| Choice
|
| | |
| 1. | The evidence suggests that, while choice is regarded by the public as an important feature of good public services, it is not necessarily their highest priority. Such schemes as direct payments for social care and choice-based lettings demonstrate that users often value the opportunity to take charge of certain decisions about services and to exercise greater power, control and choice in their lives. Some of the most frequent users of public services appear to place greater emphasis on practical choices which have a direct and immediate impact on their quality of life than on the choice of service provider. (Paragraph 142)
|
| 2. | We believe that some of the problems with choice would be eased if there was more acknowledgement of its limitations. Rhetoric does not match the reality. Too often the 'choice' label is applied to schemes in which the most the consumer can hope for is second, third or even fourth choice. It should always be made clear to people what they can realistically expect from the choices they are offered. (Paragraph 144)
|
| 3. | Secondary schools find it difficult to respond flexibly to the demand generated by parental choice. It is unrealistic to expect schools to expand and contract in the way that is sometimes suggested. Nevertheless, educational choice, especially choice of subject, can be enhanced by imaginative collaborations and partnerships between schools which make the most rational use of resources. (Paragraph 146)
|
| 4. | We believe that the evidence shows that specific, limited and targeted schemes for provider choice, such as the London Patient Choice Project and the Coronary Heart Disease Choice scheme make effective use of NHS capacity. They demonstrate that well-designed schemes can help the NHS put choice of provider to good use for the benefit of patients. However, recent ministerial comments about the potential for hospital closures in the era of patient choice raise serious concerns about the future of local service provision, and indeed about the future overall capacity of the NHS. Private hospitals have few additional resources to offer, as most of their major operations are carried out by surgeons who also work in the NHS. (Paragraph 148)
|
| 5. | The introduction of choice-based lettings has eased the process by which tenants are matched with suitable accommodation, and has enabled tenants to take more control. However, there are limits to the amount of popular housing available, and tenants' first choices often cannot be met. The limitations as well as the benefits of such schemes need to be recognised. (Paragraph 150)
|
| 6. | We have concluded that choice can be consistent with equity, but only if schemes are well-designed and motivated by a desire to reduce unfairness. We believe that certain types of selection by provider in a public service can be incompatible both with equity and with the principle of choice for the user. The Government should, in particular, consider the effects on its wider objectives of selection by schools. (Paragraph 154)
|
| 7. | We believe that costs as well as benefits result from the creation of markets and especially the use of private provision in systems to enhance choice in public services. The NHS, for example, is still coming to grips with the implications of the guaranteed level of private sector provision in the current patient choice scheme, and it is likely that it will, to an extent, prove to be wasteful of NHS resources. This effective transfer of commercial risk to the NHS will need very careful monitoring. If necessary, the design of the patient choice system will need to be changed, perhaps with less emphasis on guarantees for private providers. (Paragraph 157)
|
| 8. | The Government's plans to prevent the practice of "cream-skimming" by private providers of public services appear to us to be sketchy and inadequate. Ministers need to make an urgent effort to ensure that private providers do not exploit choice schemes to the detriment of the public interest. (Paragraph 158)
|
| 9. | The Government should also consider the broader public administration implications in cases where direct public provision of services is brought to an end. In particular, Ministers should consider: the effects of the loss of in-house expertise and infrastructure, which can make it difficult to monitor contracts; the earmarking of funds for private contracts for several years ahead, which can bind successors and restrict their ability to set suitable priorities in the public interest; and a loss of knowledge and learning that comes from the removal of direct contact with users. (Paragraph 159)
|
| 10. | We consider that there is the potential for conflict between two central goals of Government policy: the drive to produce efficiency savings and the desire to expand choice for the users of public services. It is also disturbing that there are continuing doubts about the effectiveness and efficiency of the financial and computer systems on which the NHS is basing patient choice. (Paragraph 161)
|
| 11. | We consider that the evidence about the effect on the overall performance of public services of the introduction of greater choice is still scarce and inconclusive. The pilot schemes in health which have been evaluated give some grounds for optimism, but their results will not necessarily read across to the much larger national schemes which are now being introduced. The evidence from the USA and elsewhere on education choice suggests that some schemes are effective while others are not. Choice on its own does not deliver better performance, although it may help. (Paragraph 163)
|
| 12. | Local government can do much on its own initiative to offer more choice to the users of public services. Although some councils may be resisting reform, much innovative work is being done at local level. However, local authorities do not always believe that they receive the appropriate credit and support from central government. The Government must ensure that local government is fully engaged in all relevant aspects of the design of schemes to increase choice. (Paragraph 165)
|
