Choice is usually a good thing. It means that you can get what you want rather than what someone else thinks you ought to have or what they feel like providing you. The title of this post comes from Henry Ford’s famous description of what colours customers could buy a Ford Model T in. What is less well known is that until Ford moved to using a production line, customers had a choice of colours, but black was best for the production line as it was quickest drying. So that was what customers had to have. There was a benefit to customers in that the production line also brought prices down through efficiency, but the choice of colours was removed first and purely for the benefit of the producer.
However, some people think that choice is bad and that we’d all be better off without it. One of these people is Dr Eoin Clarke who has recently republished a blog of his from last September about how because he finds ordering coffee at Starbucks too complicated there definitely should not be any choice in the NHS. Now, I know that I said that I wouldn’t use this blog to have a go at other bloggers, but this is stupendous even for the egregious Dr Clarke.
The first thing to note is that we aren’t being told that we have to choose our surgeons and hospitals. The Health and Social Care Bill doesn’t make individual patients have to do this. It changes how medical services are commissioned and by whom, but not by transferring this choice to patients to make unaided. It moves the commissioning of services from Primary Care Trusts to GP-led commissioning bodies. That is from one group of medical professionals to another. It might not be a good idea – certainly many doctors and the GPs’ professional body seem to be against it – but nowhere does it force choice onto poor uninformed patients who can’t be trusted to choose which coffee they prefer let alone make a decision about something as specialised and complicated as surgery. A classic straw man.
However, let’s leave this aside and look more closely at the main thesis put forward by Dr Clarke. Choosing is bad. Having to choose is a painful burden and it is much better that we just take what is available without needing to exercise any thought.
However, if you aren’t choosing, who is? Things don’t appear from nowhere so someone is making a choice on your behalf. How do you trust that they are making the right choice? How can you be sure that there isn’t a better choice available or that there might be if someone could be bothered to find it?
A lack of choice is invariably to the benefit of the producer. Monopolists are monopolists because there is no choice but their product. Aggressive monopolists work hard to close down the availability of alternative products so as to preserve their monopoly. That is not to say that there might not also be benefits to the consumer, but these are usually secondary. A monopolist might keep prices low to deter new entry. It might ration supply to maintain demand. It might design its products so that they don’t work well with those made by others. Consumers don’t have to put any thought into their use of the product or service because it just is what it is. Not having to think about stuff may be of some value in a hectic lifestyle or if you find evaluating things and discriminating between them difficult or tedious.
The short answer is that if the consumer isn’t choosing, the producer is and the producer’s interests are not necessarily aligned with those of the consumer. The best way of making sure that producers produce what consumers want and need is to ask the consumers themselves the question directly. What colour do you want? Do you want fries with that? Full fat, skinny or soy? Would you like a sea-view and a jacuzzi or just a room?
For some things some consumers might not care too much – for example, while I find petrol expensive and prefer not to pay too much, I’m not going to drive across town to save a couple of pence a litre filling up. However, there are plenty of people who would quite happily do so because the couple of pounds they would save means more to them. In general, the more important something is the more we care about how good it is. The petrol you get from different petrol stations is basically the same. So is the gas and electricity we use in our homes, which is perhaps the reason why, despite general moaning about high prices relatively few bother to shop around. A capuccino is quite different from an espresso and one from Starbucks can be quite different to one from another coffee shop (which is why Starbucks didn’t take off in Australia despite having an aggressive business model designed to knock out local competitors).
Some might see clothes as purely functional in keeping us decent and at a comfortable temperature and so not really mind what they wear, others will take a somewhat more aesthetic approach or be concerned with how durable or easily cleaned their clothes are and so want to choose appropriately. The houses we live in are very different and personal so most people will put quite a lot of effort into choosing their home and then decorating and furnishing it to meet their needs as best they can.
It is strange to think there is no role for choice in the most important things to us. Less strange to not care about choice in things we don’t really have an opinion on but only if we accept that our tastes aren’t representative. For example, I have no time for celebrity gossip so personally don’t think there’s a need for a range of outlets for such gossip but there are millions who disagree. That is sad but I’m not going to impose my tastes on the world. Or to think when just “good enough” is not really enough in other things that it is the best we can hope for in the most important things. Our relationships, our health, our children’s education. Dr Clarke and the dozens who retweeted his blog post with approval within minutes of it being published think not. We should let someone else decide for us. In the NHS we should leave this to the experts while depriving them of any alternatives, even though they are professionally capable of assessing the merits of different providers and also, trusted by us to put our care first.There is a role for expertise in complex matters but that doesn’t mean that we should have no choice or that the experts themselves cannot be entrusted with choosing from a range of alternatives. The difficulty with choice is sometimes that we do not have the information to be able to make a good choice. So perhaps it would be risky to put the burden on patients to choose which hospital and which surgeon they went to. Although that is not what is being proposed for England and Wales in any case – the choice and competition being introduced is competition for health care providers to be chosen by doctors and the medical professionals in GP commissioning bodies, not patients directly. Patients already can choose their GP and no-one has seriously claimed that this is a bad thing despite the fact that we will make those choices based on only the flimsiest guess at their professional competence and more on their bedside manner, the relative friendliness of their receptionists, how far we are from their surgery, the hours they operate and so on. We can make difficult choices. Even relying on “someone else” to make choices for us about the NHS involves making difficult choices – it puts a heavy burden on us as voters to choose politicians who will pass the right laws, policies and budgets to do the best for the NHS. If we’re competent to make that democratic choice why are we incompetent to have an opinion on the care we receive or to discuss the alternatives with our trusted GP? Just because sometimes we are lazy or uninterested in a particular thing doesn’t mean that choice is bad for everyone. By all means ensure that there is an adequate option for those who don’t want to choose; the “nobody got fired for buying IBM option”. Have regulation to ensure that the worst available choice still meets an acceptable standard. Just don’t paint everything black and hope for the best.