Doing With: reinventing public services in a time of crisis

The public sector still operates as though we live in the era of post-war stability when, in fact, services now face a permanent high demand/low resource reality created by multiple, overlapping crises. If the UK’s public sector is to avoid irreversible decline, we need a radical shift from a ‘do to’ to a ‘do with’ mindset, led by a grassroots movement for change.

On 15 September 2008, the world changed. That was the day that Lehman Brothers, one of the largest investment banks in the United States, filed for bankruptcy, prompting panic across global markets and the biggest financial crash in 80 years. This event proved to be the first in a long series of disruptions: a global recession; a European sovereign debt crisis; the resurgence of ethno-nationalist politics in numerous countries; the Covid-19 pandemic; the Russian invasion of Ukraine; a worldwide cost of living crisis; war in the Middle East; and disruption to global trade caused by the radical protectionism of the US government.

Given it is 17 years since Lehman collapsed and the ensuing disruption shows no sign of abating, it is clear to all but the most optimistic that the world is not passing through a short-lived period of turbulence but has entered a new era defined by interwoven and repeated outbreaks of volatility and uncertainty.

Of course, periods of intense and lengthy global crisis are nothing new in human history and they have all ultimately come to an end. However, one thing makes this period qualitatively different from past experience: the gathering environmental crisis which promises a depth and longevity of disruption that is unprecedented. Although the Covid-19 pandemic may look like an unexpected ‘act of God’ in among the other very human-generated crises listed above, it may well prove the most accurate insight into a future in which ‘natural disasters’ such as pandemics, extreme weather, rising sea levels, and food and water shortages interact in complex ways with the ongoing political and economic crisis to invoke an era of the profoundest challenge.

Indeed, a new vocabulary has already emerged to describe this prospect – ‘polycrisis’, ‘permacrisis’ and, perhaps most apt, ‘metacrisis’, a situation in which a series of overlapping disruptions creates a profound global emergency that has a form and meaning of its own, distinct from any one particular disruption, and which ultimately transforms the established modes of human existence.

The crisis vice

Although it is rarely considered in the current debate about public service reform, this new era of crisis is of enormous relevance when imagining the future of the public sector and the state.

The modern public sector and welfare state developed at a time of post-war stability. This period promised, and largely delivered, sustained economic growth, reliable tax revenues, calm financial markets, and relatively stable albeit pressurised demand for welfare and care. Looking back, this facilitated something of a golden era for public services in the UK – at least, compared with today. Funding was relatively adequate, the workforce was big enough to largely manage demand (outside of the occasional public health crisis), and major strides were taken to improve people’s health and wellbeing in the form of initiatives such as mass vaccination and through large-scale housebuilding efforts, expanded schooling, improved welfare and pension payments, and more secure, better-paid employment.

By contrast, the public sector today is being squeezed by what might be called the ‘crisis vice’. A situation in which ongoing socio-economic disruption significantly increases demand for public services while the money and workforce available to meet that demand shrinks due to the reduction in public funds caused by slower economic growth. In short, we have entered a new long-term reality for the public sector: one characterised by high demand but low resource.

This new reality requires a radical and fundamental rethink of the way public services work if we are to maintain anything like a decent welfare state that can offer quality, affordable support to the people who need it.

The alternative to that rethink is not difficult to imagine. The past 15 years since austerity measures were introduced have revealed with striking clarity how a public sector that fails to adapt to a time of radically constrained resources and rising demand will fare. There will be unchecked deterioration in the quality of service, increasing de facto rationing, and ultimately severe failure as seen in the extraordinary growth of waiting times in areas such as health care, housing, the justice system, and emergency response, as well as the unprecedented number of councils issuing S114 ‘bankruptcy’ notices.

Given the deterioration over the past 15 years, it is not inconceivable that by the time we reach 2040, public services in the UK will no longer be functioning in any recognisable or meaningful way. One only needs to extrapolate from the experience of the past decade and a half to see a world in which NHS waiting lists extend to tens of millions of people and accident and emergency (A&E) waits last days as a matter of course; criminal cases take many years to come to court; free social care is reserved solely for the destitute; food banks become the main source of sustenance in the poorest areas; and homelessness is a fact of life for millions. In short, the UK’s public realm gradually begins to resemble something one might more commonly find in one of the poorer nations in the global south.

