How we lost sight of the point of public services: The case for whole system reform moving towards strengths-based and relational services

In the first instalment of our New Thinking series, Alex Fox and Chris Fox examine the state of public services in the UK today, and make the case for whole system reform, moving towards strengths-based and relational services.

Eighty years ago, in laying out the foundations of modern public services, Beveridge set out to slay the “Giants” of Want, Disease, Ignorance, Squalor and Idleness. In 2023, with public services in crisis and those giants unslain, or even returning from the dead, it can feel like public services have lost their direction and people are losing faith.

Beveridge saw the state’s role as vital, but as needing “co-operation between the state and the individual” so as not to “stifle incentive, opportunity, responsibility” and to “leave room and encouragement for voluntary action by each individual”. Establishing that ideal mix of state and individual action has always been seen primarily as a challenge of control: how can services and their workers ‘manage demand’, prioritise people according to need, set boundaries, and move people on.

We argue that this is the wrong approach. Empowering people requires empowered, local public services and workers. A radically different approach is needed and at the heart of this approach are relational services that focus on people’s strengths. We are not the only people arguing for this, but what makes our approach distinct is that we go much further in describing the skills and capabilities that public service staff need to work relationally and the kinds of teams, organisations and systems that are needed.

Without radical reform of the organisations and systems that deliver public services, relational and strengths-based approaches struggle to take hold and tend to remain as small-scale projects, over-reliant on the drive and determination of a few charismatic and driven individuals. So ours is a vision for radical change at every level, from individual practice through to government policy.

The challenges facing public services in 2023

The challenges public services face are complex and cumulative. They are a product of under-investment over the last decade but also of ill-conceived structural reforms over the last 30 years. Too often reforms have mimicked outdated notions of competition and tighter management taken from the private sector with disappointing results. The irony is that this has happened while the best of the private sector has been reinventing itself based on new concepts of innovation, environmental and social responsibility and new, empowering organisational structures.

The challenges we face now have been in the making for decades, but are exacerbated by broader social and economic trends including a decade of low productivity, the high costs of childcare and housing relative to wages and, more recently, the increase in hybrid working and the cost of living crisis.

Strengths-based services turn away from outdated private sector management practices, based on ever greater control. Instead, counter-intuitively, they believe that the optimal balance between the activities of services, and the actions of individuals (and their families and communities), can be achieved by less control, more flexible boundaries, and more trust.

In particular, strengths-based approaches set out different ways of tackling two of the most pressing crises facing public services today.

1. Staff are less well, leaving (particularly the most experienced) and hard to replace

After ten years of austerity many areas of the public sector have seen staff numbers fall. For example, in education, the number of qualified teachers in state funded schools has not kept pace with increasing pupil numbers for a decade, leading to higher pupil to teacher ratios. Postgraduate teacher recruitment is 29% below target. Between 2010 and 2018 police numbers fell by over 20,000. The number of vacancies in social care is now at its highest rate on record with 165,000 unfilled posts, according to Skills for Care.

For example, in London, despite a significant drive to recruit new probation staff, the Chief Inspector of Probation has warned of unsustainable levels of vacancies across virtually every role and function in London. The vacancy rate is a staggering 43% across Hammersmith, Fulham, Kensington, Chelsea and Westminster.

In a number of sectors there are recruitment drives, but sometimes these are struggling to keep up with the exodus of staff. The Trades Union Congress found 32% of key workers in the public sector have already taken steps to leave their profession, to get a job in another field or are actively considering it. The Institute for Fiscal Studies (IFS) notes that rates of sickness in the NHS have increased. Looking at the UK workforce as a whole the Resolution Foundation highlights that inactivity rose during the pandemic as people got sick, retired early and/or went (back) into education. However, these trends have not all reversed as we have come out of the pandemic. Over recent months economic inactivity due to long-term sickness has continued to rise.

Even where figures suggest staff numbers are increasing, the underlying picture is more complex. For example, IFS research indicates there are 9.2% more NHS consultants, 15.3% more junior doctors and 8.2% more nurses and health visitors than in 2019. But it also shows that higher rates of sickness mean fewer people on the ground than those numbers imply and the numbers of highest and lowest paid staff are growing faster than those in the middle, raising questions about supervision and support for front-line staff.

These problems suggest we need a fundamental rethink of what it is to work in public services. It’s not just wishing those roles were more valued and therefore better paid. We need to actually create new roles which are more valued by the people they support and the people doing the job.

2. Demand is increasing and so is the complexity of that demand

The Institute for Government performance tracker reviewed the state of the main nine public services and found that modest increases in public service budgets were getting swallowed up in higher wage bills, with the main public services unlikely either to return to pre-pandemic levels of service, nor to match continuing rising demand. Local government spending is “no longer sufficient to meet demand in adult social care, children’s social care and neighbourhood services.”

