The problem with public service "choice"

Choice without the capability to exercise drives a pernicious wedge between some users and others.

"Brick by brick, edifice by edifice, we are slowly dismantling the big-state" says Prime Minister David Cameron. In its place will be, if not the much-maligned "big society", then, well what exactly? If Tony Blair’s mantra going into the 1997 General Election was "education, education, education," Cameron’s fixation can be summed up as  "choice, choice, choice."

In criticising Cameron’s choice of strategy to raise standards in schools, hospitals and other public services, I don’t intend to defend the status quo. Of course there’s significant room for improvement, there always is. Nor do I seek to deny that in some cases non-state providers may be able to augment state provision where the latter is clearly failing. But in striving to raise standards we must ask whether the reforms being brought in are the right reforms, whether they’re likely to deliver said higher standards, and if so for whom.

In launching the next phase of the government’s Open Public Services programme, the PM asserts that in giving service users a choice between providers will give them control over how they experience the service and give the providers competitive pressure to up their game. The trouble is, this assertion is just that; there is very little evidence that choice and competition in themselves lead to higher standards in public services, and what little evidence that exists is of remarkably poor quality.

For every unpublished, non-peer-reviewed study that claims to show how choice and competition raise standards, you can find many rebuttals that expose methodological and empirical flaws. Take the now infamous studies claiming that competition for elective surgery (indexed not by a measure of choice itself but by geographic density of hospitals, a poor proxy at best) improves outcomes in mortality from heart attacks (through an unspecified mechanism); the papers show weak statistical correlations at best, not a causal relationship, and yet they’re unquestioningly cited as evidence that “hospitals in more competitive areas perform better on quality and efficiency than those in less competitive ones.”

The standard practice for resolving such a lack of clarity as to whether X (in this case the existence of patient choice in where they’re treated) causes Y (higher standards of care) would be to conduct a trial: give some patients choice, measure (and this is crucial) whether they actually exercise said choice, and see whether their medical outcomes are better than a group of patients from whom choice is withheld. I’m not the first to call for well-controlled trials of social policy (doctor and health writer Ben Goldacre is amongst those who have), but in the absence of reliable evidence to date, surely there ought to be trials to show just how effective choice can be in driving up standards?

Cameron makes more than an empirical error in promoting choice, however; his “instinctive belief” (sic) that consumers – or citizens as we used to be called – exercising choice in an open market will drive up performance and productivity results from a confused view of what constitutes a public service in the first place. The confusion is laid bare in Benedict Brogan’s defence of the Tory perspective on public service reform; Brogan reveals more than he perhaps intended when he says that under the proposed system of choice in services, the consumer "will be given the same kind of protections in his dealings with the public sector that he enjoys when he buys a television set or books a holiday."

With great power comes great responsibility, Peter Parker was told; well, under the Open Public Services regime, with Great Choice comes Great Voice – the corollary to choice of provider is voice to complain, transparency of data and help in finding out how to raise your voice, so to speak. All good things in themselves and fine if you’re buying a TV or booking a holiday, a robust complaints procedure might make TV makers or airlines up their game – but outcomes from public services are often only apparent several years down the line (think schools and healthcare for chronic conditions), at which point it’s too late for a complaint to the market regulator to make a difference. If the government is indeed to become more a commissioner in a market than a provider, as is Cameron’s intention, then if voice alone is the consumer’s redress then we must accept a widening in outcomes for those able to exercise both choice and voice, and those who are less capable.

And that’s the key. It’s a crass philosophical mistake to conflate public services – that deliver public good by pooling peoples’ risk, purchasing power and the benefits they get in ways that enrich society as a whole – with transactional goods that we consume largely for our own individual benefit. Cameron remains convinced that choice is the way to promote better services – but choice without the capability to exercise it is just a pernicious wedge driven between those comfortable enough to travel large distances and research their options and those who need good public services local to them. Choice, choice, choice says the PM – excellence, equity, evidence, say I.