This long read argues that to avoid this scenario, the public sector must stop behaving as though we still live in a period of post-war stability and instead adapt to our new era of crisis. In practice, that means moving rapidly and radically from a system that largely does things to individuals, families and communities towards a system that does things with those individuals, families and communities. A system shaped by ‘withism’ rather than ‘toism’.

At a time of rising demand and shrinking funds, such a shift will have three major benefits: it will augment existing limited resource with the untapped resource to be found outside public sector institutions in communities and elsewhere; it will reduce demand by moving towards a system that prevents rather than simply treats personal crisis; and it will eliminate the wasted resource resulting from systemic failure.

In this sense, withism is a deeply realistic response to the crisis vice. Rather than hoping for or expecting a sudden wave of funding to revive the toist system, withism reconstitutes public services so they can deliver effectively under the new high demand/low resource reality.

Withism in practice

Before going into the benefits of withism in more detail, it is necessary to explore what it is. Fortunately, this is relatively easy because there are numerous withist innovations being implemented on the front line of public services by public servants who can clearly see how radical change is now an urgent necessity as the system begins to deteriorate rapidly.

Initiatives such as Community Appointment Days in Sussex, the Healthier Fleetwood and Thrive initiatives in Fleetwood, Community Led Support hubs for adult social care in the Scottish Borders and elsewhere, the Butterfly Project in a Cheshire women’s prison, the Jean Bishop Centre for frailty in Hull, the Essex Recovery Foundation and many other innovations are showing how a withist approach not only provides much more humane care but also cuts waiting lists and reduces demand. Indeed, they reveal that the key to those shorter waiting lists is the very provision of that more humane, compassionate care. (It is strongly recommended to read at least one or two of these case studies to understand how withism works in practice before reading the more abstract description below.)

Withism can also be found in the wide range of generalised approaches and models that are shaping public sector innovation and which include among others: community power, relational welfare, strengths-based working, asset-based community development, health creation, local area co-ordination, Buurtzorg, human learning systems, family group conferencing, community organising, deliberative engagement, liberated method, co-operative councils and trauma-informed practice.

Although different in their specifics and primary areas of focus, the above innovations and general approaches have three core withist practices in common: deep understanding, versatile response and collaborative delivery. This contrasts with toism, which is based on bounded understanding, fixed response and institutional delivery.

Deep vs bounded understanding

All withist innovations begin with an effort to build a deeper understanding of the people with whom the public sector engages. The way that understanding is achieved varies. It can involve detailed conversations with individuals in need of care or support as in Community Appointment Days or Community Led Support. Or it might require engagement with groups that have a shared experience or interest, as in the Essex Recovery Foundation or the Butterfly Project. Or it might be place based, involving engagement with geographical areas of varying size ranging from streets to whole towns, cities or regions, as informs Healthier Fleetwood. The engagement can be more or less formal, incorporating everything from initiatives such as citizens’ assemblies to simple one-to-one conversations, usually employing a strengths-based approach.

However, regardless of whether it is individuals or groups being engaged or whether it is formal or informal, withism emphasises listening rather than telling. It allows those outside the institution to set the tone and the agenda for any conversation, ensuring that the opportunity exists to truly understand a person or group in their full, holistic nature.

This contrasts strongly with conventional practice in the public sector. Toism uses contextual settings and the state’s authority to predetermine what a conversation focuses upon. This toist tendency to be ‘in control’ of any engagement is exceptionally common.

The clearest example of this is the medical consultation in which an expert practitioner holds a conversation with a patient about their symptoms and makes a diagnosis or referral which results in some medical action being taken. A deeper understanding of the patient’s wider life experience, beyond the strictly medical, is generally regarded as being of little relevance.

But it can also be seen repeatedly in the traditional public sector consultation, where a group of people outside the institution are asked to give their views on a specific topic determined by the institution and usually through a relatively thin form of engagement, such as a questionnaire or a focus group.

Put simply, withism aims to really understand what matters to the people with whom public servants engage. Toism aims largely to understand only the things that matter most directly to the institution for which the public servant works.

Versatile vs fixed response

Armed with a deeper understanding, withism aims to develop approaches that are truly versatile, meeting the preferences and particularities of individuals or groups. This contrasts with toism, which tends to work with a defined menu of approaches, or even a single standardised approach, to which people must adapt, rather than the institution itself adapting to their preferences and needs.

