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The paradox of pablic-service choice

Thu, 31st Mar 2016

In the Looking Glass world of management and economics, words come come adrift from their normal meanings. Sometimes they end up as their opposite, as the impoverished new meaning corrupts or subsumes the old one: consultation, flexibility, accountability, transparency, enhancement come to mind. Or ‘choice’. Competition authorities and economists rule that we have choice in financial services and groceries because there are four or five supermarket or banking chains. Never mind that all our High Streets look identical, supply chains are corrupted (horsemeat), small suppliers and retailers put out of business and every store or agency sells exactly the same things – there’s competition, so we have choice. Yes, I know the only colour is black – but, look, you can buy it from half a dozen suppliers, what more do you want?

The same specialised logic is applied to public services, where it is even less appropriate, and the consequences correspondingly more damaging. Public services are a necessity. Their job is to solve problems, not provide lifestyle choice. If there’s a fire, you want the fire service to put it out, if you’re ill you want to be cured, if there’s a hole in the road you want it filled. If they’re not, you’re pissed off.  As Vanguard’s Richard Davis puts it, ‘In Frederick Herzberg’s terms, they are hygiene factors – things that are necessary rather than desirable... What matters to me is that the service works when I need it, no more, no less. I want a good school nearby, a good hospital nearby, an effective police force ready to help me in my neighbourhood’.

When David Boyle wrote a ‘Barriers to Choice Review’ for the government in 2013, he found that there wasn’t even a glancing relationship between what people thought choice meant and what it meant in practice. Providers and recuoebts just talk past each other, leading to indifference and cynicism at best, despair at worst. ‘The difficulty is that the kind of flexibility in the services that people want, and are increasingly demanding, is also a prerequisite for many people to exercise any choice at all,’ noted Boyle.

What people mean by choice is having a service that starts from where they are rather than where ‘theorists think they should be’. Real choice is to have a carer’s visit when you want it, velcro to fasten your clothes rather than buttons or help to meet your mates for lunch every week, not a choice of medicalised universalist packages which keep you in dependency and none of which fit what you really need. In other words, the choice that people want is exactly what the current systems can’t give them: a public service that works for them, not some commissioner or government minister.

In manufacturing Fordism – scale, standardisation, deskilled labour at the service mass production and consumption – died decades ago, killed off by Toyota when it discovered how to overcome the trade-offs between volume and variety, quality and cost. ‘There is no longer any reason to rule out localisation of economic activity on the grounds of scale economies,’ wrote accountancy professor Tom Johnson. ‘Scale economy, beyond very small volumes, is a concept that should be discarded.’

But, zombie-like, Fordism and its attendant scale still rule in public services, where their deathly grips squeezes the life out of service quality, and with it engagement, community and local agency, all in the name of competition and choice. Scale is a double dead end in services, where by defeating quality it remorselessly raises, not lowers, overall costs. The greater the attempt to lower unit costs, the worse the outcome. This is why what we end up with is the shame of 15-minute care packages delivered by people with time only to fill in the paperwork before rushing on to the next job – an insult to both giver and recipient – and the desperate budget cost-cutting that makes public services another example of reversification: an exercise in rationing that leaves no stone unturned in raising thresholds, minimising service and making the rules so forbidding and baffling that they are almost impossible to comply with.

With this reductio ad absurdum we have reached the very final version of the old Fordist service operating system which, with a non-unionised workforce paid the minimum wage and on zero-hours contracts, simply has nowhere left to go. There are no more negatives or minima to retreat into. Behind it is a profoundly pessimistic, deficit-based view of public services that stigmatises those who receive them as too old, feeble in body or mind or devious to bother with: the choice of which unsatisfactory service to receive is all they deserve.

What we need, of course, is a leap to a new positive post-Fordist operating system for public services based on the idea of choice that people actually do recognise: the choice of help to put a chaotic or temporarily disturbed life together again and take the individual or family out ot the ambit of public services altogether, where the cost to the public purse is zero. This is a strength-based approach focused on self-help and control of one’s own life that aims to reduce demand by building agency, resilience and engagement.

Building this kind of self-rsustaining momentum is what David Cameron and George Osborne should be concentrating on rather than the use of crude extrinsic sticks and carrots – not so much nudge as a blow to the head with a blunt instrument. Not least, it would deliver the language of choice from the grip of Humpty Dumpty: ‘When I use a word,’ Humpty Dumpty said, in rather a scornful tone, ‘it means just what I choose it to mean—neither more nor less.’ ‘The question is,” said Alice, ‘whether you can make words mean so many different things.’ ‘The question is,’ said Humpty Dumpty, ‘which is to be master—that’s all.’


 


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User comments

Henning :: 31st Mar 16
Absolutely brilliant! (What's the garbled word in the third paragraph?)
John Carlisle :: 1st Apr 16
Henning, In answer to your question, I believe it is "receivers". But for me the key principle lacking in economics today is that of DEMAND. I cannot think of the last time a macroeconomist even mentioned it. Yet it is the raison detre for any economic activity.
Andy Lippok :: 1st Apr 16
Great article and so apt for the work in which I'm involved currently. I agree with you John how the word demand is so absent from any of the discourse. Mind you there is hope out there. As I might have mentioned previously I'm helping Scotland to test/experiment with the Buurtzorg approach to health and social care provision. Guys & St Thomas' have just started a test. and the approach is taking off all over the globe. In the Netherlands where it started it is disrupting the whole of the neighbourhood care system - and indeed the wider health system - due to its counterintuitive departure from the traditional model of task & time model of care. So disruptive is that traditional organisations are going bust because they can't compete with the Buurtzorg model of delivery at higher quality and lower cost. Simply brilliant and brilliantly simple - go take a look for yourselves.
Paul Reading :: 7th Apr 16
The public sector has embraced the language of Humpty Dumpty (and 1984) with gusto, so as services are cut, the excited enthusiasm of ever higher remunerated management for babble grows apace; The refusal of the CEO of Southern Health NHS Foundation Trust to resign on grounds she has been "clear and open about the need for improvement" is a typical example. My own organisation is pressing ahead with focus groups to further develop its values whilst actual services crumble under the Government's policy.
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