Readers of this journal will have seen themed sections on partnerships, governance and citizenship (volume 5, issue 2) and ‘consumerism in social policy (volume 2, issue 1) and might be asking exactly why a further one that combines these elements is now necessary. Having considered similar topics separately in these pages, why is it now necessary to look at them together?
A good starting point is that recent work from both academics (Le Grand, Reference Le Grand2007) and the UK government (Minister of State for Department of Health, Minister of State for Local and Regional Government, and Minister of State for School Standards, 2005) is making the case for increased user choice in welfare services by suggesting that ‘voice’ mechanisms are not working. ‘Choice’ and ‘voice’ are therefore being counterposed as alternative approaches to achieving one of the present government's central goals of welfare reform, that of increasing service responsiveness. ‘Choice’ and ‘voice’ provide not only a neat rhyming framing device for considering how users might become more involved in service delivery, but clearly link to the two main ways that Hirschman suggested, in his remarkable book of 1970, that individuals could cause firms, organizations or states to decline. Hirschman suggested that individuals, wishing to improve the service they receive, have two main strategies: exit or voice. ‘Exit’ exists where they move to another provider instead, and ‘voice’ where they choose instead to complain or to demand improved service. Of course, the two may also be combined, with complaint, or the threat of it, appearing before exit. Hirschman suggested that firms should be trying to achieve ‘loyalty’, and emphasised the problem that, where individuals leave service providers without the managers of those providers knowing why (as can often happen with exit), those providers will be without key information as to what is going wrong for them. Equally, however, a situation without exit creates the possibility for managers to become lazy and complacent where no adequate voice mechanisms exist either. This possibility seems particularly relevant to a great deal of public service provision – exit only exists for those people able to afford a private sector alternative, and voice mechanisms may be inadequate or not present at all. It may even be that the most likely groups to complain in a given situation have already deserted public provision for private, creating a situation where, Hirschman suggests, stagnation is likely to occur. The key message of Hirschman's work is that exit and voice are not necessarily opposites, but are instead strategies often used together to achieve improvement, or, in the worst cases, are both unavailable, leaving it to the professionals and the managers running public services to self-generate improvements.
Equally, there is a general tendency for recent reforms to move increasingly towards choice mechanisms, as they are meant to both improve access to services (users choose providers rather than professionals) as well as drive up standards (with providers having a strong incentive to improve as resources follow choices). Choice is therefore seen as making services fairer and more responsive. Voice is not being ignored, however, with the UK government making increased use of technology to create ‘listening’ events, as well as holding summits to which members of the public are invited so they can contribute to the future of welfare policy. Alongside this, people are encouraged to become active in health policy, in local hospital affairs; to play an active role in the running of their local school; and attend local council meetings so they are aware of how budgets for the communities in which they live are being allocated. The government appears to expect us to demonstrate choice as a transferable skill in our lives as consumers of a range of private goods, so acting as highly selective, rational and careful choosers of public services as well. However, it also expects us to make time to be involved in the running of public services as well, going to local meetings to make our voices heard. We are meant to be both choosers and concerned citizens.
How realistic is this? In an era where we are routinely told that engagement with politics and political processes generally reaches ever-lower levels (Stoker, Reference Stoker2006), is it really the case that people wish to be involved in both the choosing and running of public services? Could a greater involvement in public services actually be the means by which political apathy could be broken down? The evidence seems very mixed. In terms of choice, there is a great deal of difference between prospective choice, that is being asked whether you would like a choice over a particular service, and current choice, actually making a choice once given. If asked in the street whether we would like greater say in how our lives are run, few of us will say no. However, actually then making those choices once granted is an entirely different thing. Work from Schwarz (Reference Schwartz2004) shows that prospectively the vast majority of us would like a choice of different providers if diagnosed with a serious illness. However, once actually getting a serious illness, this falls to a small minority. This is an extreme case in many ways, but is illustrative of the problem that public service professionals, for all of the complaints and bad press often made against them, are still remarkably highly trusted to make decisions on our behalf.
