Choice is a seductive word. It implies pleasure, a leisurely pursuit of obtaining a desired item . Choice in public services is however something of a misnomer. Choice implies that service users can opt for different providers when in reality the outsourcing of public services is most usually to one monopoly supplier, operated under a contract over which democratic accountability is paralysed by the legal constraints of that contractual relationship.
David Cameron, writing in the Daily Telegraph, claims that "state bureaucracy has proved too clumsy and inefficient, stifling the innovation we need at a time when value for money is so critical. I also have an instinctive belief that parents, patients and professionals are so much better equipped to make the choices that will drive improvements in our public services. Give the power to them, allow new providers to come forward with new ideas, and good things will happen." http://www.telegraph.co.uk/news/politics/david-cameron/9171481/Brick-by-brick-were-tearing-down-the-big-state.html
But in health ‘choice’ is governed by geographic boundaries, if not by cost alone, then by the practicalities. ‘Efficiencies’ in health, education, local government, police and fire mean that ‘super centres’ and co-locations of public facilities accompanied by the loss of localised services has limited rather than enhanced choice. These limitations will increase with the budget cuts. Far from expanding ‘choice’ it will be crushed and will be increasingly dependent on the availability of decreasing resources to match increasing needs.
We should be brave enough to admit that public services are by necessity rationed.
To illustrate this I spent this morning with my daughter in the glorious new surroundings of the Royal Manchester Children’s Hospital. I was there because she had been referred to their paediatric orthopaedics unit which was excellent and I could not have asked for better care.
However the ‘choice’ of hospital meant an hour and a half drive. Chatting to another mum in the waiting room the drive seemed less of a problem because she had gotten up at 5.30 AM to dress and feed two young children (one disabled) to make her way there on public transport (a lengthy walk followed by three buses) because the sick children’s transport service – run by volunteers (remember Big Society) – could not spare a driver on short notice.
She explained that in future, despite the centre of excellence, if she could not have the transport she would simply have to opt for the nearest place she could get to for her child’s treatment. Yet again ‘choice’ boils down to choice based on ability to pay and not ‘choice for all’. To truly offer choice the transport options to exercise choice needed to be part of the equation for that woman and her children –and that is not going to happen when public sector budgets are being slashed. Choice can only work if funding holistically supports choice for all.
The Health and Social Care Act will exacerbate the differences in care between rich and poor. The less well-off will be elbowed out by the higher earners who can afford to exercise choice. The rest will have to put up with bargain basement services. And the saddest issue of all is that politicians have been allowed to talk about choice as if it were some sort of panacea when the public truly only care about getting a good service that they can access locally. It is only when politicians allow local services to fail that choice is paraded out as the answer to all evil. They should instead be promising to deliver universally good local services for all.
Anna Rose
