‘Choice’ in public services… October 1, 2012
Posted by WorldbyStorm in Economy, The Left.trackback
Here’s another thought from the Steve Richards book, Whatever it Takes:The real story of Gordon Brown and New Labour. In various parts of the book there’s a discussion of the nature of the ‘reforms’ that Blair and Brown introduced. To be honest Blair comes across at times as both manic and detached in relation to these in areas such as health, education and – albeit to a markedly lesser degree – social welfare provision. What’s as telling is that Blair’s attention seems oddly unfocussed. Reforms are announced, implemented to a degree, though often limited, and then forgotten only to reappear a couple of years later in new guise.
But here’s a central point about such reforms which Richards makes which I think is of perhaps of some relevance in the current context in this state.
Blair demanded that his ministers come up with ‘radical’ proposals, partly out of an imprecise desire to be an reforming prime minister, but also because of a genuine desire to life the quality of public services when at at last a government was investing huge sums of money. Alan Millburn his health secretary was especially obliging Milburn leapt from despair at the effectiveness of top-down targets to a desire to make the best-performing hospitals free of any national control. Milburn wanted them to spend, borrow and perform more or less as they wished, leaving patients to decide whether they were any good by choosing to go to them or somewhere else.
And Richards continues:
Blair was exicited by this vision. It ticked so may of his boxes. Patients would have ‘choice’. Hospitals would be free to innovate. The government would be kept out of it…
Brown was also battling for real causes and motivate by genuine conviction. He had a clear sense of the complexities and consequences of the simplistic debate about ‘choice’ in public services. Ultra-Blairites argued that he was against ‘choice’, again an absurd and vacuous proposition.
So what was the problem (from their perspective)?
Brown’s concerns were party those that any chancellor would have. In order for choice to be genuine there would have to be a surplus of good hospitals and schools. In giving some hospitals the right to borrow the government was taking on extra financial risks, or accepting the possibility that a hospital could go bankrupt and close, which would be politically disastrous and expensive. In one of their rows Brown pointed out to Blair that he had put his neck on the line arguing for a tax increase and now the government was going to allow some hospitals to behave more or less as they wished. He was accountable for the tax rise and yet some hospitals would be allowed to go bankrupt.
The thing is that in this discussion on ‘choice’ that would be the first thought I suspect anyone considering this in any detail would have, and not just the chancellor. And there’s another point to add to that. All this is remarkably cosmetic. What about the individual patient who happened to be in a failing hospital (and by extension the individual child in a failing school)? Choice in that context would be entirely hollow. And in some instances arguably dangerously so.
All this merely points back to the reality that in many areas of social provision ‘choice’ is a chimera, either a mask for two-tiered structures where those with access to greater incomes are able to operate with greater autonomy, or an aspiration which were it implemented in any serious fashion would result in some of the outcomes Brown feared -and Richards notes later that Brown felt that at a time when it was possible through funding and other means to raise NHS standards the plans Milburn and Blair sought implemented would have resulted in a two tier NHS with private sector expansion part funded by tax payers and failing hospitals failing yet further as successful ones soaked up resources. That too may have some implications for the debates of the last week or so.
But note the point above about social welfare provision. Here was a point where concepts of ‘choice’ had no currency – or at the most a marginal one. How could they? The economic and class power relationships, the degree of autonomy extant predicated against that entirely. No votes in that.
Very interesting. And makes me think of a discussion this morning on Pat Kenny about health insurance and risk equalisation – which I thought was quite intelligent and reasonable, except for omitting the question of why competition was reckoned to be a good idea in the first place. ‘Consumers’* of healthcare can now choose between more and more private insurers, but to a large extent the savings and competitiveness rest on an unfair distribution of the burden from the healthier young to the less healthier old (interesting to consider this in context of all the bleating about ‘intergenerational equity’). It seems to be accepted that, if even just for commercial reasons, risk equalisation is right and necessary, but there’s no serious reflection on how that should impact on people’s ‘choices’ in a market setting. Mostly, on PK, it seemed to be a regret that young (middle-class) families have their premiums increased at a time when obviously they are financially under great pressure, but no consideration of where the money would otherwise come from (i.e. tax, even greater premiums on the elderly).
(*I remember seeing a spectacularly disingenuous remark attributed recently to a US Republican supporter, who declared that while healthcare itself may be a right, health insurance is a product – and while anybody in the US can get the former in a free clinic, the latter is for those who earn enough to afford it, and government naturally shouldn’t get involved. While there’s a (small) grain of truth to it, it obviously ignores the fact that quality of healthcare is linked to its cost to somebody. But in a way it’s a depressingly accurate description of our own two-tier system: healthcare (of relatively high standard but poor access) is a right, health insurance is a privilege for the more affluent 40% of the population. Sometimes I think the only socialist solution is to ban people for paying privately for what should be the equal treatment of everyone in need of medical treatment. But that would be too anti-choice.)
That’s a thought about intergenerational equity. One thing that has often struck me about that in a slightly different way is that – whether one approves or not most people over 30-5 have experience of much higher levels of taxation. I don’t see that as a significant problem, in that proper levels of service require higher taxation but I wonder about how intergenrational equity works there as well.
I think it was Ben Elton, not long before he gave up stand-up, who did a routine about ‘choice’ in healthcare – I don’t want a choice of hospitals. I want the best hospital money can buy, close to where I live, completely free for me to use. Course, I don’t mind if other people use it as well…
You can have uniform standards or you can have winners and losers – and of course the latter is more ‘radical’ (meaning ‘alien to Labour’, meaning ‘right-wing’).
It’s a great line by Elton.
[...] beyond that is the stuff about ‘choice’, which in part was addressed here. Steve Richards did a fairly comprehensive demolition job, by proxy, on the concept in relation to [...]