39. Responsive, user-driven public services are as yet far from common. A more extensive application of user-driven services would have significant implications for the organisation of public services. This is because the elements of user-driven services—people directing and controlling the services they receive, and people taking greater responsibility for 'co-produced' services—represent what has been called a "Copernican revolution"[41] in the nature of public service provision. Matthew Taylor was very clear about the scale of the challenge to be faced:

…this is not a tactic at the edges; this is a fundamental change in the organising principles of public services.[42]

40. In this part of our Report, we consider how public services would need to change in order to become more responsive and user-driven. We examine first the issues that public service provider organisations need to weigh up in deciding where user involvement will be appropriate. We then consider implications for the relationship between service users and service professionals. Finally, we look at how the organisation of public services would need to adapt in order to meet the requirements of responsive, user-driven services.

Deciding where user involvement is appropriate

41. The first decision that public service provider organisations need to make is whether greater user involvement is feasible and desirable. In some cases, service users themselves may rule it out: people may simply not want to be involved in decisions about the services they receive. The mental health service users we heard from told us they just wanted good quality mental health services, not control over services for its own sake.[43] In other circumstances, people may not have the capacity to decide what services or courses of action are in their best interests, or may find this sort of responsibility onerous.

42. This suggests that user participation will not be appropriate to all situations; nor will it work to impose user involvement on people. Age Concern made the point that people will get involved when the issue is one that is important and relevant to them:

Mechanisms for involvement should be driven by what users want and operate on a scale that is relevant to them. The relative success of tenant management in social housing, compared to the lack of enthusiasm for public involvement in NHS foundation trusts, may be partly explained by the former being chosen rather than imposed, and by the very different geographic scales on which they operate.[44]

43. There may be other reasons why user-driven services are not appropriate. Three key considerations that came up in the course of our inquiry were concerns about fairness, risk and cost. These concerns will need to be taken into account even where service users and professionals are otherwise enthusiastic about the prospect of user-driven initiatives. We consider each of these in turn.

FAIRNESS

44. Virtually by definition user-driven services imply differences in what services will be provided to individual users, as well as how they are provided, given that individuals themselves will have different preferences about service provision. This could give rise to equity concerns. As with the choice agenda, user-driven services have been criticised for potentially benefiting articulate, well-off service users.[45] Services that focus on the user should mean that individual circumstances and needs—whatever those circumstances and needs—are identified and then addressed. However, it would be prudent for public service providers to build safeguards or provisions into service design so that less articulate users are not disadvantaged.

45. Pat McFadden MP suggested to us that there is a role for government to help less articulate or confident service users:

We are probably all familiar with, for example, parents in our own constituency who really want to do the best by their child, get the best education and so on, but maybe they are not as forceful in making their views known and having all this information and so on. I think if the state in some capacity can help those people in a world where there is choice then that is a benefit to empowering people who perhaps at the moment are not empowered.[46]

We agree that it is important for the Government to pay particular attention to reaching and helping less forthcoming service users. We explore later some of the specific ways in which it might do so.[47]

RISK AND ACCOUNTABILITY

46. User-directed services suggest that service users would take on some of the responsibility for assessing and bearing the risk of things going wrong. In many services this would require a major culture shift in attitudes toward risk. At the same time, people will need to be supported so that they understand the nature of the risk that they are taking on, and there may need to be appropriate regulatory safeguards against people bearing unreasonable risk.

47. A related point concerns the need for safeguards where there is the potential for a power imbalance to occur between service providers and service users. For example, people receiving long-term care provision are often vulnerable and dependent on the people providing their care. As a result, it may be extremely difficult for them to raise issues with their care providers if they are unhappy about aspects of their care, or to change 'suppliers'. In such circumstances, it may well be inappropriate or unfair to expect vulnerable service users to bear the responsibility for decisions about service provision.

COST

48. As observed earlier, we received varying evidence on the cost implications of user-driven services.[48] Some evidence pointed to the potential for cost savings from user-directed services. Another view is that tailoring services to individual need is expensive, and can encourage people to demand more. Service provider bodies trying to assess cost-effectiveness may find they come to different conclusions depending on the time period they consider, particularly in those cases where desired or expected outcomes are experienced over the long term. Finally, as noted earlier, we heard a very clear view from service users that user-directed services such as direct payments and individual budgets should not be used as a covert means of cost-cutting or cost-shifting.[49]

49. It is difficult to talk about the fairness, risk and cost of user-driven services in the abstract. They are, however, important considerations that will almost inevitably arise in any consideration of increased user involvement in public services. Public service provider bodies need to consider issues of cost, fairness and risk in deciding whether user-driven services are appropriate in particular instances. Where increased user involvement is being pursued, provider organisations will need to determine how they assess and handle these issues. Departments overseeing public service provision should develop guidance on cost, fairness and risk issues arising out of increased user involvement, so that public service provider bodies can make informed decisions about how best to encourage user participation.

