WHY ‘CHOICE’ WON’T GIVE US THE PUBLIC SERVICES WE WANT
Public services based on consumer choice and competition by suppliers won’t give the public what they really want from their local hospitals, clinics and schools. The Government shouldn’t get distracted from tried and tested ways of improving public services. This is the message former Cabinet Minister Frank Dobson will take to think tank Catalyst’s conference ‘Beyond the market – Public services in the 21st century’ to be held at the City University, London, on Saturday 27 November.
Mr Dobson will also say -
“All public services need to continuously improve and to keep up with the times. But that does not mean they are a basket case. Many are well thought of by their users. The NHS is the most popular institution in the country with the general public and even more popular when people are asked ‘How was it for you’. It’s also the case that parents have a higher opinion of their children’s schools than do people without children at school. So user satisfaction is obviously quite high.
“All over the public services the people running them are full of great practical ideas for making them better. The big question is how to spread the good ideas. I don’t think structural changes or franchising to the private sector are much help. The improvements that are needed are most likely to be brought about by common sense changes by the people responsible for providing the services, learning from one another, backed up by user surveys and analysis of complaints and compliments. I also believe the modernisation mantra of public service reform based on choice for consumers and competition between suppliers is misconceived. It is also fundamentally at odds with the Prime Minister’s oft-proclaimed desire for a society based on rights and responsibilities.
“For a start, it is wrong to base a policy on reducing everybody to the lowly common denominator of being a consumer. Not a patient, or a parent or a pupil, not even a passenger, least of all a citizen – just a consumer. The role of consumer or customer is all about rights, nothing about responsibilities. Take the goods and the guarantee, and off you go – all take and no give.
“But when it comes to public services, it is often not like that. With many of the public services we have responsibilities to ourselves, to others and, dare I say it, to society as a whole. As a parent, we can’t just say to a school – ‘Go on, fill little Johnny with knowledge. It’s up to you teachers to make sure Jenny gets her GCSEs’. As a parent, we have the responsibility of getting our children to school, getting them there on time, properly kitted out. We have to set them a good example, back up the teachers, make sure our offspring do their homework and get to bed in good time. We are also responsible for their behaviour, to see it doesn’t disrupt the education of other pupils. In turn, the pupils can’t just sit there defiant and demand to be taught. They have to pay attention, show an interest, do the work, do their homework. Whether it’s parent and school or pupil and teacher, it is a two-way, continuing relationship – not a ‘wham, bam, thank you ma’am’ transaction with a shop.
“When it comes to health, the contrast between a patient and a customer is even more stark. We can’t just challenge the nurse or doctor to cure us. It is a two-way relationship – they can give us advice, prescribe us medicines, but it’s up to us to take the medicine and take their advice about our diet, exercise, drinking or smoking. And we have to behave responsibly towards other health service users and the staff by keeping our appointments, turning up on time or behaving decently in Accident and Emergency even if we are feeling ratty and rotten. Just ask A&E staff and ambulance staff what happened when the Tory Government plastered their Departments with posters setting out people’s rights under the Patients’ Charter with no mention of responsibilities – assaults and abuse of staff got much worse as some users became customers not patients.
“This misunderstanding of our role as users of public services is compounded by all the talk of consumer choice. For a start, we can’t choose our local police force, fire or ambulance service. There is little evidence that people want a choice of local services – at least within the normal meaning of the word ‘choice’. Opinion surveys and personal experience show that what people want is for the local school to be good enough for their children, the local hospital to provide prompt, top-quality, treatment, local social services to really look after grandma, the local park to be pleasant and safe. They don’t actually want to shop around – to be forced to travel miles for something of a decent standard. If the local service is overstretched, they may accept the need to go somewhere else – but that isn’t usually their first choice.
“Most people also believe there is such a thing as society – and they are glad. They know that while very rich people may be able to pay for a personal tutor for their children, a personal physician for their health needs and guards for their personal protection, most people can’t afford to. They know that most of us have to work together to provide a school, a hospital, a police force and we have to club together to pay for them – co-operating together, not competing with one another. And we expect the service-providers we depend on to co-operate with one another because that is the basis of public services and what is most likely to deliver what we want. If a hospital has a spare intensive care bed, we know it is right to make it available to a patient from a neighbouring hospital. We know that fire engines and ambulances from our area should respond to a major emergency somewhere else. We expect the police forces to help out one another. No talk of competition there.
“Most people also welcome the idea of schools getting together to provide one another’s pupils with specialist teaching. Most people want to see all schools taking their share of the children who are difficult to teach. Most people want the schools serving working-class children to get the money and the resources, especially the teachers, needed to provide top-quality education. They don’t want schools competing for the best staff so that the ones with problems end up getting worse – the best off doing well and ‘devil take the hindmost’. And if Labour won’t look after the hindmost, no-one else will. “To them that hath shall be given” is not a democratic socialist slogan. It’s a Thatcherite slogan.
“And it could be the same with hospitals. The NHS was established to spread across the whole of society the risks and costs of each patient’s treatment. It was also intended to spread the risks and costs of providing the services across the NHS. Not any more. The private sector is being invited in to provide a limited menu of straightforward operations on predominantly healthy patients – leaving the NHS with a disproportionate share of the risks and costs of treating everybody else. And the private sector is getting paid more than the NHS for each patient treated. Outsourcing to reduce costs makes some sense. Outsourcing to increase costs makes no sense at all. And it’s not as if the private sector can be relied on when it comes to providing public services. People don’t join long queues for NHS dentists because private dentistry is a success. Let’s not forget how the Tories decided that care of the elderly should be transferred from local councils to the private sector, financed with taxpayers’ money. That seemed ok while ‘granny farming’ was the most profitable use of buildings – but as soon as the owners could make more money from property development, private residential care of the elderly plummeted and news media headlines described it as a crisis of the NHS.
“Throughout the eighteen Tory years of constant attacks on public services, the staff working in them struggled on. They weren’t competing. They weren’t looking after Number One. Their work was often disparaged. They were patronised while the profit-takers were lionised. They were motivated by the public service ethic. They kept the NHS going. They kept the schools going. They kept social services going. They kept the police service going. And it seems to me that if the public service ethic was good enough for the Tory lean years of under-funding, under-staffing and underpaying, it ought to be good enough now Gordon Brown’s budgets have started putting these things right.
“As part of the consumer choice agenda, some people who ought to know better are succumbing to the blandishments of ‘new mutualism’ and other proposals to hand control to small groups of users. But there are dangers in this. In relation to schools, all power to the parents sounds ok, but what about the children who can’t get into the school, what about the children who have moved into the area, what about the children who have been excluded, what about the children who will need the school in five years’ time? All power to the tenants sounds a good slogan for social housing. But what about the people who aren’t tenants but are desperate to become tenants – what about the homeless, the overcrowded? Today’s users of services aren’t the only ones whose needs have to be met by public services.
“And that brings me back to my original point about one of the internal contradictions of the modernisation mantra. We shouldn’t reduce people to the lowly common denominator of just being a consumer. Consumers are, by definition, self-regarding with little responsibility for themselves, still less for anybody else. We can’t base a decent society on the pursuit of self-interest, of rights without responsibilities. That is why we have to base our approach to the improvement of public services on the recognition of the different roles and different needs of different groups in our society and above all on the concept of citizenship – with responsibilities and duties to one another.”
