Memorandum by the National Consumer Council
(CVP 04)
The National Consumer Council (NCC) is an independent
consumer expert, championing the consumer interest to bring about
change for the benefit of all consumers. We do this by working
with people and organisations that can make change happen—governments,
regulators, business and people and organisations who speak on
behalf of consumers.
We are independent of government and all other
interests. We conduct rigorous research and policy analysis and
draw on the experiences of consumers and other consumer organisations.
We have linked organisations in England, Scotland and Wales, and
a close relationship with colleagues in Northern Ireland. And
we work with consumer organisations in Europe and worldwide to
influence governments and institutions.
We are a non-departmental body, limited by guarantee,
and funded mostly by the Department of Trade and Industry.
This memorandum responds to a request from the
Clerk of the Committee for a written submission in connection
with the Committee's Inquiry into Choice and Voice in Public Services.
INTRODUCTION
The NCC has a long-standing commitment to ensure
that people have a voice in the provision of the services and
products that affect the quality and experience of their lives.
But today's consumers are highly sceptical about involvement processes,
believing that even when they are consulted it is often cosmetic.
To promote the necessary shift in attitude from public service
providers and other bodies to make consumer involvement an essential
part of their everyday operations, the NCC published the report
Involving consumers: everyone benefits (September 2002—link
provided at end of document).
This report was the result of a major project
that examined the benefits of, and investigated the barriers to,
consumer involvement. The report showed that consumer voice is
an essential ingredient of good policy-making. The NCC recommended
that there should be:
— A central strategy for consumer involvement
that makes it a priority as part of public service reform.
— Greater co-operation between public
bodies, and joint working arrangements where appropriate.
— Practical support to make it work
that includes training, tools and techniques and sharing of good
practice.
The NCC is also concerned that the much talked-about
consumer apathy is a myth. A survey conducted for the NCC by MORI
showed that, despite consumer scepticism, people are keen to be
active, with nearly 70% of those surveyed reporting that they
had been active in some way in the past. Activities ranged from
contacting their local councillor or MP; going to a public meeting;
getting in touch with an advice agency; joining a local group
(such as parent/teacher association or passenger group); and organising
a petition.
When consumer involvement is done well it can
help service providers design and deliver services that genuinely
meet people's needs, boost standards, identify problem areas and
provide value for money.
DEFINITION OF
CHOICE
In 2003 the NCC held several focus groups and
commissioned some research by MORI, on behalf of the NHS which
started looking at the issues surrounding choice and tried to
examine a possible definition for the word. The findings showed
that in general participants felt that they did not have any choice
at present. They were concerned that all doctors' and dentists'
books are filled and that there is a restriction that confines
them to treating only people who live within a three-mile radius
of their surgery.
Respondents found it difficult to come to terms
with choice, not really understanding how it would work. Overall,
respondents felt that having a choice would be a good thing, although
there were some contradictory arguments, as some people felt that
GPs were the experts and should be able to tell you what to do.
While most people felt that they didn't currently
have any choice, it should be noted that most people also felt
that they didn't want choice. There was a widespread feeling that
people weren't used to exercising choice in healthcare, and some
felt that choice was an artificial concept in healthcare. For
example, choice of treatments came low down people's priorities,
as many participants felt that the expert opinion of doctors should
not be challenged and that there shouldn't be any "bad"
doctors.
For the less affluent—most participants
saw that the challenges to the NHS overall were to improve services
in general, rather than implement "choice". Choice was
a secondary concern when placed alongside being treated well,
quickly, efficiently and effectively. However, some did feel that
choice would mean that patients could leave poorly performing
hospitals for better hospitals and this would force these failing
hospitals to address these problems.
Some perceived barriers to choice were evident
in the responses of this focus group. For example, it was apparent
that patients were unaware that they have a choice of treatment
or hospital, as doctors do not inform them. It was also mentioned
that there often wasn't time to discuss treatment options in a
doctor's appointment.
Overall, respondents felt that having a choice
would be a good thing in theory, although doubts were expressed
as to the practical application of choice. Group participants
felt that they did not have any choice at present in NHS services.
They found it difficult to relate the concept of "choice"
to healthcare—as one participant noted, people in Britain
are not used to exercising choice in this arena of their lives.
Another felt that choice could only ever be based upon past experience,
and that most people do not have sufficient experience of the
NHS to exert that choice.
INDEPENDENT POLICY
COMMISSION
In December 2002, the National Consumer Council
(NCC) set up an independent Policy Commission on Public Services
to examine the current delivery of services to consumers and to
try to answer three overarching questions:
— What is the relationship between
choice and equity?
— What is the relationship between
consumers and citizens?
— Are consumer expectations of public
service changing?
From the beginning it was understood that the
Commission would be properly independent of the NCC and, within
the broad terms of its remit, free to undertake a wide-ranging
investigation of the current state of public services from the
consumer viewpoint. This the Commission did, using as reference
four specific public service sectors: primary health care; personal
social services; secondary education; and physical urban regeneration.
The Commission undertook its work through a
series of workshops and multi-disciplinary, cross-stakeholder
seminars with thinkers, regulators, educators, providers, consumers
and professionals across the four service sectors. Over 180 individuals
and organisations were asked to contribute to the work of the
Commission. The Commission's tentative conclusions were further
tested through direct consumer research. The report, making public
services personal: a new compact for public services has just
been published (link attached at end).
