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Last updated: 08 December 2009
1. Patients in Sweden who are not given access to care within three months can expect their local council to pay for them (including any travel costs) if they wish to be treated in another area or in the private sector. The Health Care Guarantee, introduced in 2005, halved the number of local councils not meeting the standard in just seven months.8 It now forms a core entitlement for all citizens. Many councils which have devolved responsibility for health care provision have gone further (see case study box on page 14).
‘The incentive to hospitals means that between October 2008 and May 2009 the number of people waiting too long for care has halved.’
Berlith Persson, National Coordinator, Swedish Waiting Time Guarantee
2. Fair access and quality in the best public services are not merely designed with citizens in mind: they are driven by them. Because patients in Sweden are offered the redress of an alternative service provider and travel costs if their entitlements are not met, services really take note of them. Likewise, young people in Australia are able to demand better training and support during a global economic downturn thanks to new guarantees, and users of online services in the Netherlands have access to high-quality e-government services thanks in part to rights under an e-Citizen Charter.
3. Entitlements and redress for citizens enable professionals and services to look out to their local people rather than up to central government. They allow professionals to focus on delivering for citizens, rather than on costly bureaucracy. This is because, backed up by redress, rights replace the traditionally complex processes by which individuals and communities spark improvements in their services. They reduce the need for top-down targets, because citizens themselves hold more of the power to ensure equal access to quality and standards in services.9
4. Looking at high-performing public services around the world suggests that these impacts mean that clear entitlements, backed by simple redress mechanisms, often form a foundation for a strong relationship between citizens and their services. In particular, we find that:
The ‘0-7-90-90’ health care guarantee, Sweden
Patients in Sweden have a clear set of national guarantees of timely health treatment. Health care is government funded on a principle of equal access but heavily decentralised to county councils. From the mid 1990s, health care reforms have been focused on cutting costs and improving access to specific treatments.
In 2005, the Government issued care guarantees for all procedures, based on
the ‘0 7 90 90’ rule, which stipulates instant contact with the health system, seeing a general practitioner within 7 days, consulting a specialist within 90 days and a maximum 90-day wait for treatment.
This guarantee stipulates that if the entitlement to be treated with three months cannot be met, patients may choose to be treated at another hospital in the district, within another council’s area or by a private provider, with their own local council paying for the care and any travel costs.
Patients also have the right to seek treatment in another EU country for planned care if they cannot get the care in Sweden within the normal waiting times.
In Sweden, 86% of people say they want to go to another hospital if their care guarantee is not met.
Within just seven months of the rule being introduced, the number of patients waiting longer than three months for treatment dropped by half. The guarantees now serve as minimum standards supporting continued improvement. All local time limits are now shorter than the maximum.
Some counties have also introduced their own redress mechanisms over and above this - in Jönköping, for example, a scheduled visit at a health care unit is free of charge if it is more than 30 minutes late.
Since autumn 2008, the equivalent of only £77 million has been allocated to give further incentives, to meet the guarantees - this has been shared between county councils where 80% of cases meet the three-month guarantee. This approach halved again the number of people waiting between October 2008 and May 2009.
The guarantees are also supported by training of staff in how to inform patients and in how care providers and county councils can better collaborate to manage capacity and deliver the guarantees. An information campaign, a film and a new website, including daily information on choices and waiting times for major procedures, help all citizens make an informed choice of hospital.
Sweden has some of the lowest levels of health inequalities in the world, and comes first in league tables of health for children in Europe as analysed by the University of York.
Sources: Calltrop, J. Sweden’s 0-7-90-90 care guarantee: Where simplicity meets pragmatism? 2007; Child poverty and child wellbeing: Where the UK stands in the European League Table, Child Poverty Action Group, 2009
5. Entitlements clarify and clearly communicate everybody’s rights to public services, promoting
fairness. For example, women with children in the Nordic countries who want to work are supported
by universal entitlements to high-quality childcare. So are their children. This equal start is one crucial
reason why Sweden, Finland and Denmark are near the top of world leagues for child wellbeing, and have high levels of social mobility.10
‘Many developed countries use rights and redress for citizens to support better public services and better value for money. It is a myth that people's expectations of services are insatiable: they want a good service, and people to put things right. Often, it is more vulnerable and excluded groups that need this most.‘
Ed Mayo, Chief Executive, Consumer Focus
6. Simpler accountability in public services also makes for stronger accountability. The UK is a leader in the setting of national strategic outcomes, through Public Service Agreements, and in sophisticated local performance management systems.11 In recent years, as services have improved, the number of targets has also sharply declined.12 Yet in citizens’ practical experience accountability for public services can often be opaque and indirect.
