Tag Archives: Big Society

Cameron’s “Big Society” – More Profit, Less Caring

David Cameron retreated to the relative safety of the Telegraph this morning to explain how he plans to completely revolutionise the provision of “public” services. Let’s skip over the fact that he a) didn’t tell anyone about this during the election and b) didn’t win. This is more of the desperate rushing towards change which Cameron feels obligated to do after Blair was criticised for not doing enough early in his premiership.

Cameron says he will introduce “a new presumption… that public services should be open to a range of providers competing to offer a better service.” He doesn’t talk about the level of service that people should expect, only that the government should ensure “fair access”. Where budgets are devolved (and failing) and private providers are allowed to operate where they choose, this heralds the end of our “national” health, education and social services as we know them.

Cameron feels obliged to talk about co-ops and mutuals bidding for new contracts, but when budgets are squeezed, these groups of local workers won’t have the infrastructure and resources to step in. They certainly will struggle to find the time to run the services as well as provide them. Therefore the door will be wide open for established – often foreign – providers to snap up contracts where they feel they can make money. They can take advantage of economies of scale and loss-leaders which small, local providers simply won’t be able to match. Are they likely to be hunting for contracts in difficult areas of country? Not unless the government ensures that resources are heavily weighted towards those areas, with enormous subsidies to make operating in unhealthy, poor and disadvantaged areas commercially viable. You just need to look at the tiny Pupil Premium (culled from within the schools budget) to understand how improbable this is.

Once “power is in hands of individuals” and he’s given “more people the right to take control of the budget for the service they receive”, what’s the next step? Cameron says he used to wonder why he wasn’t given control of the budget for his son’s healthcare. Perhaps because it would force almost impossible decisions on the NHS. How much is worth spending on each child? The Camerons would have been able to add their own money to make up a shortfall, but what if they were normal people? What if they chose a private hospital who put up their prices and suddenly Ivan would have been moved out because they hadn’t paid his bill? The NHS doesn’t (currently) make decisions based on price on an individual basis. Yes, price-related decisions must be made somewhere, but this is what the PCTs and Strategic Health Authorities are for. On the ground, you don’t have treatment stopped because of an outstanding bill. You aren’t thrown out of a hospital because you can’t pay.

The scope for disparity and resentment are enormous. Even as power for spending is handed to GPs, this is a serious concern. Now, the GP is on your side. In future, you may ask to be seen at a specific hospital, but be refused on the grounds of cost. And this refusal will come from the GP. In a properly competitive market, the logical progression is obvious. Fancy that lovely new private hospital? Just top up with your own money. It’s the end of a national system of healthcare and now it seems Cameron is extending the principle to every other facet of public service too.

The dangerous conclusion to this is a complete breakdown of the post-war social contract where people accepted that they pay a percentage of their income for the greater wellbeing of the nation as a whole. Why pay tax when you can simply hold onto the cash and buy your own services? Will people start to look resentfully at the amount being spent on one family’s healthcare and wonder why they are contributing when their loved ones remain healthy? What is you don’t like the local services on offer? Well, just “top-up” and buy your way to the front of the queue. The whole notion of national services unpinning our society comes under question. Why should someone who is paying for their own services also be paying for other people’s?

Very quickly we will find our country in a situation where if you can afford good services and you live in the right area, you will undoubtedly enjoy great provision. If you are unlucky enough not to be born wealthy you will have to get by on bargain basement services provided by the badly-motivated rump of the public sector. Think US healthcare.

If this seems like a faintly paranoid extrapolation, then look at the alternative. If every public service is competitively tendered, and price is a driving factor as “Big Government” budgets are squeezed, then the pressure to deregulate is enormous. Only within a very heavily (and centrally) regulated market can the service to everyone be kept at a specific level. How does the government drive new providers into the sector if it is going to keep a firm hand on the provision of services at a national level? Quite simply, it can’t, it won’t and doesn’t want to. The divisions this will create will make the current “postcode lottery” look like a minor inconvenience.

A defence of our national services requires two things – firstly, the loud and proud recognition of what they offer and what they have achieved. The NHS remains a beacon around the world, despite only recently being funded at a level close to the international average. It’s achieving record satisfaction ratings and while it’s not perfect, it does not discriminate on the basis of ability to pay. Alongside this is, perversely, the very notion of a “Big Society”. If we believe in society, then we accept that the better off contribute more, but they do so because they believe that our very Britishness is defined by fairness and a willingness to ensure every child has some basic services they can rely on, regardless of the circumstances of their birth. It comes from a recognition that everyone has a contribution to make to our country and that we share something as Britons which makes us happy and proud to contribute to the greater advancement of our nation.

A company is legally required to be amoral. This is not a criticism – its duty is to its shareholders. The state, on the other hand, has a responsibility to provide for people even when it may be messy, expensive and difficult. Remove this responsibility and all the relaunches of the “Big Society” in the world won’t keep the fabric of our nation together for much longer.

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A Quick Musing on Choice

Prompted by an article in the Guardian by Aditya Chakraborrty, I decided to muse briefly on the notion of choice in public services being a panacea for improved provision. I don’t believe for a minute it is, and here’s why:

Choice, in itself, is probably a good thing, in the sense that I’d like to be able to choose to go to hospital within 20 miles, or send my daughter to a local school with decent results. I need to have some options available to me, but the issue of privatisation is not about introducing this kind of “equal” choice.

If you, hypothetically, introduce a private healthcare system which gives everyone a basic personal budget (national insurance, let’s say) and a range of hospitals to use, then a problem quickly arises. The companies owning the hospitals have the capacity to offer “value-added” services, so for a top-up fee, they provide shorter waiting times, private rooms, better food, more nursing attention. These patients quickly become the ones that deliver the profits to the company and so they become the focus. The people using only their national insurance end up with mediocre services at best, because they offer nothing to the hospital.

In fact, the hospital doesn’t really care if the non-top ups choose the hospital or not, because there is no profit in them. Inevitably, care for national insurance patients becomes poor, and maybe drives these people away, because they have a “choice” to go somewhere else. The problem is, all hospitals are the same and so regardless of the vast array of choice on offer to national insurance patients, the reality is that their service will suffer.

Put simply, you cannot claim that choice (effectively market dynamics) improves patient outcomes without looking at the supply side issues too. Choice alone will not drive up standards unless you heavily regulate the suppliers to ensure they offer a decent service to ordinary people.

This then automatically becomes a corruption of the very market forces you are relying on to improve standards (if providers can’t properly compete, why bother) and quickly results in a two-tier system. This is why in the provision of something absolutely essential (healthcare, education), market-driven choice as a driver of improved standards is a complete red herring.

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