NHS: Why the Choice Agenda won’t work (for you*)

Monday, 16th August 2010 at 6:00 UTC 11 comments

* Of course, it will work if you have the money to make use of the options it gives you, or the free time, which as we know, is also like money.

OK, less of the sarcasm. Choice is something we humans value in many contexts, and its hardly a bad thing in itself. But the way choice is provided to us, often as a selection of options rather than actual free choice, quickly becomes problematic.

I want to start with an analogy that I believe I owe to Naomi Klein (who you should all read, but not automatically agree with): once upon a time a child received a box of lego bricks of all sizes and colours. When these bricks were scattered on the floor, the child could pick up almost any two pieces and begin assembling just about anything. The only restrictions were the number and selection of pieces (theoretically endless if the child knows how to access Daddy’s bank card) and the possibilities within the child’s imagination.

The child, genuinely, has a choice and a rather bewildering choice at that, seeing as what can be made includes creatures, vehicles, plants, terrain and objects, terrestrial, alien, historical, speculative in each of a myriad directions. I’m sure I designed some fairly steampunk creations when Lego was really like this, however anyone who grew up with Lego at my stage in society’s development will recall, even if it was never explained to them, the shift towards pre-defined kits: sets of more intricately designed pieces with which only a limited number of outcomes are available.

To be sure, many children managed to come up with designs outside the mould of these products. But each time, instead of smashing up a previous model, the child requires Dad’s bank card just to get a new model, and that model can only be selected from those already on the shelves. Lego as a company have destroyed Lego as a concept, it would seem.

When I’m ill, I don’t exactly have much choice in the matter, and only a limited number of options from which to select (the word choose, as I’ve hopefully demonstrated, means something completely different). If my condition isn’t too serious, I can probably make some serious choices, like ignoring my condition altogether, but generally a drug company somewhere would like me to visit my chemist and select one of their over priced products, and not the Boots own-brand remedy made to a recipe from the 80’s, and now out of a patent. This is because I neither have the money nor the inclination to support the pharmaceutics industries monopoly on access to life.

If I’m more seriously ill, I don’t make any selections or choices. Usually, this means I’m injured, as thankfully I’ve yet to develop anything too serious other than clumsiness*. I select a means of getting myself to the hospital, and I dammed well get myself there. Living in somewhere other than London, I basically have one A+E department that I can get to, and it’s the same one that single parents with little understanding of bureaucracy and highly agitated children frequent, and also the one drunks frequent, but I’m fine with that, as there’s no reason I should have better access to treatment because I’m a single male with no dependents and no alcohol dependency, though nurses shouldn’t have to treat drunks if violent. If I see the doctor and I’m actually ill enough to need referring, I don’t really think there is much of a choice in the matter. I want the next available appointment with someone qualified to do something about it.

If English wasn’t my first language, or if I wasn’t educated to a level whereby I can make some of the more complex decisions, I would be in difficulty even within the current configuration of the NHS. The “choice agenda” would mean nothing, other than a higher likelihood I would simply slip through the system. Evidence based medicine requires a one to be able to assess the evidence, but without time, language and education, this would be difficult. If I’m mentally impaired to start with, the problem becomes a vicious circle.

Without being able to afford to take time off work, I would be pushed into selecting certain options by default. In fact, I can’t really think of a time when I’ve wanted to select something that wasn’t the default option except when I’m allergic to a kind of medicine. And I can usually decide to select an option that requires travel time and expense.

In almost every situation, of which healthcare is by far the most acute, the ability to make any selection at all is based on privilege and wealth. This new choice agenda will only work for those who already have the option to go private, and perhaps a few who are just beyond the reach of private medicine. But private medicine is not practiced for people’s well being, it is practiced on the basis of what will make the most money. The same can be said for private and part-privatised education, the latter being the proposal of “free-schools” we are currently seeing rushed through into reality.

Personally, I can only conclude that any use of this choice to better my own personal position would be an act of selfishness and individualistic ambition, based largely on the fact that I’m an enormously privileged individual.

* Ask anyone who’s lived with me, including the 3 who witnessed me arrive home after I fell off my bike, leave again for a meeting, return, sleep, go to work by bus, return and then conclude that an x-ray might be required. I had, in fact, damaged a bone in my right elbow and would wear a sling for the next week.

Entry filed under: Conservatives, Education, Health, Participation, Politics, Poverty.

