Andrew Gray notes that the public service users are increasingly experiencing a mixed economy of relationships with their providers, which could be problematic as it makes for more complex and demanding relationships of consumption at a time when advocacy and advice are being withdrawn.
The history of political theory tells of times when the relationship of the individual to the state was a matter of open discussion. Today that relationship appears determined more by practice – by the accumulated incremental effects of piecemeal policy and service mechanisms that notably provides for the ageing population, extends higher education, or reduces neighbourhood crime. The following story from the frontline suggests changes are under way:
Bill and Annie are in their 80s. He has terminal cancer and receives palliative chemotherapy. Annie has accelerating dementia for which she takes prescribed drugs. She recognises her family but needs assistance in looking after herself.
Bill and Annie are mixed economy consumers of health and social care – both by choice (he has an old occupational private health membership) and by statute (both of them have savings that mean they have to pay towards the costs of their home care). Their explicit wish to end their days at home is now managed by their children who have power of attorney. The NHS and a private health company provide most of their health treatments at home; this reduces his suffering and her disorientation. However, the local authority’s social care provision is more fragmented as it assesses them independently.
For each there is a spouse living at home who is deemed part of the care provision – although neither are capable of providing it. Bill receives daily home help visits from the authority’s elderly care team; they visit in pairs – to help with any lifting – and are attentive to Annie even though she is not their client. Annie, on the other hand, receives her home social care from a private company contracted by the local authority. The carers are almost all young and inexperienced, visit at times to suit themselves, pay no attention to Bill’s distress (who is not their client), and record their activities in a log that ends “All well on leaving”, regardless of the reality. In the end the children dismiss the dementia care team and commission a live-in carer.
After Bill dies, Annie’s condition deteriorates and she requires a specialist care home. But Annie’s social worker refuses to provide advice on suitable homes, arguing that Annie is responsible for her own care decisions. She also admits to fears of losing her professional registration and even litigation if things go wrong.
Their story can be viewed in various ways to reveal different features of the individuals involved, their needs, circumstances and services. Underlying the events, however, are forces shaping an emerging mixed economy of consumption.
As citizens, their relationship is based on equity, rights, and universal access; everyone has the same statutory right to receive the same service at the specified and regulated common standard. Moreover, their service providers must not differentiate (i.e. discriminate) between them except in specified regulated circumstances. At the same time as citizens they engage in this pooled relationship as electors, as tax-payers and as members of their communities. These relationships give them as citizens a range of opportunities for both shaping and gaining redress from their services. They are the foundation of the individual’s relationship with public services even if, in Annie and Bill’s case, circumstances oblige others to act on their behalves.
As clients, Annie and Bill do properly receive differentiated service – on the basis of a professionally adjudicated need and potential to benefit from the service. Here the provider (such as the doctor and social worker) rather than the user is the expert and in this capacity controls access to the service. The service relationship itself is founded on personal interaction and a shared desire for a particular outcome. In turn, this outcome is dependent on mutual participation by provider and consumer.
Into this mix, Annie and Bill also form customer relationships. A customer is one who, on the basis of expectations, pays for and receives a specified product or service, has the right to choose both the product and the provider and to receive the product as specified once paid for. In return, the provider may differentiate and discriminate between different customers, target some and exclude others. Thus reciprocal and discriminating choice is inherent in a customer relationship. Annie and Bill have developed this customer relationship both by their own acts (his occupational private health membership, her deemed dismissal of the care team) and by statute (both of them have to pay towards the costs of their home care and are allowed choices of provision as a result).
Until relatively recently these sets of relationships existed in an apartheid of sectoral consumption: citizen relationships in the public sector, customer relationships in the private sector, and client relationships in both but with distinct purchaser-client patterns. Annie and Bill’s story shows that this apartheid is dissolving; few public service users now do not have this mixed economy of relationships with their providers. They face a more fragmented plurality of providers, including from outside the statutory sector, from whom they are obliged to choose, despite the burden of such choice in their adversity and the withdrawal of advice and advocacy. These providers rely in turn on a more complex mix of modes of governance. Included in this governance is a greater use of contract in which the legitimacy for action and inaction lies in the terms of the contract rather than the command of a sovereign legislature or the shared values of collective communion. For the Annies and Bills of the world, it makes for more complex and demanding relationships of consumption and makes integrated care more rather then less difficult to effect.
The text is drawn from work on the relationships of consumption in public services and his talk on ‘Unhealthy expectations? Public Services and the Individual in the Enhancement of Wellbeing’, delivered to the Public Management and Policy Association on 17th April 2012.
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Professor Andrew Gray is Emeritus Professor of Public Management at Durham University, Board member of PMPA and former Editor of Public Money and Management. His business, Academic Services for Public Management, provides research, development and teaching for public services and professionals.