Prateek Buch is head of policy and research for the Social Liberal Forum

David Cameron launches The Big Society Capital fund at The London Stock Exchange on April 4, 2012. Photograph: Getty Images.

Prateek Buch is director of the Social Liberal Forum and serves on the Liberal Democrat Federal Policy Committee.

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OK, let's do this: who REALLY won Legs-It? An exclusive investigation

Look, some of you just aren't treating this question with the seriousness it deserves. 

This morning, the Daily Mail front page dared to look past the minutiae of Brexit - can my EU partner still live here? Why is my holiday so expensive? Should we be worried that David Davis looks like a man who's ended up a minister because he lost a bet? - to ask the really big question. 

Yes, indeed. Who is Top of the Tibia? Who shines in the shin department? Which of these impressive, powerful women has lower limbs which best conform to our arbitrary beauty standards? 

In the accompanying article, Sarah Vine (herself the owner of not one, but TWO lower limbs) wrote that the women put on a show of unity with "two sets of hands clasped calmly on the arms of their respective chairs", disdaining the usual diplomatic practice of accompanying discussions about Article 50 with a solemn, silent re-enactment of the Macarena.

Vine adds: "But what stands out here are the legs – and the vast expanse on show. There is no doubt that both women consider their pins to be the finest weapon in their physical arsenal. Consequently, both have been unsheathed." That's right, people: Theresa May has been unafraid to wear a skirt, rather than a pair of trousers with one leg rolled up like LL Cool J. A departure for Mrs May, to be sure, but these are uncertain times and showing off just one calf might see the stock markets plunge.

The prime minister has come to the bold decision that her legs are the "finest weapons in her physical armoury", when others might argue it's the sharp, retractable venom-filled spurs on her fore-limbs. (Oh wait, my mistake. That's the duck-billed platypus.)

As ever, the bien-pensant left is squawking about sexism and avoiding the real issue: who really won Legs-it? Well, there will be no handwringing over how this is a belittling way to treat two female politicians here, thank you very much. We shall not dwell on the fact that wearing a skirt while doing politics is not really remarkable enough to merit a front page, oh no. Instead, we shall bravely attempt to answer that Very Important Question. 

Who really won Legs-it? 

1. David Cameron

We might not know who won Legs-It, but let's be honest - we all know who lost. David Cameron here has clearly concluded that, much like Andrew Cooper's pre-referendum polling results, his legs are best hidden away while everyone politely pretends they don't exist. 

Legs-It Rating: 2/10

2. Michael Gove

Fun fact: Michael Gove's upper thighs are equipped with sharp, retractable claws, which aid him in knifing political rivals in the back.

Legs-It Rating: 8/10

3. David Davis

Mr Davis's unusually wide stance here suggests that one leg doesn't know what the other is doing. His expression says: this walking business is more difficult than anyone let on, but I mustn't let it show. Bad legs are better than no legs.  

Legs-It Rating: 6/10

4. Boris Johnson

Real talk: these legs don't really support Boris Johnson, they're just pretending they do to advance their career. 

Legs-It Rating: 6/10

5. George Osborne

Take in these long, cool pins. These are just two out of George Osborne's six legs. 

Legs-It Rating: 9/10

6. Liam Fox

In the past, Liam Fox has faced criticism for the way his left leg follows his right leg around on taxpayer-funded foreign trips. But those days are behind him now.

Legs-It Rating: 10/10

7. Nigel Farage

So great are the demands on the former Ukip leader's time these days, that his crotch now has a thriving media career of its own, independent from his trunk and calves. Catch it on Question Time from Huddersfield next month. 

Legs-It Rating: 7/10

Conclusion

After fearlessly looking at nine billion photos of legs in navy trousers, we can emphatically conclude that THEY ARE ALL BASICALLY THE SAME LEG. Life is great as a male politician, isn't it?

I'm a mole, innit.