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Created on Thursday, 22 September 2011 11:25

Written by Alison Alcroft

Is Choice all it's cracked up to be?

The Coalition government picked up where the Labour government left off in making ‘choice’ a big issue – apparently it is all we have been waiting for in our communities – rich or poor, black or white, the answer to the evils of public services can all be eradicated if we all have ‘choice’.

It is of course very compelling: if we have choice we can literally judge the services that are provided to us by where and when we exercise our choice – if we don’t like our children’s school, move them – (better still set up your own!) If you don’t like your local hospital, why not have the operation at a better place 500 miles away? 

Some of these things really work for me on a personal level, but I am in a privileged position, I can access information, my family and I can be mobile and I understand many of the systems.  But just because it works for me on occasions does not make it right.  It has to work for the common good, it has to bet truly fair – not ‘fair’ in the way the coalition define it.

As well as providing people with more personalised services, the current government believe choice also creates improves quality through competition - another equation that I am uncomfortable with.  I can see how competition has improved quality in some areas – but in others it is completely divisive.  In the world of public services it could lead to money being spent on advertising and marketing to gain market share rather than on good front-line delivery – surely not ideal in anybody’s book.

The reality is whatever lengths the Government go to, some of us will have more choice than others.  We will need to have, and should agitate for, support for people to make the most of the choice that exists, people who can interpret data, make sense of complex information, and most importantly, people who are independent in the advice they give – not someone with a financial interest in how you exercise your choice. 

But the real issue is surely on most areas it is not choice we seek, what we seek is a good high quality service in the first place.  Getting really selfish, my Dad is having a serious operation in the morning, and frankly, neither he nor any member of our family care whether he has choice – we just want him to be well cared for and operated on by someone with the necessary competency.  I am not sure if he did have a choice how we would find ourselves in a mindset to make a judgement anyway. 

So is choice really important?  Does competition really improve quality? Even Gerry Robinson was unconvinced in his look into the impact of competition and choice in his Panorama investigation into NHS reforms.  He suggests to Andrew Lansley that he is using competition as a tool to manage change when in fact the answer was better management.  But this will not do the current government – managers in public service are treated with contempt – painted as over-paid bureaucrats bleeding the tax-payer dry.

Ironically, I had my first lecture on how competition does not drive quality, how choice can sometimes lead to poorer services, from a Hospital manager, Lowell Kruse, in the United States – probably the last place you would expect this rhetoric to be challenged.  But at Heartland Health in Missouri, two hospitals realised there were insufficient resources to support two hospitals, that the health of their population would not be resolved by them alone and that only by tackling the social determinants of health could they start to make a real difference. 

As I reflect on the lessons I learned from Missouri, I remember very clearly how they talked about accountability as the driver for quality and change, how community engagement, professionals working across disciplines – academia, health, local government and education all engaged and allowed to challenge one another, allowed to hold each other to account.

So choice may be nice on occasion when it comes to some of our public services, but in very simple terms I think improved management, greater accountability and true community engagement are the things that will truly improve our public services.  The current agenda will lead to a two tier system and is a fast track to privatisation and a place I fear there is no return.

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