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by Joe Cormack 28th August, 2018

Private providers – making the case for public services reform

The last decade has seen the most protracted squeeze on public services spending for a generation. This has created a paradox where public sector organisations have less resources and “headroom” to undertake reform. However, simultaneously, they have a pressing need for transformation to trim spending. “Doing more with less” is something councils are well familiar with. There has been an estimated 40% cut in budgets since 2010.

The challenges in this context do outweigh the opportunities. However, public sector bodies are often struggling to maintain the status quo to begin with. They can’t even consider how their offer might be reshaped to improve quality and manage demand.

Challenges facing private providers
Private providers have experienced a difficult 12 months and the collective reputation of the industry has taken a bruising. At the beginning of the year there was the fallout of the Carillion liquidation. Examples of other high-profile mishaps include G4S’ mismanagement of Birmingham prison and the continued disruption faced by rail passengers in the North of England.

Despite these examples, private providers continue to play a crucial role in the day-to-day running of our public services. They also provide ideas for how services can be delivered more efficiently and effectively in a changing society. This sentiment was outlined by the Cabinet Secretary and de facto Deputy Prime Minister David Lidington. He stated in a speech earlier this summer that “whether it is running our hospitals; operating call centres; building our railways; or supporting our Armed Forces – the private sector has a vital role to play in delivering public services, something which this government will never cease to champion.”

The private sector will remain an important partner in public service delivery under a Conservative Government. However, a number of common challenges remain for these providers; how to ensure the reputation of the industry remains high; to make sure stakeholder engagement is targeted in the right way; and to ensure the merits of the service offer are being communicated appropriately.

The third challenge means private providers must review their practice. They must ensure they are making a compelling case to public sector bodies and their commissioners. Any service offer needs to demonstrate how it will genuinely deliver the overall outcomes desired – for instance reducing unplanned primary care admissions for people with mental health and learning difficulties – rather than being a short-term, costly sticking plaster.

Theory of Change
The public sector can tend towards conservatism regarding transformation and new ways of working. This is due to a range of factors including the size of organisation, governance arrangements, ideology and financial and capacity pressures. This is understandable given the high stakes associated with changing the service delivery that vulnerable people rely on. Any suggested reforms need to be supported by a robust Theory of Change (ToC) that underpins their service. Health and Social Care commissioners view a clear and well-planned ToC as a necessary before considering decisions on the services they commission.

At its most basic, a ToC is “a methodology which maps the assumptions which inform planned interventions”. The process is regarded as an essential tool in designing and appreciating the complex network of factors which influence project outcomes.

A ToC is a method for service planning and evaluation that defines long-term goals. It then works backwards step-by-step to establish and then link the necessary conditions and changes required help meet that goal. These are often called causal linkages and can be grouped into chronological categories i.e. short-term, intermediate, long-term. A visual representation of outcomes is also essential along with clear rationales of why anticipated outcomes have occurred and how they are linked to other outcomes in the chain towards the overall goal. Another common characteristic of a ToC is allowing for effective learning feedback mechanisms to help drive continuous improvement as delivery unfolds on the ground.

To illustrate an example, the overall goal might be to reduce the amount of unplanned admissions to A&E by older people. A ToC to help achieve this goal might look at the range of issue that are negatively affecting elderly people in the UK who may have multiple long-term health conditions. Many want to be able to live as independently as possible but feel currently they may lack the support to do this, instead they may want services to be joined up and holistic – this is often called personalised integrated care.

If a type of personalised integrated care between the NHS and social care was implemented it would drive intermediate outcomes of importance to the individual that would improve their health and wellbeing. For instance, they are better able to manage the practical, social and emotional impact of their conditions and are able to better connect with the support and people that help improve their situation – such as a hobby group.

With earlier targeted holistic care, the individual is better informed, less isolated and more able to live independently for longer with less likelihood of them resorting to primary care as a knee jerk reaction. The use of positive feedback loops as part of this ToC journey, reinforces and sustain outcomes for older people and over time will demonstrate reductions in unplanned hospital admissions.

So, the challenge is clear for providers, in your conversations with, and offer to, government and public sector organisations to make sure you have invested time and resource scrutinising the service you offer and developing a ToC. This will help you to evaluate the impact of your service and will demonstrate to your client practically how your intervention will achieve the overall outcomes stated in the brief.

Many private providers can be overawed with the idea of producing a ToC. However, it is often more obvious than it appears. It usually involves working through the consequences of what the offer means – in theory and practice – and where there are opportunities for feedback and improvements to the service.

Please email joecormack@gkstrategy.com if you would like to find out more about how Theory of Change can improve your offer to the public sector.

See more articles by Joe Cormack