Public health faces a fresh start

It's year zero for the world of public health. What lies ahead for councils? Photograph: Stocktrek Images, Inc. / Alamy

Since the transfer of responsibility for public health to councils about five months ago, directors of public health in England have worked in upper-tier local authorities.

My job is in Hertfordshire, a county of 1.1m people, with 37 settlements, 10 district councils and a public health system that was really designed for unitary local government.

Some of us are very new to local government, and in a variety of places we are tasked with leading our local authorities and partners to deliver improvements to the health of the population. It can feel both exciting and slightly scary.

For most of the peers I have spoken to (around 45 in the last six months) about how transition has gone, this is essentially year zero for the new public health world.

We are all busy taking over NHS contracts and getting them where we want them to be, while grappling with the fact that for many of us the finances don't stack up without considerable support from partners.

Most of us need some support in adapting and applying our skills and portfolios as leaders. We are learning how to become capable and expert officers working well with strong political leaders. For some of us the journey is smoother than others and we recognise our local authorities have had to work hard too to make this happen.

The challenges facing us are significant. We need to do more to give our children a healthy start in life.

Our working age population is not as healthy as it needs to be to reach old age without considerable cost to the public purse from disease-related disability. The inequalities in life expectancy and disease free life expectancy between richest and poorest and for people with learning disabilities, offenders and people with severe mental health challenges sometimes feel like they're ineradicable.

However, I still think the opportunities are immense, and that they far outweigh the challenges. My peers here and in other councils tell me, as I also hear from partners locally, that there is a real realisation across NHS, county councils, district councils, third sector and criminal justice sector we are all in this together.

In Hertfordshire we are already building a public health partnership with district councils, third sector, Healthwatch, NHS, police and crime commissioner, probation and university as core partners. I know I cannot deliver public health without them.

So where are we going?
Everyone seems to have slightly different starting points but public health teams and partners seem to be getting everything in order. The best partnerships take consideration of the following:

• The opportunity to apply and test thirty years of theory and evidence on health inequalities . Our current public health challenges are a complex manifold of structural, system, behavioural and environmental challenges. Everyone has a bit of the answer. One thing the new – if fiendishly complex – system seems to be doing is spurring people to relationships not structures as a way of building public health strategies and systems.

• Public health must be put at the heart of local leadership. This is a massive opportunity for elected politicians as well as officers. How well we do this is a test of our mettle and a sign of our success in local government.

• We need to get back to people-centred public health, where we build the new system around peoples' lives and experiences, and support people to do things for themselves and with each other. Community agencies come into their own here.

• The potential of the new system needs to be considered. The sheer scale of expertise and influence which Public Health England can lever at national level and the similar scale of local delivery which directors of public health and partners can make happen at local level bode well, if we each remember clearly what we are best at.

• A number of areas are getting to grips with how to layer public health interventions across populations (targeting young smokers as well as manual and routine workers, for example) and across time (short term interventions to get people into public health services, with longer term behavioural solutions to keep people resilient.) This can only be promising.

• Networks are springing up. Counties are talking to each other about making public health work in two-tier areas. Districts are talking about their contribution. Public health teams are benchmarking themselves against each other on topics like school nurses and excess deaths. It might be informal, but it's happening.

All of this requires an enduring vision, and an ability to see beyond two years. But all of it is a sign that public health is alive, broadening its influence and alliances and recruiting new advocates.

You may find this naïve, annoyingly up-beat, hopelessly idealistic or perhaps grimly determined in the face of reality. And perhaps all that is true. But if you find a better way, I'd love to hear it.

Jim McManus is director of public health at NHS Hertfordshire and Hertfordshire county council.

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Five minutes with ... the chief executive of the Royal Society for Public Health

'I would like to see much better integration of health and social care as this will improve the quality of people's lives,' says Shirley Cramer.

Describe your role in one sentence: Leading an energetic and professional multi-disciplinary organisation that is improving the public's health.

Why did you want to work in healthcare? There is nothing more important than healthcare, especially focusing on preventing ill health. If you are unhealthy it affects every other part of your life. Healthcare is fundamental.

How do you want to see the sector change in the next five years? I would like to see much better integration of health and social care as this will improve the quality of people's lives. We certainly need to have plain packaging for cigarettes and a minimum unit price for alcohol and it should happen sooner rather than later. It is important that we improve awareness and training for the frontline workforce on improving the public's health and wellbeing.

My proudest achievement at work was ... getting Hillary Clinton to speak at a conference

The most difficult thing I've dealt with at work was ... facing down the chief executive of a company who claimed he could cure a condition without evidence. There were media interviews over several years – it was exhausting but he went bankrupt in the end.

The biggest challenge facing the NHS is ... to motivate and energise a dispirited staff. Good leadership is essential.

The people I work with are ... very professional, energetic and innovative.

I do what I do because ... the role is endlessly diverse, interesting and an exciting challenge.

Sometimes people think that I am ... Pollyana because I always look on the bright side. It's always better to be optimistic.

Right now I want to ... find more hours in the day.

At work I am always learning that ... there is another way to do things. The one thing always on my mind at work is how we can achieve our goals faster.

If I could go back 10 years and meet my former self I'd tell them ... to put maximum time and effort into the planning process, evaluate as you go along and you will get the outcomes you want.

If I could meet my future self I'd expect them to ... feel happy that I tried my best and hopefully be able to look back on a job well done.

The best part of my job is ... working with great people on public health issues that I believe will make a difference; improving the public's health is a vital role.

The worst part of my job is ... keeping my paper in order, I am filing on the floor again!

What makes you smile? Someone smiling at me for no obvious reason.

What keeps you awake at night? I usually sleep soundly but occasionally I am kept awake worrying about budgets which is always a concern when you run a charity. There is always more you could be doing.

Shirley Cramer is chief executive of the Royal Society for Public Health

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Where next for public health? – Live discussion

Public health became a local authority responsibility in April, with councils in control of public health issues such as tackling smoking. Photograph: Alamy

The transfer of public health responsibility to local authorities this April marked a turning point in how local health issues are tackled. But, five months on, what has been learned, and where do we go from here?

Richard Humphries, assistant director of policy at the King's Fund, recently commented on how the relationship between the NHS and local government has changed. He said:

Our latest research is encouraging. Relationships between councils and clinical commissioning groups are generally good, and getting better. The new health and wellbeing boards are investing time in developing relationships and joint strategies are in place.

Questions remain, he said, including how far councils will support NHS partners in delivering local services and whether austerity will compel change or damage the local relationships.

Humphries said: "This will play out differently; places with a tradition of good local relationships have a better chance of weathering the financial storm." With this in mind what do councils need to do to ensure that they build a strong relationship in the future?