Again though, the word ‘choice’ itself seems to suggest something that someone either has or they does not have This may be inappropriate when considering public services. In situations of consultation with a doctor, most of us would like to be consulted and have treatment options laid out before us. This doesn't mean we have to make choices entirely by ourselves, or that the doctor has to make the choice without consulting the patient. There are middle ways based on co-production or discussion models. These combine choice with voice, especially where the service user is making repeated visits to the professional.
Neither choice nor voice are intrinsically a good thing. Choice can be intimidating if the user feels unable or unqualified to deal with what is before them. Voice can be time-consuming and result in frustration where the user doesn't feel their opinions are being adequately taken into account. In some public services, choice mechanisms might work well, but in others a longer-term discussion without the threat or necessity of user exit might be more appropriate. Just because choice works in some areas, it does not mean it becomes a universal panacea for reform. It is still not clear, for example, exactly what benefits having a choice of train providers gives to a potential trail traveller when all they want is to get to a particular place at a particular time. Equally, however, the criticism that public services have often been extremely poor at dealing with voice mechanisms, particular in terms of holding professionals accountable (Marquand, Reference Marquand2004), is well made.
The following chapters explore the complexities of both choice and voice from a range of different perspectives. Catherine and Hugh Bochel and their colleagues examine the notion of user participation critically, demonstrating its complexity and outlining some of the key challenges faced by services attempting to achieve greater involvement. In the end, their message is a positive one, in that although there are no new magic solutions, the problems experienced in attempts to get users more involved can be at least reduced, but only if the policy process is to become more radical.
Richter and Cornfield's contribution maps the shift from service users being treated as ‘citizens’ towards instead public services treating them far more as ‘customers’. They suggest this has happened because customer-relationship management can be regarded as a transferrable ‘shrink-wrapped’ technology that encourages users to constitute themselves as customers. If service users are treated as customers, then that is how they will behave. This clearly carries with it difficulties for public services more accustomed to organising around their professionals than their users. However, there may be good economic reasons for public service professional orientation – if they are the limiting factor in service delivery, it remains an open question as to how exactly services are to be organised around the needs of users whilst professionals remain the scarce resource.
Needham's contribution explores the potential for a middle way between treating service users as consumers or citizens, exploring an empirical case of co-production, where deliberate workshops might be used to attempt to come to shared solutions. It challenges the idea that public services must treat their users as either passive figures or hyper-active consumers. Needham's case shows both the strengths and the limitations of the co-production approach, and is a valuable case study in how greater public engagement can be created if sufficient resource and time is devoted to that goal.
Allsop and Jones examine the role of complaints in healthcare settings. Complaints represent a key area of the debate between choice and voice as they form, along with co-production, a possible middle way between the individualism of choice and the collectivism of voice. Complaints can be made by individuals that improve services for all service users, provided that public organisations are adequately held to account and review their services appropriately. The story offered by Allsop and Jones, sadly, is not encouraging. Complaints procedures remain ‘lengthy and onerous’ and a more consumerist approach to dealing with complaints has come at the cost of ‘openness, independence and fairplay’.
Finally, Clarke, Newman and Westmarland present a piece that exposes the conflicts compressed in arguments about choice, showing how they move power away from ‘bureau-professional organisations’ and encourage service users, through a process of individualisation, to take a greater involvement in service decision-making. Choice-oriented policies therefore move the boundaries between the personal and private realms, remaking relationships between individuals and state. The authors suggest that choice agendas cannot be responded to by attempting to urge a return to ‘old’ public services, but that instead we must reconsider the very nature of the ‘publicness’ of pubic services.
These pieces together provide a fascinating introduction to cutting-edge debates within the field, as well as offering some guidance, following the Labour mantra of the 1990s, as to what might ‘work’. A common theme is a hostility to the unthinking extension of choice into public services that policymakers would do well to take greater account of.
