Danny Kruger is MP for Devizes. He is the founder of two charities working with prisoners and young people at risk.
Ten years ago I went to Texas to see an empty prison. The Republican leadership, overseeing a penal system that had twice the UK’s number of prisoners in a state with half the UK’s population, had recognised that the steady rise in incarceration was simply financially unsustainable. They could not afford to build enough prisons to cope with the demand. So they changed the plan, and focused instead on bringing down the numbers.
The trick, they realised, was to stop reoffending – the endless cycle of recidivism that meant most people who entered the justice system never permanently left it. So they empowered and invested in rehabilitation, mostly through a network of civil society organisations that worked with criminals to fix up their lives. It worked, hence the mothballed prison I visited (for a Radio 4 documentary).
England’s jails are full to bursting. Prisoners regularly spend 20 hours a day behind their doors, often doubling up in a cell designed for a single man, such is the shortage of space and staff. And across the public sector we face impossible pressures, manifested in the days or weeks it takes to see a GP, the months or even years you wait for hospital treatment, the tragic delays in getting an education, health and care plan for children with special needs, or a bed for a young person with an eating disorder… or almost any other service that the state promises, but cannot furnish in the volumes that are demanded of it.
The political debate around the public sector oscillates depressingly between the poles of ‘more spending’ and ‘more efficiency’. Of the two, of course, efficiency should be the preference. This week Jeremy Hunt pointed out that the trend rate of growth in the economy overall is only 1.6 per cent a year, whereas public spending (even excluding debt repayments) is forecast to rise at two per cent. Mr Micawber would disapprove; so should we all.
Jeremy’s answer is partly to grow the economy through increases in private sector productivity, and partly to squeeze more juice out of the public sector orange – also through productivity gains. He observes that output in the public sector is down nearly six per cent on pre-pandemic levels. Given the demand we have placed on the system by the effects of our Covid policies, this is shameful. Yet better productivity on its own is not enough. We need to reduce demand itself.
Rather than trying to do more with the same or less resources, the public sector should do less with less. For the avoidance of doubt – and to ensure that anyone who quotes me selectively does so in avowed bad faith – I stress that no front-line services should be cut until they are not wanted. We simply need to reduce demand for the state, and then, like those Texan jails, the supply can reduce of its own accord.
This was in fact the original vision for the welfare state, or at least for what became its totemic and titanic centrepiece, the NHS. Nye Bevan, Labour’s Health Minister from 1945, predicted that healthcare costs would fall as people became healthier. Of course he didn’t reckon with medical innovation, or with the public’s appetite for treatment. By 1950 he was complaining of ‘the ceaseless cascade [of medicines] which is pouring down British throats’; the following year Labour introduced charges for eye and teeth treatments, and the tedious argument about NHS rationing, now 70 years long, was underway.
Of course medicine is the one thing the state can provide in almost limitless quantities. It doesn’t require space, or staff, like the supply of prison places does. It just takes money.
And so it is that a fifth of the adult population is on habit-forming pills, mostly antidepressants. This pharmacopoeia is the property of vast commercial interests deriving a handsome profit from the client of their dreams: the comprehensive, universal NHS, committed to treating everyone with everything they need, including those dependent on addictive drugs, and to paying for it with public money, on behalf of a public who constantly call for more spending on the NHS. Needless to say the waste – not to mention the immense cost in human suffering, with millions of people unable to withdraw from state-sponsored dependency – is prodigious.
Ultimately, the answer to the UK’s unbearable demand pressures lies in the social conditions that give rise to them. The Children’s Commissioner and the Church of England have both recently stressed the ‘protective effect’ of families.
Yet as Miriam Cates and I have argued, current policy ‘seems designed to pull families apart by making the home as uncomfortable, expensive, and pointless as possible’: we have tiny houses, long commutes, punitive taxes, and subsidies that require you to put your children into all-day nurseries and your parents into residential care. We need to recover a vision of the household economy that makes it worthwhile for people to settle down together, have children, and look after their old folks.
And beyond the family, we need the incentives in the system to align around prevention, early intervention, and the common sense practical solutions that make for better outcomes and lower costs. Partly this is about stripping out bureaucracy and making front-line workers, or even recipients themselves, responsible for their budgets. The Dutch Buurtzorg model of social care, for instance, empowers nurses to work with their clients, their families and the messy tapestry of local civil society to provide care that suits the individual.
We get it right in pockets. The Government’s social prescribing policy has seen real reductions in demand in some places – notably Gateshead, where the Ways to Wellness programme, providing people with long-term conditions with help to live healthier, has caused a 15 per cent saving in secondary care costs. And here in microcosm is the great opportunity for public policy – and a great prize for the political party that will seize it.
The Ways to Wellness scheme is an Outcomes Partnership. This means that it brings together different actors in the public and non-profit sectors to focus on the actual improvements in life – the outcomes, rather than the ‘inputs’ of spending or the ‘outputs’ of professional activity – that people need. The upfront funding is provided by philanthropists and ‘social investors’ (wanting their money back with interest, but with a higher risk appetite and lower returns than commercial investors demand); the public sector only pays out if the specified results are achieved.
And so the taxpayer carries no risk, and the providers are incentivised to deliver. This means the providers do what is necessary for success, and what is so hard and so rare in systems whose funding does not depend on results: overcoming professional silos, empowering front-line staff, exhorting good behaviour from clients; in a word, innovating.
We are not going to transform the public sector overnight; nor should we try. Public servants are hard-pressed, only just adequately remunerated, and have no appetite for yet another restructuring. Yet alongside the status quo, on the edges, change is possible. Outcomes Partnerships can be established wherever there is willingness in the system. In the Budget in March the Chancellor created a small fund for trialling innovations like this. This should be used to inspire entrepreneurs in the public, private and non-profit sectors to show what is possible.
What is possible is more health, less pills and less time in hospital; less residential and more domiciliary social care (i.e. at home, not a ‘care home’); less welfare, more lifelong skills training and more support for people with disabilities to join the workforce; fewer large all-day nurseries and more childcare close to home; and best of all, fewer prisons.