Spoiling for Choice

The Labour-Tory market model for extending choice in the NHS will inevitably result in a dramatic decline in service-user equity. Here Marian Barnes outlines reforms that would benefit everybody.

August 1, 2004
4 min read

The sight of Tony Blair competing with Michael Howard over who could offer most choice to consumers of health services revealed just how threadbare New Labour’s vision for the development of public services is. Far more fertile ideas about improving services have come from the collective campaigning of the people who provide and, most pertinently, use services.

Choice cannot be the mechanism for empowering users or transforming services, because it does not engage with the way in which people use them. Choice per se is rarely experienced as empowering. Health services are often used at times when people are anxious, afraid and/or have come to the limits of their own capacities to resolve their problems. The offer of choice can contribute further anxiety: if you make the wrong choice you”ve only got yourself to blame if things don’t work out. Where people use services for a long time or at frequent intervals they can become experts well capable of deciding the best option for them. But in such circumstances continuity may be as important as, and maybe even more important than, choice. And what about those situations in which service use is a collective rather than individual experience? Relationships between service users attending day centres or living in residential accommodation can be as important as the formal service in determining satisfaction. Promoting individual choice can undermine the collective experience of building relationships with other service users.

There is a wealth of examples showing that when service users act collectively to improve health services what they seek is not choice but voice: a voice that would influence how and what services are delivered. Older people who made considerable use of health and social care services in Fife, for example, were supported by Age Concern to develop their own ideas about service design and delivery: shared experiences of insensitive practice around hospital discharge were transformed into a 14-point “good hospital-discharge plan” that formed the basis of joint working to improve procedure. Elsewhere, mental health patients in Birmingham developed criteria for assessing the responsiveness of services and were then commissioned by the local mental health trust to review a range of services against those criteria. User members of a patients” panel at a GP surgery in Liverpool came up with proposals for reducing the number of missed appointments by making it easier for people to cancel appointments they could no longer make. And in Salford patients of two primary care practices joined with health service professionals to create a governing body responsible for determining priorities and overseeing service improvements.

In all these examples service users worked collectively and drew on their own expertise and knowledge to contribute to service improvement. The emphasis was not on securing ways in which service users could choose which hospital they went to, or which doctor attended them, but on improving the services they already use – for their own benefit and the benefit of other users. Sometimes the improvements resulting from such an approach are modest and the people involved can be frustrated by the slow rate of progress. But there is also evidence of service improvement, and of increased trust between users and providers deriving from the experience of working together.

Why does the government fail to recognise the significance of such developments? Why doesn’t it build policies based on the principle of collective action, which will both improve public services and create relationships of reciprocal trust between public services and their users? In other contexts, as with strategies for neighbourhood renewal, these are exactly the sort of initiative that is being promoted. Yet when it comes to health and education the government wants to enable the middle classes to use services in the same way they buy a holiday or pay for a solicitor.

Encouraging poor communities to overcome the disadvantages they face seems to be one thing, but when it comes to persuading middle England not to abandon public healthcare and education the rules are different. Rather than promote the notion that health and education are genuinely public services, New Labour wants to pretend they are the same as services in the private sector. How does this contribute to public service renewal?Marian Barnes is professor of social research at the University of Birmingham’s Institute of Applied Social Studies. Her publications include Care, Communities and Citizens (Longman) and (with Ric Bowl) Taking Over the Asylum: empowerment and mental health (Palgrave)


✹ Try our new pay-as-you-feel subscription — you choose how much to pay.

Red Pepper’s race section: open editorial meeting 24 May
On May 24th, we’ll be holding the third of Red Pepper’s Race Section Open Editorial Meetings.

Our activism will be intersectional, or it will be bullshit…
Reflecting on a year in the environmental and anti-racist movements, Plane Stupid activist, Ali Tamlit, calls for a renewed focus on the dangers of power and privilege and the means to overcome them.

