What is Choice?

Lansley and Burstow and those in the Department of Health have extolled choice as an aim to strive towards in both health and social care. ‘Choice and Control’ was used as the key phrase as the agenda moved in Adult Social Care and it has been picked up as the NHS and Social Care Bill made it’s way through Parliament. After all, who doesn’t want choice? Who doesn’t want control? The answer is that not everyone is has the capacity or desire to make a number of choices in critical situations . It worked to an extent in social care in so far as those who are able and willing to choose or those who are well equipped with better funding and family advocates are able to choose.  However we have also seen the policy struggle behind in promoting true choice or in fact, any choice to those who are not as able to pick up the mantle themselves nor who have informal social networks to assist in this respect.

Does having ‘choice’ mean seizing control? Are choice and control two parts of the same coin? Does one lead to the other? Perhaps. My concern is with those who are either unable through issues of capacity or illness or unwilling (because – you know – sometimes that’s a real choice to be made too) to actively ‘choose’ the type of care they receive or the way the care is divided into a support plan.

Where we see the ‘managed’ local authority support plans, we see little ‘choice’ and no control. We see the same large agencies with block contracts tied into providing the same packages of care on the same terms that they always did. The promises of more flexibility have evaporated into the ether of local government spending cuts.

I’m not against ‘choice’  but I’m completely against false choice. I’m against the meaning of the word ‘choice’ being warped into something that makes good political capital for the government with no meaning when ‘choice’ has not been extended in any real terms. I’m against lazy use of the word ‘choice’. The government (and that’s the last government as much as this one) seem remarkably fond of it. Funny, that.

I urge anyone who hasn’t read Max Pemberton’s piece in the Telegraph a couple of days ago to take some time to read it. He writes about contract won by Virgin Healthcare to run services in Surrey.  He explains this notion of ‘choice’

. The emphasis on choice was something that was repeated ad nauseam by ministers in an attempt to sugar the bitterest aspects of the Bill. The legislation would provide choice, we were assured. Everyone likes choice, don’t they? And we all nodded in innocent agreement.

I have argued before that in a healthcare setting, choice is a misnomer: all hospitals should provide an excellent level of care because so many people – the old, the infirm – are unable to exercise choice because of geographical or physical limitations. But only now that we can see the shape of the NHS Bill can we truly assess what choice actually means.

And this is the reality as it exists more starkly in health care than in social care.

I chose my local hospital for treatment because it was the only one I could reach within an hour by public transport. The people who live where I live will be making similar ‘choices’. Those with access to cars may make other choices and go to ‘better’ hospitals further away (although I have to emphasis my treatment was great at the local hospital even though it’s ‘ratings’ and ‘feedback’ are poor!). Those who can only access public transport will have less choice.

Similarly, my GP is on the same road as me. I have had gripes. Do I go to another? No, because when I’m sick, I want the nearest surgery. I don’t have time to research the different specialisms and natures of the GPs around me. This would be even more notable if I were in a rural area.

So who is this ‘choice’ for? For the class of people that the politicians pander to. Those who have the means and ability to choose? How can we truly make choice genuine and meaningful in systems which inherently try to blind themselves to the different cultures. attitudes and natures which do discriminate in the way access to choice is made.

Perhaps this is a way to increase equitable services and access to services across health and social care. I have long believed that advocacy may be a solution. Sometimes I walk away from work and realise that the people that I spend time with on a day to day basis are not the people that politicians either speak for or to. That’s why, as a social worker, it’s important for me to remind and nip away at these groups of people who won’t be clamouring for their pens (real or virtual) to engage elected members.

We have left behind a whole swathe of people who have not been able to ‘choose’ are a part of the personalisation agenda. We must push on and the voices will grow louder as others see this happening in healthcare.

Choice is a luxury of the more able. Good universal services for everyone must be the essential bedrock.

The NHS and Social Care Act has passed, but the voices must increase. We who can choose much speak for those who cannot.

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4 thoughts on “What is Choice?

  1. I do so agree about this mythical choice. It is always choice of provider, as if that solves all problems. By the time you have discovered that your elderly mother’s care agency/personal assistant is rubbish, she may suffered all sorts of neglect and distress. I always think about mobile phones – infinite choice but how many of us find out we dont really like our phones after all? Something with far less impact on our lives than a care or health provider.

    Commissioning is in a mess. There are two completely conflicting philosphies at work. One is pile’em high, buy it cheap, but with associated protection in terms of quality assurance (though i think this is over egged) , safeguarding, investigating every complaint etc. We talk about Commissioning for Pesonalisation but really all I hear is sighs when I mention real choice, expecially for the old, who remain as ever the cinderella group whatever the rhetoric. The other is Personalisation and Choice, but no one wants the inevitable accomaniment, which is responsibility for your own decisions, and risk. hence we get people who elect to take a personal budget but as soon as it goes wrong they want commissioners to sort it out. We actually aren’t resourced to do that. The whole point of personalisation as rolled out was easy cost control and rolling back the frontiers of the state, surely we knew that?

  2. Those that knock choice perhaps do not know what is like to be denied all choice. I do. I have been detained unlawfully and the Mental Health Act and I suffered a lot of damage as a result of bad treatment.

    I am not convinced that Lansley and Burstow are offering me the choices I would like but I am suspicious of the motives of people who dismiss the concept of choice. What right do you have to force me to take cripplingly high doses of anti-psychotics? What right do you to deny me my freedom?

    If you are going to deny people the right to choose you need to accept responsibility for the consequences of the treatment you intend to impose on other people. With me I had the worst of possible worlds. No choice. Detention. Coerced into taking drugs that destroyed my capability and then afterwards the trust denied all responsibility for the damage down to me.

  3. Interesting and long needed debate about choice but it is not as simple as who has it and who does not. We all probably agree that it is a good thing if you can have it but too much choice can also be a problem. Do we not seek the services of someone else preferably a professional in order to guide us in making choices ?

    Choice like the personalisation and empowerment agenda (another less used political word) as guiltycommissioner suggests above can be both good and bad if it is used to discharge people from our services or worse provide no services at all. As Beatrice also points out the people who give choices also have the responsibility and power to make sure it is for the right reasons. something I have come to notice more recently is that people cannot make choices if they don’t know what is available to help them?

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