• What has been learned from experiences so far?

• What are the areas of highest priority?

• How can councils use the powers available to them to really make a difference?

• What approach should councils adopt?

• Do councils need more powers?

Join us 25 September from 12pm-2pm to discuss, or leave your comments and questions now.

Expert panel:
Edward Davie is a Lambeth councillor and chair of Lambeth council's health and adult social services scrutiny committee.

Jonathan McShane sits on the Local Government Association community wellbeing board, leading on sexual health and public health services. He is a councillor in Hackney, east London.

Steven Howell is senior policy and communications officer at local government thinktank Localis.

Mary Black is a medical doctor, a consultant in public health and director of public health designate for the London borough of Havering.

Helen Walters leads the health team in the mayor of London's office and works for Public Health England. She is a public health specialist with experience of working in local government, the NHS and as a GP

Liz Saunders is associate director of public health at Surrey county council.

Oswin Baker founded Rockpool Research Associates, a network of researchers with expertise in local government and healthcare.

Tom Scanlon has been director of public health in Brighton and Hove since 2002. He also practises as a sessional GP and is an Honorary Senior Research Associate at University College London Centre for International Health and Development.

Janet Atherton is president at Association of Directors of Public Health . She has been a local director of public health since 1998, first in Wirral and then Sefton in Merseyside.

Anne Bowers is an associate director at healthcare consultancy PPL.

Anna Quigley leads public sector health research at Ipsos Mori, including research with the general public and people within the health sector about public health issues.

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Councils are developing coherent, long-term public health strategies

Local authorities can now relate to the Beatles' Ringo Starr when he sang 'How do I feel by the end of the day?' Photograph: Jon Super/AP

Now councils have a major new role in public health, they once again have the chance, as Ringo Starr didn't quite put it, to help their residents feel better at the end of the day.

The report I have written for Localis clearly shows councils exploring new and innovative ways to tackle the wider social, cultural and environmental determinants of health, following April's switch of £2.7bn of public health funding from NHS control to the hands of local authorities. New health and wellbeing boards were created, enhancing the role of councils in the planning and oversight of all local health services.

With NHS acute treatment costs on a seemingly unsustainable, upwards trajectory, this shift in emphasis towards prevention and tackling the "causes of the causes" of poor health could not be more timely.

Housing, transport, children's services, leisure services and employment (among others) have all been demonstrably linked to health outcomes. It is refreshing, then, to see councils showing real innovation in pushing through short-term public health projects with the potential to deliver instant benefits. Barnet borough council told us that this year it has rolled out green gyms, "forging a closer integration between public health and leisure providers".

Alongside such "quick wins", it is inspiring to see councils developing coherent, long-term public health strategies. A mass of evidence links employment to a person's health and wellbeing, and Kent county council's long-running apprenticeships programme offers businesses grants of up to £2,000 to take on an unemployed 18-24 year-old as an apprentice.

Critics argue that the £2.7bn public health budget transferred to local authority could prove a little leaky, accusing councils of using the money to fill in holes in their budgets. But as Public Health England chief executive Duncan Selbie rightly observes, "ultimately these are local decisions".

Selbie is right to caution, however, that this approach should not be taken too far, offering reassurance that if money was spent on things "completely outside any reasonable view about what constitutes health then of course we'd have to be addressing that".

And where existing, traditional public health themes are demonstrably working, councils are continuing to support such measures. Persistent problems like smoking cessation, healthy eating, drugs, alcohol services and sexual health, are – quite rightly – still absorbing the overwhelming majority of public health budgets.

The return of public health responsibilities to the town hall is a golden opportunity to do things differently. But, crucially, restoring public health to the heart of local government requires fostering links and synergies with wider local government functions.

And to do this, councils will need more than a little help from their friends.

Gwilym Tudor Jones is a research fellow at thinktank Localis.

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Strike out bureaucracy: barriers to choice in public service delivery

From GP appointments to school timetables, more flexible systems will give people more choices Photograph: Custom Medical Stock Photo / Ala/Alamy

At the start of this year, I finished my work for the UK government as an independent reviewer on barriers to choice.

Someone from outside government was needed to look dispassionately at the way people were using their choices in public services and decide what barriers there were to prevent them.

I listened to a dizzying number of roundtables and must have spoken to well over a 100 service users face to face, and almost as many professionals.

But one person in particular stands out. She had muscular dystrophy and had to see her consultant every six months, which meant a two-hour round trip plus 30 minutes or more in the waiting room. It meant going over a large river and paying a toll. And all she said to the doctor when he asked her how she she felt was: 'I'm fine'.

What this woman really wants is to check in occasionally by phone, and see him when she's not fine. But she can't, because his slots are full seeing people who are also fine.

What struck me most forcibly was that she was asking for something quite simple, though important to her as a long-term patient. It was a 'choice' about her treatment, in a sense, but not one that is recognised currently by the system in the UK.

The new emphasis would be less about choosing between regulated options, and more about making services flexible enough to suit individuals better – closer to the 'personalisation' agenda in social care, where service users can get budgets they can (theoretically, at least) use in ways they believe are best suited to their needs.

The best approach may be to find ways to give service users the confidence to ask for something different, and perhaps provide duties on service providers to consider this. I imagine this would be like a 'right to request' flexible service delivery.

In each case, the provider would not be obliged to provide flexibility if it is impossible, but they would be obliged to explain why and make that explanation public.

This would help people cut through systems or bureaucratic arrangements. Perhaps they want a consultant who won't mind them asking lots of questions, or to study Spanish at A-level when all that prevents them is their school's time-tabling system, or to go to bed later than 5pm when their carer comes round. 

This is basic flexibility which articulate people can often get now by being assertive, but which others can't.

There are possible objections to this kind of approach. Patients may choose badly. They may fail to take responsibility for the wider system, by misusing the flexibility they are offered.

There may also be higher costs from treating people more individually, and the costs will come before the potential savings are available. Financial innovations that tie professionals too closely to narrow numerical outcomes, like the current experiments with payment by results, may also make flexibility more difficult to achieve.

More flexibility would require up-front investment and mean fewer set systems, but more human connection.

