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Research - public services - The cost of choice

Blair’s social market foundation think tank:
Essay: The importance of assisted choice policies
Jonathan Williams, Researcher, SMF, April 2004

There is serious disagreement about introducing more choice into public services. This is largely because people resist the idea that public services should be shaped around individual choices – particularly if money follows those choices, and even more so if private money follows those choices.

However there is also a debate over the value of choice itself: one side takes it as a mark of quality in public services that users should be able to make choices within them; by contrast, the other side is either indifferent to more choice, or actually resents it –pointing out that choices can be dangerous, that they can be a burden, and that in one way or another they can degrade the thing chosen.

Both of these debates touch on what is becoming an increasingly important question for choice in public services: what are the benefits of more choice in public services for people with very different capacities for choice? The question is particularly important for equity.

If the kind of service you get depends on your capacity for taking advantage of available choices, then inequality between choosers will produce inequality in outcomes. And since the worse off tend to be disadvantaged in this area – in terms of motivation and information, as well as resources, contacts and so on – it is likely to exacerbate existing inequality. The question is also relevant to the more general ‘value of choice’ debate, since the value of an additional option for you depends on your capacity for taking advantage of that option.

Policies designed to help people in making choices are crucial for dealing with these questions. Part of this is damage control. If the worry is that worse off service users will not take advantage of newly offered choices, we need policies designed to mitigate that effect. But besides the mitigating effect, assisted choice policies promise to actually close the existing gap between those who get more and less out of public services as they are now. It is well known that the only people currently able to choose better options for themselves are better off service users, because they are the ones who have the resources and the savvy to game the system. If we had a system in which the worse off were empowered to make these choices as well, that would itself reduce inequality – inequality of empowerment as well as inequality in service received– and would do a great deal of justice to the idea of effective freedom.

A recent and encouraging example of assisted choice in practice is the national coronary heart disease choice pilot, where all NHS patients set to wait more than six months for cardiac operations were contacted by a clinically trained Patient Care Advisor (PCA), offering them the choice to have an earlier operation at an alternative hospital. The PCA also gave patients advice and assistance, including free transport for them and their companions. The recent survey of the scheme by the Picker Institute shows both the importance and the possibilities of assisted choice policies. 61% of patients who took up the choice rated their PCA as ‘excellent’, compared to 38% for patients who chose to remain on the waiting lists; and this pattern was mirrored in their responses to other questions. This is preliminary evidence, but it suggests that assisted choice will be very important in making additional choice work for service users. If applied effectively, it will make a great deal of difference to the benefits of having more choice in public services. If applied progressively, it would go a long way towards making public services fairer than they are now.
For more information about the SMF’s project on choice in public services please contact Jonathan Williams on jwilliams@smf.co.uk

Applied to family life, we get: Today’s familylaw is no more than a toolbox for choosing and changing family-arrangements at convenience. There are at least eight different possibilities in the UK but probably more: (a) traditional marriage family arrangement; (b) registered partnership family arrangement; (c) living together family arrangement (d) lone parent mother-child family arrangement (by divorce or death of a partner, by choice from the start); (e) lone parent father-child family arrangement (by death of the partner or divorce) same sex family arrangement; (f) stepfamily-arrangement; (g) adopted family arrangement (lone ‘parent’ or couple); (h) foster family arrangement

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