CONSUMERS, CLIENTS OR CITIZENS? POLITICS, POLICY AND PRACTICE IN THE REFORM OF SOCIAL CARE

In the United Kingdom, New Labour articulated a consumerist view of the relationship between the public and public services. Its view of the citizen-as-consumer was the source of considerable political controversy and debate – both within and beyond public services. In this paper, I explore four aspects of consumerism in relation to social care in the United Kingdom: the political context of the rise of the ‘citizen-consumer’; the place of the citizen-consumer in social care policy; the responses of organisations providing social care to consumerist pressures and lastly the impact of consumerism on characteristic tensions in public services.

Although ideas of the consumer and choice mechanisms as means of coordinating public services have appeared in many places, the United Kingdom offers a distinctive example of their use and significance. In large part, this is a consequence of the United Kingdom's location in the networks of anglophone neo-liberalism (Clarke 2004a: chap. 5). Since the 1980s it has been both an exemplary model and exporter of ‘public service reform’ (marketisation, privatisation, New Public Management and so on). The ‘consumer’ is located in this trajectory of reform, embodying the efforts to make public services conform more closely to the ‘market model’. This figure of the consumer has been central to New Labour's approach to modernising and reforming public services since 1997 (though it has a longer history in the Conservative governments of Margaret Thatcher and John Major, see Clarke 1997,1998; Clarke and Newman 1997). In New Labour's eyes, public services were in need of reform and modernisation to bring them into line with the defining characteristics of the modern world. This modern world differed from the old world in which public services were created – the moment of post-war social democracy – in a number of critical ways. Globalisation had changed the economy and the forms and habits of work that are valued in it. Gender roles and patterns of family or household formation had altered (Miliband 2000). But most importantly for public services, Britain had become a ‘consumer society’ or a ‘consumer culture’ in which a proliferation of goods and services enabled a wide variety of wants and needs to be satisfied:

The ‘diversity’ of individual needs and aspirations formed a touchstone of modernity against which public services could, and should, be judged. In New Labour's judgement, they were found wanting – and government must make them suited to this new public and its ‘expectations of choice, responsiveness, accessibility and flexibility’. The starting point for New Labour's articulation of the citizen-consumer was its critique of the ‘old’ formation of public services – and its anachronistic character in the ‘modern world’ of consumer culture. This distinction recurred in the contrast between old state monopoly providers embodying a ‘one-size-fits-all’ model and the diversity of wants, needs and desires in the modern world:The figure of the consumer thus embodied the effects of major social changes, to which the ‘old’ model of public services was ill-adapted. But it also owed much to another discourse about the role and value of public services – the neo-liberal critique expressed in Public Choice theory. In its economic reductionist analysis, all activities are articulated through the intersection of producers and consumers. In an ideal world – the market – the interests of producers are disciplined and directed by the power of consumers. In the world of public services, however, producer interests can range unchecked since consumers are locked into monopoly provision and unable to exercise choice (Niskanen 1971; Finlayson 2003). New Labour's appropriation of the figure of the consumer brought with it this antithetical view of producer and consumer interests and the role of government as the ‘People's Champions’ against the producer interest (Clarke 1997,2004a: chap. 7):New Labour's rule involved fiercely contested arguments about the capacity of the mechanism of choice to drive and deliver changes in public services; about what the changes created by ‘choice’ mechanisms might be; and about whether people identify themselves as choice-seeking consumers in relation to public services. For some, the extension of the market model and market relations was the necessary basis for the reform of public services (NCC 2004). For others, such an extension of the market was intended to undermine conceptions and relations of social or public support and solidarity that were developed to protect people against the market (see, for example, Needham 2003; Marquand 2004). Such conflicts persist: linking questions of funding, forms of provision, varieties of responsibility, and profoundly divergent visions of the relationship between state and society, and between public and public services.