David Boyle is the author of The Human Element: Ten new rules to kickstart our failing organisations (Earthscan) and a range of other books. This article is based on a piece commissioned by the British Council for its Equality Exchange forum on public services

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Public health: cutting a deal on the minimum price of alcohol

Brighton & Hove council has a complex relationship with alcohol: it poses public health risks but businesses rely on the night-time economy. Photograph: Chris Rout/Alamy

The fallout from the government u-turn on plain cigarette packaging and a minimum unit price for alcohol continues. To date, the Faculty of Public Health, the Association of Directors of Public Health and Birmingham city council have all withdrawn from the "public health responsibility deal". This "framework of trust and expectation" between the government, public sector and businesses, first launched in March 2011, includes a number of pledges across several public health issues. I would suggest these pledges were offered as much to ward off punitive legislation as in an effort to promote the wider public good.

The chief medical officer, Prof Dame Sally Davies, has remained mute on the matter, despite drawing attention last year to an epidemic of premature liver failure in women, fuelled in large part by alcohol consumption. Public Health England, the government's flagship leadership organisation for public health, has expressed its "disappointment" – a euphemism that probably says less about a failure to satisfy hopes, desires and expectations and more about the humbling experience of having been simply ignored.

Disappointment is understandable: the consultation on the government's draft alcohol strategy was after all about at what level the minimum price would be set – not on whether or not there would be a minimum price at all.

The draft strategy was very clear ("we will introduce a minimum price for alcohol," it stated) and the scientific evidence that supported the policy has not become any weaker in the meantime.

But will the health establishment refusing to play ball with the government, proclaiming their disappointment, have any effect? Will it put any pressure on the alcohol industry to put its house in better order?

The alcohol industry hardly speaks with one voice on this matter, and there is considerable tension between retail off sales and on sales in bars, pubs and clubs. The proposed minimum price met with mixed views.

The British Beer and Pub Association (BBPA), the Craft Brewing Association, BrewDog, Greene King and the Campaign for Real Ale all voiced their support. The Association for Licensed Multiple Retailers actually wanted the strategy to go further and "get a grip on bulk sales, price-led advertising and in-store promotions".

But the Wine and Spirits Trade Association, the British Retail Consortium and Budvar UK all voiced strong opposition – as did the UK Independence party.

The moral rectitude that brings many of us into public health means while we understand the "responsibility" element of a public health responsibility deal, we don't always get the "deal" bit.

Working in Brighton & Hove council, we know that alcohol presents us with a social and economic dichotomy. On the one hand the estimated annual health, social and criminal costs from alcohol total £107m; but on the other, the annual economic turnover from its sale in the city is a massive £329m. While in the NHS the message on alcohol may be pretty straightforward – don't drink so much – for local authorities it's more tricky.

Local public health is no longer the responsibility of the NHS; it belongs to local authorities. So if we are to have any success in solving both sides of an impossible equation, we need to get our heads around the "deal" we're expected to broker.

At the local level that is what we are doing: working with pubs, clubs and retailers on initiatives to curb consumption at high-risk public events; reducing the sale of high strength beers and cider; asking businesss to sign up to codes of good practice. We have a "cumulative impact zone" where we prohibit the establishment of any new licensed premises. We don't always agree and the public health team doesn't win every dispute, but we are sitting around the table together rather than walking away.

That national picture is different, and there may be something to be made from august bodies taking a stand, but public health and the government missed the opportunity to make a genunine deal.

As part of the original responsibility deal, 30 alcohol companies including major brands such as Heineken have pledged to take 1bn units of alcohol out of the market by December 2015 through the promotion of lower strength drinks. Why not compensate for the loss of a minimum price by arguing for a pledge to take yet more units out of the market, and tie any failure to future market restrictions?

Public health has an advocacy role but it isn't an NGO – many of which walked away from the responsibility deal early on. The moral high ground will not get us far, or far enough.

But let's not beat ourselves up about this (another tendency in public health). It was, after all, the government that chose to make a u-turn, not local authorities. It's time for a bit more reflection and to come back to the discussion table with new ideas.

Dr Tom Scanlon is director of public health at Brighton & Hove council

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A Public Apology To Adam Feuerstein On Northwest Biotherapeutics

A few months ago an interesting debate took place between Larry Smith, a retired biotech analyst who writes for Seeking Alpha as well as his own website, SmithonStocks.com and Adam Feuerstein who writes for the Street.Com regarding Northwest Biotherapeutics (NWBO). Mr. Feuerstein basically called out the data from NWBO's phase i/ii trials and Mr. Smith rebutted the critique. In the comments section, I defended Mr. Smith and questioned Mr. Feuerstein's reasoning. Although I continue to believe that Mr. Smith was right with respect to the particular issue that formed the basis for their row, it has become apparent that NWBO is a horrific investment and that their technology is of questionable value.

Most biotech investors are aware of the Ratain/Feuerestein rule which basically holds that if a biotech company in a phase III trial has less than a $300 million market cap the odds are the trial will fail. The basic premise behind the rule is that if the trial were going well results would be leaking out. It's a tenet to the efficient market hypothesis. NWBO is currently conducting a phase III trial for Glioblastoma Multiforme or GBM. The trial is taking place in both the US and in Europe and looks to enroll 312 patients. The company has historically refused to reveal enrollment numbers but needless to say it has been a slow and torturous process spanning now close to a decade. The current market cap of the company is $117 million and over the last 9 months NWBO has sought financing for this trial as well as a new trial that they commenced in July, 2013. The first round of financing was underwritten by Aegis in December, 2012 whereby NWBO sold 3 million shares of common stock at $4 with 50% warrant coverage at $5. This funding was part of an up-listing plan initiated by the company allowing them to get off the Bulletin Board and on to the Nasdaq. Once concluded the deal was lauded by Mr. Smith who stated, "Raising money is not a bad thing for shareholders if it creates value."

Subsequent to the transaction with Aegis, the share price immediately fell below the deal price of $4 and finally settled around $3.50. Approximately 5 months after the Aegis deal, in April 2013, NWBO again sought to access the capital markets and this time, via an S1 they filed, hooked Sabby Management, one of 2013's most prolific pipe deal participants. This time the deal terms were $10 million worth of stock at $3.90 with 40% warrant coverage at $4.29.

The idea of investing is that as progress is made intrinsic value increases. Venture capitalist invest in the beginning with the hope that with good management and execution, the investment will grow such that each subsequent round of financing will come at incrementally better prices. Or in the words of Larry Smith, "raising money is not a bad thing for shareholders if it creates value." (italics added). After NWBO's deal with Sabby Management is was clear that NWBO was going in the wrong direction despite the company's claims of progress (prior to the deal with Sabby Management, NWBO put out a number of press releases outlining the company's achievements).

