Delivering the Vision

Public Services for the Information Society and the Knowledge Economy

Eileen Milner

• Publisher: Routledge
• Year: 2002
• ISBN:
  9781134548903
• Edition: 1
• Topic: Languages & Linguistics
• Subtopic: Journalism
• Index: Languages & Linguistics

Political rhetoric surrounding the role of information and knowledge in society in the twenty-first century is often thrown into sharp relief by the realities of practice. Delivering the Vision explores the way in which public service visions have developed globally and how successful they have been in contributing to major social and economic change.
This edited text contains a range of case studies from the United Kingdom, the Republic of Ireland, Canada, the USA and Australia. Contributors focus both on those factors critical to success and on reasons for failure, but a common theme to emerge across all contributions is the requirement for a clear political vision, commitment and leadership if the shift from traditional forms of social and economic organisation to high-value, knowledge-intensive economies is to be safely negotiated. At the same time, individual case studies provide valuable blueprints for successful implementation of an ambitious public service change agenda.
Delivering the Vision is accessible and relevant to all those interested in the management and reform of public sector organisations. It is a companion volume to the editor's earlier text Managing Information and Knowledge in the Public Sector (Routlegde: 2000)

Chapter 1
Delivering the vision An introduction

Eileen M.Milner

Public services: fast, flexible and friendly?

When Kanter argued in the 1990s that successful organisations were characterised by their ability to be ‘fast, friendly and flexible’, it is likely that her views of best practice had not been substantially informed by observation of such traits in the public services. (Kanter 1990:iii). Public services by their very nature have not been predisposed to speed of delivery, rather they have typically been viewed as being inward facing, overly bureaucratic and focused rather more on procedure than delivery. Flexibility also, is not a noted public service trait, with complex models of governance producing over time, deeply entrenched views of service domains with overtly territorial characteristics predominating. Having a capacity to be welcoming, easy to access and generally inclusive in their approach to all strata within society, are similarly, characteristics that may not be redolent with service users actual experience of engagement with public sector organisations.

However, governments who espouse ambitions to be at the forefront of developments in the creation of an information society and knowledge economy, generally do so with only partial understanding of the way in which a focus upon reengineering public services can provide a powerful catalyst for being at the forefront of such developments. Therefore, the focus of this chapter, is to provide a blueprint for public service developments which is somewhat more grounded in acknowledgement of key inhibitors and barriers, than is often the case when, for example, these profound issues of service reengineering are cloaked in the rhetoric of terms such as electronic government or digital democracy. Examples are drawn from the health service arena in the United Kingdom.

What are we seeking to do?

There is no universally agreed ‘recipe’ for the way in which public services may need to rethink their rationale however, extracting key areas of activity from globally observed practice would suggest that the following four strands are key:

1. The intention to transform the citizen experience of contact with public services to bring about not only more coherent approaches to accessing services, but to ensure that there is ongoing focus upon usability;
2. To enhance the potential for communication, consultation and engagement both internally and externally;
3. Ensuring that key ‘back office’ functions operate in open environments, such that, where it is desirable, that information can flow seamlessly and invisibly across service boundaries;
4. Where partner organisations have been tasked with delivering services on behalf of governments, that there are sufficient structures in place to ensure that the operational level knowledge and learning assets which are key to ongoing policy formulation, are not lost from the public service ‘loop’ entirely.

These points, in themselves, represent major challenges for governments. However, further complexity is added, by the fact that for successful outcomes to be achieved there is a fundamental requirement to treat this reform agenda as a coherent whole, rather than as a menu from which selected points can be extracted. Such an approach represents a critical stage in redefining what is meant by public services. A move away, perhaps, from a perception that public services were something that were essentially one-way, delivery-focused mechanisms. A move away also from a view that public services must be packaged into what were once apparently logical ‘parcels’ of activity and towards a view that what citizens expect in other aspects of life—namely, ease of use and minimum levels of complexity, are reasonable expectations of publicly provided services. Critically also, perhaps, this reform agenda represents a major challenge to the view that externalising key public services, putting the responsibility for delivery into the hands of those operating at some remove from government, is in its current dominant models of operation, likely to substantially move forward an improvementfocused agenda.

The challenge in this chapter is to consider each of the four identified ingredients in the reform and improvement recipe outlined for public services and to provide some reflection upon where barriers to progress and missed opportunities may occur.

Transforming the citizen experience

When considering pronouncements from politicians on the subject of public service reform, it is possible to establish an overriding theme of transformation as being dominant in their aspirations for moving forward in this arena. However, closer scrutiny of what is actually being advocated and precisely where the locus for transformation would in practice reside, is an area that can appear confusing and contradictory. Thus, for example, in the United Kingdom, there exist targets for public services to achieve higher levels of migration to information and communications technologies (ICT)-mediated service delivery by 2005 (www.cabinet-office.gov.uk/servicefirst). This, it might be argued is a good example of government providing leadership in a key area and embedding political vision into tightly measured performance criteria. However, for such targets to be meaningful they must, above all else, be relevant and challenging. Where, it can be argued, the United Kingdom’s 2005 aspirations fall down, is that they have been moved from the macro level of general vision, down to the micro level of delivery units, with little actual focus upon the role of the user and the transformation of their experience of service interaction. The articulation of targets thus becomes somewhat more mechanistic in focus, allowing the gathering of information to dominate, when a truly transformational agenda might be expected to consider in a more creative manner, how information could be more usefully moved through and across public service operations.

