Three Scenarios for Health Post-Election

I recently agreed, thanks largely to the charms of the young Ralph Michell of ACEVO, to be part of an ACEVO task force on health and social care. Reluctantly, because there's nothing I enjoy less than three hours of jaw-ache abou which up and coming somebodies in the Blah Blah Commission or DH we simply must get on-side.

So I arrived today, and sat through the first hour wondering what else I could be doing....Then arrived our special guest, Paul Corrigan. Paul used to advise Alan Milburn, then John Reid and Tony himself on health policy. He was here to talk us through three scenarios for health - two in the event of a Tory victory and one for hung Parliament.

What followed was was fascinating. Scenario 1. Decent Tory win - with a reform agenda on health. An emergency budget which spares health but still only gives a small increase. NHS becomes independent though a constitution (take out the politics) and has a regulator. GPs are given serious budgetary power.

This quickly picks off the PCTs as commissioners and starts quickly to impact on hospital admissions as primary care grows, proportionately, in relation to acute, hospital-based treatments. Smaller hospitals start to go bust. Lots of politics. Government holds its nerve. We have bigger regional specialist hospitals, some specialist units, both public and private for common ops that need doing locally, lots of local polyclinics in small places (like Bury St Eds I presume). Far fewer bog-standard hospitals where you hope you don't have to go if you get cancer or need tricky surgery - and want to live to tell the tale.

Under this scenario, the NHS becomes more decentralised, has a diversity of suppliers - including third sector organisations - (leading to more efficiency) and a more sane allocation of resources.

Scenario 2 - Narrow Tory win. Same pressures but this time without a reform agenda. This time a `cash agenda'. Here the Treasury is running the show. Every penny spent is in Treasury line of sight. Ultra-centralist. Reserves from Foundation Hospitals all pulled into centre and sent to prop up Trusts in Tory constituencies about to go under. Thin majority prevents strategic approach. Little in way of reform of NHS to actually drive change from below. Definite short term cash-saver but negligible in terms of long-term saving or reconfiguration of NHS into something that can deliver its own value. Third sector isn't gaining much in this scenario as current problems are `locked in' without a proper reform agenda to move things on.

Scenario 3 - Hung Parliament. Like most people I speak to, this is seen as worst of all worlds. The markets react badly. UK loses triple A, run on pound, bank rates rise and we are effectively, in the hands of the banks. Politically there is a total vacuum as the Government struggles for overall direction. We end up with an austerity budget but no policy on health to go with it.

Huge tumult as society and public goes through febrile period as it becomes clear we lack clear leadership. Everyone is fighting for life and working short-term. Not easy. Third sector is resilient and uses its `asset-base' - the public's trust, its own relationships and creativity - to find a role.

What made this presentation so compelling was Paul's clear sense of how the state works in particular scenarios. I asked at the end how he saw things in five years. His hope is for the main triad of the current `20th century' welfare state - hospitals, prisons and welfare' - and the producer interests that underpin them - to be rendered obselete by alternative generated by civil society.

Nobody, he said, would create the particular response to the problems we have now by inventing today's welfare state. It needs to be superceded and third sector organisations - with their innovation, ability to involve users and create value-adding partnerships - were part of the answer.

If you ever get a chance to hear him speak, go. Paul Corrigan. Superb.

So What Are Your Overheads?

Today in Third Sector magazine, the Tory Shadow Charities Minister Nick Hurd lays into Futurebuilders for...shock...a 16% management overhead.

Now, I am not sure where he has worked before - I think it was for a bank - but I am not sure Nick has a lot of idea of what it takes for charities to be effective. This sort of political dog-whistling is just what we don't need. My overheads are around 16% and I'm happy to say so. Ask most CEOs and they will tell you the same. OK, I am pushing mine down to 14% to stay competitive but 16% isn't unusual.