50. Where concerns about user willingness, fairness, cost and risk have been evaluated and addressed, user-driven public services might then be considered both achievable and desirable. We turn now to examine the implications of making services more responsive and user-focused, and how government might encourage the conditions for user-oriented services to succeed.

Rebalancing the relationship: the role of service professionals

51. Greater user involvement implies a rebalancing of the relationship between people employed in the public services and the people using those services. Ed Miliband MP has acknowledged the shift that needs to occur:

The first challenge is to involve users as people who shape and contribute to the service…It is about the nature of the relationship between user and professional. Of course, doctors will often have greater information and expertise—we will always be dependent on them. But the question is whether that relationship recognises the users' role.[50]

52. The New Economics Foundation informed us that:

Co-production requires professionals and service managers to move out of traditional roles as 'experts' and 'providers' into partnership models that work with 'clients' and 'communities'. This enables them to find a solution together to the complexity of their problem and sometimes requires that the 'problem' be redefined.[51]

53. There are several ways in which the role of professional staff would need to change in order to adapt to the demands of user-oriented services. The New Economics Foundation suggests that professionals need to adjust from being 'fixers' that focus on problems to 'catalysers' who seek to encourage people's abilities.[52] The commentators Charles Leadbeater and Hilary Cottam have proposed a variety of roles for service professionals:

• Advisers: helping users to assess their needs and forge plans for their future care.
• Navigators: helping users find their way to the services they want.
• Brokers: helping users to put together a package of services that meets their needs, where services might come from different sources.
• Service providers: retaining a role in direct service provision to users.
• Risk assessors and auditors: helping users assess risks that may arise (this will be particularly relevant in the case of vulnerable people).[53]

54. Increasing the extent of service user involvement and control would mean a major change in the role of service professionals, which in turn would require careful management. Service professionals are likely to be wary about any perceived threats to their autonomy and expertise, and as a consequence might resist moves to give users a bigger role in public services. During our visit to the Newham community care navigators, we were told that GPs were initially sceptical about the scheme, though in time they came to recognise that their patients were benefiting from it. The National Consumer Council cites an example of successful collaborative working using its 'Shared Solutions' approach to involving both service users and staff:

…social housing tenants and housing officers were brought together to discuss existing services, identify problems, build relationships and agree shared priorities. Shared Solutions showed that, although users and staff initially regarded each other with mutual suspicion and open hostility, by the end they had identified common aspirations, diagnosed shared problems and come up with agreed suggestions for improvement.[54]

55. These illustrations suggest that as user-driven services become more widespread, increased familiarity will go some way toward bringing about the cultural shift needed among those working in public services. Nevertheless, both professional bodies and the Government have important roles to play in promoting greater user responsiveness. Strong leadership from professional bodies, along with changes to professional training requirements and professional standards, would help to foster a culture of public service professionalism that is focused on involving users. As Peter Beresford of the user network Shaping Our Lives told us:

…what is crucial is that real involvement starts with practitioners and professionals, that they learn to work, to practise…in a way where they are always asking, checking out with the service user: 'What do you want from me? How can I usefully help?' They do not have their own agenda which is then imposed on the service user. It is a process of co-production because that is the only place that naturally and routinely service users all have contact with the services and the people who work in them. It gets neglected but it is awfully important. It raises big issues there about training and the future of training.[55]

56. The Government, equally, has a key part in changing the culture of public service. All staff working in public services should be driven by a strong belief in public service and a sense of personal commitment to the people they serve. We believe that the public service ethos is as important and relevant to user-driven services as it is to all other public services. Greater user involvement should complement the public service ethos rather than conflict with it. This was also a conclusion of the Report by our predecessor Committee on The Public Service Ethos, which emphasised the importance of the principles that underpin public service. Two of the principles proposed in that Report bear repeating because of their relevance to our present discussion. The principles, which are directed at people and organisations providing public services, are as follows:

• Treat public service workers and users fairly and equitably, and involve them as much as possible in service issues.
• Remember at all times that public service means serving the public, not serving the interests of those who provide the service, and work collaboratively with others to this end.[56]

57. We agree with our predecessor Committee that these principles should be upheld by the Government and by public service providers. As part of their adherence to an overall ethos of public service, we believe public service workers should give due importance to involving and engaging with service users. This is what good public servants do. The Government should actively promote principles of public service that recognise the value of involving users. It should ensure that an understanding of service user involvement is reflected in programmes designed to develop public service skills, such as Professional Skills for Government. Professional bodies also need to identify how they can promote responsiveness to public service users among their professional members, and make the necessary changes to, for example, professional training and standards.