The Community Led Support (CLS) approach to adult social care stands as an example of this aspect of withism. Dispensing with the formal assessment usually undertaken by local authorities, social workers instead have a detailed conversation with those drawing on care and then develop a response that is unique to that individual. In some cases that may mean conventional offers of home, day and residential care. But equally, it could well mean finding alternatives that suit the individual’s unique preferences and needs.

For example, one person accessing a CLS hub in the Scottish Borders area was supported to develop a response to his early dementia by playing his saxophone at local jamming sessions rather than being encouraged to go down a pre-ordained standardised route such as day care. Similar initiatives such as the Community Appointment Days regularly develop responses to individuals’ musculoskeletal conditions that address issues such as bereavement and isolation. The Essex Recovery Foundation puts significant power into the hands of those in recovery to identify and develop responses that work for them; these can include activities as varied as mountain biking or developing public speaking skills.

The same principle applies to communities. Healthier Fleetwood, for example, will only pursue responses that are identified and developed by the community. Hence the recent focus on children’s mental health seen in the Thrive initiative is a priority set through close dialogue with the residents of Fleetwood, not by the hierarchy of any public sector institution. Similarly, the Essex Recovery Foundation is very clear that it is constituted of a community made up of those in recovery and the responses the Foundation develops to their needs is determined entirely by that community rather than public sector professionals.

Collaborative vs institutional delivery

Finally, withism seeks to develop and deliver approaches in close collaboration with the individuals and groups they serve rather than assuming, as toism does, that the public sector institution is the only body with the necessary expertise and resource to design and deliver a service or response.

What this means in practice is redesigning services, operating models and strategies in such a way that the expertise and resource of the institution are combined as seamlessly as possible with the assets of the individual, group or community. The latter assets are varied, including volunteer and paid labour, expertise, influence, connections, buildings, green space and a range of other unique strengths that can be brought to bear on a practice or initiative.

The Fleetwood initiative has made it a priority to encourage and support the establishment of over 100 community-led groups focused on different aspects of health and wellbeing. Community Appointment Days and Community Led Support make extensive use of local charities and community groups to provide support to those drawing on care. The Butterfly Project mobilises members of the prison community to connect with other prisoners to support them in improving their health. Thrive draws on a wide variety of community provision such as gyms, art groups and young people’s support networks to help those with mental health challenges.

These three elements of withism make a powerful, self-perpetuating whole when applied together in a thoroughgoing fashion: deep understanding, versatile response and collaborative delivery reinforce and require each other. Healthier Fleetwood is a good example of this, with the three principles blending to create a fundamentally distinct and common-sense way of working from that employed by the conventional public sector. What those working in Fleetwood sometimes call a ‘different way of being’.

Why withism works

While the perpetuation of toist practices pushes the public sector into ever greater levels of unsustainability, withism offers a route to stabilisation and even improvement. Community Appointment Days have radically reduced waiting times for routine physiotherapy appointments while scoring very highly on patient experience. Community Led Support has reduced waiting lists for adult social care wherever it is tried while showing no decline in the quality of care. Thrive reports a very significant fall in referrals to mental health waiting lists, the Jean Bishop Centre states that it has cut emergency admissions for frail people by half, and The Butterfly Project has promoted far higher cervical screening rates in prisons than for the English population as a whole. In every case this has been achieved by providing more holistic and humane care based on the three principles outlined above.

There are three chief ways in which withism can deliver these outcomes.

Augmenting limited public resource

The most innovative parts of the front line are adopting withism because it is clear to the people working there that with rising demand and shrinking resources no single public sector institution has the capacity to fulfil its duties, let alone meet wider socio-economic challenges. Withism responds to this pressure by augmenting institutional resource with the assets, energy and insight that individuals, families and communities can bring to the delivery of services. All the innovations mentioned above do this very consciously, finding different routes to augment public sector resource with the untapped capacity of pre-existing community assets or by catalysing new assets within communities.

Toism, by definition, is unable and unwilling to undertake this necessary augmentation. Trapped within a framework that can only understand extra-institutional actors as passive recipients of care, the current public sector weakens its own sustainability by wrongly assuming that it still has the internal capacity to meet the deepening challenges associated with the socio-economic crisis of the last decade and a half.