This focus on our overheads is very fucking tiring, to be honest. As Martin Brookes from New Philanthripy Capital recently said, we need to be much less fixated with costs and a lot more interested in outcomes. If this is as clever as the Tories re going to get about our sector I would actually rather deal with another five years of the newly humanised Gordon Brown.

I like Nick Hurd as a bloke. He is fresh, human and bright. These sort of attacks don't do him or the Tories any favours. If he wants to call time on initiatives like Futurebuilders, I would respect him a lot more if he just came out and said it rather than engage in this kind of showboating.

The Entrepreneurs Bill

Yes I know there is too much legislation already. Indeed I read that it is Steve Hilton's idea for the Tories to pass NO new legislation during a first term. A very good idea too but one that shows that Hilton is, at the end of the day, a blue skies man and not a pol.

Anyway, what do we need an Entrepreneurs Bill. Well, we need, at the end of the Brown-era to rediscover enterprise. Now that there are no jobs, we need, as we did in the 80s, to encourage a new generation of people to have a go in business. To do this we have, again, to create a culture of entrepreneurship, a buzz and energy about it that has been missing in this era of Easy-Job.

What would be in it? Five things. First, everyone setting up a new business would be given a one-off payment of £4000. Just enough to get a laptop, a landline and the time to win your first order. Secondly, there should be no tax (0%) on all new businesses for their first five years. People setting up businesses shouldn't have to worry about the taxman. They need every penny they can get.

Thirdly, there should be tax-breaks for Angel investors. Angels give start-ups the help they desperately need when nobody else is there. Fourthly, nobody running a small business should have to put their home up as security. The state should stand behind small business people as solidly as it stood behind the banks. Take away the punitive risks associated with business-failure and many more people will be liberated to take risks.

Fifth, the old chestnut, red tape. Employees of new businesses will waive their employment rights for a further year. New businesses will not to be VAT registered for three years.

This may not even need legislation. But a bill setting all his out would see thousands of new ventures spring up overnight, reducing the dole queue and liberating the energy of tens of thousands of people to set up the businesses whose taxes will eventually pay our way out of this mess.

You Say Goodbye, I Say Hello

Last night was my final Annual General Meeting as CEO of Speaking Up. I am going on April 6th. But not off into the horizon. Into the Chair.

AGMs are normally stolid affairs. Rows of mostly empty plastic seats in a dusty community centre. A drone through an arcane agenda followed by cheap coffee, a digestive and let's get the hell out of here.

Not ours. The Speaking Up AGM is a proper AGM - don't get me wrong - accounts, constitutions, elections and all that. We just make it fun and celebratory. The rule of thumb is that the more boring the subject matter the more fun we try to make it. So the finance report told people how many more Mars Bars our reserves this year boughtthan last's year figure. You get the idea.

We also acknowledge achievement. Our users present the best of the work we have done alongside them. Last night, our `Promote the Vote' team told the story of how they helped hundreds of people with learning difficulties to get registered for the 2010 General Election.

My goodbye speech, as usual, didn't follow the plan I had made earlier. Following a valedictory round of applause from the audience instigated by Fred Heddell, my mischievous Chair (who knows I don't like a big fuss), I made three points.

First that I wasn't the right guy to lead anymore, that Jonathan (Senker, CEO of Advocacy Partners) was and that they should support him as much as they had supported me.

Second that we are already feeling the pain of the public sector recession and that it will get worse before it gets better.

And finally, to quote Eleanor Roosevelt, that failure, on any level, is not about being knocked down - its about not getting up. That resilience will see us through. That being on the leading edge of social change isn't an easy meal-ticket - and that we need to dig deeper than ever into our creativity to take forward our mission.

Patrick Butler, Head of Education, Health and Society at the Guardian, who was our special guest, told us the story of Kodak, who used to make the film that went in cameras. For a while they thought digital cameras were a fad. They carried on thinking this until it was nearly too late.