In addition to political challenges, New Labour also had to address the institutional conditions of ‘customising’, ‘personalising’ or ‘contractualising’ the relationship between the public and public services. Social care was a late arrival to New Labour's consumer choice agenda where education and health had been the consistent preoccupations, reflecting their high public visibility and their ‘universal’ character. Nevertheless, social care has been subject to an extensive reform programme with changes in policy, organisational design and substantial new systems of regulation that have all been marked by distinctively New Labour approaches to ‘modernisation’ (Newman 2001). As a result, a range of initiatives have been taken to reform the provision of social care, beginning with the 1998 White Paper that established independence as a dominant theme for the future of social care:

By 2002, however, greater emphasis was being placed on ‘choice’ as a key principle that should govern the organisations of social care:These two statements mark an arc of policy change from independence to choice. The first expressed an established social work concern with autonomy and independence (embedded in both professional cultures and policy, at least since the 1990 National Health Service and Community Care Act) and made it the guiding principle for services to adults. The desired state of independence is contrasted with the stigmatised and stigmatising status of dependence (see also Leeson et al. 2003 on the salience and complexity of the concept of ‘independent living’ in later life). Social care's development has been marked by a series of struggles by different user movements about relations of domination and dependency which have challenged both policy and practice, particularly the normative exercise of professional power over service users. To some extent, the arguments above speak to this history – challenging dependency-inducing practices and putting ‘users first’. But more than other public services, social care is dogged by the question of ‘need’ – and this skews the argument about choice in peculiar ways. So, the 1998 White Paper was organised around the specificity of need:

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  care should be provided to people in a way that supports their independence and respects their dignity. People should be able to receive the care they need without their life having to be taken over by the social services system.

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  services should meet each individual's specific needs, pulling together social services, health, housing, education or any others needed. And people should have a say in what services they get and how they are delivered. (DoH 1998: para. 1.8; my emphasis)

Need distorts the ‘choice’ agenda, since need is never simply a matter of ‘what people want’. Need (rather than want) implies the existence of an objective condition – in social care such conditions are discoverable through processes of ‘needs assessment’ (Barnes 1998). But need has been a profoundly contested concept, with user movements being highly critical of professional claims to expertise about people's needs. Traces of this contested character can be found in policy documents. For example, the Social Services Inspectorate argued that:This marks the problematic relationship between professional and lay understandings of need – one that was exacerbated by the increasing centrality of ‘choice’ in New Labour's approach to social care. A consultation paper (Green Paper) published in 2005 (Independence, Well-being and Choice, DoH 2005) saw choice as the critical means of promoting both independence and wellbeing but contained a characteristic stumble around the problem of need:This model of negotiation is rather at odds with the concept of choice that the remainder of the paper celebrated (this is more fully discussed in Clarke et al. 2006). The subsequent White Paper (Our Health, Our Care, Our Say, Secretary of State for Health 2006) emphasised ‘putting people more in control of their own health and care’ through a variety of means: more voice, more choice and more responsibility. People ‘will be given more control over – and will take on greater responsibility for – their own health and well-being’ (Secretary of State for Health 2006: 13). The tension between needs and choice (or control) appears to have been resolved in favour of a presumption that needs are objective conditions and that choice is about the means selected to meet such needs. Choice means primarily choice of provider (whether commissioned by the local authority or purchased individually through direct payments).

This particular policy initiative – direct payments – has provided an exceptionally powerful articulation of autonomy and choice:

Direct payments emerged from user struggles – in particular, disabled people's movements – to exercise control over the forms and relationships of support that they receive. New Labour extended the principle of direct payments to older people, children and their carers. In the most recent Green and White Papers, it has become a defining principle – to be extended in its own right and shaping a related mechanism (‘individual budgets’, where money would be held by the local authority on behalf of the user). The direct payments model has a strong association with ‘autonomy’, but there are contested issues about its practice that have given rise to concerns about whether it is a model that can be readily universalised (see, for example, Glendinning et al. 2000a Glendinning et al. 2000b; Glaisby and Littlechild 2002). There has been ambivalence on the part of providers and users about whether direct payments deliver autonomy and choice – or are so conditional that they either dissuade or constrain ‘choice’ on the part of users. The negotiation of local authority ‘needs assessment’ remains central to the process of direct payments, but what users perceive as ‘bureaucratic’ constraints about accounting processes and acting as an ‘employer’ are also significant elements that make ‘choice’ a problematic, rather than a desirable, option (see also Barnes and Prior 1995 and Schwartz 2004 on the problem of choice).² As the following sections demonstrate, the move towards a more consumerist model of social care was accompanied by a degree of ambivalence on the part of social care ‘providers’ and had the effect of intensifying some characteristic tensions in the processes and relations of social care.

One central element of our research aimed to explore how ‘consumerism’ was being interpreted and put into practice in the three different services. Rather than a single formation, we discovered different ‘consumerisms’ as services adapted the general orientation (Clarke et al. 2007). Public services are settings where active translation, transformation and enactment take place. Each public service is marked by a distinctive institutional formation, and a distinctive institutional trajectory.

By institutional formations we mean the composite of organisational and occupational cultures, dominant (and other) patterns of relationships within organisations, between organisations, and between services and the public. Social care has its own distinctive formation – organisationally dominated by its place within local authorities; occupationally dominated by social work (Clarke 1996). These institutional formations are not static. There is a danger of treating processes of institutional adaptation as one change (here, the arrival of consumerism) being absorbed or adapted by a settled institutional formation. In public services, however, processes of policy, organisational and occupational change have been pursued relentlessly for the last two decades. We use the idea of institutional trajectory to capture this sense of tracking the combined effects of multiple changes on the service. Bound up in these trajectories are new policy initiatives; shifting organisational contexts (internal markets; multiple providers; spatial realignments; etc.); changing occupational culture and composition; new pressures from the public, users, and citizens; and new governmental imperatives (e.g., the rise of the ‘audit’ or ‘performance’ culture: see, for example, Power 1997; Clarke 2005).

Managers in social care identified a ‘consumerist orientation’ as emerging over a relatively long period – several of them identifying the 1990 National Health Service and Community Care Act as a critical turning point in relationships between service users and providers.³

In such observations, people drew rather different points out of this history that begins with the 1990s Act – the new centrality of ‘complaints’; the shift to ‘needs led’ services; becoming ‘person-centred’ and the diversification of provision (away from ‘in-house’ services). But questions of choice and challenge were identified as things to which social care organisations have (more or less successfully) adapted. As a result, current initiatives were, to a large extent, seen as going ‘with the grain’ of institutional formation and, especially, institutional trajectory (see also SCIE 2004). However, this was not a simple history: people saw the increasing salience of ‘choice’ and more ‘personalised’ services as shaped by a mix of other forces:There are complex mixes of contexts, conditions, forces and pressures that accounted for the contemporary salience of ‘choice’, and the way in which it had been embodied in changing structures, systems and cultures of service provision. Indeed, one dominant theme was that – even if the language was difficult – social care services had been substantially transformed to a more user/person/customer-centred mode of working during the last decade. This was viewed as a positive development. But it was not a story without problems or disjunctures. We think there were some recurrent themes in how social care managers talk about delivering social care in a more consumerist environment that centre on the difficult relationships between resources; priorities. The relationship between ‘choice’ and resources was one that preoccupied managers. They perceived the wish to create more choice or more options as unreasonably constrained by the availability of resources – frustrating both them and (would-be) users:At one level, this is a mundane point. Social services department have, since their inception, encountered problems about managing the relationship between demand and resources (as do most public services). But it means that ‘choice’ (interpreted as ‘what people want’) encounters a variety of processes: individual needs assessments, charging policies, the ranking of competing needs, and collective bureau-professional priority setting. Interviewees spoke consistently of the need to be ‘clear’, ‘open’ and ‘honest’ with users and applicants to establish ‘reasonable’ expectations. Both corporate/managerial effort and individual worker–user encounters were directed to processes of managing expectations, managing demand and managing scarce resources.

