House of Commons - Public Administration

Select Committee on Public Administration Fourth Report

2 THE GOVERNMENT'S PLANS FOR CHOICE AND VOICE IN PUBLIC SERVICES

7. This chapter outlines the background to the Government's existing programmes and plans for the future of choice and voice in public services. It describes two main types of public service choice: one in which users are offered a choice of "provider" (for instance a choice between hospitals or schools) and the other where choices are offered without any option as to the provider (what has been called "choice from variety", which might include choice of school subject or medical treatment). We also outline the Government's plans to give people a more active say in the running of services—what is usually called "voice".

8. Governments have for some time promised greater choice for those who use public services. But in recent years the idea of choice has begun to play a far more prominent role in the debate on public service reform. The notion of minimum rights for service users was set out in detail for the first time under the Major administration in the Citizen's Charter of the early 1990s. However, it was after the election of the present Government in 1997 that the idea of users also being given choices as consumers of public services gained greater currency. In March 1999 the Modernising Government White Paper set out Ministers' plans for reforming the machinery of government. One of the White Paper's five commitments was to increase the responsiveness of public services to make them meet the needs of citizens rather than the convenience of service providers. The document declared that:

"People are exercising choice and demanding higher quality. In the private sector, services standards and service delivery have improved as a result. People are now rightly demanding a better service not just from the private sector but from the public sector too".[

9. In 2001, the Prime Minister said that "the key to reform is redesigning the services around the user—the patient, the pupil, the passenger, the victim of crime".[4] He went on to outline four key principles of public service reform: national standards and accountability; devolution to the frontline; diversity and promotion of alternative providers; and greater choice.

10. In a series of Government policy announcements in June 2004, choice appeared yet more prominently as the central tenet of public service reform. Five year plans on health and education both outlined ways in which services were to be made more responsive to users, with more choices being built in. The Prime Minister told his monthly press conference:

Choice of provider

11. There are many categories of choice, but the schemes that have been most widely debated and most contested have been intended to give patients, parents and tenants a choice of service provider. These schemes for choice of provider in Britain have tended to be:

introduced across the whole country;

highly publicised;

the cause of widespread ideological and/or political debate;

based at least partly on greater use of private or voluntary sector providers; and

intended to offer single and fairly straightforward choices, often for those who do not make heavy and repeated use of complex and multiple public services.

12. We now examine in more detail a number of such schemes.

CHOICE OF SECONDARY SCHOOL

13. A great deal of choice is already, in theory, available to parents of children who are moving on to secondary education. The 1944 Education Act introduced a requirement for local authorities to have regard to parental choice in secondary education. This right has been central to legislation in succeeding years, including the 1988 Education Act which extended choice by widening the scope of parental preference beyond the boundaries of the child's home Local Education Authority.

14. However, the right to express a preference for a school does not mean that the child is guaranteed a place at the preferred school. If a parent applies to a school and there is room, he or she must be offered a place (unless, for example, it is a specialist school and the child does not meet the requirement). If, however, there are more applicants than places, the admissions authority will use "oversubscription" criteria to decide which pupil should be offered a place. These criteria are published each year by the admission authority (which is either the Local Education Authority or the school itself if the school is voluntary-aided). Some commonly used criteria include: whether the child has a sibling already at that school; whether the child lives in the catchment area of the school; and whether the child and his or her family is of a particular faith. If a child fails to get into a school of his or her choice they have a right to appeal to an independent appeals panel. A further right of appeal, to the Local Government Ombudsman, also exists. There is in addition the Schools Adjudicator, to whom parents can appeal if they object to the published admissions arrangements.

15. Some changes are now being made to the arrangements by which secondary school places are decided, with the intention of reducing or removing parents' opportunities for manipulating the system to their advantage. At present parents may make applications to schools in more than one admission authority, and may therefore receive more than one offer of a place for their child. From the applications round in 2005, parents will complete the common application form of the local education authority in which they live, and use the form to apply to any maintained schools they wish, regardless of where they are situated. The local education authority will act as a clearing house and notify the admission authorities of the school to which an application had been made. The admission authority will notify the local education authority about whether the child can be offered a place. Where a parent can be offered more than one place, the local education authority will apply criteria to decide which place is offered.