Less than 4 months after Sabby Management's deal with NWBO, a few weeks ago in August 2013, sold $15 million worth of stock to two institutional investors and as you may have guessed the price was once again lower than the last round. Although the investors were not disclosed the terms were-- $15 million of common stock were sold at $3.35 with 25% warrant coverage at $4. Moreover, the institutions were given an "over-allotment warrant" for additional $3.75 million exercisable for a year. Or in other words, they were given above and beyond their warrant coverage an option to buy up to an additional $3.75 million worth of stock at $3.35 for up to a year. Wow they were given warrants and warrants on top of warrants! Once again, for the third time in less than a year, NWBO engaged in a capital raise on terms more onerous than the last. Either the CEO is the worst negotiator in the world or what they are selling investors just are not buying.

It should also be noted that the company prior to the last raise changed accountants and converted a trade payable in the amount of $11 million to an affiliated party, Cognate Bioservices (the manufacturer of their vaccine), into restricted stock. Whether the institutions that took the last deal made these conditions to the deal has not been stated by the company but their proximity to the deal makes it apparent.

NWBO was burning approximately $5 million a month and as of the end of June 2013 they had less than $2 million in cash on hand. By the time of their last raise just 3 weeks ago, they were again in the red and per the company's 10Q needed a loan from an insider to get by. The $15 million they just raised will thus be gone in about 6 weeks (they were, by my calculation, in the red $3 million at the time of the raise and with their new trial their burn is now closer to $6 million a month. The August raise then of $15 million netted them about $12 million and with a burn of $6 million a month will get them through September). With another raise coming, the 4th in less than a year, each one at successively lower valuations, it is time to throw up my hands, admit defeat. and say to Adam Feuerstein... you were right, and I was wrong.

For those that are long the stock, however, I would not necessarily sell it down here. There are a number of "catalysts" coming up in the near future that should provide a nice exit point. Some of these catalysts would include the commencement of their Phase III trial in Germany, additional sites for their Phase i/ii trail and perhaps interim analysis on their Phase III trial expected before the end of the year. None of these are binary in the sense they will validate or refute the company's technology but they might provide information starved investors some reason to bid up the stock and provide those frustrated longs a chance to finally bid adieu.

Disclosure: I have no positions in any stocks mentioned, but may initiate a long position in NWBO over the next 72 hours. I wrote this article myself, and it expresses my own opinions. I am not receiving compensation for it (other than from Seeking Alpha). I have no business relationship with any company whose stock is mentioned in this article. (More...)

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Are social enterprises fit for the future of public services?

Spin outs need investment to compete for contracts against organisations with more financial muscle. Photograph: Johannes Eisele/AFP/Getty Images

Social enterprises are playing a growing role in the health and social care sectors in the UK. Major growth is coming from spin-outs – organisations leaving the NHS to become independent social enterprises. Primarily as a result of the previous government's Right to Request programme and its successors, by the end of 2011 spin-outs were delivering £886m worth of health services and that figure is growing.

Social Enterprise UK (SEUK)'s 2013 State of Social Enterprise survey, The People's Business, reported both an increase in the percentage of social enterprises that have the public sector (in general) as their main source of income (23% compared to 18% in 2011) and that 15% of social enterprises trading for three years or less are operating in healthcare compared to 5% of older social enterprises.

Discussions at SEUK's Fit For the Future conference on social enterprise in health and social care in June illustrated there are at least two groups of social enterprises currently operating in health and social care.

One is spin-outs, many of whom are competing for large contracts worth tens or in some cases, hundreds of millions of pounds. Another is those social enterprises whose starting point is similar to traditional voluntary sector organisations and who are looking to win relatively small locally-based contracts.

Both groups face new challenges and opportunities as result of changes to the NHS following the implementation of the Health and Social Act 2012. Speaking at Fit for the Future, Andrew Burnell, chief executive of Hull-based spin out City Healthcare Partnership CIC noted that: "We've worked really hard to demonstrate our differentiation from the SERCOs. How are others in the sector doing that? We are, in part, open to being picked off."

Burnell's comments illustrate two of the key challenges currently facing spin-outs: to demonstrate why they're different and better to alternative providers from both private and public sectors and to ensure they can both keep existing contracts and win new ones in an increasingly competitive market place. Both of these points are partially addressed in Spin-Out, Step Out, a new SEUK report that looks at the challenges faced by spin outs in raising finance to develop and grow.

The report, which is based on a survey of 27 existing health spin-outs, said: "the respondents were not very strong in articulating their social impact. Some of the organisations surveyed are known to have produced relatively robust social impact reports but this did not come through in the survey for the spin-outs as a whole."

There is clearly a need for spin-outs to get better at explaining what it is they offer that's demonstrably better than what their competitors can provide, however the primary focus of Spin-Out, Step Out is on how spin outs can find the investment that will enable them to compete for contracts against organisations with more financial muscle.

The report quotes one spin out leader talking about the difficulty of bidding against private sector competitors: "I saw how they worked. There is absolutely no way my organisation can compete with them… They were prepared to invest to make sure they won the contract…We can compete with Serco [on delivery] but we just don't have the [bidding] resources."

It would be easier for spin-outs to compete with private sector, if they could attract investment for social investors. Unfortunately, despite spin-outs being relatively large businesses by social enterprises standards – with a median turnover of £2.9m compared, more than 15 times the median UK social enterprise turnover of £187,000 - only 1 of 27 spin-outs surveyed had done so.

The report claims this is partly because social investors are wary of investing in spin-out, based on the fact that: "these businesses are sometimes perceived negatively to have a limited track record as new entities, just one or two contracts, a lack of assets, to be operating in a highly unpredictable market environment with highly aggressive, professional and well capitalised competitors."

A video made at Fit for the Future conference by Pioneers Post suggests that social investors concerns may be based more on myth than reality.

Unfortunately, even if social investors were prepared to put their money into spin-outs, there is still a problem that the money they provide is too expensive and many spin outs have been surprised that the fact they deliver positive social outcomes, doesn't mean investors will offer them a better financial deal: "where social return is taken into account it does not necessarily influence the investment terms in a way that makes them any more generous than finance provided by purely financially motivated commercial investors. Yet the spin-outs, like many other social enterprises, interpret the rhetoric around social return and social investment to suggest that there could be a good generous offer on the table."

Beyond the world of large scale spin-outs and direct competition with SERCO, Virgin Care and others, smaller local social enterprises are trying to work out how to navigate the NHS landscape.

Earlier in the year SEUK and IVAR produced The Power of Partnerships, a resource to promote better working between new local health structures - Clinical Commissioning Groups (CCGs) and Health and Wellbeing Boards (HWBs) – and local charities and social enterprises based on work in four local areas in England.

At Fit for the Future, commissioners and social enterprise leaders involved in the project discussed ways that social enterprises can build relationships with commissioners in CCGs in local authorities.