Shifting to prevention

Withism also offers a much more effective framework than toism for the redesign of services with the aim of keeping people healthy and happy rather than waiting for them to get ill or face personal crisis – what is often described as a move from a treatment-based or acute service model to a preventive one. It is widely acknowledged that such a shift is essential if the enormous demand pressures on public services are to be reduced.

When someone is ill or in deep crisis, often what is required, at least initially, is treatment by an expert. In many cases such an approach is justified – someone suffering a heart attack or drug overdose will obviously benefit from a toist response from health professionals.

But this approach is not well-suited to keeping people happy and healthy rather than merely restoring them to health and happiness after something has gone wrong. The former goal is both deeply contextual and quotidian, rooted as it is in the quality of our social networks, our local environment and the micro-decisions we make every day around what to eat, whether to exercise, and so on. Changing those aspects of people’s lives is not something that can be done with a toist, treatment-based mentality structured around individualised consultations focused on relatively short-term interventions.

Contrast that with the withist case studies presented above. They aim to keep people happy and healthy not by telling them to stay so but by building trusted relationships with local networks to provide people with a supportive and understanding context within which they can flourish. It is telling, for example, that Healthier Fleetwood makes no use of the usual toist public health messages about quitting smoking, eating well or taking exercise. Instead, people are encouraged to take part in, or are just drawn to, networks of people who incidentally encourage healthy and happy living by forging human connections and having fun.

In this sense, withism is the key to a successful shift to prevention. An approach that understands that it is the role of public services to engage in deep listening and dialogue with individuals, families and communities and to develop collaborative ways to improve the daily context and environment in which they live in a fully holistic and empowering fashion. Toism is simply unable to deliver such an approach.

Eliminating the waste of systemic failure demand

Failure demand is a concept developed by the organisational theorist John Seddon. His analysis showed that many organisations deal with unnecessarily high levels of demand simply because their customers require resolution of something the organisation has done wrong: sending incorrect information, failure to keep to an appointment, taking too long over an order. According to Seddon, the levels of failure demand can be surprisingly high in the private sector but reach extraordinarily high levels in public sector settings.

Failure demand is often applied to processes: administrative errors, lack of effective communication channels, technological flaws. But it is also useful to think about failure demand in the wider sense of systemic failure. This is when the way a whole system operates – its very structure and culture – denies people the most effective care and hence means they place more demand on that system than they otherwise would have as their conditions or problems go unresolved or worsen.

The chief cause of this systemic failure demand, and hence the vast waste of increasingly scarce resource, is toist practice. Instead of providing the sophisticated holistic care that a great deal of research shows is the best way to keep people happy and well and prevent crisis, toism reduces individuals to a collection of unconnected problems or conditions, each one of which needs to be addressed by a different specialist, department or institution who are rarely in any contact, let alone co-ordination, with each other. Indeed, many are in active and intensifying competition as they seek their share of a shrinking pool of funding.

This aspect of toism is partly the result of its origins in a highly reductionist and mechanistic model of care, based on the scientific method, which believes that the best treatment comes from hyper-specialisation – an approach that may work well for treating specific medical conditions but which fails repeatedly on the broader goal of promoting and maintaining general health and wellbeing.

Withism, with its emphasis on holistic and collaborative care driven by a primary focus on the outcomes sought by the individual, family or community, offers a way out of this systemic failure demand. It can create the culture and practices that ensure people not only receive better care but that unnecessary demand is reduced and hence public funds are used more sparingly.

Changing a resistant system

Despite the greater relevance of these withist practices to an era of crisis, toism still dominates the public sector. The mindset and accompanying practices generated by the principle that the public sector alone has the necessary expertise and resource to design and deliver public services is deeply embedded. Put another way, the public sector has an overwhelmingly toist culture.

But toism is also reinforced by a complex web of incentives and sanctions that maintains the approach: training and career advancement for public servants that expects people to operate within a toist frame; forms of contracting and commissioning that expect suppliers to deliver against toist practices and criteria; regulation of public services which assumes that toism is the only or best way to deliver services; imposition of national and local targets that require the speedy, inhuman processing of people through the system that is a key characteristic of toism.

All of this is underpinned by the hierarchical structures and culture of much of the public sector. These not only ensure that toist practices are widely and easily maintained by managers but further embed the toist culture in the form of senior staff doing to rather than doing with more junior and frontline staff.