However, the problem isn’t simply that demand is rising: its also getting more complex. The BMJ reported that following Covid-19, England saw the biggest fall in life expectancy since records began. Schools are seeing lower levels of language and speech development in young children  post-pandemic. The 2020 follow up to the Marmot Review (which presented compelling evidence of the complex causes of health inequalities in 2010) found that we will spend more of our lives in poor health, with sharp differences in life expectancy and other key measures for people in the most deprived areas.

Increased pressures, threadbare teams and poorer results are leading workers to re-evaluate their role in public services and leaving to work in other industries. Others who remain are making different decisions, for instance, not to move from front-line practitioner to middle manager.

These issues will not be resolved simply by weathering the Covid storm. Pre-pandemic, a large survey by charity, Mind, found a higher prevalence of mental health problems in the public sector, and a “shocking” lack of support for those workers. The UK has witnessed a rolling wave of sector strikes since 2022 with staff voicing their frustrations.

It will be tempting for public service leaders to seek ever greater control in response: making it more exacting for people accessing services to prove themselves eligible, setting ever-tighter boundaries around the support organisations can offer, and closing cases more quickly. But such approaches simply shift need from one service to another (cuts in social care resulting in more hospital admissions) or create different kinds of crises (cuts in mental health services resulting in more police call-outs). Radical change is needed, but what form should it take?

Among the options for public service reform, one stands out

The Social Market Foundation (SMF) identifies three popular strategies for public service reform, all proposed and supported by numerous change agencies. The first is making service delivery more evidence-based, including training practitioners to make better use of evidence and tasking regulators with more explicitly promoting evidence-based practice. The second is increasing the development and use of technology ranging from digitising services to robotics. The third is making services more personalised and relational. All have something to offer, but we believe it is only the third which has the potential to be transformational.

Service delivery has become more evidence-based, but there remain limits to the connections between formal evaluation and real world practice.

Creating an evidence-infrastructure in the form of the What Works Centres and investing in more robust impact evaluations and systematic reviews, is one of the UK’s success stories of the last twenty years. What Works Centres cover over £250 billion of public expenditure and the largest centres, the National Institute of Clinical Excellence and the Education Endowment Foundation (EEF), have had a significant impact on the relationship between practice and evidence in their respective sectors.

But even in sectors where What Works Centres are large and well-established, the transformation of the sector is progressing slowly. In some sectors, there is a loose relationship between evidence, practice and regulation. For example, school’s regulator Ofsted does not use EEF guidance in a formal and systematic way to inform its inspection of schools, according to the SMF report. There is also a tendency for evidence about ‘what works’ to focus on comparing different interventions, and pay less attention to professional practice. This results in doing more to shift funding from one intervention to another, than to shift workforce culture and behaviour.

Technology can boost efficient service transactions and provide greater insight, but is no substitute for the human interaction of people-focused services.

Smartphone and wearable technology can help in monitoring health conditions and behaviours, helping people to take more control of long-term health conditions. Schools are increasingly making more use of technology in the classroom. But there are also challenges. As Toby Nangle notes, as part of a Joseph Rowntree project, high-contact sectors such as social care, childcare, healthcare and education are the sectors where productivity gains have been most elusive, and where reaching more people can be a quality reduction “masquerading” as a productivity gain.

It is unrealistic to expect technological solutions to fundamentally change this unless we accept a dystopian future in which our children and elders are cared for by robots, communicate primarily on-line and are entertained primarily in virtual realities. Few of us would choose these approaches for ourselves or our loved ones, if effective and compassionate human care was the alternative. The problems they purport to solve are those of service funders and organisation owners, not those of either low paid and over-worked support workers nor of people who make the most use of services, and who can become unhealthily isolated in the process.

Making services more strengths-based and person-led has the potential for deeper system change. This could make public service roles more valued, and meet the complexity of demand.

Strengths-based working implies that people who are usually seen as the passive recipients of services have knowledge that has value for shaping their own lives, the service offered to them, and service systems more generally.

Strengths-based approaches do not ignore needs, but they do look beyond them. They do not impose a single, uniform service on people according to what the service regards as their needs. Practice must be person-led: with the individual identifying their own strengths and goals and working towards them at their own pace, rather than the service deciding what matters.

There is a risk these approaches are over-simplified. At worst they can simply result in ignoring people’s needs and looking vaguely to ‘the community’ to provide more support than services. But genuine strengths-based working seeks to empower people to build their capabilities and increase their self-efficacy. In this way, strengths-based approaches do not ignore needs, but they look beyond them and support citizens’ development of their capacity and their opportunities to exercise agency.