A key message for social enterprises looking to engage with new NHS structures is that its important to find out what is going on in your area because every area will be different. As Dr Johnny Marshall, Policy Director at the NHS Confederation, told the conference: "There's already an old adage: when you've met one CCG, you've met one CCG."

David Floyd is managing director of Social Spider CIC. He writes the blog Beanbags and Bullsh!t.

This content is brought to you by Guardian Professional. To join the social enterprise network, click here.

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Are social enterprises fit for the future of public services?

Spin outs need investment to compete for contracts against organisations with more financial muscle. Photograph: Johannes Eisele/AFP/Getty Images

Social enterprises are playing a growing role in the health and social care sectors in the UK. Major growth is coming from spin-outs – organisations leaving the NHS to become independent social enterprises. Primarily as a result of the previous government's Right to Request programme and its successors, by the end of 2011 spin-outs were delivering £886m worth of health services and that figure is growing.

Social Enterprise UK (SEUK)'s 2013 State of Social Enterprise survey, The People's Business, reported both an increase in the percentage of social enterprises that have the public sector (in general) as their main source of income (23% compared to 18% in 2011) and that 15% of social enterprises trading for three years or less are operating in healthcare compared to 5% of older social enterprises.

Discussions at SEUK's Fit For the Future conference on social enterprise in health and social care in June illustrated there are at least two groups of social enterprises currently operating in health and social care.

One is spin-outs, many of whom are competing for large contracts worth tens or in some cases, hundreds of millions of pounds. Another is those social enterprises whose starting point is similar to traditional voluntary sector organisations and who are looking to win relatively small locally-based contracts.

Both groups face new challenges and opportunities as result of changes to the NHS following the implementation of the Health and Social Act 2012. Speaking at Fit for the Future, Andrew Burnell, chief executive of Hull-based spin out City Healthcare Partnership CIC noted that: "We've worked really hard to demonstrate our differentiation from the SERCOs. How are others in the sector doing that? We are, in part, open to being picked off."

Burnell's comments illustrate two of the key challenges currently facing spin-outs: to demonstrate why they're different and better to alternative providers from both private and public sectors and to ensure they can both keep existing contracts and win new ones in an increasingly competitive market place. Both of these points are partially addressed in Spin-Out, Step Out, a new SEUK report that looks at the challenges faced by spin outs in raising finance to develop and grow.

The report, which is based on a survey of 27 existing health spin-outs, said: "the respondents were not very strong in articulating their social impact. Some of the organisations surveyed are known to have produced relatively robust social impact reports but this did not come through in the survey for the spin-outs as a whole."

There is clearly a need for spin-outs to get better at explaining what it is they offer that's demonstrably better than what their competitors can provide, however the primary focus of Spin-Out, Step Out is on how spin outs can find the investment that will enable them to compete for contracts against organisations with more financial muscle.

The report quotes one spin out leader talking about the difficulty of bidding against private sector competitors: "I saw how they worked. There is absolutely no way my organisation can compete with them… They were prepared to invest to make sure they won the contract…We can compete with Serco [on delivery] but we just don't have the [bidding] resources."

It would be easier for spin-outs to compete with private sector, if they could attract investment for social investors. Unfortunately, despite spin-outs being relatively large businesses by social enterprises standards – with a median turnover of £2.9m compared, more than 15 times the median UK social enterprise turnover of £187,000 - only 1 of 27 spin-outs surveyed had done so.

The report claims this is partly because social investors are wary of investing in spin-out, based on the fact that: "these businesses are sometimes perceived negatively to have a limited track record as new entities, just one or two contracts, a lack of assets, to be operating in a highly unpredictable market environment with highly aggressive, professional and well capitalised competitors."

A video made at Fit for the Future conference by Pioneers Post suggests that social investors concerns may be based more on myth than reality.

Unfortunately, even if social investors were prepared to put their money into spin-outs, there is still a problem that the money they provide is too expensive and many spin outs have been surprised that the fact they deliver positive social outcomes, doesn't mean investors will offer them a better financial deal: "where social return is taken into account it does not necessarily influence the investment terms in a way that makes them any more generous than finance provided by purely financially motivated commercial investors. Yet the spin-outs, like many other social enterprises, interpret the rhetoric around social return and social investment to suggest that there could be a good generous offer on the table."

Beyond the world of large scale spin-outs and direct competition with SERCO, Virgin Care and others, smaller local social enterprises are trying to work out how to navigate the NHS landscape.

Earlier in the year SEUK and IVAR produced The Power of Partnerships, a resource to promote better working between new local health structures - Clinical Commissioning Groups (CCGs) and Health and Wellbeing Boards (HWBs) – and local charities and social enterprises based on work in four local areas in England.

At Fit for the Future, commissioners and social enterprise leaders involved in the project discussed ways that social enterprises can build relationships with commissioners in CCGs in local authorities.

A key message for social enterprises looking to engage with new NHS structures is that its important to find out what is going on in your area because every area will be different. As Dr Johnny Marshall, Policy Director at the NHS Confederation, told the conference: "There's already an old adage: when you've met one CCG, you've met one CCG."

David Floyd is managing director of Social Spider CIC. He writes the blog Beanbags and Bullsh!t.

This content is brought to you by Guardian Professional. To join the social enterprise network, click here.

View the original article here

Strike out bureaucracy: barriers to choice in public service delivery

From GP appointments to school timetables, more flexible systems will give people more choices Photograph: Custom Medical Stock Photo / Ala/Alamy

At the start of this year, I finished my work for the UK government as an independent reviewer on barriers to choice.

Someone from outside government was needed to look dispassionately at the way people were using their choices in public services and decide what barriers there were to prevent them.

I listened to a dizzying number of roundtables and must have spoken to well over a 100 service users face to face, and almost as many professionals.

But one person in particular stands out. She had muscular dystrophy and had to see her consultant every six months, which meant a two-hour round trip plus 30 minutes or more in the waiting room. It meant going over a large river and paying a toll. And all she said to the doctor when he asked her how she she felt was: 'I'm fine'.

What this woman really wants is to check in occasionally by phone, and see him when she's not fine. But she can't, because his slots are full seeing people who are also fine.

What struck me most forcibly was that she was asking for something quite simple, though important to her as a long-term patient. It was a 'choice' about her treatment, in a sense, but not one that is recognised currently by the system in the UK.

The new emphasis would be less about choosing between regulated options, and more about making services flexible enough to suit individuals better – closer to the 'personalisation' agenda in social care, where service users can get budgets they can (theoretically, at least) use in ways they believe are best suited to their needs.