Transformation in this context requires, initially at least, the prioritisation of creativity and innovation in the process of public service design. Critical here is the need to consider patterns of human behaviour, to understand emergent priorities and the ways in which citizens engage with others, particularly those who act as service providers. Considering current public service structures and citizen interactions with them will, almost always, provide an imperfect basis upon which to move forward, for innovation and creativity cannot be reliant upon simply asking service users how things might be improved (Milner 2000:150). To seek to use views of current structures or delivery mechanisms as ready springboards for achieving change is essentially limiting. However, creativity that is capable of underpinning high levels of service transformation, is far more likely to emerge from researching the changing behaviours exhibited by citizens in relation to other aspects of their daily lives. The public service mission in this context has been articulated by the United Kingdom’s Prime Minister, Tony Blair:

Our challenge is to modernise government and raise the quality and accessibility of all our public services. We acknowledge that people leading busy working lives should not be obliged to queue up during the working day to get to the services they are entitled to. They should be able to access services how and when they want. There are some first rate services…like NHS Direct, or NHS Walk-in Centres, which show the way forward. We need to build on these examples.

The first-rate public services of tomorrow will respond quickly to the needs and wishes of its users and produce innovative solutions to the problems that emerge. It will reach out to all groups in the community, old and young, men and women, with or without disabilities, of whatever ethic community. It will value its staff and make best use of them. (Cabinet Office 2001:1)

Certainly the agenda set out above is transformational in its language, and realistic in its assessment that such a reform agenda remains, at best, a work in progress. Yet, if we consider the two particular examples of good practice alluded to by the Prime Minister in his statement, those of NHS Direct and NHS Walk-in Centres, and measure them against the first of the four tenets of good practice outlined at the commencement of this chapter, we will find that there remains some scope for constructive criticism. The requirement to focus on achieving coherence of the citizen access experience and a prioritisation of usability of service raises important questions in respect of both exemplars. The rationale for both service developments is described as:

Making health services more accessible to all is a priority for the Government. There are some exciting new initiatives in the National Health Service (NHS) that are making quality healthcare available to people at times to suit them, reinforcing the message that the patient must come first. (Cabinet Office 2001:2)

To consider first the case of walk-in centres, the roll out of which commenced in London in January 2000 and which has continued to gather momentum since then, with the inclusion, under this umbrella, from 2001, of dental services operating under the same ‘drop in’ principle. Such is the level of resource investment in these services and the similar high level of political expectation that surrounds them, that it is worth careful analysis of how they are described by their architects:

In a number of towns and cities in England patients are able to walk into NHS centres from early morning until late in the evening and get healthcare advice and treatment for minor injuries, illnesses and ailments from professional, experienced NHS nurses—and all without having to make an appointment.

NHS Walk-in Centres have been introduced by the Government to help people who need easy access to flexible services because of their busy lifestyles or particular circumstances. The 40 existing NHS Walk-in Centres can be found in a variety of convenient places, like alongside Accident and Emergency departments of NHS hospitals and some GP practices. Peterborough and Bristol have the first high-street NHS Walk-in Centres and there’s even one at Manchester Airport.

NHS Walk-in Centres are open seven days a week, typically from 7.00 a.m. to 10.00 p.m. during the week and 9.00 a.m. to 10.00 p.m. at weekends. They complement local GP and hospital services, offering fast and convenient access to local NHS advice, information and treatment for minor injuries and illnesses such as cuts sprains and minor infections. (Cabinet Office 2001:2)

So what can we extract from this in terms of measuring the extent to which these walk-in centres are likely to enhance the overall coherence of the citizen experience of health care? Perhaps the critical question to raise here, is the extent to which such centres form part of a coherent model of health care delivery, exploiting opportunities for seamless engagement with other elements of the complex organisational model which has long been a characteristic of the United Kingdom’s NHS. A first concern to raise is to acknowledge that the parameters for delivering health care through such service points must be limited by the current inability to have portable individual health records. That is to say that in the UK, as is the case in many other major countries, citizen health records are not typically accessible at all service delivery points. The concept of a working model of electronic patient record is embedded in the 2005 targets discussed at the outset of this chapter, however, even if this aspiration is met in full, it is unlikely that by this date, that centres such as this will have access to a full, detailed electronic health record. The reasons for this relate to the complexity of the undertaking in seeking to transfer current paper based records and partial electronic holdings, into a uniform set of data which can be contained within one robust system for a population of some sixty million people.

