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For every unpublished, non-peer-reviewed study that claims to show how choice and competition raise standards, you can find many rebuttals that expose methodological and empirical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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“We can’t do this again”: Labour conference reactions to Jeremy Corbyn’s second victory

Overjoyed members, determined allies and concerned MPs are divided on how to unite.

“I tell you what, I want to know who those 193,229 people are.” This was the reaction of one Labour member a few rows from the front of the stage, following the announcement of Jeremy Corbyn’s victory at the Labour party conference. She was referring to support received by his defeated contender, Owen Smith, who won 38.2 per cent of the vote (to Corbyn’s 61.8 per cent).

But it’s this focus on the leader’s critics – so vehement among many (and there are a lot of them) of his fans – that many politicians, of either side, who were watching his victory speech in the conference hall want to put an end to.

“It’s about unity and bringing us all together – I think that’s what has to come out of this,” says shadow cabinet member and MP for Edmonton Kate Osamor. “It shouldn’t be about the figures, and how many votes, and his percentage, because that will just cause more animosity.”

Osamor, who is supportive of Corbyn’s leadership, is not alone in urging her colleagues who resigned from the shadow cabinet to “remember the door is never shut”.

Shadow minister and member of Labour’s National Executive Committee (NEC) Jon Ashworth – not a Corbyn loyalist, but focusing on making the shadow cabinet work together – shares the sentiment.

Standing pensively in front of the now-empty stage, he tells me he backs shadow cabinet elections (though not for every post) – a change to party rules that has not yet been decided by the NEC. “[It] would be a good way of bringing people back,” he says. “I’ve been involved in discussions behind the scenes this week and I hope we can get some resolution on the issue.”

He adds: “Jeremy’s won, he has to recognise a number of people didn’t vote for him, so we’ve got to unite.”

The former Foreign Secretary Margaret Beckett, another MP on the NEC, is sitting in the audience, looking over some documents. She warns that “it’s impossible to tell” whether those who resigned from Corbyn’s shadow cabinet would be willing to return, and is concerned about talent being wasted.

“We have a lot of excellent people in the party; there are new people now in the shadow cabinet who have had a chance to show their mettle but you need experience as well as ability,” she says.

Beckett, who has urged Corbyn to stand down in the past, hopes “everybody’s listening” to his call for unity, but questions how that will be achieved.

“How much bad blood there is among people who were told that there was plotting [against Corbyn], it’s impossible to tell, but obviously that doesn’t make for a very good atmosphere,” she says. “But Jeremy says we’ll wipe the slate clean, so let’s hope everybody will wipe the slate clean.”

It doesn’t look that way yet. Socialist veteran Dennis Skinner is prowling around the party conference space outside the hall, barking with glee about Corbyn’s defeated foes. “He’s trebled the membership,” he cries. “A figure that Blair, Brown and Prescott could only dream about. On average there’s more than a thousand of them [new members] in every constituency. Right-wing members of the parliamentary Labour party need to get on board!”

A call that may go unheeded, with fervent Corbyn allies and critics alike already straying from the unity message. The shadow justice secretary Richard Burgon is reminding the PLP that, “Jeremy’s won by a bigger margin this time”, and telling journalists after the speech that he is “relaxed” about how the shadow cabinet is recruited (not a rallying cry for shadow cabinet elections).

“If Jeremy wants to hold out an olive branch to the PLP, work with MPs more closely, he has to look very seriously at that [shadow cabinet elections]; it’s gone to the NEC but no decision has been made,” says Louise Ellman, the Liverpool MP and transport committee chair who has been critical of Corbyn’s leadership. “That might not be the only way. I think he has to find a way of working with MPs, because we’re all elected by millions of people – the general public – and he seems to dismiss that.”

“If he sees it [his victory] as an endorsement of how he’s been operating up until now, the problems which led to the election being called will remain,” Ellman warns. “If we’re going to be a credible party of government, we’ve got to reach out to the general electorate. He didn’t say anything about that in his speech, but I hope that perhaps now he might feel more confident to be able to change direction.”

Corbyn may have called for cooperation, but his increased mandate (up from his last stonking victory with 59.5 per cent of the vote) is the starkest illustration yet of the gulf between his popularity in Parliament and among members.

The fact that one attempt at a ceasefire in the party’s civil war – by allowing MPs to vote for some shadow cabinet posts – is in contention suggests this gulf is in danger of increasing.

And then where could the party be this time next year? As Osamor warns: “We should not be looking at our differences, because when we do that, we end up thinking it’s a good thing to spend our summer having another contest. And we can’t. We can’t do this again.”

Anoosh Chakelian is deputy web editor at the New Statesman.