Memorandum from the TaxPayers' Alliance
SUMMARY
The Public Administration Select Committee's
inquiry is, in its own words, "looking at how public services
can improve by listening to the experience of service users—whether
through complaints and user surveys, or through user representation
in the design and delivery of services".
The TaxPayers' Alliance rejects the premise
of the inquiry, namely, that "voice", as opposed to
"exit" can be effective in improving public services.
In our view, the key element that public services currently lack
is accountability to those who use them. We do not believe that
increasing "voice" will have a genuine impact on the
levels of public service accountability and hence it will not
make any meaningful difference to how public services are run.
Real accountability in public services would
be achieved by giving those who use them the ability to take their
custom elsewhere, as is the case in much of Europe and in every
other walk of life in the UK. We cannot imagine ministers and
civil servants deciding what people eat and occasionally asking
them whether they agree with the decisions that have been made.
We should not continue to deny people on modest incomes the ability
to express their opinion on the quality and timeliness of the
service they receive by opting to go elsewhere should that service
not be satisfactory.
Our submission has three sections:
Section 1 describes how Britain's state schools
and the NHS as currently delivered are failing its people, particularly
the poorest members of society. The evidence itself shows that
tinkering at the edges is far from sufficient: the problem is
so great that major change is needed.
Section 2 presents evidence of how education
and healthcare services can be made fully accountable to the people
who use them, by examining the way healthcare is delivered in
Germany and Switzerland and how education is delivered in the
Netherlands and Sweden.
Section 3 concludes that to meaningfully
increase accountability of public services to those who use them,
as a general rule, users should be given the right to take the
money spent on their behalf elsewhere, if they so desire.
Section 1: Public services—failing
the very people they are designed to help
(1.1) Education, failing society...
1.1.1 The inability of the current system
to provide a high standard of education is jeopardising the future
well-being and prosperity of the country. It is condemning a large
section of the population to low-paid work with little opportunity
for upward mobility, and depriving the country of the highly-qualified
people it needs to compete with lower-cost developing countries.
The current state education system is failing children at every
stage. For example:
— 11 year-olds. 25% leave primary school
without sufficient ability in reading and writing to tackle the
secondary school curriculum. [114]
— 14 year-olds. Almost 30% do not reach
the expected levels in English, Maths and Science to tackle GCSEs.
[115]
— 16 year-olds. Almost 60% do not achieve
a GCSE grade C or better in all the three core subjects of English,
Maths and Science. [116]
1.1.2 After 11 years of state education
at a cost of over £75,000 per child, pupils are leaving school
functionally illiterate, innumerate and unskilled:
— 40% do not achieve at least a C grade
in GCSE English. [117]Some
seven million adults in England cannot locate the page number
for plumbers in an alphabetical index to the yellow pages. [118]
— 47% would be unable to achieve a
grade G at GCSE maths. [119]
— The OECD ranks Britain 29th out of
30 OECD countries as having the second highest level of low-skilled
25-34 year olds— twice the number of Germany or the USA.
[120]
1.1.3 In fact it will be increasingly hard
for the country to operate effectively, when at present:
— The average attainment of those entering
a B.Ed course is below 3 C grades at GCE A-level. [121]
— 52% of would-be prison officers failed
a simple literacy and numeracy test. [122]
— 33% of nurses completing their training
failed to achieve the 60% pass rate in basic English and maths
tests, despite having GCSEs in these subjects. [123]
— 1.1.4 ...especially the disadvantaged
— The worst primary schools are exclusively
in deprived areas. More than 50% of their 11 year-olds fail to
achieve the required level in English compared with the national
average of 25%.[124]
— Only 26% of pupils eligible for free
school meals achieve five or more GCSEs at grades A*-C, compared
with 56% of pupils who are not eligible. [125]
— 75% of children leaving care have
no educational qualifications. Within two years half will be unemployed,
a third mothers or pregnant, and a fifth homeless. [126]
(1.2) The NHS, failing society...
1.2.1 The National Health Service spending
on health care has reached the OECD average of 8.9% of GPD[127].
However reports by the National Audit Office, The British Medical
Journal and the European Union rank the healthcare provided by
the NHS as just about the worst amongst 19 developed countries:
— The British Medical Journal ranked
the NHS one from bottom on the quality of healthcare provided.
[128]
— The British Medical Journal ranked
the NHS bottom on mortality amenable to health care. [129]
— The National Audit Office in 2000
ranked the NHS the worst on hospital acquired infections. [130]It
estimated that at least 100,000 patients are affected resulting
in at least 5,000 patient deaths a year. [131]
— A recent EU study found that NHS
patients are up to 40 times more likely than other Europeans to
contract infections in hospital. [132]
1.2.2 And the list goes on. The NHS has
amongst the longest waiting lists and the lowest cancer and stroke
survival rates in Europe.