A second area of strain concerned the relationship between individual need and collective priorities. ‘Choice’ – if understood as being embodied in rights to a service – threatened to unhinge the organisational control of the demand/resources tension:

There were questions about the relationship between voice, advocacy and priority setting, with managers articulating anxieties about who makes claims on public resources. Given the possibility of ‘differential voicing’ among different groups and individuals, a context in which the service was committed to ‘listening to users’ could create difficult tensions in the process of resource and demand management:The concern with inequality here has been reflected in other discussions of voice and choice. For example, the National Consumer Council reported fears that ‘choice’ models produce (or reinforce) ‘social and economic polarization’ (2003: 11–12). Nevertheless, ‘choice’ remained a potent political and policy value – expressed in the view of direct payments as marking a distinctive shift in relationships between services and users, since cash allows people to exercise ‘consumer choice’ in the support services that they purchase. Our interviews revealed some ambivalence about the place and consequences of direct payments:Concerns about managing direct payments, managing employment contracts and a suspicion about ‘devolving stress’ echoed user anxieties reported elsewhere (Age Concern 2004; Griffin 2004). The view that ‘what people want’ is ‘good services that respect them and their dignity’ reflected other studies of public services. For example, the National Consumer Council's study of ‘Expectations of Public Services’ noted that ‘the general public's interest is to have access to services that work effectively, and that are reliable and trustworthy’ (NCC 2003: 12; see also Clarke et al. 2006).

This final section explores a set of tensions associated with the development of a consumer orientation that recurred across the services we have studied, albeit in institutionally different forms. They may be more accurately understood as reworkings of persistent sites of strain and conflict in public service provision.

The first concerned the problematic intersection of resources, rights and rationing. The United Kingdom, like many other societies, has experienced a period in which governments have struggled to reduce what they describe as ‘dependency’ on the state and to reduce or retrench public spending in the pursuit of efficiency (Clarke 2004b). Yet the same period – and the imposed anorexia of public services – has done little to dim the enthusiasm of the public for public services or their demand for improved quality. If anything, ‘claim making’ has increased as efforts to enlarge who counts as the public run alongside demands that public bodies and public services take ‘responsibility’ for new insecurities and risks. At the same time, there are shifting positions about the ‘empowerment’ or ‘responsibilization’ of citizens, in which enabling Do-it-Yourself provision, co-production of service outcomes and the creation of ‘expert users’ (such as the ‘self-managing patient’) have blurred the boundaries of the public and private realms (Newman and Vidler 2006). However, political conflict about resources, levels of public spending and taxation seem likely to continue (Taylor-Gooby and Hastie 2003). So too do arguments about the ways in which claims or choices are enforceable – with a prospect of individual juridical interventions shaping ‘rights’ in an ad hoc way. These difficult questions of rights and resources intersect critically around forms, sites and processes of rationing. What priorities are set, how they are set – and where and by whom they are set – remain intractable problems at the point where politics, policy and the public meet (or sometimes fail to meet).

The site for resolving such problems in social care has been the local authority social services/social work department, where local political and professional judgements have been combined in the apparatuses of eligibility criteria, charging policies, priority setting and individualised needs assessment as the process of implementing national policy and guidelines. The ‘localness’ of local political judgement has been central to this arrangement, as has the professional judgement of trained expertise. Judgements about individual ‘cases’ are thus framed nationally and locally, as well as politically and professionally – but often in ways that are impenetrable to the eyes (or the choices) of individual members of the public. As I argued in the previous section, both ‘rights’ and ‘choice’ have the potential to disrupt this complex of judgements, and in unpredictable ways. The juridical logic of one and the economic logic of the other reveal possible means of enforcing individual wants or needs. Both ‘rights’ and ‘choice’ promise to pre-empt institution-centred judgements about the balance of needs and resources. As a result, the question of resources – and their rationing – remains profoundly troubling for the future of public services. While rights, wants or needs outstrip resources, some processes of ‘demand management’ will necessarily come between demands and outcomes. Our study revealed significant organisational effort being expended on trying to construct ‘responsible consumers’ who would have ‘reasonable’ expectations of what services could provide. This level of effort reflected anxiety about the ways in which the ‘choice’ agenda might inflate expectations in difficult ways (Clarke forthcoming).

