It has now been ten years since I finished my work as an independent reviewer for the UK government.
I had never done such a thing before, but they needed someone from outside government to look dispassionately at the way people were using their choices in public services – and decide what barriers there were to prevent them.
I fear the only effect I had was to excise the word ‘choice’ from the government lectionary. I haven’t heard a minister mention the word since I hung up my official clipboard.
This may have been because I pointed out in my report that all three political traditions mean something completely different by the word. In the Department of Health alone, there were two entirely different approaches working next door to each other.
So I organised and listened to a dizzying number of round tables to find out, and must have spoken to well over a 100 service users face to face, and almost as many professionals.
But one in particular stands out.
She had muscular dystrophy and had to see her consultant every six months, which meant a two-hour round trip plus half an hour or more in the waiting room. It meant going over the Humber bridge and paying a toll, and all she said when the doctor asked her how she was – was ‘I’m fine’.
What she really wanted was to check in occasionally by phone, and see him when she wasn’t fine.
But she couldn’t do that because his slots were full seeing people who were also fine.
What struck me about her was that she was asking for something quite simple, though important to her as a long-term patient. It was a ‘choice’ about her treatment, in a sense, but not one that is recognised currently by the system in the UK.
The new emphasis would be, not so much on choosing between regulated options, but making services flexible enough to suit individuals better – closer to the ‘personalisation’ agenda in social care, where service users can get budgets they can (theoretically, at least) use in ways they believe are best suited to their needs.
The best approach may be to find ways to strengthen the confidence of service users to ask for something different, and perhaps provide duties on service providers to consider this.
I imagine this would be like a ‘right to request’ flexible service delivery.
In each case, the provider would not be obliged to provide flexibility if it is impossible, but they would be obliged to explain why and that letter must be posted on their website.
It would be aimed particularly at situations where systems or bureaucratic arrangements get in the way of what people need.
For example, if they want the choice of a consultant who won’t mind them asking lots of questions.
Or to study Spanish at A level when all that prevents them is their school’s timetabling system.
Or to go to bed later than 5pm when their carer comes round.
These are basic flexibilities in the system which articulate people can often get now by being assertive, but which others can’t.
There are certainly possible objections to this kind of approach. Patients may choose badly. They may fail to take responsibility for the wider system, by misusing the flexibilities they are offered.
There may also be higher costs from treating people more individually, and the costs will come before the potential savings are available. Financial innovations which tie professionals too closely to narrow numerical outcomes, like the current experiments with ‘Payment By Results’, may also make flexibility more difficult to achieve.
A more flexible system would mean fewer set systems, but more human connection. That would certainly require up-front investment.
It would also mean a rigorous concentration on preventing those diseconomies of scale that cost so much in the inflexible systems we have developed.