Enabling and empowering: the role of service users

58. For those services where people are able and willing to take on a more active role, user-driven services are an exciting development. We believe that, in these circumstances, the Government should positively encourage greater user involvement in service design and delivery. People will need sufficient support, advice and guidance to play a larger part in service provision, and particular attention should be given to the requirements of vulnerable individuals. There are likely to be situations where people become less able or willing to make decisions about service provision over time—for example, as they become older, frailer or more ill. Staff working in the public services therefore have a crucial part to play in providing necessary support and monitoring people's ability to remain involved in service decisions.

59. Experience suggests it can be worthwhile to create dedicated personal advisers who provide individual support and advice to users. An increasing number of schools now have parent support advisers that work with parents to improve children's behaviour and school attendance.[57] A National Audit Office evaluation of Jobcentre Plus personal advisers has found that advisers have contributed to the high employment rate in the UK, by enabling jobseekers to develop the confidence and skills to find work.[58]

60. Peer networks of other service users can also empower people so that they are in a position to direct or influence services, as this evidence from a Sussex member of Breakthrough Breast Cancer's advocacy network demonstrates:

We also set up our own, task-focused working groups that take up issues. We prioritise, like follow-up appointments for breast cancer patients and training staff to treat newly diagnosed patients sensitively. We also identified that some GPs were unaware that a genetic test for breast cancer is available and are working to communicate better with GPs to end this.[59]

61. David Holmes of Mind gave us another example relating to the guidelines on self-harm used by the National Institute for Health and Clinical Excellence (NICE):

NICE's own guidelines on self-harm are almost entirely stolen from the self-harm network which service users got together, a brilliant example because there was not a medical model of self-harm. There was no doctor to tell you that you were self-harming so you needed this drug. Self-harmers got together; they worked out what they wanted; they worked out what worked for them; they worked out what they needed and, because there is no medical model alternative, it has been adopted and it is now clinically approved by NICE and is effective.[60]

62. Our witness panel of public service users cautioned about changing the role of users too quickly or without adequate support. They told us that if users have relied on a certain mode of provision and are then suddenly expected to assume greater control, this can create fear and a desire to stick with the existing service—even if that service does not work very well. David Holmes gave us a pithy illustration of this:

If I have spent twenty years going to a day centre being told that all I am capable of doing is drinking tea and doing a jigsaw and then someone tells me the day centre is closing and I am going to get a job, I am going to fight to keep the day centre.[61]

63. In contrast, Peter Beresford of Shaping Our Lives told us that blanket assumptions should not be made about people's capacities, and that people can often handle the demands of participation if given the necessary support:

If I could give one example, it is an example where people have sometimes said perhaps they should not be involved; it would be inappropriate, unfair and burdensome. It is people who use palliative care services, people who are facing life-limiting terminal illnesses. We did a big project where we spoke to more than one hundred people in depth who used such services to ask them what they wanted from social workers. It is clear that people do want to contribute their views and they can contribute them if they are sought in appropriate and sensitive ways…You have to make sure, for example, that perhaps the oxygen is there for somebody and so on, but people do want to be involved in all sorts of ways.[62]

64. In order for service users to take on a larger role in public services, they need clarity about what is expected of them and what they can in turn expect of others. The Healthcare Commission told us that successful user-driven services were more likely where there was a good understanding between users and professional staff about what the service was intended to achieve.[63] Peter Beresford agreed that people needed to be clear about what they could expect from user-directed services—and, further, that service users should have realistic expectations about what such services involve:

Getting involved as a service user does not mean you will get everything you want. It does make possible the negotiation of different interests.[64]

65. We conclude that successful user involvement is more likely where people can see the relevance of getting involved to the quality of their lives. In some cases people will not actually want, or be able, to take a larger role in influencing or directing the public services they receive. If this is the case, people should not be penalised (e.g. by access to lower quality services) for not wanting to engage. Where people do want to take on a greater role in service design and delivery, they should receive the necessary support, advice and guidance from service provider organisations to do so. This means that public service providers and their overseeing departments should ensure that:

• professional staff working in those services are able to provide the support that service users will need;
• there is regular monitoring of each user's ability to manage their own service provision, in case their ability or desire to do so deteriorates;
• where necessary, personal advisers are available to support individual users, along the lines of Jobcentre Plus personal advisers and parent support advisers in education;
• the development of peer networks of service users is encouraged; and
• there is clear communication to service users about what is expected of them, and, equally, of what they can expect from service provider organisations.

