Wednesday 29 January 2014

We will always need some kinds of choice

I've learned to distrust the fantasy that many writers have, which is that people are talking about you.  Your ears burn, your backbone shivers - it doesn't mean a thing, I can tell you.

But then suddenly I discover a fascinating online debate where the name David Boyle gets gargled with occasionally.  It doesn't happen very often, and I missed it.

So thank you to Mark Pack, who reviewed the system thinker John Seddon's key text Systems Thinking in the Public Sector on the Lib Dem Newswire blog.  Seddon has responded there with his own challenge.   The argument has continued in various places, notably around the table at the Lib Dem public services commission - and it seems to be summed up like this:

Can we so improve public services that choice is unnecessary?  Or, as Seddon puts the question himself: is there any evidence that choice improves services.

The problem about this is that the weasel word 'choice' remains undefined, and this is important because all the political traditions define it in different ways,

New Labour choice was about formal economic options between public sector providers.  It was invented by economists and depended largely on choosing between rival bits of real estate - one hospital versus another, or one school versus another.

Conservative choice is about the private sector.  If there is a private sector provider to choose, there is choice - if not, there isn't.  But the actual choice may be made by commissioners rather than users.

Lib Dem choice is about consumer rights: are there other options apart from the mainstream?  If things go wrong, can you choose differently?  It is an approach to choice which is an end in itself rather than a means to a different end - driving up standards (New Labour) or privatisation (Conservative).

What is most peculiar about this is that these different interpretations are rarely discussed, and are largely unacknowledged.  It is hardly surprising people disagree.

But back to John Seddon.  This is what he says about my Barriers to Choice Review last year:

"I have read David Boyle’s report. It was an attempt to seek ways to extend the idea of choice; the report didn’t question whether choice improved public services. The evidence for choice improving public services simply doesn’t exist."

In fact, there is some evidence that formal choice (read New Labour choice) has improved standards - both in schools and hospitals - but not a huge amount, and the evidence also suggests a negative impact on equality.  But what John doesn't say - though I'm sure he is aware of this - is that the Barriers to Choice Review tried to extend the idea of choice to cover what he is doing to make public services more flexible.

This is what I called during the Review 'broad choice'.  It implies two things:
  • Whatever the mechanism, people need services to be much more flexible if they are going to get their needs met effectively and inexpensively.
  • If the mechanisms of formal or narrow choice make services less flexible, then flexibility is more important.
But does that rule out choice?  I remember one round table I held during the Review.  The first speaker, a patients' advocate, told me that nobody wanted choice (though this is not what the polling data says).  The next one, a long-term patient, said this:

"I would have travelled to another country to get another choice when my consultant was unpleasant to me.  They said I could have a second opinion. I said, I don’t want a second opinion, I want another choice.”

I take that seriously.  That patient, and all those like her, may not have wanted a formal choice between hospitals, but she did want the option to shift when things went wrong - because professionals were rude or incompetent.  Or for a host of other reasons.

Even if systems thinking was improving services everywhere - and I'm sure it eventually will - people will still need some rights in what will always be an imperfect system.  To say that there will be no imperfections means putting ideology and theory above ordinary everyday reality - and that's what got us into trouble before.

So flexibility, yes.  And if public services are genuinely flexible, then we can expect those formal choices to be used less and less - but what do we do in the meantime?  Remove people's right not to be treated by people they don't trust in places they don't like?

The bottom line is this.  However successful systems thinking is going to be in transforming services, we must never remove people's rights on the grounds that the system will be perfect, because it never can be.  


Anonymous said...

Hi David, Do you think you could take up the challenge John set for Mark Pack then and please tell us more about any evidence for choice improving standards? Thanks, Brendan

David Boyle said...

Brendan, this is a tough one and I might write something longer on the subject. I don't want to find myself defending narrow choice against what I might call the broad choice of flexibility. Part of the problem is that there is always a tendency for quality targets to go up, for all the reasons you and John have argued.

There is also a problem in the literature that, once you look at it closely, choice is successful because it successfully drives competition - and the correlation with real quality goes by default.

As I understand it, there is more evidence that choice improves quality in healthcare than in education - where anyway, nobody strictly speaking has choice (they have the right to express a preference). You might look at this one on health:

Aldo for a summary of the arguments back in 2011, you might try this one:

Both publications come out of CMPO at Bristol University, which is the centre of academic research on this kind of thing.