7. Entitlements are one way a number of European countries make clear to citizens and service leaders the relative responsibilities, not just between the individual citizen and the state in general, but between different levels of governance. In more federal states, such as Germany, national entitlements, including to social security and social care insurance packages, set at what people can - and, by implication, what they may not - expect from their public services whoever they are and wherever they are in the country.
8. Such clarity is good not just for individual citizens. It also underpins service improvement. One of the common features we have found looking around the world is that in the best services - whether the Swedish health service or the Canadian school system - everyone is clear what the critical priorities are and who is responsible for delivering them.
9. International experience also suggests that by establishing a base of fair access and standards, entitlements allow for local innovation and flexibility in services. This, in turn, means a far leaner central government. In the Nordic countries national entitlements, for example to universal health care, sit alongside significantly decentralised and diverse provision. Finland’s considerable devolution of health care responsibility to local government during its early 1990s recession was facilitated by protecting core rights of access for all patients. Finland’s central government now has a far more focused role, protecting key entitlements but not managing the detail of delivery. Civil servants are also freed up to focus strategically on cross-cutting issues - Finland is a world leader in joining up services.13
10. In Denmark, the management and quality assurance of childcare has been devolved to local authorities. Central government did get more involved in prescribing aspects of quality and providing substantial investment as childcare infrastructure was being expanded.14 Once this initial phase was completed, however, central government’s role focused on guaranteeing entitlements.
11. Across the world, a diverse range of public, private and third sector service providers, along with greater devolution to local government, has often helped meet the diversity of people’s needs and aspirations. Such diversity has also driven innovation and value for money. Entitlements have helped maintain these benefits of flexible provision, while providing security and equity for all citizens. While all parents in Finland, for example, have a right to full time childcare for pre-school children, this is provided by a mix of public and independent providers.15
12. Public services can only deliver better health, education, crime reduction and other outcomes when responsibilities are shared with citizens, whether as parents, patients or local residents. This depends on empowered citizens knowing what they can expect from public services - what services and quality should be delivered in return for public investment. It also depends on people knowing clearly what is expected of them - their responsibilities on which fairness depends. As many countries struggle with complex and costly social issues and adjust to lower spending growth, frameworks of rights and responsibilities which help to unlock the resources of local communities - their time, voices and support - are becoming even more important.
Social rights and minimum standards in health and childcare, Finland
In Finland, rights are used to guarantee services and set minimum standards for the whole country. Basic rights to education, sufficient health care and income security are set out in the constitution.
Municipalities have an obligation under public law to organise services, and ways of providing social welfare and health care can vary considerably, drawing on public and private sectors. Municipal councils are responsible for health, social care and other public services, often facilitating greater integration. The central government is small and strategic.
However, in order to ensure standards and equity in this decentralised system, Finland was one of the first European countries also to set out specific rights for parents and patients on a national basis. In the context of its early 1990s recession, the 1990 right to childcare for children under three years of age was introduced, and then extended to all children under school age. The number of children in municipal day care rose from 178,000 in 1994 to 220,000 in 1999.
Another example of how Finland relaxed its central steering of municipalities while guaranteeing equitable delivery of core public services is in health care. Maximum waiting times were set out in national legislation which came into force in 2005. This also set out universal principles of care which support medical professionals’ decision-making, and reduced major regional differences in how health care is organised.
To support transparency and performance, health care providers publish information online about waiting times. The number of those who had been on waiting lists for more than six months was halved over a four-month period.
Finland's is among the very highest performing health care systems against OECD measures of healthcare quality, while per capita expenditure is below average.