1.2.3 ...especially the disadvantaged
— The Prime Minister has admitted that
the UK has a "deeply unequal" healthcare system, where
the poorest too often receive the worst service. [133]
— The Department of Health also acknowledges
the scale of inequity. "Despite improvements, the gap in
health outcomes between those at the top and bottom ends of the
social scale remains large and in some areas continues to widen.
These inequalities mean poorer health, reduced quality of life
and early death for many people." [134]
Section 2: Meaningful public service accountability—successful
case studies abroad
2.0 Across Europe, people enjoy better and
more equitable services because social democratic governments
there have discovered that there are better ways of making their
ideals of universal and high quality services a reality.
(2.1) A Better Way: Education in the Netherlands
and Sweden
2.1.1 The Netherlands has allowed parents
to determine which school their child is sent to, with government
money following the child, for almost 80 years. All schools in
the Netherlands, whether state or independent, are given an amount
equal to the cost of educating a child in the state sector. The
money is given by the Dutch government for each child that the
school educates.
2.1.2 It is very straightforward to set
up a new school in the Netherlands that receives government funding—all
it takes in a small town for example is 50 parents to get together
and set up a school. About 70% of children go to independently-run
schools, and there are very good vocational options for teenagers,
giving the less academic pupils the opportunity to excel.
2.1.3 The system of education in the Netherlands
is more effective at educating the country's children than Britain's:
— The OECD's 2003 PISA study, which
measures the comparative performance of 15-year-olds in reading,
maths and science, ranked the Netherlands higher than Britain
in all areas.
Table 1
THE NETHERLANDS EDUCATES ITS CHILDREN BETTER
THAN THE UK
| OECD PISA Rank |
Reading | Maths |
Science |
| Netherlands | 9th | 10th
| 8th |
| UK | 12th | 17th
| 12th |
Source: PISA 2003, OECD
2.1.4 The Swedish education reforms in 1992 closely followed
the system in the Netherlands. Parents are able to send their
children to any state or private school, with government money
following the child.
2.1.5 Any organisation or group of people in Sweden that
wants to set up an independent school and receive government money
may do so as long as teaching follows the basic intentions of
the national curriculum and meets basic educational standards.
The school must also be open to all pupils and must not select,
and is forbidden from charging additional fees.
2.1.6 The policy has been a huge success:
— The number of independent schools in Sweden has
risen almost six-fold, from just over 107 to just under 576. Independent
schools in Sweden educated almost 70,000 pupils in 2004, compared
with only 8,500 in 1992. New independent schools have opened in
the poorest municipalities as well as the richest. [135]
— Swedish students have achieved higher grades and
test scores in schools with more private competition and state
schools in Sweden that face competition tend to use their teaching
resources more efficiently in the provision of education. [136]
(2.2) A Better Way: Healthcare in Germany and Switzerland
2.2.1 Both Germany and Switzerland have compulsory social
health insurance systems. The premiums of the poor are paid for
by the government. So, unlike in the USA, no-one is uninsured.
But everyone can determine their insurance provider. And, because
there is a large range of insurers—300 in Germany, 100 in
Switzerland—everyone, including the poor, is empowered to
pick the best.
2.2.2 The Germany and Swiss governments are also not
worried about who owns and runs their hospitals:
— In Germany, around 54% of hospital beds are in
the public sector, about 38% are run by non-profit organisations
and 8% are in private, for-profit institutions. [137]
— In Switzerland, around one third of hospitals
are private and the rest public or not for profit. [138]
2.2.3 This diversity of provision is not a barrier to
the German or Swiss government's aim of universal, high-quality
healthcare for all. It is in fact key to achieving it.
2.2.4 Everyone in society, from richest to poorest, can
decide which hospital to go to and which doctor or dentist to
visit. If the service is poor or untimely, they can go elsewhere.
This empowers everyone with more control over how and when they
are treated.
2.2.5 But the most important thing about social health
insurance systems is that they deliver better healthcare than
in Britain:
— In Germany and Switzerland, waiting lists are
almost unheard of. Appointments are generally on the same day.
Imagine that in Britain!
— Cancer survival rates are far higher in Switzerland,
Germany and the rest of Europe than in the UK.
Table 2
ALL-CANCER (EXCEPT FOR SKIN) ONE-YEAR SURVIVAL RATE
| Switzerland | 80% |
| Germany | 76% |
| European average (including eastern Europe and Russia)
| 72% |
| UK | 67% |
Source: A pan-European comparison regarding patient access
to cancer drugs, Karolinska Institute, 2005.
