Since the 1990s, policy makers and academics have had a pet project in public service reform. Over time, they have called it differently but always meant essentially the same: public services collaborating with each other to improve service quality. At some point, it was called partnerships (remember the Partnership Agenda under Tony Blair’s government?), then it was service integration, a term particularly popular amongst health care professionals.
But what drives this collaborative agenda and where should it lead? Have we achieved anything over the last decades or was this all just hot air?
Academics have pointed out for a long time that there is a glaring gap in the partnership and integration project – evidence. We know from studies that working together does make a difference to professionals. This would be good if the main objective was to overcome service fragmentation per se, yet what drives much of the public policy announcements are intentions to improve service quality for users and patients.
Conceptualising service collaboration has been a well tilled field. Personalisation of services, where public services are shaped around the needs of the user is one way of thinking about improving public service delivery. Direct payments are a powerful instrument to re-orientate public services by putting the user in control. Yet, direct payments have been met with fierce resistance from some corners of the professional establishment, whilst the Welsh Government actively discouraged local authorities to use them until recently. Consequently, the take up of direct payments has been low.
In addition, producing evidence of the effects of service collaboration has proved to be the proverbial ‘holy grail’. The main stumbling block to it has been to establish a robust link between organisational changes and service improvements. As services improve their collaborative practices, the interface between users and professionals may often be largely unaffected. Organisational changes may not be noticeable for users. My paper on multi-agency protocols shows that even where the evidential link between changes and outcome is well defined, effects may be marginal and introspective at best.
Another reason is that service improvements are most urgent when users or patients draw on support from many different professionals because of the complexity of their needs. In the field of children’s services it is not uncommon to have families dealing with fifteen different professionals or more at a time.
The complexity of service delivery impacts on how organisational changes are perceived by the users and how they are affected by them. Key working may be a useful example. Potentially, key workers were supposed to reduce the number of professionals working with a service user, yet there is little evidence that they have had this desirable effect. More often than not, key workers joined the long list of professionals without reducing the need to be in contact with others. In other words, they turned into another layer of service delivery on top of the already existing ones.
So, why is it so difficult to improve service delivery in collaborative contexts? The answer lies in the discrepancy between policy objectives and the levers for change we have available. Policy makers constantly profess a desire to improve services by urging professionals to work together. Yet, there is only one player in this game who really knows what would constitute better services: the user. As long as professionals are in the driving seat, users will be a polite afterthought to their practice. Whether you call it partnership or service integration, collaborative practice grows from user demand. Better public services for users with complex needs should not be a product of professional generosity but an outcome of user demand. Until the user is in control of the service they get, service collaboration will remain little more than hot air.
Axel’s article, ‘Multi-Agency Protocols as a Mechanism to Improve Partnerships in Public Services’, is published in Local Government Studies.
Dr. Axel Kaehne is currently Chair of GORWEL, the Welsh Foundation for Innovation in Public Affairs and a Senior Research Fellow at the Faculty for Health and Social Care, Edge Hill University. He is also Senior Research Fellow at the Alder Hey Children’s Hospital NHS Trust in Liverpool.