Sources: Jarvelin, J. Health care systems in transition: Finland, 2002; Ham, C. and Dickenson, H. Governance of health care in small countries, University of Birmingham, 2008; National strategy report on social protection and social inclusion 2008, Ministry of Social Affairs and Health, Finland, 2008; Health at a glance, OECD, 2007
13. In Australia, for example, entitlements to employment, training or education for young people are being strengthened, along with responsibilities to ‘earn or learn’ (see case study box opposite).16
14. We have also found that entitlements can enable and encourage wider engagement in public services, for example, entitlements such as the right to information about services and to a choice of services drive parental engagement with schools. The Netherlands’ Exceptional Medical Expenses Act sets out seven rights concerning care for those with a long-term illness or disability, relating to functions that support greater independence and control for users, including access to a personal budget.17 In the Netherlands, entitlement to a choice of channel (including digital channels) through which to access public services has led to improved levels of online engagement.18
Compact with Young Australians
Young people in Australia are being given a new guarantee of employment, training or further education. The guarantee also places new responsibilities on unemployed young people - if a young person or their parents want to receive some government benefits the quid pro quo is that the young person must be working or earning a core qualification.
The recently introduced ‘Compact with Young Australians’ is based on three principles:
As part of Australia’s response to the global recession, this new guarantee aims to bring forward by five years the country’s target for 90% of young people to be suitably qualified. It is expected to provide up to 135,000 young people with higher qualifications. It also aims to address inequalities in life chances, with indigenous Australians currently about half as likely to have the core ‘year 12’ qualification as non-indigenous Australians.
An additional ‘Compact’ with the recently unemployed will ensure that, from 1 July 2009, workers aged over 25 years who are made redundant will be entitled to a training place towards a government‑ subsidised vocational education and training qualification, where this will result in the individual achieving a higher qualification.
This new entitlement will be offered until the end of 2011, and then reviewed.
15. More broadly, looking at services as a whole we have not found evidence that empowering citizens through clear entitlements and open redress mechanisms has led to more adversarial or litigious relationships. Indeed, the countries where such approaches are most used, such as in Scandinavia, are often the countries where professionals, parents and patients have some of the most positive and productive relationships (as chapter 5 sets out in more detail). The pressure on services to look ‘outwards’ appears to stimulate greater engagement rather than confrontation. Moreover, lawyers themselves have called for greater clarity about people’s rights in public services, and for simpler systems of redress, in order to reduce public bodies' liabilities, costs and legal claims.19
16. In the most successful systems, entitlements sit within wider mechanisms to support the delivery of social and economic objectives and improve value for money. High-level outcome targets which cross a range of services, efficiency audits and careful regulation still have a role.20 Canada’s Patient’s Bill of Rights and waiting-time guarantees in health care sit within a world-class performance management system that aligns funding streams to strategic outcomes, driving cost effectiveness and delivery.21
17. Entitlements for citizens are particularly useful to maintain and drive access and quality in services. Unlike top-down targets, entitlements can be owned and policed by citizens themselves. They put the focus of accountability between the service and the user, rather than between the service and the Government.
Figure 1: The role of different drivers of service improvement
18. Entitlements around the world have often been initially developed through service charters. These were often largely based on improving ‘customer service’ in public services, and brought in alongside the introduction of better performance monitoring and management in public services. Many helped change the culture of services. From the early and mid 1990s, charters of quality in services have been introduced in similar forms in France, Spain, Germany, Italy, Canada and Australia, often drawing on the UK’s service charters.22
19. In recent years, stronger entitlements have increasingly focused on a smaller set of high-priority standards, rather than seeking to specify minor aspects of customer service. Waiting times in health services are particularly meaningful to patients and are also indicators of productivity. This is why they are the most common entitlements found in other countries. . Such focused entitlements to access services can help to narrow equity gaps. For example, they may be useful in increasing awareness and take-up of services such as health checks among more disadvantaged groups, helping to tackle health inequalities.