Secondly, consumerism has a problematic relationship to both old and new patterns ofinequalities. The deepening inequalities of Britain in the 1980s and 1990s posed a challenge to any reform of public services (Goodman and Oldfield 2004). To what extent could – and should – public services remedy or redress such inequalities? Did Britain's insertion into the world of global neo-liberalism necessitate such inequalities as a condition of market dynamics and as a form of entrepreneurial incentive? New Labour's relationship to such inequalities was the focus of persistent conflict – with critics pointing to the persistence of inequalities, while its defenders highlighted ‘redistribution by stealth’ and the commitment to eradicate child poverty. Nevertheless, public services have been viewed mainly as a means of overcoming social exclusion, rather than challenging or redressing inequalities. Although New Labour policies for social care recognised some forms of inequality, these were mainly understood in terms of marginalised or vulnerable groups with ‘particular needs … young people, mothers, ethnic minorities, people with disabilities, people at the end of their lives, offenders and others’ (Secretary of State for Health 2006: 8). The result of this particular way of framing inequality and difference is a characteristic New Labour conception of equality: ‘public bodies can and should do more to support individuals and give everyone an equal chance to become and stay healthy, active and independent’ (Secretary of State for Health 2006: 25).

But consumer-centred reform has raised other questions about public services and inequality. Choice mechanisms carry the risk of reproducing economic inequality (as people spend to ‘trade up’ within or beyond public services), or they may produce choices shaped by the unequal distribution of what Bourdieu calls social and cultural capital (Greener 2002). People who are recognised as ‘reasonable’ (or even ‘desirable’) consumers may be privileged in exchanges with public services, by contrast with those who lack the proper demeanour, character or skills. Those who possess the appropriate calculating frameworks, knowledges and capacities may advantage themselves in comparison with those who lack such cultural capital (see, for example, Gewirtz et al. 1995). It may be that the distribution of social and cultural capital does not exactly map onto systematic economic inequality. It is possible that new mechanisms will valorise new aspects of cultural capital (becoming the ‘expert patient’, or having the capacity to participate in ‘online’ exchanges, for example). But such new developments may well reproduce, or be marginal variations on, the architecture of inequality in the United Kingdom.

Finally, there is an unresolved tension in public services that we have described elsewhere as the knowledge/power knot. Our image of this ‘knot’ draws on the work of Michel Foucault, reflecting his concern with the ways in which forms of knowledge and relations of power are intertwined. The changing context of public services has emerged from challenges to particular elements of this knowledge/power knot – and, to some extent, ‘consumerism’ aims to both speak to, and resolve, the uncertainties created by these challenges. Historically, public services have involved the exercise of ‘professional judgement’. In social work, medicine and policing, expert knowledge has formed the basis for forms of discretionary power exercised over the users or recipients of such public authority. As we have seen, in social care the core of the knowledge/power knot has been the assessment of need – a locus of organisational control typically working through professional knowledge and skills (assessment and evaluation of needs and remedies).

