Public services: of choice and voice

http://www.guardian.co.uk/commentisfree/2013/jan/27/public-services-choice

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"When I use a word, it means what I choose it to mean," as Humpty Dumpty explained to Alice. "Neither more, nor less." So it is when politicians discuss choice in public services: in their hands, the very term becomes as multifaceted as a diamond. Is it about competition or cost? Quality or transparency? These questions have only got more vexed in David Cameron's age of austerity.

One version of choice was on display this weekend as thousands protested against the closure of accident and emergency services at Lewisham hospital – part of the fallout of a costly PFI scheme meant to give patients a better service. That is what you might call Bad Choice: botched improvements on the cheap. But late last week there was also something you might call Good Choice: a thoughtful review of what choice means to patients of the health service, users of social care, and school pupils (and their parents). And it came from the Cabinet Office, of all places. The first thing to say about the Barriers to Choice study is that it doesn't feel like a government review at all. As an independent author, David Boyle is evidently not all steamed up about bringing in more private-sector players. He is also refreshingly level-headed about the benefits of providing patients and parents with ever more information: none of those Google-your-way-to-a-heart-transplant enthusiasms indulged in by Mr Cameron and Steve Hilton at their most tiggerish. But this very lack of Conservatism is what makes Mr Boyle's survey so interesting, because here may be the makings of a Lib Dem view of public-service reform.

As the review points out, the public like the idea of choice, but are both confused about what it means – flexibility in choosing a hospital, for instance, or responsibility for mapping out your entire treatment – and find it difficult to actually exercise. This is especially the case for those from disadvantaged groups, who don't have internet access to research options, say, or a car to take them to the best hospital. Mr Boyle confines himself to making a limited number of relatively modest recommendations: allowing those under care having some say about when they go to bed. These are the sort of amendments prospective MPs could explain easily on the doorstep.

The big question is how to extend choice to those less articulate or confident (mandatory patients' representatives, perhaps?). But by pulling the issue away from the old market vs state argument and reframing choice as an issue of user power, Mr Boyle has done us all a favour. Would-be reformers though, should mark the affection the public feel for their institutions, whether the BBC or their local hospital. As one weekend marcher tweeted: "3 generations of my family were born in Lewisham General: me, my Mum and Gran."