20. The best entitlements to public service access are those which support broader social outcomes, as well as individual aspirations. For example, the evidence clearly shows that childcare represents an investment for a society in terms of both child wellbeing and long-term economic growth.23 In childcare, parents need reliable guarantees of access, while entitlements support a more equitable take-up.24 It is no coincidence, therefore, that it is a service most European countries, including now the UK, offer as a universal entitlement.
21. The best public service systems are those where it is not a struggle for people to fight ‘the system’. Simple, immediate redress, tied to specific guarantees, helps circumvent the bureaucratic processes and costs associated with complex complaints and litigation. Furthermore, it provides a far more powerful drive for improvement than aspirational charters. Simple redress ensures that entitlements are not hollow - that they directly assure quality and access to services for citizens.
22. People want redress at the most accessible level, but our analysis suggests that the development of redress mechanisms lags behind that of entitlements in most public service systems. In one survey in the UK a few years ago, 78% of those asked of redressed systems in the public sector we're less responsive than those inthe private sector.25 That was despite central government alone spending £500 million on redress mechanisms annually, of which the vast majority went on redress mechanisms annually, of which the vast majority went on anistrative costs rather than financial compensation.26 Moreover, the complexity of complaints processes can exclude more disadvantaged user groups, such that ‘those who complain are not those who have most to complain about.’27
The e-Citizen Charter, the Netherlands
In the Netherlands a recent charter sets out how citizens can expect to be treated in an age of advanced information and communication technologies. It includes, for example, rights to interact with services through a choice of ‘channel’, such as through the telephone or internet, and rights to accessible performance information. It sits alongside the Dutch Government’s aim to have a public service with ‘less red tape, fewer regulations and less procedural complexity’, reducing administrative costs by 25%.
Ten principles of quality are formulated as rights of citizens. At the heart of the charter are two entitlements: ‘Government ensures that my rights and duties are at all times transparent’ and ‘Government compensates for mistakes and uses feedback information to improve its products and procedures.’
A programme called Citizenlink, with a ‘People’s Panel’ and online discussion boards, supports the enforcement of the charter. Following the recommendation of the OECD peer review, the charter has been adopted as the national standard for public service delivery. Since 2008, the Government has used the charter to examine and benchmark the performance of its services. Quality codes have been developed to turn the general principles of the charter into specific implementation measures, which are then used in (for example) hospitals to measure compliance with the charter.
While it is a national charter, to make the charter more enforceable and accountable every city mayor is required on an annual basis to present a report to the city council explaining why standards have or have not been met. Municipalities then take action to address the mayor's recommendations.
The Netherlands ranks in the top five of OECD and United Nations countries for the provision of e-services to citizens, and the charter has won a UN Public Service Award.
Sources: Poelmans, M. Reinventing public service delivery by implementing the e-Citizen Charter, 2007; Bayens, G. E-government in the Netherlands: An architectural approach, 2006
23. In the leading-edge innovations in redress around the world, citizens get support and information to access their entitlements and clear, simple routes to obtain redress.
24. In many countries, redress simply takes the form of compensation. In Ontario province in Canada, for example, new parents who do not receive a birth certificate for their child within 15working days get their charge (around C$25 to C$45) refunded.28 But making amends for falling short does not have to mean financial compensation to individuals. Often, what most people want when things go wrong in public services is an apology, an explanation, and, decisively, action to ensure that it does not happen again.29
25. The best examples of redress therefore go further than compensation. They offer people action when standards fall short: redress works either to restore the service for the individual, or to resolve the problem for all. Patients in Canada, Sweden and Denmark, for example, are given the redress of access to health care in another municipality if national maximum waiting time guarantees are not met. In public services where replacing or exiting the service is not so straightforward, redress can also involve triggering intervention to tackle poor performance in existing services. In Finland, for example, learning from complaints against schools is a part of the school improvement strategy. Similarly, where health rights are not being met by local councils the central ministry will get more involved.
26. Do such systems of redress have to be costly? Our analysis suggests that the power of more immediate redress means that it often assures a good local service, with few people actually having to access it. Guarantees in Sweden led to waiting times falling dramatically with only a few people actually changing their health care provider.