| 13. | We conclude that the Government needs to look more carefully at the detailed design and implementation of schemes for user choice. Evidence from the front line of public services suggests that greater provider choice in NHS healthcare is being introduced with insufficient attention to the need to win the acceptance of either users or staff. We hope that the reforms being carried out to the system by which parents choose secondary schools will be effective in reducing the inequities and distortions which have arisen in the system. (Paragraph 166)
|
| 14. | The Government needs a more coherent approach to the question of what is the most effective method of providing a representative voice for the user of public services. The uncertainties over Sure Start and foundation hospital boards raise questions about the voice of service users. The Government has welcomed innovation in the field of 'choice'; it should equally welcome innovation in 'voice', initiating a programme of pilots to test and assess the merits of various models. (Paragraph 184)
|
| | |
| | |
| Voice |
| | |
| 15. | We repeat our earlier recommendation that the Government should move promptly to introduce legislation to remove the 'MP filter' on cases which are sent to the Parliamentary Ombudsman. There should be early action to modernise the system by which the Ombudsman's jurisdiction is determined, so that it should become the presumption that her jurisdiction includes any central government body. (Paragraph 197)
|
| 16. | We commend comment cards as a straightforward but effective means for establishing user experiences from which the providers can learn and improve their service. (Paragraph 205)
|
| 17. | We believe that there should be a more concerted approach to the measurement of public satisfaction with public services. The Canadian experience has shown that such an approach can be very useful in ensuring that lessons are learned and services improved along the lines that consumers require. Consideration should therefore be given to the development of a Public Satisfaction Index (PSI) which would be used to measure satisfaction with individual services. This should play a part in performance assessment and should be rigorously audited by an independent body such as the National Audit Office or Audit Commission. (Paragraph 209)
|
| 18. | Building on the success of NHS Direct, we believe the trial of a Public Services Direct would be a valuable addition to the voice mechanisms available to users. (Paragraph 210)
|
| 19. | We recognise that, just as there are constraints on choice, there are constraints on voice, whether expressed in representative bodies or through complaints systems and user surveys. More careful and imaginative consideration needs to be given to making voice mechanisms effective. The problems being encountered by the Parliamentary Ombudsman in gaining active and practical Government support for modernisation is one example of the current difficulties. Together, choice and voice can contribute to making public services responsive and giving more power and control to those that use them, but they must be treated with equal seriousness by the Government. (Paragraph 213)
|
| | |
| | |
| Towards responsive public services
|
| | |
| 20. | Patient care advisers have been crucial to the success of the pilot schemes for patient choice. It is clear to us that something similar, and indeed something rather more ambitious, would be of considerable benefit to those patients who are now offered the wider choice of hospital for elective surgery, and in particular those patients who are especially vulnerable and find the NHS system difficult to navigate. We are disappointed that the Government has not yet acted to ensure that adequate support and advice will be available. The Department of Health, working closely and consulting fully with local NHS bodies, should give urgent consideration to encouraging the provision of adequate support, through patient care advisers or other means, to make sure that some patients will not be disadvantaged by the introduction of NHS patient choice. (Paragraph 219)
|
| 21. | The Government should urgently examine the scope for an expansion of the Expert Patients Programme. EPP is an important and innovative way in which patients can equip themselves with the information and expertise needed to strengthen their hand in the era of choice. It needs to be promoted by the Government with much greater vigour and commitment. (Paragraph 225)
|
| 22. | The experience of school lotteries in the USA suggest that there should be further exploration by the Government of the use of that method of allocating places in this country. (Paragraph 227)
|
| 23. | We believe that progressive vouchers should be given serious consideration as one way of combining choice with equity. (Paragraph 228)
|
| 24. | With all these models available, it should be possible to devise a developing set of Public Service Guarantees (PSGs) which may apply either nationally or locally and which would be pledges of services being provided to a minimum standard. They would: support policy outcomes; be precise as to the level of service to be expected (e.g. an operation in six months, or a passport in six weeks); have a clear statement that the service could be delivered by a provider of the user's choice and clear arrangements for redress in the event of failure. (Paragraph 242)
|
| 25. | If public service guarantees are to be credible, they will need to be monitored by a range of bodies which would co-operate to ensure that compliance with performance standards is measured accurately, and that their recommendations for improvement have authority. We are attracted by the idea of a "strategic alliance" of such bodies, which would include the PCA, NAO, the Audit Commission, OFSTED, the Healthcare Commission and others. This would develop common principles and share best practice to inform the work of all the inspecting bodies. The general issue of coherent performance monitoring, across all public services, and the most appropriate organisational arrangements to service this, is one to which the Committee will return. (Paragraph 246)
|
