Can we afford choice?

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Three articles really caught my attention yesterday. Set against a background of the developing financial crisis that is unfolding within the world banking system, each struck me as an accountant and economist, and not on this occasion as a tax specialist.

Simon Caulkin in the Guardian delivered yet another of his timely pieces on management, at which he is so good. Under the title 'We're getting choice, whether we want it or not' he made the simple, and yet obvious point, that the 'choice' agenda of New Labour is ideological. There is no evidence of demand for it. Worse, it can be positively harmful. As he put it:

The other objection is that choice of this kind is an admission of bankruptcy - a wholesale transfer of responsibility from provider to recipient not only for their own service but for the improvement of the system as a whole. In the NHS, getting proper treatment in a fragmented system already demands near full-time management by a dedicated family member. Even its proponents concede that full-on choice would require that role to be formalised in the shape of 'patient care advisers', significantly adding to cost. As for elderly or otherwise vulnerable people having to assemble their own social care packages - isn't that what adult social care was created to avoid in the first place?

Some degree of choice - call it flexibility - is of course necessary to keep any system running smoothly. But to expect it to 'drive down underperformance' in a badly designed system is hopeless: a costly placebo that won't work.

He's right. And he's also undoubtedly right that:

Contrary to all current trends, almost all public services, from policing to health, are best delivered locally and directly, so that providers can react to the specific needs of their own patch. Where this approach is used, 'choice' becomes a red herring, because people get what they need.

Ironically, in healthcare such a personal-service model already exists. It's called the GP's surgery. If it worked properly, why would anyone need a 'patient care adviser'? Unfortunately, the government seems bent on dismantling it in favour of impersonal treatment and advice factories, where no one 'owns' the patient - no one except themselves, aided by the fabled NHS computer.

In his last sentence he provides a complete explanation of why it doesn't work.

And yet in the Sunday Times we had one of the architects of that failure, in the form of former health minister Alan Milburn, arguing:

People want to know they are not alone. But they want also to control their own destiny. So the modern state has to step forward where citizens individually are weak - providing collective security and opportunity - but step back where citizens individually are strong - exercising personal choice and responsibility.

But this is madness. It assumes three things. First of all that people know what they want. In health, for example, they don't. They know they feel ill, but they don't know if they have a disease or not, or what it might be if they do or how it should be treated, or who might do that, let alone best, or where that service is available. What is more, to give them choice on all these issues might be acceptable when they are well, when they might have the strength, time and energy to find out the right choice for themselves. But if they are really ill then they are quite unable to make such 'choices'. What they actually need in that circumstance is not a 'patient care adviser' to guide them through the NHS; what they need is a person who they know and can rely upon to help them. That's called a GP who can make the decisions they need taken for them and guide them to the best possible solution.

Of course on occasion that will involve some hit and miss. 70% of all patients who present to the NHS never get a diagnosis. Whatever symptoms they have do not fit the medial model of disease and therefore no identifiable cause for their complaint can be identified, and no cure offered. That's not the doctor's fault. That's a limit of understanding (a fact which has passed most in the commercial health sector and minsters by). Even when a diagnosis might be achieved the difficulty of sorting the symptoms until a combination that fits a disease can take time. But who's best to guide that process? A paid 'carer' with little medical knowledge who works as an additional tier to manage a person through the competing levels of the health service, or a GP? It's like asking someone who wants their tax affairs sorted if they'd like a social worker to assist them with the task of finding the right combination of accountants to provide the help they need, or would they like an accountant who can do it all? It really is like that. And since GPs still have about the highest level of professional service satisfaction rating in the UK - many, many times that of accountants., for example I think we can answer that question quite simply in this case. And it's also obvious which choice (in both cases) is the most efficient and, inevitably, the cheapest.

In other words, choice is the last thing people want form the health care system. What they want are people who can get them better as fast as they can, or at least reassure them as to how they might live with the symptoms when a cure is not known. Choice offers no solution here. It assumes, and this is my second point, that there is an answer to every demand. And that is not the case. Thirdly, Alan Milburn's madness assumes we have unlimited resources available to provide this 'choice'.

But let's be clear about what 'choice' requires. It demands that we create excess capacity in our systems, so that we can always have an either / or option. At least some of the time the 'or' has to go to waste or the choice is not available. Do we want to create that option in health, education, policing and so on, our core public services? Do we want to pay that price? It is enormous, and it's the cost of choice that is pushing up the price of healthcare now but without perception of improved service. That's because we aren't getting improved service: we're investing in waste to provide choice.

But do we also want to accept that those who are rejected should fail? Do we want a hospital to close because it's optional services are not being chosen? What happens then when emergencies arise? What happens then to those who cannot travel? What happens then to the community with no service at all? And what happens to the good services in that place, because it is rare that a hospital or GP surgery or whatever will always be good or bad? Can we afford this price of failure.

Which took me to my third article, which was by Will Hutton in the Guardian. He's a man about whom I can blow hot and cold, very easily. In his article today entitled 'A deluded Wall Street threatens the world economy' he makes the point that the banking crisis is the result of:

The Americans hav[ing] invented a system with no commitment, trust or long-term human relationships and the result is mayhem.

That's what market choice provided. And yet the choice was illusory. Worse, it was a charade because the banks that supposedly epitomised the free enterprise culture were in fact trading in products which were not what they seemed, about which there was massive information supplied, and which failed to deliver expectation (in this case, financial credibility). The reason is simple: these things could be traded, and choice could be made between them but no one was being paid to stand up and say 'you're choosing between false options - none of these things work'. Wisdom was priced out of the market. The expertise needed to stand back and say 'this will end in tears' was swept away in the desire to make money from the next trade.

But we all knew it was mad. We all knew house prices could not rise for ever. We all knew mortgage multiples were unsustainable. The wisdom was there, but the mad men who were on the make believed that so long as they could trade in choices, however illusory they might be and however ill suited they were to meet the needs of real people, all would be well.

This is why markets fail. This is why those with almost no understanding of them like Alan Milburn are so dangerous. This is why his option of 'choice' has to be rejected, very firmly.

Right now we're going to see a loot of belts tightened. That is going to require choice. And the best choice that can be made for public services right now is to eliminate choice. The best option is to rely on experts who can decide upon the basis of incomplete information what is likely to be best,m and who can live with the risk that they might be wrong (as will always be the case, on occasion). It is to give the experts the tools they need. To give teachers the resources in classrooms, and the flexibility to use them best with the children who sit in front of them. To give GPs the time they need with patients, and to not have to spend their time advising patients how to book their appointments on line. To give hospital staff the resources they need, and not have to spend much of their day buying and selling operations completely meaninglessly within an NHS internal market where all services are bought and sold are from the same person (the state) at the end of the day.

Cut the choice. But supply the service. Use the capacity of the resources we have to best effect. Assume it is possible that people might get things right, and might when that confidence is placed in them, seek to do so, most if not all the time. Eliminate always the paperwork first (so put hospitals, ambulance services, GPs and mental health services, for example, all under one authority that will not spend endless hours at vast cost reconciling meaningless accounting statements). Commit to servicing the need, not providing meaningless choice. Do it locally, so as Simon Caulkin says, people have some say (and if necessary do this by electing some of the board members) but whatever is done, let people use their wisdom.

Wisdom is the scarcest resource we have. And it is not marketable. It cannot be priced. It has value beyond measure, making it invaluable. Markets equate price with value. That's why wisdom questions markets.

Alan Milburn isn't wise.