Wednesday 13 November 2013

The many meanings of 'choice'

I had a fascinating day yesterday with the energetic management team at Nottinghamshire Healthcare NHS Trust, and it was an impressive experience.  It is a big, integrated trust and integration is the big challenge for the NHS right now.

I was there to talk about barriers to choice, the title of my independent review for the Cabinet Office which was published in January, but I found myself talking again about the peculiarities of the word.

I became intensely aware of these while I was doing the review.  One room full of hospital doctors (I won't say where), sat there with their arms crossed, tight-lipped and clearly enraged with me as some kind of ideological emissary from Whitehall.

Here is the problem.  There are many different kinds of choice - from the approved choice of provider, which is the traditional mode, right through to the choice to contribute yourself in some way (co-production).  There are three models of choice, each very different, promoted just within the Department of Health and the Department for Education.

But there is a political problem too, and I was reminded of that while I was talking.

There is a Labour way of 'choice', which is the one introduced by public service economists from 10 Downing Street during the Blair years, which tends to mean a formal choice of provider, promoting competition within the public sector.

There is a Conservative way of choice too, which I think is primarily about competition.  That is how Conservatives understand the word, even though it could mean that the people who choose are actually just service commissioners.

There is also a Lib Dem way of choice, perhaps rather less articulated, which is closer to consumerism.  To have Lib Dem choice, people need to have options.

Now, the difficulty comes because these different interpretations are not obvious, even in Whitehall.  The term is used to cover all three interpretations.  Often it is simply assumed to cover all three.

Outside Whitehall, in some way, the opposite can also be true.  People assume that when they hear the word 'choice', that what was meant was precisely the opposite of what they would like it to mean.

It may be time we dumped the word altogether, because its baggage is weighing it down.  So we need to ask ourselves: what goes beyond choice?  The answer, it seems to me, is flexibility.

And here is the ultimate irony.  Formal choice as constituted might sometimes mean flexibility, but sometimes it means an extra layer of formality in the system, rendering it even less flexible than it was before.

1 comment:

Anonymous said...

The key missing element in all the various definitions and discussions of "choice" in public services is that none of them work unless you have an appropriate level of excess capacity.

The "free market" manages this by an ongoing rotation of firms entering and leaving the market. But this model of "Startups and Bankruptcies" poses a number of difficulties for a public service. Not least of which is that even this method of creating excess capacity costs more money than an administered service.