Equality and Choice in Public Services

Julian Le Grand Equality and Choice in Public Services People should not forget the current system is a two-tier system when those who can afford it go private, or those who can move house get better schools.. .. Choice mecha­ nisms enhance equity by exerting pressure on low-quality or incompetent providers. Competitive pressures and incentives drive up quality, efficiency, and responsiveness in the public sector. Choice leads to higher standards. . . . The overriding principle is clear. We should give poorer patients ... the same range of choices the rich have always enjoyed. In a heterogeneous society where there is enor­ mous variation in needs and preferences, public services must be equipped to respond. —Prime Minister Tony Blair, Speech to South Camden Community College, January 23, 2003 These choices will be there for everybody.. . . Not just for a few that know their way around the system. Not just for those who know someone “in the loop”—but for everybody with every referral. That’s why our approach to increasing choice and increasing equity go hand in hand. We can only improve equity by equalizing as far as possible the infor­ mation and the capacity to choose. —John Reid, UK Secretary of State for Health, Speech to the New Health Network, July 16, 2003 social research Vol 73 : No 2 : Summer 200 6 695 [W]hile increased patient choice may put pressure on poorly performing providers to improve their services, there is no reason to think, despite the Prime Minister’s assertion, that this will ensure equal treatment for equal need. Hence extending choice puts at risk a key objective of the NHS [National Health Service]—equal access for equal need. —Appleby, Devlin, and Harrison (2003) [CJhoice is an obsession of the suburban middle classes. But when some families choose, the rest accept what is left. And the rest are always the disadvantaged and dispossessed. —Hattersley (2003) INTRODUCTION THE EXTENSION OF THE INDIVIDUAL’S RIGHT TO CHOOSE TO PUBLIC services such as health care and education is a major policy issue in the developed world. As the preceding quotations indicate, it is a matter of intense political controversy in Britain, where debates concerning choice in public services figured prominently in the 2005 general elec­ tion campaign. In the United States, it is most prominent in the longrunning controversies over education voucher programs and charter schools—and it may begin to surface in health care, as voucher debates begin to develop there as well (Hoxby, 2003; Emanuel and Fuchs, 2005). New Zealand, Denmark, and Sweden have all experim ented with choice in public education and health care; Germany, France, Belgium, and the Netherlands have choice programs, in some cases long estab­ lished (Le Grand, 2003, chaps. 7 and 8; Blomqvist, 2004; Van Beusekom et al„ 2004). Despite this experimentation, in most countries the right to exercise choice in areas such as public education and health care has historically been limited. Many public education systems required, and still require, parents to send their children to the neighborhood school. Under systems of public health care, patients commonly have little or no choice over their physician or hospital. Further, the case for such 696 social research restrictions is often made on the grounds of equity or fairness; if no one has choice, if everyone has to go to the same school or hospital, then there is equality of provision or utilization. And, if there is equal­ ity of utilization, there is equity—or so the argument goes. Further, it is contended that this achievement of equity would be threatened if the restrictions on choice were removed; the well-off are better placed to make the relevant choices than the poor and therefore are likely to be advantaged by any system that allocates resources on the basis of choice. In this paper, I address these arguments. I begin with an elucida­ tion of the terms involved, including choice, equity, and public services. The next section asks—and tries to answer—the question: Does extend­ ing individual choice in publicly funded services promote or reduce equity? There is a brief concluding section. It should be noted that the paper concentrates only on the equity arguments concerning choice; there are...