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11 Comments Add your own

  • 1. Greg  |  Monday, 16th August 2010 at 9:37 UTC

    ” But private medicine is not practiced for people’s well being, it is practiced on the basis of what will make the most money. The same can be said for private and part-privatised education, the latter being the proposal of “free-schools” we are currently seeing rushed through into reality.”

    Well thanks, you’ve just trashed the teaching careers of both my parents. Is there anyone else you’d like to naively insult while you’re at it? Do you ever think about what you write or do you pull it all out of a hat?

    • 2. Xavi  |  Monday, 16th August 2010 at 15:35 UTC

      Both private medicine and private education aim to provide excellent service to the individual who can afford to pay for it (or whose parents can). I don’t think Graham’s arguing with that. Private schools can generally afford to employ very good teachers.
      The point was that they aren’t set up and run for the benefit of people in general, they are run for profit. Ultimately, then, they only care about educating the rich (and those attending on a scholarship or bursary).

    • 3. Graham Martin  |  Monday, 16th August 2010 at 17:07 UTC

      First of all, there is some distinction to be made in terms of workers and owners: it is generally held amongst Climate activists that those who actually make cars are not the problem – its where the jobs are, and they may be less sucky jobs than others on offer. We don’t actively target the workforce of airlines either (there is only so much you can do without disrupting them too, so ‘actively’ is important here).

      It depends somewhat on how you characterise the different people in the process, but effectively, the parents use their wealth to pay the school, who will use that money on all sorts of outlets. Your parents may have taught in a private school for any number of reasons, including reasonable cases of convenience.

      I also admit that I missed the point (and so did you) that many older Public Schools are currently charities, which actually gives them a lot of tax relief, but obviously they can’t make a profit as such. Thankfully a lot of these schools are now having their status as charities stripped because they can’t justify it.

      And to answer your last question, yes: I’ve just had a lot of things stored up as blog posts, and I’m thankfully no longer in any mood to self-censor just because I know that you (specifically) are going to rant back.

  • 4. Clive Billenness  |  Tuesday, 17th August 2010 at 5:25 UTC

    Having just renewed my medical insurance, in which they have confirmed that my wife and I would have access, without question, to Herceptin, Avastin and other drugs which NICE have put out of the reach of most people, I have to ask whether or not I am expected to die for a principle ?
    I would prefer to pay more to the NHS to get proper care but they don’t want to do this – if they were to run a proper not-for-profit insurance scheme, I would sign up on the spot. Until then, however, I will just have to shell out a fortune to the private sector.

  • 5. Greg  |  Tuesday, 17th August 2010 at 11:21 UTC

    It’s good you’ve remembered, most* private schools are in fact charities. Ignoring the mysterious reason why you think that charity status is a bad thing and why the only non-evil provider of medicine or education is the state, this rather undermines both your point and Xavi’s: these schools are emphatically not set up for profit!

    Things we can deduce from your blog post:
    1) Graham knows sweet f.a. about the economics or motives of private education, evidenced by his misinformation about their profits.
    2)Graham nonetheless feels free to insult thousands of people without bothering so much as to check his facts.

    Are you proud of that?

    *Not just “some of the older”. The GDST for example, the largest group of independent schools in the UK, is one such charity.

    • 6. Graham Martin  |  Tuesday, 17th August 2010 at 12:46 UTC

      Charitable status is an interesting area of discussion full stop; there’s a certain air of legitimacy given to an organisation for being a charity, and of course there’s the tax incentives. A charity should perform some kind of public good – giving children born to privileged parents a route out from spending time in schools with kids off the local estate – which was massively valuable to myself – and training them up to go straight into top jobs and internships? Charities should meet people’s needs, not their greed.

      Of course, we’re dealing with a situation our forebears didn’t iron out when setting up the state school system beginning 150 years ago. Public schools existed in opposition to private schools (i.e. those run for a single family’s benefit, perhaps slightly wider, but still closed access), long before state schools. Before state provision, it might have been arguable that those who provided education to anyone who would take it (for the fee) would be charities.

      The bursaries argument is an interesting one. Is it a hang over from the days before good free education, or does it serve a purpose as a way of extracting public sympathy or ensuring the most academically talented students owe a debt to ‘high society’ and won’t oppose its whims?