Flexible and responsive services: implications for how public services are organised

66. As we have seen, successful user-driven services will require the efforts of committed service professionals and service users. This is not quite enough, however—what would also be needed is for the organisation of public services to allow this new kind of relationship to flourish. We heard that the situation is too often the opposite case. David Boyle of the New Economics Foundation told us:

There is no doubt that that is a big challenge for professionals because what you are asking them to do is to look at the person in front of them, not entirely about their needs and what they cannot do, but also to sum up a little bit about what they can do and to have some kind of institution which allows them to exercise that. It is difficult to do that in the way that public services are currently administered.[65]

67. Sophia Parker of Demos went on to say that often professional staff had to go against normal procedures in order to involve people in service delivery:

What is very interesting is that where it is working in practice it is usually working because of some extremely dedicated professionals who have done everything they can to circumnavigate the system as it is officially configured because that is what they have to do in order to achieve this way of working, this way of involving parents, kids and so on, whatever it is.[66]

68. Where greater user involvement in public services is desired, the Government has a role in ensuring that the organisation of services facilitates and encourages this. We heard from service users that, in their view, services should be organised so that people can be involved in service design and delivery at the points relevant to them. Members of Shaping Our Lives said this should include involvement in service commissioning and in the evaluation and monitoring of services, but that the type and extent of involvement would vary from person to person.[67] Andrew Harrop of Age Concern agreed that there was no one-size-fits-all model for involving people:

…you do need to take a varied approach and fit the model to the circumstances: accept that different people aspire to different levels of engagement with the services they are using. I think the best example of this is the housing sector where you have a really wide range of approaches from direct tenant management through to much looser models of involvement, with things like representation on boards.[68]

69. This suggests that public service provider organisations will need to be rather flexible and creative in the services they offer. They may, for instance, want to give service users a menu of options for involvement from which people can choose—ranging from minimal participation through to complete user control over services (e.g. through individual budget holding and service commissioning). This scenario is quite different from the standardised provision that has characterised many public services in the past, as Peter Beresford of Shaping Our Lives observed:

There is a lack of fit between the ideal of user involvement which is a very practical and workable ideal and the fact that policy tends to work in very uniform ways.[69]

70. There may be circumstances where the pursuit of other government policies or targets conflicts with greater user involvement and the flexibility of provision that that might entail. One example is the effect departmental targets for efficiency savings could have on flexible, user-driven service provision. Our predecessor Committee considered this issue as it arose in relation to the choice agenda in public services. Sir Peter Gershon suggested that limiting choice and diversity in service provision can increase efficiency:

If you take, for example, the issue about electronic filing of employer PAYE returns, the Government has clearly set out a course now [under] which, by 2010, every PAYE employer will have to file electronically. That will be the only way of doing it; all other mechanisms will be removed…Yes, that is a restriction in choice; it improves efficiency. At the end of the day it is the elected politicians who have to make the decision about how far do you let one agenda run where it may start to impact on another agenda.[70]

71. The reverse situation will also hold true. It can be inefficient to provide a variety of service provision options, which is what many user-driven services would require. We agree with Sir Peter that the pursuit of potentially conflicting policy objectives will be a question of balance. However, we also urge the Government to be consistent in its support for responsive public services, and to ensure that relevant departments have the right incentives to encourage user-driven services where they are considered appropriate and desirable. The Government needs to ensure that it is setting the right framework for service provider bodies to adapt to user-driven services. In particular, it needs to be careful that other policies or targets (such as requirements for efficiency savings) do not work against service providers and their staff having the freedom and flexibility to develop responsive, user-driven services.

