“What’s a nice guy like you doing with a bunch of Tories?” one journalist asked me as I discussed the Barriers to Choice Review.
“You see, I’m a Liberal Democrat,” I explained…
The truth is that this was not a coalition problem. It was a problem about the word ‘choice’.
My task as an independent reviewer, appointed by the Cabinet Office and the Treasury, was to find out how people used the choices they have been given in schools, hospitals, social care and so on – especially disadvantaged people.
But the word ‘choice’ itself divides people, even those who might otherwise agree on pretty much everything.
On one side there are those who believe it is a weasel word, designed to obscure a push towards privatisation. On the other side, there are those who take the word at face value, but worry about the logistics.
Nobody seems to be quite agnostic about the idea, because – since the political establishment sometimes uses ‘choice’ and ‘competition’ interchangeably – this is often a proxy for an argument about competing service infrastructure.
What I have found talking to a large number of service users around the country, and polling them more widely, is that a large majority of people are positive about choice in theory – the polling certainly suggests that too – but are sometimes confused about it in practice.
They don’t see the neat demarcations between services, the carefully delineated and defined rights to choose. They certainly want to choose – there was really no desire to go back to a deferential system where you got the service you were given – but they want to choose in a whole range of other areas where, at the moment, they can’t.
This was an important message in the report of the review, which is published today (Thursday).
Competition certainly has a role, but people also want – and sometimes believe they have been offered – choices around a range of other areas.
They might want the choice of 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 timetabling system.
Or to go to bed later than 5 o’clock when their carer comes round.
Choice could cover a whole range of possible approaches, including:
- The choice of providing institution: this is the choice which is largely offered under recent policies. It provides people with a choice of school, hospital or social care provider, as set out in the choice ‘frameworks’, and is designed to encourage competition between providers.
- The choice of professional: this is implied by the choice of provider, but is actually something different, though people are increasingly able to choose a named professional as well. When surgeons or consultants work peripatetically between local hospitals, as many do, then the choice of provider may deliver patients exactly the same professional.
- The choice to switch: this is the choice of ‘exit’; in a rare emergency – when your consultant is unpleasant or your children are being bullied at school – it means the choice to change provider. It is something that confident people tend to get, just by demanding it, but there are usually no guarantees under the current system.
- The choice of solution: this is the choice of different treatments, curriculums or styles of social care, which most service users are not normally given (though personal budgets holders get it, in theory). This requires a flexibility of service which rarely exists at present, and which depends very much on the presiding professional and how constrained they are.
- The choice to share responsibility: this goes beyond choice, and implies the option – which many users certainly prefer – of a grown-up conversation with a professional, which might include discussions about options but which also implies a shared responsibility for the decision. This is guaranteed under the NHS constitution.
- The choice to contribute: this is the option, rarely given at the moment, to give back in some way, and to play a role in the delivery of public services, using your time or specific knowledge of your own condition to help others, and broadening the range of choices before other users. It is also known as co-production.
As service users know very well, there are times when choice and competition are aligned, but there are also times when they cancel each other out. This is so, for example, when the actual choice is made, not by patients, but by service commissioners choosing between two alternative candidates for block contracts.
Or when the weight of demand is such – as it is for some popular schools or GP surgeries – that the choice is made by the institution, not by the user. In both cases, there is competition, but no user choice.
This is a long-term problem for the choice agenda. It means that choice is politically unstable, vulnerable to a change of political leadership just as it is vulnerable to professionals who disapprove of or misunderstand it.
The review recommends a Choice to Switch, in extremis, putting people into another provider in the same position in the queue, with some safeguards. It also recommended a broadening of the Choice to Contribute.
But the review also heard from people who wanted flexibilities within their service. There is a case for this to be a new cross-service Right to Request Flexible Service Delivery.
In each case, the provider would not be obliged to provide it if it is impossible, but they will be obliged to explain why and that letter must be posted on their website.
This could not be an obligation on service providers, but it could be organised along similar lines to the ‘right to request’ parental leave.
This kind of right has a political power beyond its immediate effect. It could potentially shift power in the system and do so without expensive changes in institutional framework.
It is part of a much broader agenda for choice that has the potential to make public services more flexible and much more effective.
David Boyle has been the independent reviewer of the government’s Barriers to Choice Review. His report is at www.cabinet-office.gov.uk/news