Two NHS staff walk with an elderly patient outside St Thomas' Hospital in London. Photograph: Getty Images.
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We need a revolution in public services to tackle multiple needs and exclusions

By focusing on prevention, prioritising relationships and driving down power to the lowest level possible, we can provide the support the most vulnerable in our society really need.

Across the country there is a small group of people who face multiple problems like homelessness, substance misuse, mental health problems and offending. They slip between the cracks of mainstream public services and they fall out of a political debate that is unrelentingly focused on majoritarian concerns.

And right now, the tricky politics of multiple needs and exclusions is even harder than ever. All contemporary policymaking operates within a brutal fiscal environment (on current forecasts, UK government spending will fall from 44.7 per cent of GDP in 2012 to 39.4 per cent in 2017) and whilst strict adherence to the present austerity trajectory should not be seen as a political inevitability, whoever forms the next government will not simply be able to open the spending sluices again. But tight public finances needn’t be a block on innovation. Large chunks of cash were spent on the problem under the last government and still resulted in insufficient progress. Now there isn’t any money anyway, it’s perhaps time to rip up the old models and start again. 

By coupling centrally-mandated targets and structures with substantial investment, New Labour achieved some notable successes in raising the standard of living for the poorest and most vulnerable in society, particularly children and pensioners. Yet critics on the right and left have described Labour’s approach as "poverty plus a pound", overly focused on income transfers to meet statistical definitions of poverty, rather than addressing its broader, structural causes. What’s more, the preponderance of an overly technocratic and managerial statecraft was ultimately too unresponsive to complex human needs.

The answer, perhaps, lies in the "relational state", an idea to which increasing attention is being paid. Rather than doing things to and for people, a state that works with people; that’s more strategic and less controlling; that prioritises the strength of human relationships over outcomes. It’s an approach that is particularly relevant for the issue of multiple needs and exclusions, with all the evidence of the last 15 years pointing towards the relational approach as being the best way of reaching a hugely problematic and expensive group of a defined size. As Lisa Nandy argues in the new Fabian pamphlet Within Reach, we are all unique individuals with our own lives, contexts and distinct solutions: we need a richer, more complex approach to public services that works with the "whole person" to find structural answers to deep-rooted problems.

This will require designing services around people and driving down power to the lowest level possible, rather than catch-all systems. As Julian Corner has written, people who face multiple needs and exclusions "are effectively where all the faultlines in the existing systems converge". He argues they should therefore be a "litmus test for the effectiveness of services used by a much wider group of people". Rather than trickle down, effective service design should geyser up.

People’s problems rarely sit comfortably within one government department, and this is especially the case for those living chaotic lives. Politicians are finally looking seriously at the opportunities of greater service co-ordination, which can drive the cost-effective improvements in standards that neither the market nor the central state alone can deliver. This is coupled with renewed interest in localism in policy circles, in part due to the diminishing returns achieved from the centre over 13 years of Labour government, and in part due to a growing recognition of the democratic empowerment potential of central government "letting go". This doesn't mean abandoning the central state’s role, but changing it, so that it is acting more as a hands-off convenor, setting a series of questions which local authorities are then empowered to answer.

Politicians from all parties can agree there is both a fiscal, social and moral case for providing extra support for severely disadvantaged groups, though they have different emphases and goals – both the Centre for Social Justice's Christian Guy and Nick Clegg’s former adviser Richard Reeves suggest that a commitment to this case is shared across the political spectrum. By focusing on prevention, getting the relationships right, and seeing the whole person, we can provide the kind of support the most vulnerable in our society really need. By taking a long-term approach, with better policy co-ordination across Whitehall and service co-ordination at a local level, we can save money and strengthen communities at the same time.  

‘Within Reach: The new politics of multiple needs and exclusions’ can be found on the Fabian Society’s website here

Ed Wallis is the editor of Fabian Review

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Is anyone prepared to solve the NHS funding crisis?

As long as the political taboo on raising taxes endures, the service will be in financial peril. 

It has long been clear that the NHS is in financial ill-health. But today's figures, conveniently delayed until after the Conservative conference, are still stunningly bad. The service ran a deficit of £930m between April and June (greater than the £820m recorded for the whole of the 2014/15 financial year) and is on course for a shortfall of at least £2bn this year - its worst position for a generation. 

Though often described as having been shielded from austerity, owing to its ring-fenced budget, the NHS is enduring the toughest spending settlement in its history. Since 1950, health spending has grown at an average annual rate of 4 per cent, but over the last parliament it rose by just 0.5 per cent. An ageing population, rising treatment costs and the social care crisis all mean that the NHS has to run merely to stand still. The Tories have pledged to provide £10bn more for the service but this still leaves £20bn of efficiency savings required. 

Speculation is now turning to whether George Osborne will provide an emergency injection of funds in the Autumn Statement on 25 November. But the long-term question is whether anyone is prepared to offer a sustainable solution to the crisis. Health experts argue that only a rise in general taxation (income tax, VAT, national insurance), patient charges or a hypothecated "health tax" will secure the future of a universal, high-quality service. But the political taboo against increasing taxes on all but the richest means no politician has ventured into this territory. Shadow health secretary Heidi Alexander has today called for the government to "find money urgently to get through the coming winter months". But the bigger question is whether, under Jeremy Corbyn, Labour is prepared to go beyond sticking-plaster solutions. 

George Eaton is political editor of the New Statesman.