16. In another move towards wider choice, the Government is committed to increasing diversity in the types of secondary schools, with a substantial growth in the number of specialist schools and academies. Almost two-thirds of secondary schools already have specialist status. There is also to be increased freedom for all secondary schools to own their own buildings, manage their assets, employ their staff and engage outside partners. Schools will find it easier to expand and it will become easier to establish new schools. The long term aim is to establish a system that gives "every parent and pupil the choice of an excellent education".[6] As Dr Philip Hunter, the Chief Schools Adjudicator, said, "There is now far more for parents to choose from. All political parties are keen to develop schools that pupils, parents and staff perceive as tailor-made for them".[7]

CHOICE OF HEALTHCARE PROVIDER

17. In this section we concentrate in particular on patients' choice of hospital for surgery and other treatment. At one time there was a strong tradition of choice of provider in the NHS. Professor Allyson Pollock of University College London explained that:

"until 1991 there was extraordinary choice in terms of providers. All patients were entitled to second or third opinions, and to go to the provider of choice".[

18. However, a series of NHS reforms, including the development in the late 1980s and early 1990s of the internal market, as the NAO told the Committee, "effectively limited the extent of cross boundary movement and halted the previous pattern of referrals. Non-fundholding GPs in particular became limited in the choice of specialist to whom they could refer their patients, although the Patient's Charter did provide for the right to be referred 'to a consultant acceptable [to you]'".[9] The internal market was abolished in the late 1990s by the new administration, which then went on to create Primary Care Trusts to act as the main commissioners of hospital services.

At the beginning of the current century the idea of choice began to move to the forefront of the NHS debate. The 19. Patient Choice scheme in coronary heart disease was introduced on 1 July 2002 as a national pilot. Under this scheme, a patient who has been on a waiting list for a heart operation for six months is offered the choice of remaining on the waiting list of the same hospital until an appointment becomes available, or transferring to the list at another hospital where he or she can be treated sooner.

20. A similar scheme, the London Patient Choice Project, was established in October 2002 to increase the options for patients who are clinically eligible for elective treatment and who have been waiting for treatment at an NHS London hospital for some time. The scheme currently covers orthopaedics, ear nose and throat, general surgery and urology procedures. Beginning in July 2004, the scheme has also included a number of projects which offer choice at the point of referral, which avoids the need to be on a waiting list for six months. The London scheme has to date offered choice to 18,427 patients, and has had an encouraging overall take-up rate of 66%.

21. The Government announced a timetable for expanding patient choice:

From August 2004, patients waiting more than six months for elective surgery are offered faster treatment at an alternative hospital;
From January 2005, patients requiring cataract surgery (including those referred directly by an optometrist) are offered a choice of hospital at the time they are referred for treatment;
From April 2005, patients who need a heart operation will be offered a choice of hospital at the time they are referred for treatment;
By December 2005, patients who require an elective referral will be offered a choice of 4-5 hospitals (or suitable alternative providers) and a choice of time and date for the booked appointment, at the time they are referred by their GP or primary care professional.[10] The range of service providers would include independent sector hospitals as well as NHS and Foundation Trusts.

22. In order to allow fair comparisons between providers, and to ensure that money follows the patient when they have made a choice, a system known as Payment by Results (PbR) has been established under the NHS reforms. This means that purchasers (normally Primary Care Trusts) will increasingly pay hospital trusts and other providers for the exact amount of activity that they undertake, instead of paying through block agreements. The new payments are adjusted for "casemix"—the difficulty and complexity of the procedures involved.

CHOICE OF MANAGER OF SOCIAL HOUSING STOCK

23. There have also been moves to extend choice of provider in the field of social housing. All homes in the social housing sector have to comply with the Decent Homes standard by 2010, as first set out by the Housing Green Paper of April 2000.[11] Since 2001, the Government has refused to provide specific funding for the achievement of the Decent Homes target for stock retained under the management of local authorities. Unless local authorities are able to fund the achievement of the Decent Homes target out of their existing funding streams, they have a number of options, which all entail moving the ownership or management of the housing stock partly or wholly out of council control: stock transfer to a registered social landlord, the establishment of an arm's length management organisation (ALMO), or the creation of a Private Finance Initiative (PFI) scheme. In the latter two cases, the council retains the management of the housing stock, though these schemes are only available to high performing councils. All local authorities are obliged to carry out a thorough options appraisal and have it approved by the Government Office in their region no later than July 2005.

DIRECT PAYMENTS FOR SOCIAL CARE

24. Direct payments enable individuals to choose to purchase social care from a number of providers, rather than the council choosing a provider for all their residents. Direct payments allow individuals to purchase services from their own support workers, sometimes called personal assistants. This means that individual direct payments recipients can become employers. According to the Department of Health website "Giving money in place of social care services means people have greater choice and control over their lives, and are able to make their own decisions about how care is delivered".[12]

25. The scheme began as an option for councils, but from April 2003 local authorities have been required to offer direct payments to all eligible individuals (disabled people aged 16 or over, to people with parental responsibility for disabled children and to carers aged 16 or over in respect of carer services). Following the April 2003 policy change, figures for take-up rose considerably from 9,300 adults aged 18 and over in 2002-03 to 17,000 during 2003-04. The National Consumer Council's Independent Commision on Public Services praised the direct payments system for improving accountability and promoting independence.[13]