Then, finally, they reinvented themselves as a digital company, building on their trusted Kodak brand. But not before losing tens of thousands of jobs and almost going under.

The lesson is that it is important to change ahead of the curve if you can. Patrick's view, and I think I agree, is that the public sector, indeed all of the social sector, is about to have its Kodak moment.

Those best placed to survive, he predicts, will be the innovative, the passionate, the connected and the forward-thinking. Generously, he included Advocacy Partners Speaking Up in that category.

I hope he is right. For we face some big challenges. We are in a sector - advocacy services - which is maturing. The big growth has gone. We are seeing the commodification of the sector as a uniform product that is seen by customers as the same whoever sells it - like oil or potatoes. There is evidence of a race to the bottom now in price in which new players, unencumbered by any historic pattern of delivery, are coming along with models of delivery which, while probably not better ,are certainly a lot cheaper.

Do we join this race with all the risks that involves? Or do take another kind of risk - and move away from this business over time, leaving them to it, and develop our mission into new as yet unexploited space, so that our organisation looks very different to what it does now in five years time?

All these are the big strategic challenges that I, as Chairman of Trustees, will be asking our CEO to work through with all of our people with over the coming months following merger.

While we don't have to make a one-off decision to jump one way or another, we have to decide, within a year at the most, what the most effective way to realise our mission actually is in the 2010s. An exciting task - but a daunting one. Because the risks, either way, are high and unknown.

Afterwards, one of our business supporters said, `This is your 2007 - see it like that and you'll find it a lot easier'. Time to both dig in and imagine our way out.

Rage at the Machine

I was recently lifted by Charlie Leadbeater who talked about Participle's amazing work buiding services from the bottom up. Then y/day I attended the living death that is the Children and Young People's Scutiny Committee.

Here we get the biblical detail of all sorts of services the council either provides or pays for. So much detail in fact that you need a detective's eye to find the real story. But what strikes you between the eyes is the sheer scale of the mountain to climb if anything is ever going to change in relation to the way we organise for good outcomes. Everything to do with children and young people is done in a `multi-agency' way. Which sounds great. But what that actually adds up to is a lot of meetings, a lot of IT and not a lot time spent working with children and families.

What I find hardest of all is that nobody is saying anything. Not even the Tories. Even they, in local government at least, have bought into the Ed Balls world of multiple strategies, directives and a style of service that is shaped around regulation, not around the user or customer.

`Safeguarding' is the latest example of this. Now everyone who gives a kid a lift to school football or plays the guitar in a school play has to be checked on a register. Let's not pretend this is about looking after kids. Its about protecting organisations. God only knows what all this costs - and its another fad, imposed on all of us by a Government that has, frankly, lost the plot a time ago.

I actually admired some of the people who had to pitch up yesterday in front of a bunch of Councillors (half of whom know very little about the subject) and explain what is being achieved, where the challenges lie etc. I don't envy them their jobs. Many look grey and strained from years of managing upwards and working in ways that I am sure are counter-intuitive.

What's the answer? I honestly don't know. Politically someone has to say this is enough and it isn't working. That the emporor we all worship is naked and failing. My fear is that even with a change of Government, we aren't going to see much change in the over-strategised and machine-like approach of the state to our major challenges.

Ed Balls' legacy will be safe for many years to come, I suspect.

Tower Block of Horrors

Four MPs, four poor families living in inner city tower blocks. It's Wife Swap meets Question Time. And very entertaining it is too. The MPs (Austin Mitchell, Mark Oaten, Nadine Dorries and Tim Loughton) have to live-in and cope on benefits.

Three are toe-curlingly awful. Austin Mitchell is, well, basically a twat. The kind of person for whom term-limits were invented. A fat, complaisant salary-taker who has clearly lost any sense of purpose.

Nadine Dorries is a hungry self-made Tory. Attractive and personable on one level but horribly self-satisfied too. Fifty quid from home sneaked into her bra didn't endear her to her Scouse host.

