. For more information on this very
well-received report please see http://www.jrf.org.uk/knowledge/findings/government/1963.asp
Participation in delivery
There is much to be learnt from the successes
of transferring housing stock to TMOs. The forthcoming Quirk review
will explore questions around people directly delivering services
in much greater depth and it is an area that needs more exploration.
Beyond this, earlier Demos work suggests that there is a vital
role to be played by third sector and user-led organisations in
building the capacity, confidence and networks of people to play
an active role in service delivery. For more information please
see P Skidmore and J Craig, Start with People: how community
organisations put citizens in the driving seat (this can be
downloaded for free athttp://www.demos.co.uk/publications/startwithpeople).
Participation in design
Co-design of services is arguably at its most
developed in the arena of social care, where the piloting of Individual
Budgets has led to some radical shifts in the relationship between
users and the service, from which much can be learnt. Key lessons
from this highlight the importance of where people are
involved in their service design: assessment of need appears to
be a critical place in terms of giving a person genuine opportunities
to influence their service experience. Furthermore it is vital
that there is the appropriate support for people: the power of
direct payments and individual budgets does not rest with simply
handing a person a cheque to spend on services, but helping them
navigate what some users call `service land'—a complex landscape
that is often hard to comprehend even to the most seasoned users.
One of the fears that people have expressed
in workshops on this subject is that if you ask people what they
want, they will ask for more than they can possibly get. Time
and again this proves to be an unfounded worry. For example a
Barnados survey of what children wanted from their schools revealed
that their top priorities included `a roof that doesn't leak'
and `a warm classroom'—far from the chocolate classrooms
that one teacher suggested her students would demand! Properly
facilitated and supported, people can bring real insight and clarity
to how to improve the design of a service.
The most powerful example of user involvement
in service design I have come across is the In Control model of
social care provision. More can be found out about this here:http://www.in-control.org.uk/home.php.
The evaluation of the first three years of the scheme indicates
that satisfaction has risen hugely, even though costs have stayed
stable and in some cases gone down, indicating that often user
involvement can lead to much smarter, more efficient as well as
more personalised forms of resource allocation.
Involving people in `total service design'
PASC is absolutely right to ask about what types
of decision people should be involved in. It is a political decision
as to whether people are consulted on pre-defined decisions, or
whether people have a right to be involved in an earlier stage
of policy development. As the rest of this note indicates, I believe
there are powerful arguments for such early involvement, both
for the sake of better public services, and because there is an
important moral dimension to such participation.
Deliberation and dialogue are often spoken of
as solutions, as panaceas even, to all our contemporary quandaries.
However there is still a real capacity gap in government—at
local and national level—in terms of the kinds of skills
this way of working demands. Design, psychology, conflict resolution,
systems thinking, futures methods and many other disciplines demonstrate
that consultation is not just something that anyone can do. Done
badly, attempts to involve users can breed cynicism. Promising
dialogue and delivering a one-off, superficial discussion will
only serve to enhance that cynicism.
But research in psychology and neurology shows
that real deliberation—the weighing up of contradictory
options—can be distressing, troubling and uncomfortable.
This has consequences for how we think about user involvement,
and how we address it. First, we all need to recognise that genuine,
`deep' dialogue is not an all-round feel good experience. Second,
those engaged in such deliberation need to be given the time and
space for participants to get past the anxiety that the confrontation
embedded in the act of deliberation triggers. Finding new ways
of supporting and encouraging such `deep dialogue' needs to become
a major policy objective—one that will require the wisdom
and bravery of the politicians to make it possible.
With the skills required in mind, I think there
is a real opportunity for what Matthew Taylor has called a Copernican
revolution in the process of policy making—where the user
moves from the periphery to the driving force. This government
aspires to the `transformation' of public services. It's a big
word, and a big aspiration. What it should describe is a willingness
to shift the organising logic that currently underpins our public
services in order to meet the goal of services that are both excellent
and fair. The participation of users in shaping this agenda has
enormous potential so long as it is done properly.
5. HARD CHOICES
— How does user influence relate to
wider issues of democratic accountability?
— How should measures of public satisfaction
take account of complaints about policy rather than administration?
— Are there situations where the views
and experiences of users are irrelevant?
Specifically on the question about whether there
are any situations where the views and experiences of users are
irrelevant: some of the most challenging conversations I have
had in the course of my research in this area has been with officials
working in the realms of international development, security and
defence. They often struggle to identify a specific user beyond
the very general `UK population'. After conversations it emerges
that there are specific user groups: for example in defence,
MOD staff identified soldiers and families of soldiers. But what
these conversations reveal is that there is never simply one user—and
it is not always easy for service organisations to focus on the
`final' user (in MOD's case, the UK public). This is an area that
requires further investigation.
The reflections outlined under point 4 underline
my belief that the public do have the capacity and should have
the opportunity to participate in debates about policy as well
as about administration. Public services are about far more than
provision of goods alone: many people see them as a reflection
of the kinds of values held by society. In that sense, the public
has a right to be involved in decisions about difficult trade-offs
as much, if not more so, as they have a right to be involved in
the ways in which specific services are run and managed.
This kind of participatory democracy is often
pitted against representative democracy as if more participation
will lead to less representation. PASC should investigate how
these debates are played out in government at the local level.
The recent Local Government White Paper underlines the role of
frontline councillors and from my experience of working with Kent
County Council I believe they could play a key role in knitting
together participation with the more traditional forms of representative
democracy.
However in order to realise that ambition, we
need a much sharper focus on the ways in which councillors are
trained, and the expectations placed upon them in carrying out
their role. The best frontline councillors already see themselves
as advocates on behalf of their local communities and they are
not threatened by more direct participation in debates about public
services. The challenge is to ensure that this is a view that
is universally held, and that such roles are recognised by local
council leaders and their cabinets.
As Ronald Heifetz has argued, the key goal for
public services has to be to get people to believe they are part
of the solution. Politicians needs to develop a narrative—and
a set of public service institutions—that share power between
elected representatives and citizens more generally. If standardisation
and mass production were the defining characteristics of our relationship
to the state in the 20th century, we need to make collaboration
and participation the leitmotifs of the 21st century.
January 2007
49 YouGov poll for Ed Cox LGiU report. Back
50
Of 23,000 people with a long-term health condition. Quoted at
a Nuffield Trust seminar, 13th February 2006. Back
51
P Cullum, The Stupid Company: how British businesses throw
away money by alienating consumers m(NCC, 2006).
Back
| 
