Thursday 24 January 2013

Broadening out the choice debate

The Barriers to Choice Review, which has dominated my life for the last six months, is finally published and there has been a  positive response from the government.  Three points about it:

First, that the bureaucratic barriers to choice are pretty powerful if you are less confident or articulate, and if you want something slightly out of the mainstream.  I have looked at ways in which we can increase people’s authority in the system, so that they feel more able to ask for what they want.

Second, the need that people have, especially disadvantaged people – not just for information, though that can be problematic too, but for face to face advice.  They get around eight minutes from the doctor, some support from the social worker doing their social care assessment, but otherwise very little.

Now I don’t believe there is any appetite, or budget, to insert a new layer of professionals into an already complex system.  So what I’ve proposed is to pilot an extension to existing schemes providing peer support from volunteers, so that they’re trained up to provide navigation support - to help people make decisions, find their way around the system, maybe just help them with the internet.

During the last six months, I have seen the ways that informal support, provided by other service users, can transform people’s experience.  I believe it has the potential to do the same for choice.

Finally, what you find when you talk to people about choice in detail is that the kind of choices they think they are getting are often not what they’re actually being offered. 

They 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.

These are basic flexibilities in the system which articulate people can get by being pushy, but which others can’t.  This is a broader agenda for choice than just competition – to give people more authority in the system at least to ask if their specific needs can be accommodated. 

That’s what my recommendations are designed to achieve.  I've recommended that people don't just have the choice of hospital for their first out-patients appointment, but also the right to switch in extremis - if their consultant is unpleasant to them or their children are bullied at school.  

This is not a right they should need to exercise very much, because I hope it will so change the relationship between professionals and users that they won't need to.

There is also a case for 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 would be obliged to explain why and that letter would have to be posted on their website.

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. But it requires some consideration across government about the best way in which it can be made effective. 

Either way, the broad choice agenda needs to embrace the kind of shared decision making between users and professionals that is required to underpin progress so far, to improve treatment and share responsibilities better between professionals and clients. 

The implication of the choice agenda – so far unrealised – is that everyone might not be treated alike, even if they have the same symptoms or problems. It implies that different options are available, and different possible outcomes, and that there needs to be a contribution from the service user to reach that decision.

That is the new direction, and we need to shift the debate about choice so that it is much broader than just about competition.  So that it also covers people’s needs for flexible, human services that can accommodate their needs effectively.

This is what I said at the launch this morning.

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