This means that the people who deliver strengths-based services must be able to listen and empathise deeply, and to be able to recognise the wider context of a person’s life, such as the inequalities they may be experiencing. These include the well-evidenced inequalities created or perpetuated by our current public services themselves.

A strong commitment to reflective practice (workers reflecting on their practice with peers, and learning from what worked and didn’t) will imbue individual practice. Work will tend to be psychologically informed, including a high awareness of the impact of trauma on people’s behaviour and capacity. Fundamentally, the relationship between people who seek and people who offer help will change dramatically from the highly managed, narrowly defined transactions characterising current services.

So, a strengths-based approach addresses power imbalances in services which lead to people becoming stuck in a dependent role. This could explain why co-production emerged in parallel to strengths-based working as a practical response to the same perceived limitations in traditional public services. It developed as part of rights-based movements led by disabled people and others who found themselves relying on services which were involved with, and therefore exerted power over, the most intimate aspects of their lives.

Co-production at its most genuine involves people who use services, and people who provide and organise them, codesigning services together. It can extend to co-delivering and co-owning those services. Strengths-based and co-produced ways of working are two sides of the same coin: it is hard to imagine one being credible without the other. Recognising people’s strengths as well as their needs challenges the established power dynamics in public service organisations and systems.

Strengths-based services attempt to unlock the potential of people to help themselves. And through changing the practice expected of workers, they also require and enable practitioners to support people in ways which are more personally-tailored, empowering and ultimately more impactful. That double increase in value – with both participant and worker contributing more – is what creates the potential to be transformational in their impact for people using services.

How would relational and strengths-based practice lead to wider organisational and system change?

Strengths-based working requires deep changes to the structure and culture of organisations and local systems at every level. There are some common characteristics of strengths-based organisations:

• Values-led recruitment which attracts people who have strong communication skills, self-awareness and empathy.
• Teams delivering strengths-based and co-produced services which tend towards self-management.
• Authentic Leaders who also embody the qualities of strengths-based front-line workers, such as self-awareness, strong values and self-reflection.
• Co-creation – the idea that people with lived experience are integral to the design and running of services – features in organisational governance structures.
• Evidence is collected for learning rather than control, striving to be learning organisations which are constantly innovating.
• Strengths-based organisations recognise that solutions to the challenges people face normally need system-wide responses and that the system can often be a cause of some of the challenges that people face. They therefore tend to create flatter organisational structures with porous organisational boundaries, based on networks rather than hierarchies, where knowledge can flow across organisational boundaries and new innovative solutions can be developed both within and across organisations.

It is only possible to create, sustain and scale strengths-based organisations within funding, commissioning and regulatory environments which recognise and reward the new kind of value they create. The NHS’s new Integrated Care Boards, for instance, which aim to set place-based goals for healthy populations across traditional service boundaries, give a tantalising glimpse in some of their visions, if not always in their cultures and practices, of what a strengths-based place could look like.

In What next for strengths-based areas? Mayday Trust, the Social Care Institute for Excellence and Think Local Act Personal looked at what could be learned from those areas which aimed to coproduce a strengths-based vision for public services. We discussed how that might be built into more simple and human systems, commissioned through more tailored and responsive services, and measured through a more holistic set of outcome measures shared across service boundaries.

Whole-system, strengths-based reform shows that sustainable systems change is possible. It posits an approach to public service productivity which does not aim simply to drive more activity, more throughput and more ‘caring’ from an exhausted and demoralised workforce. Instead, it creates individual, family and even societal change from a transformed core set of relationships at the heart of our public services.

Moreover, it presents an opportunity to focus in on the strengths and assets that public services have already, building on the impact of existing local practice. It is not just about funding, but about how capacity is allocated. It also doesn’t require top-down structural reform to be achieved. As the Labour party turns its attention once more to public service reform, strengths-based approaches could provide some of the solutions we are seeking.

Alex Fox OBE FRSA is chief executive of Mayday Trust which provides strengths-based coaching to people going through tough times and helps organisations and local areas to redesign public service systems. Alex developed the Asset Based Area model, chaired a government review of charities and wrote A new health and care system: escaping the invisible asylum (Policy Press).

Chris Fox is Professor of Evaluation and Policy Analysis at Manchester Metropolitan University where he is also Director of the Research Centre for Applied Social Sciences. His work focuses on innovation in public services. His most recent book examined Payment by Results and Social Impact Bonds: Outcome-based payment systems in the UK and US and his most recent research has explored the relationship between social investment and strengths-based services.

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