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The Other Invisible Hand

The Other Invisible Hand: Delivering Public Services through Choice and Competition

Copyright Date: 2007
Pages: 208
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  • Book Info
    The Other Invisible Hand
    Book Description:

    How can we ensure high-quality public services such as health care and education? Governments spend huge amounts of public money on public services such as health, education, and social care, and yet the services that are actually delivered are often low quality, inefficiently run, unresponsive to their users, and inequitable in their distribution. In this book, Julian Le Grand argues that the best solution is to offer choice to users and to encourage competition among providers. Le Grand has just completed a period as policy advisor working within the British government at the highest levels, and from this he has gained evidence to support his earlier theoretical work and has experienced the political reality of putting public policy theory into practice. He examines four ways of delivering public services: trust; targets and performance management; "voice"; and choice and competition. He argues that, although all of these have their merits, in most situations policies that rely on extending choice and competition among providers have the most potential for delivering high-quality, efficient, responsive, and equitable services. But it is important that the relevant policies be appropriately designed, and this book provides a detailed discussion of the principal features that these policies should have in the context of health care and education. It concludes with a discussion of the politics of choice.

    eISBN: 978-1-4008-2800-5
    Subjects: Political Science

Table of Contents

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  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Acknowledgements
    (pp. ix-xii)
  4. Introduction
    (pp. 1-5)

    Ask people what they want from the public money that is spent on health care and education, and the answer will be simple: a good service. Sometimes they will add that they would like this service to be on their doorstep: a good, local service. A high-quality local school; a caring, responsive, family doctor; a top-class district hospital.

    This short book is about how these aims can best be achieved. It examines four means of doing so: trust, where professionals, managers and others working in public services are trusted to deliver a high-quality service; targets and performance management, a version...

  5. CHAPTER ONE Ends and Means
    (pp. 6-37)

    As noted in the previous chapter, when considering publicly funded services such as health care and education, most people simply want a good service. But what exactly is a good service? And how do we get it? Put more precisely, what are theendsthat we are trying to achieve with our public services and what are themeansfor achieving those ends? And what are the advantages and disadvantages of particular means for achieving particular ends? This chapter and the next address these questions in a general fashion, reserving more detailed discussion of the special (but important) cases of...

  6. CHAPTER TWO Choice and Competition
    (pp. 38-62)

    The previous chapter analysed some of the advantages and disadvantages of three ways of, or models for, delivering public services: trust; targets, performance management, and other forms of command-and-control; and voice, both individual and collective. We concluded that all have their place in any system of public services, and indeed that it would be difficult to imagine a system that did not have some of these elements within it. However, we also argued that each of them had considerable problems as a sole, or even principal, model for public service delivery; and, if the aim of obtaining a good public...

  7. CHAPTER THREE School Education
    (pp. 63-93)

    Education systems around the world have been experimenting with extending parental choice in school education. In Britain, since 1989 parents have in principle had the right to send their child to any state school of their choice, subject to there being spaces available. Sweden introduced parental choice between state schools and publicly funded independent schools in 1992. New Zealand has offered some parental choice of school since 1989. In the United States, there have been extensive experiments in recent years with various education voucher schemes. And Belgium and Holland have long had parental choice of school, with funding following the...

  8. CHAPTER FOUR Health Care
    (pp. 94-126)

    Both the current British government and the principal opposition party are committed to increasing patient choice in the provision of publicly funded health care. Other countries are also moving in this direction, including Norway, Sweden, Denmark and the Netherlands. Many continental European countries, especially those, such as Germany and France, whose health systems have a tradition of being financed through social insurance, have long offered patients choices of various kinds, including choice of providers. And in the United States, patients have historically had considerable freedom to choose their clinician or hospital, even within the publicly funded systems of Medicare (for...

  9. CHAPTER FIVE New Ideas
    (pp. 127-155)

    So far in this book we have concentrated mostly on examining choice and competition policies that have either already been implemented or are in the process of being implemented. This chapter is more speculative. It looks at some of the possible ways to go beyond these policies and to extend some of the basic ideas into other areas. However, rather than a general treatment that would mean going over ground that has already been covered, it seems better to provide some concrete illustrations of the ways in which this extension might be done. So the chapter concentrates on three specific...

  10. CHAPTER SIX The Politics of Choice
    (pp. 156-168)

    The politics of choice and competition in public services are complex. The issues involved do not fit neatly into the boxes of left or right, of social democrat, socialist, conservative or liberal. On the contrary, political parties of whatever stripe are generally divided over the policies concerned, with influential groups within each party pulling in opposite directions. Even those directly involved, including both providers and users, are often unclear about the relevant arguments and, in consequence, where they stand on the issue.

    In this chapter I review some of these tensions. I consider two kinds of interest group: ideological and...


    • An American Perspective
      (pp. 169-173)
      Alain Enthoven

      Beyond sharing a common language, democracy and the rule of law, American and British people also share frustration about the performance of their public services, particularly elementary and secondary education and medical care. The problems in medical care are somewhat different on the two sides of the Atlantic. American Medicare and Medicaid spending is running out of control, whereas the British NHS has spending under much better control. But people in both countries have good reason to be concerned about the quality of health services, as well as their accountability and responsiveness. We have similar problems in education: too many...

    • A Sceptic’s Perspective
      (pp. 174-179)
      David Lipsey

      As a politician-turned-journalist-turned-politician I am a trained killer controversialist. My first instinct is to run direct at the opposition with head down and horns sharpened. I expected to play that role when Julian Le Grand asked me to contribute a commentary to his new book on choice in public services, something about which I have been privately and publicly critical.

      But I cannot. I hope it is not just the clarity of Le Grand’s argument and the breadth of his evidence that has weakened me as the banderillero weakens the bull. Headlong charge against this remarkable volume is not possible....

  12. Further Reading
    (pp. 180-182)
  13. Bibliography
    (pp. 183-195)