Magazine article Kennedy School Review

Too Much Is Not Enough: The Rhetoric and Reality of Choice' in Health Policy and Service Delivery in the UK and Australia

Magazine article Kennedy School Review

Too Much Is Not Enough: The Rhetoric and Reality of Choice' in Health Policy and Service Delivery in the UK and Australia

Article excerpt

During the past ten to twenty years, welfare states such as the United Kingdom and Australia have used the concept of "choice" to promote greater competition in health services and an increased role for private sector providers in the delivery of those services. Choice is framed as objectively good, as citizens have been recast as consumers who deserve the freedom to choose from a wide range of services. Under the banner of efficiency and the admirable aim of maximizing value for taxpayers, choice has also provided the necessary cover for these governments to stage a partial withdrawal from direct provision or funding of public health services. Simultaneously, those same administrations have begun directly funding some private health providers and giving tax breaks to citizens--generally middle and upper class--who can afford such services and thus exercise their "choice" to "opt out." The welfare state "guarantee"--the idea that government should use taxes to provide universal access to basic (or better) levels of health--is now regarded as quaintly old-fashioned. Instead, choice is an attractive proposition for policy makers as it promises consumer freedom, autonomy, and a supposedly wide range of options in services, the manner in which they are delivered, and how and when they are consumed.

To understand choice, we must ask and answer three major questions:

1. What are the choices?

2. Who exercises the choice? Is it the purchaser, the payer, the provider, or the end user?

3. What sort of utility does the end user derive from having choice available?

Regarding government health services, choice has been positioned as a way to empower citizens and offer them a menu of services. Having choice, however, does not always mean greater utility.

Despite ideologically different governments for the last ten years (this changed in 2007 in Australia), the United Kingdom and Australia have promoted and implemented "choice" to varying degrees in their respective health systems. Although the United Kingdom has a national health service ("socialized medicine"), both countries have universal public health insurance. Comparing British and Australian contexts helps us explore this idea of choice: what does choice cost? How does it impact health indicators and inequalities? Is the consumer more satisfied as a result of choice?


Choice has generally been associated with reform of the National Health Service (NHS) under the Labour government after 1997. Reform attempts have been so frequent under successive governments that it is difficult to concisely summarize such activity--indeed, some have drawn attention to the tautology of the phrase "NHS reform." From 1997 to 1999, Labour did not increase expenditure but worked to reverse two reforms in public services established by the A mid-career master in public administration candidate at the Harvard Kennedy School, JAMIE SNASHALL was a political adviser and press secretary for three years to Australias Labor Party Deputy Prime Minister Julia Gillard. SNASHALL has also been a federal civil servant and a public affairs consultant for one of Australia's leading strategic communications firms. Conservatives--the internal market in health (a split between the purchase and provision of healthcare in order to promote competition between NHS providers) and grant-maintained schools, both hugely politically sensitive issues.

Political and health policy commentators in the United Kingdom have always assumed that former Prime Minister Blair favored choice, but mention of its benefits only began to appear in his speeches in 2004, just prior to Labour's third election win. Blair's delay in embracing the rhetoric of choice led to speculation that he was only able to talk about choice as a result of Labour's massively increased financial investment in the NHS during his second term, which eventually bore fruit and created sufficient capacity so that "exercising choice" became a real option. …

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