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Can greater transparency and payment by results transform public services?

  • 19 Jul 2011
  • 3-min read

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Last week, in his speech to launch the Public Services Reform White Paper, the Prime Minister set out five principles that will guide the government's approach to the reform of public services: choice, decentralisation, diversity of providers, fair access and accountability. These overarching principles sound very laudable, but the real challenge is translating them into practice in public services as diverse as the NHS, policing and education.

The White Paper sets out two ways in which public services will be held to account: firstly through greater transparency of information on the performance of public services and what they spend their money on, and secondly by linking funding to outcomes. These approaches are set to replace the role of targets and top-down performance management – but can transparency alone deliver improvements in care in the NHS?

The government has already published data on rates of criminal activity, such as burglaries, by local areas. Presumably the idea is that if local people are concerned that the police are not doing enough to tackle crime in their neighbourhood they will voice these concerns (rather than move to crime-free areas!)

The Cabinet Office Minister Francis Maude made an announcement last week that got little attention: he committed the government to publishing data by the end of the year on the clinical quality of general practice and prescribing, hospital complaints and staff satisfaction. It is not clear whether the government expects patients to use this information to choose a GP or hospital, or to demand better services from the local NHS.

There is already a wealth of information on NHS Choices and other patient feedback sites, such as Patient Opinion and iWantGreatCare. But our research on patient choice found that as few as 4 per cent of patients who were offered a choice consulted the NHS Choices website. And most people found it very difficult to interpret this information and use it to identify a high-quality hospital.

The previous government was also keen on greater transparency, and introduced a requirement for all providers of NHS-funded care to publish quality accounts. We analysed the first year of quality accounts and found that the information was difficult to interpret and in many cases did not enable people to judge the quality of local services. If the government wants people to act on this information they will need to make sure it is relevant, comparable and easy to interpret.

As we have argued elsewhere, transparency can support accountability but is not entirely sufficient. There must be consequences if care is not of an acceptable standard or does not deliver value for money. The government seems to believe that the consequences for providers are either that patients choose to go elsewhere (and so the provider loses money), or that the public will lobby those who have the power to take action, such as regulators, commissioners and local authorities.

The benefits of greater transparency are unlikely to be delivered through patient choice or public voice. Evidence suggests that the real value of transparency is the effect it has on providers; concerned about their reputation, providers are 'shamed' by coming near the bottom of a league table and this spurs them on to improve. The Prime Minister seems very fond of repeatedly citing economics research showing the positive effects of competition on quality. Perhaps we can yet persuade him that yardstick competition based on comparative performance data is a powerful driver for improving quality.