Table 3
ALL-CANCER (EXCEPT FOR SKIN) FIVE-YEAR SURVIVAL RATE
| Switzerland | 61% |
| Germany | 58% |
| European average (including eastern Europe and Russia)
| 52% |
| UK | 48% |
Source: A pan-European comparison regarding patient access
to cancer drugs, Karolinska Institute, 2005.
— If Britain could achieve the cancer survival rates
of the best countries in Europe for each cancer, over 25,000 lives
a year would be saved, while if it could reach the European average,
nearly 10,000 lives a year would be saved. [139]
Section 3: Conclusion—how to meaningfully improve
accountability in Britain's public services
3.1.1 Members of the select committee may disagree about
implementing wholesale change of the public services along the
lines outlined in section 2. An idea which committee members may
be able to agree upon is to give individual public service users
the right to take the money that is spent on their behalf by the
Government elsewhere, if they so desire.
3.1.2 For example, in education, each pupil has an average
of around £5,000 spent on them per annum. Parents should
be given the right to take that money elsewhere, if they so desire,
subject, of course, to the requirement to spend it on educational
services.
3.1.3 For disabled families, the opportunities offered
by such a policy would be even greater. The money currently spent
on social service commissioning could be allocated directly to
disabled families if they so desired, which would allow them to
spend the money on the care of their choice. At current expenditure
levels, this would be worth at least £115 per week. [140]
3.1.4 We believe that similar proposals could work for
the NHS, although the amount spent on each patient each year is
much more variable than for pupils.
3.1.5 Crucially, the granting of such a right to service
users would public service managers all the information they need
about how satisfied or otherwise users are with the service being
provided.
January 2007
114
Percentages of pupils achieving Level 4 or above and Level 5 or
above in Key Stage 2 tests and teacher assessments by gender,
2004-06, Department for Education and Skills, August 2006. Back
115
Percentage of pupils achieving Level 5 or above in the Key Stage
3 tests, England, 1995 to 2006 (provisional), Department for Education
and Skills, September 2006. Back
116
GCSE attempts and achievements in selected subjects of pupils
at the end of Key Stage 4 in schools by the end of 2005-06, Department
for Education and Skills, October 2006. Back
117
House of Commons, Hansard, 22 May 2006, col. 1374W. Back
118
Moser Report, February 1999. Back
119
The Skills for Life Survey: a national needs and impact survey
of literacy, numeracy and ICT skills, DfES Research Brief, RB490,
October 2003. Back
120
Figure 8.1, OECD Economic Surveys, United Kingdom, 2005. Back
121
House of Lords Hansard, 10 March 2005, col. 840-842. Back
122
The Times, 31 August 2006. Back
123
Daily Telegraph, 5 August 2006. Back
124
Achieving Equity-Education, Journal 2005, Reform, September 2005. Back
125
Ibid. Back
126
Handle with Care: an investigation into the care system, Harriet
Sergeant, Centre for Policy Studies, September 2006. Back
127
Table 8.2, Comprehensive Spending Review, HM Treasury, 2004; OECD
Health Data 2006. Back
128
Measuring the health of nations: analysis of mortality amenable
to healthcare, Nolte, E and McKee, M, British Medical Journal,
November 2003. Back
129
Ibid. Back
130
The NHS: has the additional funding worked? Online Briefing, Civitas,
2005. Back
131
The Management and Control of Hospital Acquired Infection in Acute
NHS Trusts in England, National Audit Office, February 2000. Back
132
Meticillin-resistant Staphylococcus aureus, Barry Cookson
et al, The Lancet Infectious Diseases, October 2005. Back
133
Tony Blair, speech to the Fabian Society, June 2003. Back
134
Tackling Health Inequalities: a programme for action, Department
of Health, 2003. Back
135
A survey on the development of independent schools in Sweden,
Fredrik Bergstrom, Reform-commissioned research by the Swedish
Research Institute of Trade, September 2005. Back
136
School vouchers in practice: competition will not hurt you, Bergstrom,
F, & Sandstrom, M F, The Research Institute of Industrial
Economics, 2002; Efficiency in Public Education, Waldo, S., Department
of Economics, Lund University, JEL 128, 2002. Back
137
Healthcare in Germany, David D Green et al, Civitas, 2005. Back
138
The Swiss healthcare system, Civitas, 2002. Back
139
EUROCARE-2: survival of cancer patients in Europe, F Berrino et
al, 1999. Back
140
People, not budgets: valuing disabled children, Florence Heath
and Richard Smith, Centre for Policy Studies, September 2004. Back
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