Choice from variety: some alternative dimensions

26. But choice of provider is only one of the many choices that are or might be made available to users of public services. The Government memorandum produced for this inquiry acknowledges that "giving a choice of provider is not always practical or desirable, and examples from local government demonstrate that the alternative dimensions of choice can also provide positive outcomes for users".[14] The Local Government Information Unit categorised these alternative choices as 'choosing from variety':

27. Some of these schemes identified as "choice from variety", where choice of provider is not offered, enjoy a warm welcome among professionals and among users. In this respect, their reception is sometimes in contrast to the unsympathetic response to some schemes which offer a choice of provider. This is perhaps because schemes offering choice from variety tend to be significantly different from those offering choice of provider:

often, though not invariably, small-scale and local;
based on the use of existing providers, overwhelmingly in the public sector;
not very highly publicised;
long-term; and
intended for heavy users of (often multiple) public services.

28. We examine below a number of programmes which have been introduced by Ministers with the aim of offering greater choice from variety, an approach which has clear similarities to what the Government has described as "personalisation".[16]

PERSONALISED LEARNING

29. The Government has, for instance, recognised that schools need to adapt more effectively to the requirements of individual students. The former Schools Minister, David Miliband MP, has said:

"…we need to embrace individual empowerment within as well as between schools. This leads straight to the promise of personalised learning. It means building the organisation of schooling around the needs, interests and aptitudes of individual pupils; it makes shaping teaching around the way different youngsters learn; it means taking the case to nurture the unique talents of every pupil".[

30. As part of the Government's "personalised learning agenda", all schools are encouraged to hold reviews with pupils at the end of Key Stage 3 (age 14) that leads to the development of an individual learning plan.

EXPERT PATIENTS PROGRAMME

31. Although such "personalised" services are planned largely by professionals and provided to patients or clients, other approaches go further, offering users the chance to build up the skills to design their own services and to have an active role in working out how they are managed. The Expert Patients Programme (EPP), for example, is a Government initiative which appears to offer more real choice to patients. This is an NHS-based training programme that provides the opportunity for people who live with long-term chronic conditions to develop new skills to manage their condition better on a day-to-day basis. Set up in April 2002, it is based on research which suggests that "people living with chronic illnesses are often in the best position to know what they need in managing their own condition. Provided with the necessary 'self-management' skills, they can make a tangible impact on their disease and quality of life more generally".[18]

32. Pilot EPP courses began in 2002, and by May 2004 about 300 Primary Care Trusts had either implemented pilot courses or had committed themselves to joining. The NHS estimates that up to 19,000 patients will have benefited from this series of pilots by the time they finish.

CHOICE-BASED LETTING

33. Traditionally, social housing in the UK has been allocated by housing officers on the basis of the comparative needs of those applying for housing. The Government has judged that this approach offers too little choice for tenants. A new choice-based lettings (CBL) pilot scheme began to operate in April 2001 following the April 2000 Green Paper 'Quality and Opportunity for All'. A programme of 27 CBL pilots was supported with £13m from the Office of the Deputy Prime Minister (ODPM), with the aim of testing different approaches to providing choice in different contexts. The most popular model of choice-based lettings in the UK is based on the Delft system which has been in operation in the Netherlands for over ten years. This involves giving the prospective tenants, rather than a housing officer, the decision as to whether to apply for a property. The Government now plans that all local authorities should have introduced schemes for CBL by 2010.

When provider choice may not be appropriate

34. Although choice can be valuable in giving users more power and control, we also recognise that it is not appropriate for every public service. Many services, especially those intended for the most vulnerable, are inherently sensitive, and we heard evidence of the difficulty of introducing greater choice in those services. For instance, the Sainsbury Centre for Mental Health demonstrated clearly that wider choice in mental health services could prove difficult to deliver:

"choice in mental health care will inevitably be constructed differently to other areas because, for example:

many people come into the system compulsorily—they do not have an option of exit;

most services are organised geographically—community services are limited to specific areas so choosing between them is not an option".[

35. The Centre pointed out that the "episodic nature" of many mental illnesses meant that patients were sometimes incapable of making choices because of their condition, while at other times they were perfectly able to consider the options. Moreover, in complex services working with scarce resources, one person's choice can be another's shortage, as the Democratic Health Network argued:

36. Some public services are inevitably collective in nature and therefore not well-suited to schemes to increase individual choice. It is evident that people are not able to choose what police force, or army, to use. As the Local Government Information Unit pointed out:

The role of "voice"

37. In any case, wider choice is only one aspect of the policy of reform. The Government has come to believe that greater involvement by individual citizens in public bodies is also needed if public services are to improve. Effective representative institutions, complaints systems and user surveys—all mechanisms for giving users a "voice"—are also necessary to maintain services that respond to changes in the needs and preferences of users.