27. When it is designed correctly, redress can also save public money and professionals’ time by maintaining pressure on performance but reducing the need for heavy top-down management systems. Before recent reforms to local authority targets in England, independent accountants estimated that each council typically spent £1.8 million on reporting to central government each year.30
‘There are no additional funds for the e-citizen charter in the Netherlands. It works by organisations being ‘named and shamed’ if they have not met people’s entitlements to access services.’
Matt Poelmans, Director, Citizenlink, Netherlands
28. When entitlements are not met or resolved at the service level, independent, expert judgement may be required. In some countries, such as Austria, ‘people’s panels’ have been developed to make initial decisions on complaints about health care, significantly reducing the legal costs and compensation bill. In the UK and around the world, ombudsmen adjudicate upon disputes and provide redress without the need to go to court.
29. Ombudsmen are independent and impartial. They investigate complaints referred to them by individuals and in appropriate circumstances provide redress, without involving lawyers.31 They also play a role in improving services more widely. For example, the Parliamentary and Health Service Ombudsman in the UK frequently makes recommendations for systemic change, such as recent improvements in tax credits following a series of complaints.32 In Australia and New Zealand, this role for the Ombudsman - to improve administrative practice for all - is a statutory obligation.
The National Ombudsman, Netherlands
A National Ombudsman for the Netherlands was created by law in 1981 and enshrined in the constitution in 1999. The National Ombudsman is the public face of an independent expert body. Appointed by Parliament for a five-year tenure, the Ombudsman acts as ‘a single person to counter an often faceless bureaucracy’.
As part of an administrative law system of redress for citizens, the Ombudsman has strong powers of investigation. He or she can inspect all public bodies, reports annually to Parliament and makes recommendations to government. The ombudsman role facilitates individual redress, while also driving wider improvement in services. The annual report ‘names and shames’ agencies with poor complaints records to drive accountability, while agencies are supported to improve.
The remit began with central government and the police, but now covers all 500 autonomous government bodies and the provinces. Municipalities can either choose to be covered by the National Ombudsman, or develop their own body. A single free telephone number enables people to access services, while the Ombudsman’s casework approach involves a staff member working closely with complainants to assess their claim and support them through the system.
This approach means that most complaints about services are dealt with within just six weeks, and people’s rights to services are protected without issues escalating to litigation. In 2008, 45% of complaints were submitted digitally to the Ombudsman’s website. In the same year, 89% of complaints were resolved through direct intervention from the Ombudsman, and a further 7% resulted in an investigation of an authority. Compared to the potential cost of litigation, the cost is relatively low - the system runs on just over e12.4 million a year.
Source: The citizen in chains: 2008 annual report of the National Ombudsman of the Netherlands, National Ombudsman’s Office, The Hague, 2008
30. Looking around the world, ombudsmen have also developed innovative practice in providing an integrated and casework approach for citizens across public services, and in improving accessibility. A single ombudsman for the full range of public services, such as the Dutch National Ombudsman, enables citizens to get support across, for example, their health, social care and benefits services. This prevents people being pushed ‘from pillar to post’ and concerns falling through the cracks.
31. Alongside this, the best ombudsman systems make it easy for people, including vulnerable groups, to use them and to know about their entitlements, through investing in public awareness, single telephone lines and direct online ‘petition’ systems.33 In Australia and New Zealand, for example, issues do not have to be put to the Ombudsman in writing.
32. The UK Government is increasingly using entitlement approaches across public services as part of a vision for public services driven by strategic government and empowered professionals and citizens.34 The NHS Constitution, the Policing Pledge, and most recently the new pupil and parent guarantees and NHS waiting-time entitlements, will strengthen the rights of those who use services. The Government has recently signalled an intention to go further on redress too.35
33. Our survey reinforces the potential of entitlements, backed by simple redress and better information, to empower all citizens. They can help citizens work together, with professionals and with their local services. Not only that: by providing powerful incentives to improve quality and equity, entitlements can drive productivity and performance without central government bureaucracies having to do so. From such a secure base of high and fair standards can spring greater personalisation, professionalism, innovation and efficiency in public services.