CHOICE AND
VOICE
The findings of the Commission suggest that
public service reform is beginning to deliver but progress is
patchy. The report concludes that services must now adapt to social
and cultural change—shifting family structures, growing
individualism and greater diversity of race and culture—or
public confidence may ebb away from key sectors such as health
and education.
The Policy Commission examined how both "choice"
and "voice" should be extended to rebalance services
towards the interests of users. In pursuit of greater responsiveness,
but within public service values, it argues that there should
be more experimentation with funding streams that follow individual
choice. The report also argues that, while choice can be an important
driver to improve quality and make services more responsive, voice
also plays a crucial role in making sure that services really
meet people's needs. The Policy Commission recommends that, as
well as improved public involvement and consultation, government
should use its purchasing power to embed stakeholder engagement
throughout the service delivery chain.
A strong message to emerge from the Commission's
discussions with public service users was that people want public
services to be more personal. Users prize the relationship they
have with professionals whose treatment of them colours their
experience.
However, while the report holds that choice
should be extended, there are distinctions about consumer choice
that need to be made. For example, it is necessary to distinguish
between different types of choice (including choice over different
types of service or over different providers, and economic and
non-economic choices) and the limits on choice, for example, where
individual choice conflicts with the public interest.
In addition to choice, the expression of voice
is critical to empowering users. This covers a spectrum from complaint
and redress to full stakeholder dialogue. Voice is a critical
tool in enabling managers, providers, commissioners, procurers
and regulators to balance the conflicts that arise from the allocation
of limited resources, and from competing interests. This voice
must be heard at the point at which services are commissioned,
regulated, inspected and monitored and not just at the point of
supply.
CHOICE
The report puts forward both choice and voice
as effective tools for ensuring responsiveness in public services.
However, neither can be thought of as a panacea and both have
strengths and weaknesses. It is not always the case that individuals
are well enough informed in the exercising of choice. We should,
therefore, deploy choice and voice to best effect where they contribute
to specific outcomes, and also recognise where they do not work,
and know how to proceed when they conflict with the public interest.
In some cases, the extension of individual choice
conflicts with the public interest—for example, in the case
of the MMR jab. It is the job of government to ensure the extension
of individual choice does not adversely affect others. The need
for explicit public values that guide arbitration between the
public and consumer interests is paramount. In addition, the report
covers some important considerations in recognising the limits
to choice:
— Choice can compound inequalities
as take-up of choice varies across the social divide.
— Choice can compound inequalities
when disadvantages like information poverty are not addressed.
Advice, information and advocacy may be needed by vulnerable consumers
to avoid making existing disadvantage even worse.
— Greater clarity is needed on outcomes
when introducing choice. For example, an outcome could be to rebalance
disadvantage or discourage exit from public services by the more
affluent.
— A lack of clarity of the technical
indicators that warn that choice is not effective. This occurs,
for example, when service providers cannot accommodate greater
consumer power, when there is no flexibility regarding resources
or when economic means (such as vouchers) are not sufficient to
compensate for different needs.
VOICE
The report considers the democratisation of
public services across a spectrum, which includes public involvement
and consultation, stakeholding and public involvement in new forms
of governance. The Commission holds that there is a disconnection
between people and public services when the public is limited
to expressing its voice by the rather abstract rights afforded
through citizenship. Users need to be able to make choices at
an individual level, to contribute to the negotiation between
different groups of interest at a stakeholder level, and voice
opinion as part of the wider collective public interest.
While the report calls for a greater extension
of voice for users at an individual and stakeholder level, it
recognises the following constraints:
— The extension of voice is dictated
and managed by providers and therefore does not offer the same
bottom-up empowerment that choice affords.
— Consultation processes can conflict
with efficiency if the desired ends are not clear or if they are
unrealistic.
— Stakeholder processes are subject
to capture by unrepresentative groups if not carefully managed.
— Involvement and consultation that
doesn't affect outcomes can increase cynicism and contribute to
"consultation fatigue".
— User involvement in governance needs
to be matched by a mature understanding of risk sharing if individuals
are to take on greater responsibility for decisions that directly
affect others.
— Processes involving the public need
to develop in sophistication and appropriate use if they are to
build public confidence. Experience in this remains limited, particularly
in the area of governance.
CUSTOMER SATISFACTION
In February 2004 NCC wrote to selected Government
Departments regarding their Public Service Agreements (PSAs) and
in view of the Comprehensive Spending Review (CSR) 2004.
Whilst we welcome the current Public Service
Agreements (PSA) we feel that the government needs to ensure that
consumers are at the heart of policy. The NCC is concerned that
only seven out of around 130 PSAs focus explicitly on customer
satisfaction. There are a number more which focus implicitly on
customer satisfaction. However the NCC would like to see more
quantifiable consumer-focused measures at the heart of the next
round of PSAs, through:
(a) Explicit inclusion of improved satisfaction
or experience of your public service users in the formulation
of PSAs and/or;
(b) The explicit application of customer
satisfaction measures as a way of assessing PSAs. We understand
that PSA formulation is not changing in this CSR 2004 but we do
want to highlight the implicit impact on customer experiences.
The NCC would like to see the Government's commitment
reflected in a further range of realistic targets.
NCC will be considering the Policy Commission's
findings over the coming months and will be more than happy to
discuss these issues further with the Committee. For your information
please find enclosed Chapter Three of the report which relates
specifically to "choice and voice".
I enclose below the link to the full Policy
Commission report:
http://www.ncc.org.uk/pubs/pdf/policy_commission.pdf
The link below is to the report Involving
consumers: everyone benefits
http://www.ncc.org.uk/pubs/pdf/involving_consumers.pdf
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