We need choice to mean something broader

A year ago, I was getting into my stride running the Independent Review into Barriers to Choice, wandering round the country asking everyone I met what their own experience had been.  More about this in the report published back in January.

But there is no doubt that ‘choice’ is a strange concept, when it is an end in itself. The basic problem in the NHS at least – there is a different basic problem in social care – is that choice happens despite the existing systems and institutions.  It is that much harder, if you are less confident or less educated, to push as hard as you sometimes need to.

That central issue - whether choice can make service inequality worse - is the one that the British Council in Denmark has been wrestling with.  They have commissioned five articles from radical thinkers about public services in the UK about exactly this issue, including me, and they are published today.

I have tried to develop the idea that emerged in the Review report, that we need to look again at choice - not as a semi-formal economic choice between different institutions, but as a way of injecting flexibility throughout the system.

My article suggests that broadening the scope of choice – so that it emphasises flexibility rather than just competition between providers – might make choice more widely accepted, might increase the equality between service users, and might open the way to cost reductions too.

That is the big question.

A more flexible system would mean fewer set systems, but more human connection. It would certainly require up-front investment, and it would mean a rigorous concentration on preventing those diseconomies of scale that cost so much in the inflexible systems. 

It would mean fewer organisations, more local, multi-disciplinary teams, and a shift from back office costs to frontline costs – and organisation for the huge number of volunteers that would be required to humanise services and allow them to reach out. 

It would be hard to prove its costs and benefits to officials wedded to the current industrial processes, so this is as much about a cultural shift – taking localism to its local next stage – as it is about organisational change.

But one anecdote makes the point. It is about the famous doctor’s surgery with the hedge outside which is trimmed once a year in the summer, and – when it is trimmed – all these rejected prescriptions fall out. 

 What happens is that patients come out of the door with a prescription they don’t really want and shove it in the hedge. It is wasted because doctors and patients were unable to communicate properly about what was needed and what was wanted.  

It is a symbol of the waste in the system when it is too inflexible.