|
Research - public services - The cost of choice
There is serious disagreement about introducing more choice
into public services. This is largely because people resist
the idea that public services should be shaped around individual
choices – particularly if money follows those choices,
and even more so if private money follows those choices.
However there is also a debate over the value
of choice itself: one side takes it as a mark of quality in
public services that users should be able to make choices
within them; by contrast, the other side is either indifferent
to more choice, or actually resents it –pointing out
that choices can be dangerous, that they can be a burden,
and that in one way or another they can degrade the thing
chosen.
Both of these debates touch on what is becoming
an increasingly important question for choice in public services:
what are the benefits of more choice in public services for
people with very different capacities for choice? The question
is particularly important for equity.
If the kind of service you get depends on your
capacity for taking advantage of available choices, then inequality
between choosers will produce inequality in outcomes. And
since the worse off tend to be disadvantaged in this area
– in terms of motivation and information, as well as
resources, contacts and so on – it is likely to exacerbate
existing inequality. The question is also relevant to the
more general ‘value of choice’ debate, since the
value of an additional option for you depends on your capacity
for taking advantage of that option.
Policies designed to help people in making choices
are crucial for dealing with these questions. Part of this
is damage control. If the worry is that worse off service
users will not take advantage of newly offered choices, we
need policies designed to mitigate that effect. But besides
the mitigating effect, assisted choice policies promise to
actually close the existing gap between those who get more
and less out of public services as they are now. It is well
known that the only people currently able to choose better
options for themselves are better off service users, because
they are the ones who have the resources and the savvy to
game the system. If we had a system in which the worse off
were empowered to make these choices as well, that would itself
reduce inequality – inequality of empowerment as well
as inequality in service received– and would do a great
deal of justice to the idea of effective freedom.
A recent and encouraging example of assisted
choice in practice is the national coronary heart disease
choice pilot, where all NHS patients set to wait more than
six months for cardiac operations were contacted by a clinically
trained Patient Care Advisor (PCA), offering them the choice
to have an earlier operation at an alternative hospital. The
PCA also gave patients advice and assistance, including free
transport for them and their companions. The recent survey
of the scheme by the Picker Institute shows both the importance
and the possibilities of assisted choice policies. 61% of
patients who took up the choice rated their PCA as ‘excellent’,
compared to 38% for patients who chose to remain on the waiting
lists; and this pattern was mirrored in their responses to
other questions. This is preliminary evidence, but it suggests
that assisted choice will be very important in making additional
choice work for service users. If applied effectively, it
will make a great deal of difference to the benefits of having
more choice in public services. If applied progressively,
it would go a long way towards making public services fairer
than they are now.
For more information about the SMF’s project on choice
in public services please contact Jonathan Williams on jwilliams@smf.co.uk
Applied to family life, we get: Today’s
familylaw is no more than a toolbox for choosing and changing
family-arrangements at convenience. There are at least eight
different possibilities in the UK but probably more: (a) traditional
marriage family arrangement; (b) registered partnership family
arrangement; (c) living together family arrangement (d) lone
parent mother-child family arrangement (by divorce or death
of a partner, by choice from the start); (e) lone parent father-child
family arrangement (by death of the partner or divorce) same
sex family arrangement; (f) stepfamily-arrangement; (g) adopted
family arrangement (lone ‘parent’ or couple);
(h) foster family arrangement
|
