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)


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