The best approach may be to find ways to give service users the confidence to ask for something different, and perhaps provide duties on service providers to consider this. I imagine this would be like a 'right to request' flexible service delivery.

In each case, the provider would not be obliged to provide flexibility if it is impossible, but they would be obliged to explain why and make that explanation public.

This would help people cut through systems or bureaucratic arrangements. Perhaps they want a consultant who won't mind them asking lots of questions, or to study Spanish at A-level when all that prevents them is their school's time-tabling system, or to go to bed later than 5pm when their carer comes round. 

This is basic flexibility which articulate people can often get now by being assertive, but which others can't.

There are possible objections to this kind of approach. Patients may choose badly. They may fail to take responsibility for the wider system, by misusing the flexibility they are offered.

There may also be higher costs from treating people more individually, and the costs will come before the potential savings are available. Financial innovations that tie professionals too closely to narrow numerical outcomes, like the current experiments with payment by results, may also make flexibility more difficult to achieve.

More flexibility would require up-front investment and mean fewer set systems, but more human connection.

David Boyle is the author of The Human Element: Ten new rules to kickstart our failing organisations (Earthscan) and a range of other books. This article is based on a piece commissioned by the British Council for its Equality Exchange forum on public services

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Public health: cutting a deal on the minimum price of alcohol

Brighton & Hove council has a complex relationship with alcohol: it poses public health risks but businesses rely on the night-time economy. Photograph: Chris Rout/Alamy

The fallout from the government u-turn on plain cigarette packaging and a minimum unit price for alcohol continues. To date, the Faculty of Public Health, the Association of Directors of Public Health and Birmingham city council have all withdrawn from the "public health responsibility deal". This "framework of trust and expectation" between the government, public sector and businesses, first launched in March 2011, includes a number of pledges across several public health issues. I would suggest these pledges were offered as much to ward off punitive legislation as in an effort to promote the wider public good.

The chief medical officer, Prof Dame Sally Davies, has remained mute on the matter, despite drawing attention last year to an epidemic of premature liver failure in women, fuelled in large part by alcohol consumption. Public Health England, the government's flagship leadership organisation for public health, has expressed its "disappointment" – a euphemism that probably says less about a failure to satisfy hopes, desires and expectations and more about the humbling experience of having been simply ignored.

Disappointment is understandable: the consultation on the government's draft alcohol strategy was after all about at what level the minimum price would be set – not on whether or not there would be a minimum price at all.

The draft strategy was very clear ("we will introduce a minimum price for alcohol," it stated) and the scientific evidence that supported the policy has not become any weaker in the meantime.

But will the health establishment refusing to play ball with the government, proclaiming their disappointment, have any effect? Will it put any pressure on the alcohol industry to put its house in better order?

The alcohol industry hardly speaks with one voice on this matter, and there is considerable tension between retail off sales and on sales in bars, pubs and clubs. The proposed minimum price met with mixed views.

The British Beer and Pub Association (BBPA), the Craft Brewing Association, BrewDog, Greene King and the Campaign for Real Ale all voiced their support. The Association for Licensed Multiple Retailers actually wanted the strategy to go further and "get a grip on bulk sales, price-led advertising and in-store promotions".

But the Wine and Spirits Trade Association, the British Retail Consortium and Budvar UK all voiced strong opposition – as did the UK Independence party.

The moral rectitude that brings many of us into public health means while we understand the "responsibility" element of a public health responsibility deal, we don't always get the "deal" bit.

Working in Brighton & Hove council, we know that alcohol presents us with a social and economic dichotomy. On the one hand the estimated annual health, social and criminal costs from alcohol total £107m; but on the other, the annual economic turnover from its sale in the city is a massive £329m. While in the NHS the message on alcohol may be pretty straightforward – don't drink so much – for local authorities it's more tricky.

Local public health is no longer the responsibility of the NHS; it belongs to local authorities. So if we are to have any success in solving both sides of an impossible equation, we need to get our heads around the "deal" we're expected to broker.

At the local level that is what we are doing: working with pubs, clubs and retailers on initiatives to curb consumption at high-risk public events; reducing the sale of high strength beers and cider; asking businesss to sign up to codes of good practice. We have a "cumulative impact zone" where we prohibit the establishment of any new licensed premises. We don't always agree and the public health team doesn't win every dispute, but we are sitting around the table together rather than walking away.

That national picture is different, and there may be something to be made from august bodies taking a stand, but public health and the government missed the opportunity to make a genunine deal.

As part of the original responsibility deal, 30 alcohol companies including major brands such as Heineken have pledged to take 1bn units of alcohol out of the market by December 2015 through the promotion of lower strength drinks. Why not compensate for the loss of a minimum price by arguing for a pledge to take yet more units out of the market, and tie any failure to future market restrictions?

Public health has an advocacy role but it isn't an NGO – many of which walked away from the responsibility deal early on. The moral high ground will not get us far, or far enough.

But let's not beat ourselves up about this (another tendency in public health). It was, after all, the government that chose to make a u-turn, not local authorities. It's time for a bit more reflection and to come back to the discussion table with new ideas.

Dr Tom Scanlon is director of public health at Brighton & Hove council

• What do you think? Email sarah.marsh@theguardian.com if you want to contribute an article to this debate.

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View the original article here

Are social enterprises fit for the future of public services?

Spin outs need investment to compete for contracts against organisations with more financial muscle. Photograph: Johannes Eisele/AFP/Getty Images

Social enterprises are playing a growing role in the health and social care sectors in the UK. Major growth is coming from spin-outs – organisations leaving the NHS to become independent social enterprises. Primarily as a result of the previous government's Right to Request programme and its successors, by the end of 2011 spin-outs were delivering £886m worth of health services and that figure is growing.

Social Enterprise UK (SEUK)'s 2013 State of Social Enterprise survey, The People's Business, reported both an increase in the percentage of social enterprises that have the public sector (in general) as their main source of income (23% compared to 18% in 2011) and that 15% of social enterprises trading for three years or less are operating in healthcare compared to 5% of older social enterprises.

Discussions at SEUK's Fit For the Future conference on social enterprise in health and social care in June illustrated there are at least two groups of social enterprises currently operating in health and social care.

One is spin-outs, many of whom are competing for large contracts worth tens or in some cases, hundreds of millions of pounds. Another is those social enterprises whose starting point is similar to traditional voluntary sector organisations and who are looking to win relatively small locally-based contracts.

Both groups face new challenges and opportunities as result of changes to the NHS following the implementation of the Health and Social Act 2012. Speaking at Fit for the Future, Andrew Burnell, chief executive of Hull-based spin out City Healthcare Partnership CIC noted that: "We've worked really hard to demonstrate our differentiation from the SERCOs. How are others in the sector doing that? We are, in part, open to being picked off."