This is why those advancing withist approaches experience intense resistance to their work. These innovators regularly attest to facing repeated objections to their initiatives, a lack of co-operation from other parts of their organisation or local systems, having funding or permission to continue withdrawn or not approved in the first place, and being dismissed as insignificant. The resulting outcome can be easily summarised: an overarching system that remains overwhelmingly toist despite its self-evident and intensifying failures punctuated only here and there by precarious pockets of impactful withist innovation.

It would be easy to think that the solution is to persuade the most senior public sector leaders in Westminster and Whitehall to adopt a withist outlook and then require the approach to be replicated across the whole system. But this approach immediately runs up against the fact that the chances of central government adopting a thoroughgoing withist perspective are very slim.

Toism is such a foundational part of the culture of Westminster and Whitehall that it is barely noticed by those embedded in it, let alone questioned. This is not a mindset that will be shifted, no matter how much evidence and reasoned argument is presented for a radical change. What has been seen in the past will continue to be seen in the future: withist ideals and practices appearing occasionally in statements, guidance and strategies but ultimately losing out to a much wider and consistently pursued preference for doing things to rather than with people.

The recently published 10 Year Health Plan for the NHS is a case in point. The plan aims to drive a wholesale shift from treatment to prevention and from hospital to community, and sets the ambition to move patients from being ‘passive recipients of care’ to ‘active partners’. In places, the 168-page document adopts the language of withism, but the hard, tangible actions are more narrowly focused on improving patient experience, gathering patient feedback, and giving patients choice. All are worthy endeavours, but they fall far short of the fundamental transformation in mindset and behaviours required right across the state to make those shifts a meaningful reality.

Trapped in an outdated frame that still sees service users as individualised consumers, the reforms largely overlook the necessity of directly engaging empowered people and communities in the design and delivery of public services. The plan seems to suggest that the system will still decide on and design what services are needed, and patients will feed back on whether it works or not. This is still doing to rather than doing with – it misses the opportunity for working with people and communities to design and deliver those services in the first place, to work with local people to ensure that neighbourhood health services meet their needs, and even more than this, to recognise the assets that the community itself brings.

If public services are to be protected for future generations, then change will primarily have to come from an alliance drawing together the many public servants who are frustrated by a system they know is failing, and those who engage closely with, or draw regularly on, public services and experience that failure daily. In effect, the creation of a grassroots movement for withist change.

Movements of this sort have two great advantages. First, they create change on the ground without requiring permission from more senior figures within a system. They do this by shifting discourses, changing expectations, challenging inertia or resistance, and just getting on with doing things differently. In effect, movements shift organisational cultures in the way decrees from above rarely can.

Second, they use pressure and momentum rather than persuasion to shift the mindsets and practices of politicians and other leaders who feel the need to either relent in the face of a widespread and organised desire for change or to ‘jump on the bandwagon’ in order to be regarded as forward-looking leaders.

This is not to say that grassroots movements are perfect – they often face challenges and take wrong turns. But as a route to an urgent and radical shift in the public sector, such a movement offers the best chance of success.

It is in recognition of this reality that efforts to launch a ‘DoWith’ movement have taken off in recent months. In January, a group of 30 national organisations published a joint call to action demanding a withist shift. Over 800 people attended an online event in March inspired by the call to action. Gradually, awareness, meetings and groups are starting to appear around the country and existing networks are cohering under the banner of ‘DoWith’.

What is emerging is something extremely significant for the future of public services in the UK. The intellectual and strategic void left by the failure of both centralised statist and market-based perspectives to public service reform is now being filled by a wholly new approach. Perhaps, most interestingly, it is an approach originating not in the elite environs of Westminster and Whitehall, as was the case with those previous perspectives, but being designed and demanded by those delivering and receiving services themselves.

As such, we need not simply hope that central government begins to see the urgency and the radicalism of the shift required. This is a change we can all start delivering by drawing together and using our collective voice and energy to demand withism and start putting it into practice in the here and now. Without such a shift, the future holds only a deepening of the deterioration in the public sector seen over the last 15 years. But if we can make withism the commonplace reality then we will be on the path to creating a more humane, more sustainable system better adapted to the era of crisis and better able to give people the public services they want and need.