Evaluating the performance of user-driven services

72. Processes for evaluating government performance and capability will need to adapt to the demands of user-driven public services. At present, the model of capability for the Departmental Capability Reviews makes only passing reference to the need to "understand what your customers and stakeholders want".[71] It does not contain questions to check the efforts departments are making to enable people to get involved in public services, rather than simply understanding their needs. This is in sharp contrast to the statutory requirements that have recently been placed on local authorities and NHS organisations to inform, consult and involve people in the provision of local services.[72]

73. Similarly, evaluation frameworks need to be put in place to assess the effectiveness of user-driven services—a crucial part of which entails getting the views of service users themselves. To this end, we have been heartened by recent proposals for the Comprehensive Area Assessment (CAA) framework for local services, which will replace the Comprehensive Performance Assessment (CPA) regime from 2009. The Audit Commission explained how the new framework is designed to involve people in evaluating local services:

CAA, when implemented, will help to engage citizens and people who use services by:

• concentrating on what local people care about most;
• gathering intelligence about their experiences in order to assess local services…Such information will carry significant weight in CAA so that local people feel they have real influence in how local services are assessed;
• assessing the quality of involvement of local people, including those in vulnerable circumstances, to check whether their voices are heard and heeded; and
• providing information to people about the findings from CAA so that they can be better informed about the quality of local services and be better placed to exercise choice and influence.[73]

74. According to the Audit Commission, CAA will "put the experience of citizens, people who use services and local taxpayers at the centre of the new local assessment framework".[74] This objective was supported by the service user groups that gave evidence to us. They informed us that service users have a key role to play in evaluating the performance of public services, in particular through defining the outcomes that should be used to assess service effectiveness.[75]

75. More broadly, user-driven services have some implications for how audit and inspection bodies evaluate public services. In particular, inspection bodies will need to adjust the criteria they use for assessing services. Evaluation frameworks should to some extent include service users' own assessments of the services they receive, as explained above. This will need to be done carefully, however, due to possible concerns about the subjectivity of user assessments such as customer satisfaction measures. At the same time, inspection bodies will need to ensure that standards of public services are safeguarded, so that people can be sure they are getting an adequate level of provision. Inspection bodies therefore need to consider how they would adjust their evaluation frameworks and measures to deal with the demands of user-driven services.

76. Government bodies need to ensure that proper evaluation mechanisms are in place to monitor and assess the performance of user-driven public services. For departments that oversee public services, the relevant Departmental Capability Reviews should contain questions to test whether departments are creating the right environment for user-driven services to flourish. Inspection bodies should institute evaluation frameworks for user-driven services that ensure standards of public service provision are safeguarded, and which allow for direct input from service users into evaluation.

42   Q 406 Back

43   Q 368 Back

44   Ev 171 Back

45   Q 444 Back

46   Ibid Back

47   See para 58 ff Back

48   See paras 34-37 Back

49   See para 37 Back

50   "Putting users and communities at the heart of public services", speech by Ed Miliband to Unison and Compass, 18 January 2007 Back

51   Ev 177 Back

52   Ev 178 Back

53   Charles Leadbeater and Hilary Cottam, "The User-generated State: Public Services 2.0", Public Matters: The Renewal of the Public Realm, (London, 2007), p 102 Back

54   Ev 215 Back

55   Q 371 [Professor Beresford] Back

56   Public Administration Select Committee, Seventh Report of Session 2001-02, The Public Service Ethos, HC 263-I, para 75 Back

57   Department for Children, Schools and Families, The Children's Plan, para 1.20 Back

58   National Audit Office, Jobcentre Plus: Delivering effective services through Personal Advisers, HC 24 Session 2006-07, 29 November 2006, p 5 Back

59   Ev 291 Back

60   Q 380 [Mr Holmes] Back

61   Q 387 [Mr Holmes] Back

62   Q 371 [Professor Beresford] Back

63   Ev 252-253 Back

64   Q 373 [Professor Beresford] Back

65   Q 401 [Mr Boyle] Back

66   Q 411 [Ms Parker] Back

67   Ev 153 Back

68   Q 365 Back

69   Q 388 [Professor Beresford] Back

70   Oral and written evidence of the Public Administration Select Committee, Session 2004-05, Civil Service Effectiveness, HC 307, Q 67 Back

71   Civil Service Model of Capability, www.civilservice.gov.uk (see also Public Administration Select Committee, Ninth Report of Session 2006-07, Skills for Government, HC 93-I, Appendix 1) Back

72   Local Government and Public Involvement in Health Act 2007, section 138; and National Health Service Act 2006, section 242 (as amended by the Local Government and Public Involvement in Health Act 2007) Back

73   Audit Commission, Comprehensive Area Assessment: A joint consultation by the Audit Commission, Commission for Social Care Inspection, Healthcare Commission, HM Inspectorate of Constabulary, HM Inspectorate of Prisons, HM Inspectorate of Probation and Ofsted, November 2007, p 13 Back

74   Ibid, p 2 Back

75   Q 367, Q 380 [Mr Harrop], Ev 153 Back