Equality, equity and choice
August 30, 2013
We need a system of choice in public services which can genuinely tackle inequality, says David Boyle.
Flexibility is as important as formal choices between different public services. That is what I discovered as the independent reviewer for the government’s Barriers to Choice Review, published earlier this year.
This is not to criticise competition, which has its place, but to point out that ‘choice’ goes much further than that. You can have competition and give service users no choice at all, either because it is all decided by the commissioners of services or because everyone wants the same school or hospital and the managers decide.
The users I met were certainly interested in choice, but what they meant by this often went way beyond the formal options they were being offered. I was interested because we need a system of choice that can genuinely tackle inequality, and it made me wonder how it might be possible to broaden the choice agenda – so that it is not limited to competition between providers, and the relatively narrow choice between them.
The new emphasis would be, not so much on choosing between regulated options, but making services flexible enough to suit individuals better – closer to the ‘personalisation’ agenda in social care, where service users can get budgets they can (theoretically, at least) use in ways they believe are best suited to their needs.
The best approach may be to find ways to strengthen the confidence of service users to ask for something different, and perhaps provide duties on service providers to consider this. I imagine this would be like a ‘right to request’ flexible service delivery.
In each case, the provider would not be obliged to provide flexibility if it is impossible, but they would be obliged to explain why and that letter must be posted on their website.
It would be aimed particularly at situations where systems or bureaucratic arrangements get in the way of what people need.
For example, if they want the choice of a consultant who won’t mind them asking lots of questions. Or to study Spanish at A level when all that prevents them is their school’s timetabling system. Or to go to bed later than 5pm when their carer comes round.
These are basic flexibilities in the system which articulate people can often get now by being assertive, but which others can’t.
There are certainly possible objections to this kind of approach. There may also be higher costs from treating people more individually, and the costs will come before the potential savings are available.
But one anecdote makes the point. It is about the 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.
- This article is based on a think piece commissioned by the British Council, the UK’s Cultural Relations organisation for Equality Exchange, a new forum for exchanging ideas, skills and know-how for adaptive public services that contribute to fairer, more inclusive and more equal societies in the Nordics and the United Kingdom.
- The full think piece is available at http://www.britishcouncil.org/denmark-projects-equality-exchange.htm