38. The Chancellor of the Duchy of Lancaster, Rt Hon Alan Milburn MP, explained the background in December 2004:

"reinventing government means reinventing the relationship between the state, services and citizens. It is time to take politics out of Whitehall, even beyond the town hall—to reconnect politics and the public where it counts most—in local communities".[

39. Referring to the falling turnout in elections, Mr Milburn identified an underlying democratic weakness "the public is not so much turned off by politics, as the way politics is done. Or for that matter, the way public services are run. Too often we shut people out when we should be letting them in".[23]

40. The Government clearly values the power and control that choice can give the service user who may be frustrated by the lack of a proper voice. For the NHS, Rt Hon John Hutton MP, Minister of State for Health, made the case for choice and voice to work together to bring better NHS services. He argued that giving service users a voice without allowing them to exit the service and choose another limited the effectiveness of voice:

41. Ministers have also made the complementary point that choice without "voice" is much less effective. As David Miliband MP, when Schools Minister, said "choice and voice are strengthened by the presence of each other: the threat of exit makes companies and parties listen; the ability to make your voice heard provides a tool to the consumer who does not want to change shops, or political parties, every time they are unhappy".[25]

THE GOVERNMENT'S PLANS: MORE VOICE FOR THE USER

42. The Government has recently begun to flesh out its broad statements on user voice with some more detailed proposals. To help correct the shortfall in democratic involvement he describes, Mr Milburn makes it clear that "giving individual citizens more information and more choice" is critical to reform, and puts particular stress on what he called "new mechanisms… for empowerment". These include citizens' juries and community surveys, but also new bodies aimed at shifting accountability "outwards and downwards". Neighbourhood-level decision-making as part of the New Deal for Communities scheme is seen as a pioneer, but other similar moves in building up local decision-making bodies to help fight crime and poor urban environments are being developed. Mr Milburn also applauds more radical innovations in cities in Brazil and the USA, which give people direct control over their neighbourhood's budgets and services. He comments "the results are impressive—both for public engagement, and service improvement".[26]

43. These statements have been followed by the publication of the ODPM's Five Year plan, along with two papers 'Citizen Engagement and Public Services: Why neighbourhoods matter' and 'Vibrant Local Leadership'.[27] Together they set out a number of proposals for involving communities more effectively in decision making. There are proposals for Neighbourhood Charters which set out standards of the services which local people can expect, and the control or influence that local people would exercise over these services. This might include giving local people the power to require action if the quality of service they receive falls below minimum standards, delegating budgets to ward councillors, who would be encouraged to take on a greater community advocacy and leadership role, and giving communities ownership of local assets.

44. Whilst the Government is planning to allow local authorities to devolve power to communities and small, very local neighbourhoods, a number of measures are also being taken to bolster traditional local government. The Government is revisiting the use of directly elected mayors to provide leadership for local government. It is also proposing to accept a recommendation of the Electoral Commission which aims to make democratic structures easier to understand by moving to all-out election for all councils in England every four years, in place of the present system of staggered elections. Local councillors are to be encouraged to be effective advocates and leaders for wards and neighbourhoods, and should be "at the heart of neighbourhood arrangements, stimulating the local voice, listening to it, and representing it at local level".[28] The Government states that:

Conclusion: the benefits of choice and voice

45. The Government, then, believes that wider choice, and especially choice of provider, is vital to give users a central role in public services, while a stronger voice through a range of representative public bodies and complaint and redress mechanisms is needed to complement it. Choice and voice, Ministers believe, can work together to ensure that public services are responsive.

3 Cabinet Office, Modernising Government White Paper, Cm 4331, 1999, para 9 Back

4 Prime Minister's Speech on Public Service Reform, 16 October 2001 Back

5 Prime Minister's Press Conference, 15 June 2004 Back

6 Department for Education and Skills, Five Year Strategy for Children and Learners, Cm 6272, July 2004 Back

7 Philip Hunter, "Schools: more options: less choice", The Guardian, 9 March 2004 Back

8 Q167 Back

9 CVP 12, para 30 Back

10 Department of Health, "Choose and Book"-Patients Choice of Hospital and Booked Appointment: Policy framework for choice and booking at the point of referral, August 2004 Back

11 Department for Environment Transport and the Regions, Quality and Choice: A Decent Home for All-The Housing Green Paper, April 2000. The Government defines a decent home as being "warm, waterproof" and with "reasonably modern facilities". The ODPM's PSA target 7 for the 2004 Spending Review is "By 2010, bring all social housing into a decent condition with most of this improvement taking place in deprived areas, and for vulnerable households in the private sector, including families with children, increase the proportion who live in homes that are in decent condition." Back

12 www.dh.gov.uk Back