Improving public services
28. Proponents of user participation in public services
claim that there are obvious benefits to service users from involving
them in service provision. We were told that it reduces the risk
of providing unsuitable or inappropriate services, as users will
often be in the best position to judge their own needs.[29]
In addition, user involvement can encourage people to better understand
their own service needs and improve their confidence. This, in
turn, can have positive effects on the outcomes they want to see,
such as improved health or educational progress.
29. The public service users that we heard from expressed
this view very forcefully. Members of Shaping Our Lives, the health
and social care user network, stated:
We are the experts! We know what we need.[30]
30. David Holmes of Mind told us that user-directed
services were necessary because user consultation did not go far
enough. For him, user control was the only way of guaranteeing
that services would actually meet his needs:
In our experience the reason people have started
to seek user control is that the mechanisms and involvement do
not seem to have brought about the changes they would like. They
have been consulted but they seem to have been excluded from the
real decision making…they tell people what they want and
they do not get it. If service users were truly heard and services
were truly responsive to their needs then I do not think that
the issue of control would come up.[31]
31. We heard that greater user involvement and control
benefits practitioners and professionals working in the public
services as well. Encouraging service users to help define and
direct the services they receive should allow professionals to
share some of the responsibility for achieving desired outcomes
such as better health—relieving them of the burden of unrealistic
expectation, and avoiding creating or perpetuating a culture of
dependency.[32] Matthew
Taylor of the Royal Society of Arts (RSA) and Sophia Parker of
Demos explained that this can increase job satisfaction for people
working in public services:
I think there is an agenda here which again is not
about placing more demands on public servants; it is about that
job of public servants being one which feels much more useful
to them.[33]
…when you start talking about involving people,
about some of the principles implied by co-production, it taps
right back into that value set that got people into the public
services as a professional in the first place.[34]
32. Formal evaluations of user participation and
direction provide evidence of tangible improvements to services.
In social housing, a government-commissioned evaluation of tenant-led
management concluded that it resulted in improved delivery of
housing services such as rent collection and repair work, as well
as higher tenant satisfaction and longer-term retention of tenants.
Indeed, in most cases, tenant management organisations performed
better than their host local authorities.[35]
The General Teaching Council informed us that personalised
learning has beneficial effects such as higher pupil self-esteem
and positive attitudes to learning.[36]
Research by the (then) Department for Education and Skills found
that, in schools with a strong commitment to personalised learning,
individualised assessments of pupils' learning needs had improved
pupil progress and raised educational attainment.[37]
33. The evidence we received suggests that increasing
user involvement has distinct benefits for both service users
and service professionals. Improved service delivery and higher
satisfaction with the services provided are, in turn, likely to
translate into better service outcomes. Initial evaluations should,
however, be treated carefully as some early assessments of user
involvement consider small pilot schemes where participants are
typically enthusiastic and well-informed. As this will not always
be the case, it is difficult to extrapolate from these studies
the effects of extending user involvement more widely. We turn
now to consider the issue of how to assess the cost-effectiveness
of user-driven services.
Cost-effectiveness and value for
money
34. Advocates of user-driven services sometimes refer
to cost-based arguments—that increased user control can
bring about cost savings in public service provision. We have
seen little systematic evidence so far about the cost-effectiveness
of user-driven services. Liz Stone of Mencap did suggest to us
that individual or personal budgets that allow people to choose
and purchase the care and other services they want are cheaper
than other forms of provision.[38]
We also heard anecdotal evidence from our visit to the Newham
community care navigators scheme that their service resulted in
people needing fewer GP visits and less hospital treatment.
35. Systematic evaluations of user-directed services
are still quite rare, given that there are few established programmes
of user control over services. An initial evaluation of the 'In
Control' programme, which piloted greater user control over social
care provision through the use of individual budgets, suggests
the initiative was cost-effective:
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.[39]
36. Nonetheless, in some circumstances it will be
more, not less, expensive to tailor services around the individual.
This is especially likely to be the case where service delivery
moves away from cost-conscious block provision, or where there
are economies of scale from large institution-based provision.
Cost savings may also be constrained by the extent to which the
labour of service professionals or practitioners can be substituted
for that of service users—for example, in making assessments
about the suitability of care packages.
37. Public service users put to us very strongly
that moves toward user-directed services should not be about cost
cutting or the transfer of costs to service users. In their view,
user control is not a replacement for adequate public funding
of services.[40] Indeed,
additional funding would be needed where user-focused services
are more expensive to provide due to higher administrative and
staff time costs. The logical conclusion of this view is that
better value for money will hinge on the improved outcomes that
can be expected from increased user involvement in service provision,
rather than on potential cost savings.
38. There are many advantages claimed
for user-driven public services, including strengthening citizenship
and improving public services. An evaluative evidence base is
starting to emerge, indicating that user-oriented services have
resulted in higher satisfaction with services and better outcomes.
There is little evidence as yet on their cost-effectiveness, however.
We recommend that government departments overseeing public service
provision put in place rigorous and coherent programmes to monitor
user-driven initiatives (such as individual budgets in health
and social care). These should identify both the costs and the
outcomes of user-driven initiatives, in the short and the longer
term.
26 Ev 177, 187 Back
27
Ev 194 Back
28
Q 522 Back
29
Ev 156, 159, 170 Back
30
Ev 153 Back
31
Q 368 Back
32
Ev 176-177 Back
33
Q 401 [Mr Taylor] Back
34
Q 401 [Ms Parker] Back
35
Liz Cairncross, Caroline Morrell, Jane Darke and Sue Brownhill,
Tenants Managing: An evaluation of tenant management organisations
in England, Office of the Deputy Prime Minister, November
2002, paras 4.10-4.54 Back
36
Ev 267-269 Back
37
Department for Education and Skills, Assessment for Learning:
8 schools project report, May 2007, pp 29-40 Back
38
Q 369 Back
39
Ev 193 Back
40
Q 388 [Mr Harrop, Professor Beresford] Back
