Hostname: page-component-6898cfcb55-zkb6p Total loading time: 0 Render date: 2026-11-11T06:34:15.338Z Has data issue: false hasContentIssue false
  • English
  • Français

J. Le Grand (2007), The Other Invisible Hand: Delivering Public Service through Competition and Choice. Princeton: Princeton University Press. $14.95, pp. 195, pbk.

Review products

J. Le Grand (2007), The Other Invisible Hand: Delivering Public Service through Competition and Choice. Princeton: Princeton University Press. $14.95, pp. 195, pbk.

Published online by Cambridge University Press:  01 October 2008

ADAM OLIVER
ADAM OLIVER*
Affiliation:
London School of Economics
Rights & Permissions [Opens in a new window]

Abstract

An abstract is not available for this content. As you have access to this content, full HTML content is provided on this page. A PDF of this content is also available in through the ‘Save PDF’ action button.

Information

Type
Review
Information
Journal of Social Policy , Volume 37 , Issue 4 , October 2008, pp. 714 - 716
Copyright
Copyright © Cambridge University Press 2008

Julian Le Grand specifies that the five ‘ends’ of public services are quality, efficiency, responsiveness, accountability and equity, and he argues that there are four possible ‘means’ by which to attempt to achieve these ends; namely, trust, targets, voice and/or choice. In this review I will first consider each of the means in turn, challenging some of the assertions made in the book, although I will confine myself to my own area of expertise – i.e. health care – rather than the broader scope encompassing also education and social care, adopted by Le Grand.

The means

(i) Trust

Le Grand argues that the basic idea behind the trust model is that the ‘government sets the overall budget for the service; those who provide the service spend it as they wish’, but that ‘in spending the budget, these professionals are trusted to do so. . .professionally’ (p. 16). In essence, the trust model, according to Le Grand, assumes that the professionals will act as ‘knights’ to provide a service that is high quality, efficient, responsive, accountable and equitable, but he argues that the perceptions of these paternalistic knights as to what people really ‘value’ may well be limited.

(ii) Targets

Le Grand suggests that targets involve ‘a fairly heavy-handed application of rewards and punishments’ for health care institutions and professionals, applied with respect to performance against given criteria (p. 27). Heavy handedness, however, is not an inevitability in the target model, particularly if the principal source of opposition to targets – i.e. doctors – are involved in the target-setting process. Even if performance management does serve to demoralise the professions, Le Grand's preferred choice model − discussed below, where ‘demands’ on health care managers are theoretically set by patients rather than politicians − may require at least as much ‘command and control’ as targets, given doctors traditional resistance to those who work in management. Le Grand further contends that once a target has been met, there is no incentive to go further (p. 28); however, targets can be periodically reset, as has been the case with considerable success in NHS waiting times targets.

(iii) Voice

Le Grand argues, probably rightly, that the problem with relying on voice is that the relatively disadvantaged in the UK – in terms of income, jobs and education – use fewer public sector services than the relatively advantaged due to the ‘sharper elbows’ of the latter (p. 34). Given that this is the case in health care systems with and without choice, does this lead to a legitimate advocacy of choice?

(iv) Choice

Choice is nonetheless advocated, principally because this model would theoretically provide self-sustaining incentives for providers to offer continual improvements in service. However, as alluded to above, choice may in itself be de-moralising for providers (a point Le Grand himself points out on p. 167). Moreover, the form of competition inherent in patient choice, whereby patients theoretically move across different care sites in search of better service, may not only be demoralising for providers – it may also undermine continuity of care, and thus prove detrimental to health outcomes. Possibly the most contentious argument put forward in favour of choice, however, is that it can improve equity within the system (p. 42), with it being suggested that choice will serve to give voice to those who have traditionally been deprived of this benefit. It is plausible, however, that those who have demonstrated more voice in the past would be the most adept at acquiring and expressing ever-more voice if given the opportunity and encouragement to do so.

Do people want choice?

Le grand cites evidence from a YouGov poll that found that 66 per cent of people considered it important that they have more choice of hospital (p. 48), and a MORI survey that found that 60 per cent of respondents thought that having more choice of health services would improve services, with only 4 per cent thinking that it would make them worse (p. 49). However, these types of questions are arguably flawed in the sense that a description of the possible implications of introducing choice ought also be presented to respondents in these surveys. Respondents might answer quite differently if they were informed that choice may raise patient expectations, fueling health care costs, and thus require additional tax contributions, or that they may make the system more inequitable if those with greater voice use it ever more effectively, or that choice could lead to the closure of some local, seemingly poor performing, hospitals, with the latter possibility being a necessity if choice and competition are to work effectively.

Vouchers for patients?

Drawing lessons from social care, Le Grand proposes giving patients their own health care budgets (p. 136), akin to a voucher system, because he contends that their desire for choice, and their being the best judges of their own health care needs, will empower patients and give the appropriate incentives to medical providers to offer better and more responsive care. He is careful, however, to point out that these patient budgets would not be appropriate for the acutely ill, or for those who are incapable of making decisions for themselves. For very specific services, for example smoking cessation interventions, the piloting of patient budgets might well prove worthwhile. However, overall, it does not appear to me that there is sufficient evidence that choice outperforms performance management and the target model. Some would disagree. For instance, at the end of the book, Alain Enthoven provides an afterword in which he states that the ‘Canadian and British experience with global budgets is not positive. In that model, there is no incentive to improve efficiency and treat more patients, with the inevitable result of longer waiting times. So the Blair government is moving to more competition and choice to motivate efficiency improvement’ (p. 172). This, to me, is not an altogether accurate reflection of reality, in that the percentage of people waiting more than six months for treatment fell from 24 per cent to 0 per cent between 2001 and 2007 (Department of Health, various years), and this was achieved through the use of targets and performance management.

References

Department of Health various years, Hospital Inpatient Waiting List Statistics, England NHS Trust Based: The ‘Green Book’, London: Department of Health.Google Scholar