What’s the proper role of choice in public services?

Everyone likes choice: which colour shirt to put on, what to have for supper, where to go on holiday this year. Being able to make choices – to decide on one course of action rather than another – can also be an expression of our uniqueness as individuals.  Providing we have mental capacity we have the right to make unwise or risky decisions. Choice is also fundamental to very important policy guidance and legislation. In education, parents have the right to choose which school to which to send their children. In the NHS, ‘Choose and Book’ enables patients to choose which hospital from which to receive treatment, and in Adult Social Care, personal budgets and Direct Payments enable people with social care needs to decide what care and support to buy, from whom and when. Choice is ubiquitous in public services, and in policy documents it is seen as something as uncontroversial as motherhood and apple pie.  Why would we not want to be able to exercise choice when it comes to public services? There are some powerful arguments. It open things up to competition; it sweeps away professional dominance (‘We’ve heard quite enough from experts…’). It’s claimed to drive up standards and quality; it’s more efficient; it’s empowering too: people can be free of bureaucratic interference, and it enables people to be more autonomous and independent.

In this short discussion, I’d like to suggest that choice is often more problematic than we like to think.  I’m not going to argue that choice is wrong, of course, but that there may be a need to consider if offering choice is always the right thing to do.  I’m also going to focus on choice in public services, and mostly in Adult Social Care.

There are all kinds of things that can influence and affect the exercise of choice.  Here are a few of them.

First of all, there’s money.  This puts an immediate constraint on what can be chosen.  As Bernard Shaw reportedly said ‘The law is open to rich and poor alike – like the Ritz’. Though he was talking about the law, the argument applies elsewhere. If your Personal Independence Payment, Universal Credit, or whatever only cover the basics to enable you to survive, some choices are going to be immediately out of reach.  Some people might say, well, that’s life: I’d like a bigger house/faster car/helicopter, yacht etc., but I accept I’m never going to be able to afford one. To which one might say that this isn’t an argument for equality so much as an attempt to address gross inequality – where in some cases, your choice may be between heating your home or feeding your children. Choice does little to help great a more equal society. Rather, it’s often argued that it perpetuates inequality – with the kicker that if you make the wrong choices, then it’s all your fault, no-one else’s. This has been described elsewhere as transferring risk from the state to (all too often vulnerable) citizens.

Second, economists sometimes say that choice only really exists if it’s possible for a consumer to ‘exit’ – withdraw their custom and go elsewhere.  But with public services, this is often difficult: (for example, there may not be another GP Practice in the area able to take on more patients, there may be only one hospital offering the specialist treatment someone may need within reasonable range of where they live. There needs to be enough money in the system, too, to create the market diversity needed to support choice. In Adult Social Care, there is so much demand and so little resource after over a decade of austerity that it’s care providers who are exiting the market, not social care consumers.  In a survey of older people who had a Direct Payment I did a few years ago, I found that having a budget made little difference to when people could eat, bathe, or go to bed. Choice was severely restricted by market realities.

Third, some people can find it very difficult to make a choice. It’s one thing to choose which tin of peaches to buy in the local supermarket, but quite another to choose which hospital will have the best surgeons to operate on you, the best school to which to send your child, the best care home to move into if you can no longer live independently. These kinds of choice can provoke great anxiety for some people. Here, choice also depends on the availability of high quality information, made available in ways people can understand, at the time they need it and relevant to their particular needs. Where should people go, in a local care economy, to get this kind of information? Who should they trust in an age of disinformation and fake news?  And what are the consequences of making the wrong choice? An elderly couple I interviewed for some research a few years ago said they’d asked their social worker but been told that they couldn’t possibly advise on which care agency would best meet their needs, because it was ‘commercially sensitive’. Local authority service commissioners in this local authority actively discouraged local professionals from offering advice: the very people older service users would be most likely to turn to. Commentators have also noted that the exercise of choice – even if there is abundant information and the choice is informed – can often be associated with unhappiness, as people regret choices they may have made, or are anxious that they may have got a better ‘deal’ if they’d shopped around for longer.

Fourth, what does the introduction of choice within public services do to our sense of relationship with others, the institutions we depend on, and the state? As one commentator put it, using public services is ‘not like shopping’.  Traditionally, individuals have had a ‘relational’ rather than a ‘transactional’ relationship with public institutions. This means there was some recognition that their use of the service came with reciprocal obligations and that their own relationship with the service had to be set alongside the relationship other people might also have with it.  This has started to change. One good thing about this has been less deference and a greater willingness to question and challenge by people who use public services; but it has also been argued that it re-frames our understanding of citizenship, replacing ‘social rights’ – universal entitlements to things like free health care, or education for example –  with ‘market rights’ where entitlement is contingent on cash and the ability to pay. You pays your money and you takes your choice. Individual rather than collectively based purchasing decisions can also have knock-on effects. In adult social care, older people given purchasing power through a Direct Payment often choose not to go to traditional care services such as day care.  As fewer people attend, the centre becomes economically unviable and closes, with potentially very serious consequences for a minority of attenders, whose friendship groups may just revolve around the centre.

Over the last century, public institutions have always had to struggle to decide how to spend their resources in ways that benefit the greatest number, or those in greatest need. There’s a good case for saying that they’re not inherently inefficient, monolithic and bureaucratic (as is often claimed) but that they may actually have been rather good at spreading the jam where it can do most good.  That’s why we might have to wait a few hours in an A&E Department: we still, mostly, trust clinicians to triage patients, dealing with the sickest first. (Yes, I know the Daily Mail would have us believe differently, but if you really believe that kind of stuff, you’re probably beyond help). But elsewhere, the customer is increasingly king, and distrust of public institutions and ‘experts’ is growing. It’s hard to say if the trend away from relational to transactional will continue and where it will end. The Government is pressing ahead with plans to extend, for example, the use of Personal Health Budgets for people with long term health needs. Though this makes sense in many ways, it could, with some minor policy adjustments, represent an existential challenge to the founding principles of the NHS.

So, what is the proper relationship between our social rights as citizens, our access to public resources, and rationing?  One approach might be to re-frame choice not as a pre-eminent objective of public services but a second order concern. In Adult Social Care, for example, choice has undoubtedly benefitted some service users: particularly younger physically disabled people, and people with long term illnesses, but these same market forces have not really helped older people – by far the largest group of people who require social care. Might the solution be to recognise that social care, as well as other public institutions, are a social right and not things that consumers have to purchase?  Rather than relying on the market to allocate public services, shouldn’t we start to recognise that some things are just too important to be left to market forces?  Wouldn’t it be so much better to have well managed and regulated public services, with the staff who are highly skilled and properly supported, with the right skills and training, and able meet public and individual needs and aspirations?

John Woolham