Encounters with public services have typically involved people submitting themselves (or being obliged to submit) to such knowledge and office-based authority, so it is not surprising that these condensations of knowledge and power have also been the focus of challenges to their discriminatory or oppressive application. The use of ‘stop and search’ powers by the police has been a source of considerable tension between the force and black communities. Disabled people's movements challenged the conceptions of disability embedded in the ‘medical model’ – and the power which that knowledge gave to experts to define the ‘needs’ of disabled people. Women opposed their subordination to male medical power being exercised over their bodies. As a consequence, we know that professional knowledges, practices and routines involve contestable relations of power and subordination. New Labour's conception of the consumer both drew and transformed such challenges. There was a strong sense of ‘challenging’ professional power visible in New Labour's championing of the consumer (against ‘Producers’). This view of consumers had a strong populist character, expressed in anti-paternalist and anti-elitist imagery. But it is not clear that the challenges and demands of such social and user movements could be contained or represented by a model of consumer choice. The attemp t to harness such diverse struggles to a Public Choice model of producers versus consumers fails to engage with their diverse and difficult politics – and the complexity of the public service knowledge/power knot itself.

This knowledge/power knot is not just about professional paternalism – the claim that ‘professionals know best’. We use the image of a ‘knot’ because it is woven out of multiple strands. Paternalism as a mode of address and a form of relationship is indeed deeply frustrating and disempowering. But it sits alongside the discriminatory exercise of discretionary authority in which both access and treatment are differentially distributed through social criteria. The knowledge/power knot typically reified and valorised some forms of knowledge (‘expertise’) over others (‘experience’). In the conflicts over public services, some forms of ‘experience’ have become re-valorised as types of ‘expertise’ to be consulted. Specific ‘user groups’ have been identified as possessing forms of knowledge that service providers should take account of. More generally, surveying the experience of service users (around the issue of ‘satisfaction’) has become a central part of performance management and evaluation. The ‘indeterminate involvement’ of the public in consultation and participation processes is both a potential source of power and a constant site of frustration. Finally, the institutional knowledge/power knot is difficult because it may contain knowledge that people – as users and as the public – value and wish to be applied. In all three of the services we studied, people approached services to seek assistance or support in dealing with situations or conditions that they wished to be remedied, improved or transformed. They sought such assistance because they could not deal with the situation themselves. This defines a relation of interdependence – neither passive dependence nor autonomous independence (see Williams 2000).

‘Choice’ does not begin to deal with this mixture of knowledge and power, particularly because there are critical questions about what modes of power could make our choices come true. In particular, ‘choice’ – in its marketised form where choices are enforceable through the exchange of money for specific goods or services – is problematic in the realm of public services precisely because they were more or less intentionally ‘de-commodified’ (Esping-Andersen 1990). Public services were removed from the logic of the market because the unequal distribution of income, wealth and well-being was reproduced there. But in the absence of the ‘cash nexus’, how can choices be enforced? For some, money or proxy money (vouchers, for example) needs to be the basis for empowering individual choice (NCC 2004). There remain substantial problems of limited resources (who gets money?); of apparatuses of means testing (one solution to ‘who gets money?’) and of whether to operate ‘closed markets’ in which those who have money cannot buy better or extra services.

In conclusion, then, the citizen-consumer is a profoundly contradictory figure. In terms of its origins the citizen-consumer tries to draw together and reconcile a very diverse set of challenges to the bureau-professional model of public services. These do not all sit comfortably together, especially in the attempt to make them all fit with an individualised and marketised image of the consumer as a self-directing, rationally choosing individual. In terms of its effects on the institutional arrangements of public services, the citizen-consumer figure also has contradictory consequences. It both speaks to the sense that service providers are unsettled and trying to renegotiate their relationships with the public (Clarke forthcoming). But it reworks such dilemmas into the discourse of individualised choice and, as I have tried to show, exacerbates persistent tensions in public service provision. How to rearrange the relationships between publics and public services is a challenge that is unlikely to be resolved through a consumerist model. The difficult political and policy question is whether there are other models that could resolve the basic tensions more convincingly.

John Clarke is Professor of Social Policy at the Open University, UK. His work has been focused on the political and discursive struggles involved in the transformation of public services and welfare states, with a particular interest in the impacts of managerialism and consumerism. His most recent book is Changing Welfare, Changing States: New Directions in Social Policy (London: Sage, 2004).