      Seeing as you know so much about the philosophy of these schools, can you explain to me why every time I see an advert for a private school it reads along the lines of “Giving your child the confidence to get ahead”. To me that still sounds like a profit-motive, even if its the parents, but then adverts shouldn’t be trusted.

      Are you going to claim that these young people are taught to look out for the needs of those much worse off than themselves? I don’t want education that gives a select bunch of highly privileged kids “the confidence to get ahead”, I want them to have the humility to go back and serve those far less fortunate.

  • 7. Greg  |  Tuesday, 17th August 2010 at 18:23 UTC

    You’re sidestepping. You’ve made unsupported accusations about people you don’t know, based on data about which you have no idea. Do you fancy apologising?

    As for people’s “greed”, I’m glad you think that spending several thousand pounds a year to do the best for your child counts as greedy. Would you like to tell that to all the parents who aren’t rich but who sacrifice their holidays, car etc to put their kid in a different school after they’ve had a bad experience with the local one? Incidentally, the public good comes from the fact that every child educated privately is saving their local authority the several thousand pounds a year that it would cost to educate the child in a state school.

    As for your last paragraph, you’re speaking out of ignorance and it shows. Why not stop trying to invent charges, admit you were wrong to insult the motives of thousands of people you didn’t know, apologise and promise to stick to what you know in future rather than making stuff up in aid of some sort of class war.

    There’s simple way to stop me ranting. Check your facts before calling people evil.

    • 8. Graham Martin  |  Wednesday, 18th August 2010 at 17:16 UTC

      Greg, you seem to think I’ve never met someone from a private school. Pretty stupid assumption on your part, don’t you think? Its not like a good third of York People and Planet could take offence at this (and most could have seen this linked on facebook). You know what annoys me about your arguments? Its when you say things like “Incidentally… [statement of fact]”. You want me to deal with your inaccuracies, or are you just going to assume you’re right and I’m wrong? Or if I argue with your supposed fact, am I “sidestepping” again?

      Incidentally (sic), that argument about saving councils money doesn’t hold up because you’re paying to have a (presumably highly skilled) teacher who could be teach 30 kids from an estate teaching 20 kids who’s home background already puts them in a strong position. This situation rather undoes the social good through “brain drain” amongst state school staff, and it also distorts the wages of teachers.

      I rather think you’re trying to ignore the main attack I’m making, which is that competitive parents are destroying any hope of building an equitable society where we are all committed to those at the bottom. I could write entire posts about what I think is wrong with private/fee paying education, verses free knowledge and collaborative learning that aims to bring people together, rather than stratify society. Also, Prescott was on the radio earlier and he cited private education as a main cause of social immobility in British society.

  • 9. Greg  |  Wednesday, 18th August 2010 at 22:59 UTC

    Nope, I’m assuming nothing. “is not practiced for people’s well being, it is practiced on the basis of what will make the most money. The same can be said for private and part-privatised education” is simply, unarguably untrue as a matter of fact. Inescapably, you don’t know what you’re talking about because you’ve made a mistake with the basic, checkable facts of your case. You’ve then partially backtracked but haven’t been able to bring yourself to go the whole way.

    Everyone’s allowed to make mistakes. What’s bad is that from your base of ignorance (evidenced, remember, by your comic book blunder) you’ve seen fit to insult all the people employed in a sector. That is nothing but needless sh*t-strirring and it’s completely indefensible. Remind me of your degree title again?

    Just a tip: Don’t get a job that involves writing anything, you’ll get sued for libel sooner or later.

  • 10. Tom  |  Friday, 20th August 2010 at 20:02 UTC

    argument seems to be getting out of hand here, and while it might be true that Graham has dug a hole (although I am not sure if he has cause I cannot be bothered to review the waffle of the last 9 comments in full and engage my brain in it) I think that the argument that Graham is making generally that the private education system in the UK does not help social mobility and leaves many at an unfair disadvantage is not an uncommon or so illogical arguement as Greg is making out.

    As for the offence thing – offence is a strange thing isn’t it. Mostly used to stifle debate. Can’t anyone hold an opinion on anything because someone might be offended because someone they know might be involved in the issue. Seems like a means of stifling debate to me

  • 11. Tom  |  Sunday, 22nd August 2010 at 16:22 UTC


    “It’s scandalous that in 13 years of power New Labour did not abolish the charitable status of public schools. These schools are businesses, many of them with extensive land-owning interests, and they should be taxed as such”


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