Thus, one may argue that in the short to medium term at least, that the scope for taking on substantive tranches of work from general practitioners and hospital accident and emergency departments staffed by doctors, is limited. The reasons for such limitations arise from the degree of risk that exists when seeking to deliver health care on the basis of having little or no patient-specific information to hand.

So whilst it may certainly be possible to argue that such centres, staffed by highly qualified nurse practitioners adhering to carefully constructed triage procedures, represent a significant step forward in health provision, there must remain significant concerns around the costs and associated benefits resulting from them. To date it has not been possible to identify any empirical research that supports a view that in areas where such centres exist that there has been a resultant decline in pressure on other frontline healthcare services.

Achieving enhanced coherence and improving effectiveness of service in this context, therefore, would appear to be reliant upon having the ability to work with patients on the basis of properly understood case histories. Without access to such information the predominant operational culture is likely to be one of clinical defensiveness, with referral on to other elements of the service model likely to predominate in all but the most straightforward of cases. There are, additionally, dangers inherent in approaches such as the walk-in centre, whereby patterns of behaviour and presentation of certain injuries may not be accurately fed into the patient’s health record. This could actually serve to reduce the ability of health professionals to work in the coherent manner aspired to and lead to some actual decline in the overall pattern of patient care. So whilst developments such as these may ostensibly achieve high scores against usability and coherence criteria, the reality may, at this relatively early stage, be somewhat different. Real service enhancement, achieved through creative use of resources, it seems clear, in a context such as health care provision, is only really likely to be realised when there can be confidence that such services are secure in their underpinning operational frameworks.

Developing this theme still further, significant investment in the NHS Direct call centre model represents a response to wider societal exposure to, and acceptance of, remote access service acquisition and delivery, particularly evident in industries such as insurance and financial services. Moving such an approach out into the health care environment certainly represents an ambitious attempt at creating new behaviours and expectations within the citizen community. Allied to these expectations has been an anticipation that roll out of the call centre service would serve to reduce work pressures on general practitioners and hospital accident and emergency departments. However, to date, as for the walk-in centres, no empirical evidence has been produced to support a view that these anticipated reductions in pressure on frontline services had actually come about. Indeed, within the general practitioner community there exists a prevalent view that investment in an area such as this is wasted, with NHS Direct being referred to by many as no more than a political ‘gimmick’ (Rumbelow 2001).

The damning term ‘gimmick’ is critical in making any assessment of critical success factors around transformation of public services, be they in the health services or in revenue collection. The UK government is by no means alone in responding to the changes evident in society where rigid barriers and hierarchies are increasingly being broken down and new service offerings developing. The aspiration to transform the experience of accessing and using public services is entirely proper given even cursory understanding of changing behaviours and expectations within large elements of society.

Yet, if we review the key issues emerging from current developments in the United Kingdom’s National Health Service, we see that in one instance, that of the drop-in centres, the potential to undertake significant areas of work is critically limited by the lack of an electronic patient record. In the case of the NHS Direct call centre approach, the opportunities for actually impacting on workloads experienced at the frontline of care are limited by the fact that remote diagnosis, on the basis of computerised triage procedures is, at best, such an inexact science that the likelihood of referral on to other parts of the NHS may actually be increased. In both examples it is possible to argue that the reasons a sense of missed opportunity resonates across any analysis, arises from issues related to both opportunities and weaknesses inherent in the application of information and communications technologies. For the dropincentres, potential is limited by the absence of sufficient patient information. For NHS Direct there appears to have been rather too much expectation invested in the capacity of ICT-mediated diagnostic procedures, without proper realisation that remote risk assessment is likely to increase frontline referral rates rather than to decrease them.

Of course, when discussing the theme of achieving major public service cultural transformation, it is all too easy, particularly when considering an area as emotive as health care, to be largely negative around current developments. However, to be overly critical is to miss a crucial stage in the transformation process, that of actually raising awareness that new offerings can be made and to establish familiarity with their use. Walk-in centres and NHS Direct are, under their present operating parameters certainly limited in scope. However, the networks that are being created and the expectations and behaviours becoming established in their use, should ensure that they serve as ready platforms for moving forward new models of service delivery as the technology becomes available to support such work. Thus, the NH...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Delivering The Vision
• Illustrations
• Notes On Contributors
• Preface
• Acknowledgements
• Chapter 1 Delivering The Vision An Introduction
• Chapter 2 Seven E-government Milestones
• Chapter 3 Centrelink, Changing Culture And Expectations
• Chapter 4 Brisbane A Reflection On A Journey
• Chapter 5 Beyond 20/20 Vision, Improving The Human Condition A Canadian Perspective
• Chapter 6 Reasoned Strategy Or Leap Of Faith?
• Chapter 7 Vision And Leadership In The Digital Economy
• Chapter 8 E-government, Strategic Change And Organisational Capacity
• Chapter 9 Delivering The Vision