Mark Oaten is a strange one. How this tissue-skinned man ever through a selection meeting I don't know. He was clearly very upset when recognised by local youths in Dagenham as the bloke who shagged rent boys (referred to by Oaten himself as `affairs').

Tory Tim Loughton is the only one who came out with any credit. Low-key, unjudgemental, human, helpful and kind. He was the only one who attracted any respect from his hosts.

And what of the hosts? All were nuclear families with two parents and two or more kids. Few worked. Most were sympathetic on one level but were clearly held back by long-term worklessness and its associated problems. One woman spent a third of her £150 weekly shopping budget on cigs. She justified that on the grounds that MPs were also abusing their expenses. Fuzzy logic but it worked for her.

I came away a bit depressed. The MPs were low calibre and of limited character. Their hosts seemed hopelessly locked into stand-still lives on benefits. Their kids were wonderful but poignantly still unaware of the world they had landed in. Still happy, still open, like all kids. Seeing them sharing a box room with four siblings and eating only microwave food had my eyes pricking.

As an elected politican I felt a tinge of shame. Tower Block of Commons, although essentially soap, communicated something fundamentally true about the self-seeking nature - be it for money (Mitchell), status (Oaten) or advancement (Dorries) - of most MPs. And their inability - or lack of real interest - in representing the needs of society's most disadvantaged people.

A smaller Commons please.

Two Conferences, One Message

My week started at Voice 10 the annual social enterprise shindig - this year in Cardiff. Stars of the show were Peter Holbrook, the new SEC CE, and the Social Enterprise Mark, the new badge of respectability for social busineses.

The Mark is discussed in depth on the Social Business Blog but I would say, for now, that I am still to be convinced of its utility. I hope I am actually wrong here - but I am not quite sure it's going the way of Fairtrade or the Soil Association marks, which have been transformative in their fields.

Voice is a good place to meet people. Social enterprise has a lot of good characters. People who care - but also get things done. This, really, on reflection, is why I come.

My week ended at the Guardian Public Services Summit at the Grove, Herts. This is one of those rather plush country conference centres with a golf course, White Company toiletries and enough fluffy white bathtowels for a Premier League football team.

This was a good conference, opening with the former Canadian PM Paul Martin telling delegates how he cut a quarter from public budgets, prioritised spending (rather than taking equal slivers from all budgets) and used social entrepreneurs to address a range of long-standing needs. His advocacy of social enterprise was perhaps the surprise for many of the public sector delegates. His big message, one I hope, the Tories hear, was the need to open up both public and capital markets to the social business sector. Right on,

My favourite presentation was from Participle-founder Charlie Leadbeater. Participle are working with Swindon Council where there are 316 chaotic families. The chaos in these families is added to, Leaderbeater told delegates, by the welter of professionals working with these families, from the police, schools and health services. Each child from one of these costs Swindon about £250k per annum. The results we get from this are well known - low achievement and often a life of crime and replication of these problems in the next generation.

After months spent among these families - living among them and listening to them - Partciple came to the conclusion that two keyworkers, costing around £50k would do as much good as the current arrangement. That's quite stunning. The reason, he says, is that public services spend 70% of their time dealing with the accretion of processes and systems which have arisen around vulnerable children. And, over time, adversarial relationships with these families have resulted in massive `gaming'of the system, which further increases direct and transactional costs.

The legacy of this event, if there is one, the take-away message is that there is no real way to adapt the system incrementally if substantial savings are to be made or outcomes improved. Therefore it all comes down to whether it is possible to reboot the public sector as something quite different both in shape and core purpose.

It has taken a crisis of this scale to generate these kinds of thoughts. It may well take another crisis of an even bigger one to generate the kind of radcial innovation at scale to overcome what one writer recently termed `The Blob' - the huge, pervasive and powerful collection of interests in keeping the fundamentals of the public sector just as they are.