West Yorkshire calls for devolution of politics
When communities feel that power is exercised by a remote elite, anger and alienation will grow. But genuine regional democracy offers a positive alternative, argue the Same Skies Collective

How to resist the exploitation of digital gig workers
For the first time in history, we have a mass migration of labour without an actual migration of workers. Mark Graham and Alex Wood explore the consequences

The Digital Liberties cross-party campaign
Access to the internet should be considered as vital as access to power and water writes Sophia Drakopoulou

#AndABlackWomanAtThat – part III: a discussion of power and privilege
In the final article of a three-part series, Sheri Carr gives a few pointers on how to be a good ally

Event: Take Back Control Croydon
Ken Loach, Dawn Foster & Soweto Kinch to speak in Croydon at the first event of a UK-wide series organised by The World Transformed and local activists

Red Pepper’s race section: open editorial meeting 19 April
On April 19th, we’ll be holding the second of Red Pepper’s Race Section Open Editorial Meetings.

Changing our attitude to Climate Change
Paul Allen of the Centre for Alternative Technology spells out what we need to do to break through the inaction over climate change

Introducing Trump’s Inner Circle
Donald Trump’s key allies are as alarming as the man himself

#AndABlackWomanAtThat – part II: a discussion of power and privilege
In the second article of a three-part series, Sheri Carr reflects on the silencing of black women and the flaws in safe spaces

Joint statement on George Osborne’s appointment to the Evening Standard
'We have come together to denounce this brazen conflict of interest and to champion the growing need for independent, truthful and representative media'

Confronting Brexit
Paul O’Connell and Michael Calderbank consider the conditions that led to the Brexit vote, and how the left in Britain should respond

On the right side of history: an interview with Mijente
Marienna Pope-Weidemann speaks to Reyna Wences, co-founder of Mijente, a radical Latinx and Chincanx organising network

Disrupting the City of London Corporation elections
The City of London Corporation is one of the most secretive and least understood institutions in the world, writes Luke Walter

#AndABlackWomanAtThat: a discussion of power and privilege
In the first article of a three-part series, Sheri Carr reflects on the oppression of her early life and how we must fight it, even in our own movement

Corbyn understands the needs of our communities
Ian Hodson reflects on the Copeland by-election and explains why Corbyn has the full support of The Bakers Food and Allied Workers Union

Red Pepper’s race section: open editorial meeting 15 March
On 15 March, we’ll be holding the first of Red Pepper’s Race Section open editorial meetings.

Social Workers Without Borders
Jenny Nelson speaks to Lauren Wroe about a group combining activism and social work with refugees

Growing up married
Laura Nicholson interviews Dr Eylem Atakav about her new film, Growing Up Married, which tells the stories of Turkey’s child brides

The Migrant Connections Festival: solidarity needs meaningful relationships
On March 4 & 5 Bethnal Green will host a migrant-led festival fostering community and solidarity for people of all backgrounds, writes Sohail Jannesari

Reclaiming Holloway Homes
The government is closing old, inner-city jails. Rebecca Roberts looks at what happens next

Intensification of state violence in the Kurdish provinces of Turkey
Oppression increases in the run up to Turkey’s constitutional referendum, writes Mehmet Ugur from Academics for Peace

Pass the domestic violence bill
Emma Snaith reports on the significance of the new anti-domestic violence bill

Report from the second Citizen’s Assembly of Podemos
Sol Trumbo Vila says the mandate from the Podemos Assembly is to go forwards in unity and with humility

Protect our public lands
Last summer Indigenous people travelled thousands of miles around the USA to tell their stories and build a movement. Julie Maldonado reports

From the frontlines
Red Pepper’s new race editor, Ashish Ghadiali, introduces a new space for black and minority progressive voices

How can we make the left sexy?
Jenny Nelson reports on a session at The World Transformed

In pictures: designing for change
Sana Iqbal, the designer behind the identity of The World Transformed festival and the accompanying cover of Red Pepper, talks about the importance of good design

Angry about the #MuslimBan? Here are 5 things to do
As well as protesting against Trump we have a lot of work to get on with here in the UK. Here's a list started by Platform