The Tyranny of Choice

July 24, 2009

‘Tyranny of choice’ is not a reference to the non-choice that faced voters in Norwich North yesterday, even if the presence of Craig Murray and the oddball new outfit of the Libertarian Party UK made the contest more colourful than most parliamentary elections.  Rather it refers to the Blairite idea of choice in public services.

The idea, which has the dual function of providing a back-door for privatisation and appealing to the middle-classes’ sense that they know better than public service providers by virtue of their BA in English Literature, is that individual hospitals, schools, GP surgeries and other service providers should be set in competition with each other, thus raising ‘standards’.

Now the issue of standards itself is a vexed one.  In the fields of healthcare and education how you define what is ‘good’ service provision depends on the values you believe a public service should be based on.

Some would argue that healthcare should be judged to the extent it prolongs life, whereas I would add that prolonging healthy life (without the sort of public health badgering we see too often today), while providing a comfortable and dignified end to life are as important.

In education the divide is even greater, between the philistines who see education merely as a preparation for employment, and those like myself that see the value in education in itself, in addition to preparing children for the world by equipping them practically and intellectually to deal with it, question it and shape it.

When compiling statistics to aid parents or patients in their ‘choice’, only those things that can be measured can be included.  This excludes matters of dignity, mental well-being, being inspired by literature, nature, space, the human condition, history, and other things which can’t be measured but are critically important and possibly life-changing or life-defining.

Only measurements that reflect the depressingly short-termist utilitarian outlook of the political establishment will be included.  This means crude statistics and targets will concern how many people can be made fit for work, or can pass an exam above a certain arbitrary grade.

A league table or other means of comparison is then constructed using these flawed measurements.  People are then encouraged to exercise a choice on this basis.  Without adequate information people cannot choose the service provider that will best meet their needs.  But in some parts of the public sector choice will be exercised, and it has a damaging impact on those without the resources and bullish confidence/arrogance of the middle classes.

In large urban areas (which, if you read newspapers, are the only places that seem to exist, outside of chocolate box villages which exist purely to provide second homes for journalists) the issue of schools is a vexed one.  The matter is made more vexed by the league tables and the spurious statistics in them.  It is a simple fact that the exam results of a school reflect the intake of pupils.

Pupils from middle class backgrounds, with access to plentiful books, a computer, the Internet, a quiet place to work and supportive and pushy parents have a much better chance of succeeding academically than those from a working class background without those factors.

Of course, there are many working class families where these things are present because of the sacrifices and hard work of the parents, and I am a grateful product of one such of these families.  But in general, working class children are disadvantaged from the outset.

The experience of choice is that schools with good results (which helps to attract teachers, and more funding and equipment from various sources) attract the middle class parents, who are able to gain entry for their offspring by a variety of means, not restricted to changing (or finding) religion, moving and pulling strings.

Choice and a market result in better schools and facilities for middle class children (the ones who don’t necessarily need it) and a worsening situation for working class children.  This has been the experience elsewhere in the world (most notoriously New Zealand).  We should be looking to Finland for their progressive educational policies, not the US and New Zealand.

So choice results in worse outcomes for working class children.  What else?  It results in a decline in quality, and not just in the sense that resources and effort are directed towards those things that are measured and valued, leading to teaching to the test and the ridiculous consequences of the target culture in the NHS.  The decline in quality comes from the fact that improvement in public services completely depends on cooperation and the sharing of expertise and new ideas, techniques and ways of thinking.

I never cease to be amazed by the story of a trailblazing school, hospital, department, teacher or doctor that has tried something new, refined it with colleagues or other instititutions, and then disseminated it, leading to an overall improvement.  There are dramatic examples to be found, for example with the invention of a simple check list for operating theatre staff to go through before a procedure, which has dramatically reduced mistakes and adverse outcomes, which has been trialled and is now being spread globally.

There are also the everyday, humdrum, innovations and resources developed up and down Britain and across the world.  The patient questionnaire developed by a hospital that helps a department improve their procedures and treatment.  The technique that helps an autistic child understand a concept or event in History that they previously had trouble with.  It is the instinct of public sector workers to spread this good practice, and it benefits us all when they do.

What puts this at risk is the idea of competition, which is a necessary companion to the choice agenda in public services.  Managers will likely clamp down on cooperation and spreading of good ideas, or at least slap a price tag on it.  This will harm us all, and damage our public services.

It is commonly said that what people want isn’t choice, but just a good, local, hospital, dentist or GP surgery, or school.  This is true in several different ways.  The first, most obvious one, is convenience.  I live in a largely rural area, and have always thought that the rhetoric of Government ministers always seemed to ignore the fact that if choice made the local hospital a danger to health, it is slightly more than a quick tube ride to the next nearest hospital.  Rather it is a lengthy journey on unreliable, infrequent, expensive and often non-existent public transport.  Even if you do live in a large city, it can be the difference between a half-day and a full day’s wages lost.

The second one is that people don’t like choice, not necessarily in a conscious sense, but in the sense that choice can leave you more dissatisfied than a lack of choice.  After all, if you choose something and it is lacking in some way, you are likely to experience regret, perhaps guilt, and dwell on the choice that you could have made that in hindsight would have been better.

If in the case of schools, choice has a toxic effect on the parents, children and schools, in healthcare the public’s reluctance to choose anything other than their local hospital and GP surgery has agitated some of the thrusting modernisers.  In the most recent issue of Private Eye, the health editor, the doctor and comedian Phil Hammond, notes that some of the ‘reformers’ want to generate more ‘churn’ in the rolls at GP surgeries.  Apparently, people aren’t chopping and changing their GPs like washing up liquid.

The mindset (rightly mocked by Dr. Hammond), that compares the long-term relationship, built on trust, mutual knowledge and respect, between a patient and their GP, to choosing an interchangable product that doesn’t require these qualities (which can’t be measured of course, and are therefore deemed worthless), sums up the philistinism, ignorance, and blind allegiance to ‘markets’ and ‘private enterprise’ that infects the managerialist half-wits that makes up the British ruling class.

I don’t want to advocate the 1945-79 social democratic, paternalist model as a perfect one by any means.  It did work though, particularly after grammar schools were abolished across most of the country (though not, scandalously, in my local authority).  Certainly in terms of overall provision to working class people, and the ability to collectively improve through collaboration and cooperation.

I would favour a system where the choice isn’t the narrow Blairite one between competing service providers, but the ability to involve yourself in the running of local services, either as a worker, a patient, or concerned citizen.  This concept of popular democratic control and accountabilty is one we must argue for, while we do the necessary work of defending universalist, publicly owned services which constituted a historic advance for the working class, and provide something that can be built on and improved through thorough democratisation and mass participation.

Advertisements