Burnell's comments illustrate two of the key challenges currently facing spin-outs: to demonstrate why they're different and better to alternative providers from both private and public sectors and to ensure they can both keep existing contracts and win new ones in an increasingly competitive market place. Both of these points are partially addressed in Spin-Out, Step Out, a new SEUK report that looks at the challenges faced by spin outs in raising finance to develop and grow.

The report, which is based on a survey of 27 existing health spin-outs, said: "the respondents were not very strong in articulating their social impact. Some of the organisations surveyed are known to have produced relatively robust social impact reports but this did not come through in the survey for the spin-outs as a whole."

There is clearly a need for spin-outs to get better at explaining what it is they offer that's demonstrably better than what their competitors can provide, however the primary focus of Spin-Out, Step Out is on how spin outs can find the investment that will enable them to compete for contracts against organisations with more financial muscle.

The report quotes one spin out leader talking about the difficulty of bidding against private sector competitors: "I saw how they worked. There is absolutely no way my organisation can compete with them… They were prepared to invest to make sure they won the contract…We can compete with Serco [on delivery] but we just don't have the [bidding] resources."

It would be easier for spin-outs to compete with private sector, if they could attract investment for social investors. Unfortunately, despite spin-outs being relatively large businesses by social enterprises standards – with a median turnover of £2.9m compared, more than 15 times the median UK social enterprise turnover of £187,000 - only 1 of 27 spin-outs surveyed had done so.

The report claims this is partly because social investors are wary of investing in spin-out, based on the fact that: "these businesses are sometimes perceived negatively to have a limited track record as new entities, just one or two contracts, a lack of assets, to be operating in a highly unpredictable market environment with highly aggressive, professional and well capitalised competitors."

A video made at Fit for the Future conference by Pioneers Post suggests that social investors concerns may be based more on myth than reality.

Unfortunately, even if social investors were prepared to put their money into spin-outs, there is still a problem that the money they provide is too expensive and many spin outs have been surprised that the fact they deliver positive social outcomes, doesn't mean investors will offer them a better financial deal: "where social return is taken into account it does not necessarily influence the investment terms in a way that makes them any more generous than finance provided by purely financially motivated commercial investors. Yet the spin-outs, like many other social enterprises, interpret the rhetoric around social return and social investment to suggest that there could be a good generous offer on the table."

Beyond the world of large scale spin-outs and direct competition with SERCO, Virgin Care and others, smaller local social enterprises are trying to work out how to navigate the NHS landscape.

Earlier in the year SEUK and IVAR produced The Power of Partnerships, a resource to promote better working between new local health structures - Clinical Commissioning Groups (CCGs) and Health and Wellbeing Boards (HWBs) – and local charities and social enterprises based on work in four local areas in England.

At Fit for the Future, commissioners and social enterprise leaders involved in the project discussed ways that social enterprises can build relationships with commissioners in CCGs in local authorities.

A key message for social enterprises looking to engage with new NHS structures is that its important to find out what is going on in your area because every area will be different. As Dr Johnny Marshall, Policy Director at the NHS Confederation, told the conference: "There's already an old adage: when you've met one CCG, you've met one CCG."

David Floyd is managing director of Social Spider CIC. He writes the blog Beanbags and Bullsh!t.

This content is brought to you by Guardian Professional. To join the social enterprise network, click here.

View the original article here

Public health: cutting a deal on the minimum price of alcohol

Brighton & Hove council has a complex relationship with alcohol: it poses public health risks but businesses rely on the night-time economy. Photograph: Chris Rout/Alamy

The fallout from the government u-turn on plain cigarette packaging and a minimum unit price for alcohol continues. To date, the Faculty of Public Health, the Association of Directors of Public Health and Birmingham city council have all withdrawn from the "public health responsibility deal". This "framework of trust and expectation" between the government, public sector and businesses, first launched in March 2011, includes a number of pledges across several public health issues. I would suggest these pledges were offered as much to ward off punitive legislation as in an effort to promote the wider public good.

The chief medical officer, Prof Dame Sally Davies, has remained mute on the matter, despite drawing attention last year to an epidemic of premature liver failure in women, fuelled in large part by alcohol consumption. Public Health England, the government's flagship leadership organisation for public health, has expressed its "disappointment" – a euphemism that probably says less about a failure to satisfy hopes, desires and expectations and more about the humbling experience of having been simply ignored.

Disappointment is understandable: the consultation on the government's draft alcohol strategy was after all about at what level the minimum price would be set – not on whether or not there would be a minimum price at all.

The draft strategy was very clear ("we will introduce a minimum price for alcohol," it stated) and the scientific evidence that supported the policy has not become any weaker in the meantime.

But will the health establishment refusing to play ball with the government, proclaiming their disappointment, have any effect? Will it put any pressure on the alcohol industry to put its house in better order?

The alcohol industry hardly speaks with one voice on this matter, and there is considerable tension between retail off sales and on sales in bars, pubs and clubs. The proposed minimum price met with mixed views.

The British Beer and Pub Association (BBPA), the Craft Brewing Association, BrewDog, Greene King and the Campaign for Real Ale all voiced their support. The Association for Licensed Multiple Retailers actually wanted the strategy to go further and "get a grip on bulk sales, price-led advertising and in-store promotions".

But the Wine and Spirits Trade Association, the British Retail Consortium and Budvar UK all voiced strong opposition – as did the UK Independence party.

The moral rectitude that brings many of us into public health means while we understand the "responsibility" element of a public health responsibility deal, we don't always get the "deal" bit.

Working in Brighton & Hove council, we know that alcohol presents us with a social and economic dichotomy. On the one hand the estimated annual health, social and criminal costs from alcohol total £107m; but on the other, the annual economic turnover from its sale in the city is a massive £329m. While in the NHS the message on alcohol may be pretty straightforward – don't drink so much – for local authorities it's more tricky.

Local public health is no longer the responsibility of the NHS; it belongs to local authorities. So if we are to have any success in solving both sides of an impossible equation, we need to get our heads around the "deal" we're expected to broker.

At the local level that is what we are doing: working with pubs, clubs and retailers on initiatives to curb consumption at high-risk public events; reducing the sale of high strength beers and cider; asking businesss to sign up to codes of good practice. We have a "cumulative impact zone" where we prohibit the establishment of any new licensed premises. We don't always agree and the public health team doesn't win every dispute, but we are sitting around the table together rather than walking away.

That national picture is different, and there may be something to be made from august bodies taking a stand, but public health and the government missed the opportunity to make a genunine deal.

