The idea that people expect to be treated as consumers by public services has become a central theme in public service reform. Our research explored what people who provide and use public services thought about this idea, and to investigate the changes it is bringing about. We have surveyed and talked to the public, front line staff and managers in three services - health care, policing and social care - during 2003 and 2004.

A more assertive public?

We found that people were becoming more assertive in their relationships with public services: less deferential, more willing to express their needs and to challenge providers. The services we studied are trying to adapt to this more assertive public and its changing expectations. Despite the changes to service relationships, both the users and providers of services emphasised that there are many ways in which 'It's not like shopping'.

In search of choice?

People who use services were rather more positive about the anticipated benefits of choice than service providers. But choice expressed very divergent aspirations and expectations. Choice often did not mean a choice of provider, but more flexibility and responsiveness in the ways in which services are delivered. And choice was often not the primary value: respondents wanted something more - skilled people in whom they could trust, and services to provide assistance, attention and support at points of crisis or difficulty in their lives.

We're all consumers now?

People take up many different roles in their relationships with public services. They may be patients, citizens, empowered experts or supported service users at different moments. Most were aware of - and concerned about - the constraints of resources and competing demands on services. They carried wider identifications as members of the public and local communities alongside service specific encounters. While expectations of what can be delivered are rising, people who use services do not think of themselves as customers or consumers.

The future of professional expertise?

The consumer ethos apparently expresses a fundamental challenge to professional power. Yet we found versions of consumerism that are highly compatible with current professional thinking; for example in health, the emphasis on creating 'expert patients'; in social care, the commitment to empowering service users; in policing, the idea of more community involvement in shaping services. Nevertheless, there are potential fault lines around the question of 'who knows best' - where professional judgment and authority encounter lay expertise and a greater role for users' voices.

Meeting need or managing demand?

Consumerism adds to established tensions around how to reconcile needs and resources. Service providers - and people who use their services - are anxious about how to manage this issue in ways that are efficient, equitable and transparent. The emphasis on choice is seen as individualising issues that have collective - or public - dimensions; and as devolving the problems of reconciling resources with increased demand (and expectations about choices being fulfilled) to organisations and their encounters with the public.

ASPECTS OF CONSUMERISM

A survey of frontline staff and service users sought responses on four key aspects of consumerism. For each aspect, people were asked to agree or disagree with several statements. The maximum score on any issue would be 100 if everyone agreed strongly with a positive statement.

Challenge: Are people becoming less deferential, less trusting, more willing to challenge authority and to make demands? Do providers welcome the challenge posed by informed, empowered consumers?

Table One: Challenge
 

Choice: Do frontline staff and users welcome the prospect of more choice and perceive it as a driver for improving public services?

Table Two: Choice

Responsibility: Do users and staff expect individuals to take on greater responsibility (for example, for their own health and well-being or for local crime and disorder issues)?

Table Three: Responsibility

Inequality: Do staff and users believe that increased choice and voice would disproportionately benefit those with either the skills to negotiate the system or with the loudest voices?

Table Four: Inequality

MORE THAN CONSUMERS? WHO DO WE THINK WE ARE?

Table Five: Identities (up to two choices per respondent)

Asking people who use services to reflect on what words best describe themselves in their relationship with providers, the vast majority rejected the label of consumer or customer. In health care many people contrasted the personal, ongoing relationship with providers (e.g., with a GP) with the anonymity and discontinuity experienced by customers. And ideas of 'consumerism' and 'choice' sat uneasily with the idea of public services among both staff and users:

We are not Tesco, Marks and Sparks, or BT. We are not in consumables or domestic appliances. In short we are the police service… Therefore we serve members of the public and members of the local community with the capacity of a public service.

Interviews with managers and frontline staff indicated that terms used in the past, such as patients or clients, were problematic in the face of changing public expectations. Yet 'consumer' or 'customer' was perceived as difficult for several reasons: because some people, particularly in policing and social care, are obliged to receive services; because of the absence of genuine choices in a resource-constrained service environment; and because of the 'public' rather than the 'commercial' nature of public services.

These themes were reflected in interviews with service users: 

Finally, people regarded themselves as engaging in, and moving between, many different types of relationship with services - as users, carers, taxpayers and citizens.

MESSAGES FOR POLICY AND PRACTICE

This project has identified some key dynamics around relationships and choice, and some tensions around needs, rights and resources that will continue to shape the future of public services:

Relationships to public services are critical for people who use them, a key concern for policy development, and central to the challenges facing organisations delivering public services.

• The quality of interactions (rather than choice of provider) is a critical concern for people who use public services. 
• People place a high value on feeling part of a larger public entitled to use public services.
• There is an unresolved tension around the question 'who knows best?' - the expansion of lay voices and ideas of lay expertise sits uncomfortably alongside professional expertise and authority. 

Both service organisations and people who use services are ambivalent about choice. Choice is the focus of both hopes and anxieties.

• People want improved services that meet their needs and that "get it right first time".
• People want these services to be locally accessible.
• People want services that treat them well as individuals.
• But equity matters: both staff and users express fears that current changes risk creating inequalities. 

Here the challenge is to develop new forms of relationship with a changing public that take account of the multiple aspirations that 'choice' represents, rather than focusing on choice of provider as the single driver of change.

• Managers and staff in service organisations are struggling to manage demand efficiently and equitably in the face of the current choice agenda. 
• Many people who use services have become more assertive but also have an understanding of these dilemmas faced by service providers. 

The current policy agenda conceals the tensions between needs, choice, rights and rationing and devolves them to service organisations. Choice appears to be making those decisions more difficult. More transparency about such tensions and how they are being managed would create more productive public dialogue.