As part of the original responsibility deal, 30 alcohol companies including major brands such as Heineken have pledged to take 1bn units of alcohol out of the market by December 2015 through the promotion of lower strength drinks. Why not compensate for the loss of a minimum price by arguing for a pledge to take yet more units out of the market, and tie any failure to future market restrictions?

Public health has an advocacy role but it isn't an NGO – many of which walked away from the responsibility deal early on. The moral high ground will not get us far, or far enough.

But let's not beat ourselves up about this (another tendency in public health). It was, after all, the government that chose to make a u-turn, not local authorities. It's time for a bit more reflection and to come back to the discussion table with new ideas.

Dr Tom Scanlon is director of public health at Brighton & Hove council

• What do you think? Email sarah.marsh@theguardian.com if you want to contribute an article to this debate.

Not already a member? Join us now for more comment, analysis and the latest job opportunities in local government.

View the original article here

Strike out bureaucracy: barriers to choice in public service delivery

From GP appointments to school timetables, more flexible systems will give people more choices Photograph: Custom Medical Stock Photo / Ala/Alamy

At the start of this year, I finished my work for the UK government as an independent reviewer on barriers to choice.

Someone from outside government was needed to look dispassionately at the way people were using their choices in public services and decide what barriers there were to prevent them.

I listened to a dizzying number of roundtables and must have spoken to well over a 100 service users face to face, and almost as many professionals.

But one person in particular stands out. She had muscular dystrophy and had to see her consultant every six months, which meant a two-hour round trip plus 30 minutes or more in the waiting room. It meant going over a large river and paying a toll. And all she said to the doctor when he asked her how she she felt was: 'I'm fine'.

What this woman really wants is to check in occasionally by phone, and see him when she's not fine. But she can't, because his slots are full seeing people who are also fine.

What struck me most forcibly was that she was asking for something quite simple, though important to her as a long-term patient. It was a 'choice' about her treatment, in a sense, but not one that is recognised currently by the system in the UK.

The new emphasis would be less about choosing between regulated options, and more about making services flexible enough to suit individuals better – closer to the 'personalisation' agenda in social care, where service users can get budgets they can (theoretically, at least) use in ways they believe are best suited to their needs.

The best approach may be to find ways to give service users the confidence to ask for something different, and perhaps provide duties on service providers to consider this. I imagine this would be like a 'right to request' flexible service delivery.

In each case, the provider would not be obliged to provide flexibility if it is impossible, but they would be obliged to explain why and make that explanation public.

This would help people cut through systems or bureaucratic arrangements. Perhaps they want a consultant who won't mind them asking lots of questions, or to study Spanish at A-level when all that prevents them is their school's time-tabling system, or to go to bed later than 5pm when their carer comes round. 

This is basic flexibility which articulate people can often get now by being assertive, but which others can't.

There are possible objections to this kind of approach. Patients may choose badly. They may fail to take responsibility for the wider system, by misusing the flexibility they are offered.

There may also be higher costs from treating people more individually, and the costs will come before the potential savings are available. Financial innovations that tie professionals too closely to narrow numerical outcomes, like the current experiments with payment by results, may also make flexibility more difficult to achieve.

More flexibility would require up-front investment and mean fewer set systems, but more human connection.

David Boyle is the author of The Human Element: Ten new rules to kickstart our failing organisations (Earthscan) and a range of other books. This article is based on a piece commissioned by the British Council for its Equality Exchange forum on public services

• Want your say? Email us at public.leaders@guardian.com.

To get our articles on policy and leadership direct to your inbox, sign up to the Guardian Public Leaders Network now.

Looking for your next role? See our Guardian jobs site for senior executive jobs in government and politics.

• For the latest on public services leadership, follow us: @publicleaders

View the original article here

Public sector contracts: the good, bad and ugly – from healthcare to rail

If the purpose of a hospital cleaning contract is to reduce infection, why not let a contract to reduce infection? Photograph: Nigel Hillier/UNP

The specification for Merseyside Waste and Recycling Authority's (MWRA) proposed £1bn contract, which could see Merseyside waste transported to the north-east of England for processing, may have been what MWRA believed was needed, but failed to reflect what local people, those who pay MWRA's bills, wanted.

Had the contract been let to the losing bidder, energy-from-waste company Covanta, which was hoping to develop the country's biggest eco-waste plant in a joint initiative with Peel Environmental, it would have resulted in £500m of investment in the north west and the creation of 600 construction and 100 operational jobs.

What has this to do with hospital cleaning? All hospitals let cleaning contracts, and specifications usually require so many cleans per day of toilets and floors. But such contacts are expensive, so why let them? 12 cleans per day of the toilets (only two cleans at one hospital I visited recently) does not guarantee cleanliness and hygiene. At two relevant conferences, delegates agreed that the purpose was to reduce infection and to make the environment more pleasant.

If the purpose of the contracts is to reduce infection – which at worst can kill people and can cause wards to be shut down, delay operations, create much inconvenience and huge expense – then why not let contracts to minimise infection? This would allow for innovation and all-round attempts to improve hygiene. People might be compelled to wash after using the toilets, to use the alcohol cleansers regularly, to disinfect shoes on entry to the hospital, as happened near farms to prevent the spread of foot and mouth disease in 2000. Nurses might have to change into hospital-sterilised outfits rather than use them travelling between home and hospital. A key contract performance measure could be the number of infections.

So why doesn't it happen? Residents and hospital chief executives would no doubt have infection control high on their list of objectives, but this does not seem to have been passed down to operational staff – budget holders and on to procurement personnel. In an example of Chinese whispers, the outcome is cleaning contracts.

Virgin won its appeal against the award of the West Coast rail franchise. However, much of the concern in the North West was the suspicion that the proposed contract was more about trying to raise income for the Treasury rather than about customer service and supporting economic development. The existing contractor, Virgin, was perceived to be providing a good service. I don't recall any consultation with people who live along the route and use the line about what they expected from the service. Let us hope for effective consultation before the specification and evaluation criteria for the re-tendering are determined.

What is the lesson in all this? Those letting public sector contracts need to be clear about the purpose of the contract and make sure the specification is aligned to that purpose. Repeating an old formula may not deliver what is needed. They also need to be clear about who are the stakeholders and ensure that their views are properly reflected in the specifications and evaluation criteria. There are no prizes for buying the wrong things well.

Colin Cram is contributing editor to the Public Leaders Network

• Want your say? Email us at public.leaders@guardian.co.uk.

To get our articles on policy and leadership direct to your inbox, sign up to the Guardian Public Leaders Network now.

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View the original article here