The Difference Between Choice and Control

The fourth in a series of blogs from Finland, Simon Duffy explores the different meanings of choice and the options available for health and social care reform in Finland.

Author: Simon Duffy

In this, fourth in a series of blogs from Finland, Simon Duffy explores the possible different meanings of the term choice. He argues that personal budgets give not just choice, but control, and that this is a more developed and creative form of choice. This offers certain possibilities that are not available to systems of vouchers or on models where the 'money follows the patient'.

This is the fourth of my Finnish blogs. I have been very lucky to get the chance to work with KVPS, to meet up with old friends and make some new friends. Over the past few weeks I’ve met people who are using personal budgets, professionals who are trying to implement them and politicians and policy-makers who are wondering where they fit in Finland. It is a fascinating experience and I am honoured to have been given this opportunity to try and offer an international perspective.

The current Government in Finland has embarked on an ambitious project to reform the whole health and social care system. In fact there seems to be a consensus, across most political parties, that the system needs reform. It is also assumed that choice must be central to any future policy.

But what kind of choice?

I think it is useful to consider the different kinds of choice possible. For not all choices are equal.

The most primitive, and important kind of choice is consent - saying yes or no. In fact the most important word in any language, and one of the first that children learn is ‘no’. It is only when we can say ‘no’ that we can assert our existence and our rights. Without the ability to say ‘no’, without active consent, we can become just a cog in somebody else’s machine.

The institutions, where too many people with learning disabilities are still forced to live, are machines for encouraging people to say ‘yes’. If you resist, if you say ‘no’, you will be treated as a trouble-maker as someone who is non-compliant. The price of non-compliance in an institution is very high indeed. This is one of the ways that institutions erase our identity and dehumanise us.

But while consent is important, it is still an extremely primitive form of choice. What I am consenting to is shaped utterly by others.

A slightly more advance form of choice is to choose between options - saying ‘I want A, not B’. Choosing lets us build an identity for ourselves from the options we are offered. I like blue, you like red; I like Led Zeppelin, you like ABBA. The options are created by others, but I get to choose the ones I prefer.

In our modern consumerist society this version of choice has become dominant. No longer are we a cog in the machine, we are shoppers, we are customers. Our choices don’t just change us, they also change the world: we give business to these people, we take business away from those people. This kind of power, simplistic as it is, is very attractive, especially when you feel generally powerless.

In health and social care reform this is often the kind of choice policy-makers are considering. I can choose my doctor, my hospital, my therapist or my service provider. This may be useful, it may have some beneficial effects on the system, and it may make it easier for me to fit into the existing system. But I am still largely passive. I choose - I don’t generate the options.

The third kind of choice is control. I control something when I shape it, when I make it - I say ‘I’m going to try this…’ This is an active process where I am changing the world, and changing myself through the process. I am not just assembling a life from the parts given to me by others, I am building a life for myself. When you hear the stories of how people have used personal budgets in Finland and elsewhere this is what you discover. People are not shopping - they are building, they are creating, they are innovating.

For example, one man with a brain injury, instead of being depressed in a day centre, is flourishing as he uses his personal budget to make music with his old band-mates.

Personal budgets will not be the best system for every part of the health and social care system. But there are several reasons why personal budgets will be the right approach in many cases:

  1. Sometimes we want don’t want people to fit into a service, we want support to help people build a life. All of social care and many health care services are more about helping people live well - they are not about treating people.
  2. Sometimes the people who make most of the difference are the person, their families and their friends. If we want things to get better we need to move the point of control as close to the person as possible.
  3. Sometimes we just don’t know the right thing to do - we’ve just got to try things out - to innovate. This is a process of control - not choice. We can only choose what already exists - innovation means creating something new.

There is a fourth kind of choice - cooperation - working together - where we say ‘Let’s try and do this…’ Often what we are trying to achieve cannot be done by one person; it takes many of us. When we cooperate we can become a community, not a machine, not an institution. In this process we may even forget who did what.

Some critics of personal budgets claim that personal budgets are too individualistic. They prefer the notion that we should do things together. However they seem to forget that we can only really cooperate if we have the means to do so.

If I have a personal budget I can work together with others to achieve what we all want.

If I have no control over myself or my life I cannot cooperate.

Together with my colleague Aarne Rajalahti we developed the graphic below. What we are trying to show is, not that personal budgets are the only way to organise health and social care, but that this is an approach which is particularly valuable when you want citizens to become innovators and problem-solvers. The other forms of choice on offer do not give people the means to really shape new solutions to meet their needs and to advance their citizenship.

In Finland, it seems to us, personal budgets should become central to the organisation of social care, mental health services and support for people with chronic long-term health conditions. In other words, at those times when people themselves need to be an essential part of finding the right solution for their own circumstances.

It is interesting to compare the idea of personal budgets with another important social innovation that Finland is currently considering - basic income. This week I was lucky enough to meet up for a drink and a chat with Jurgen De Wispelaere, one of the leading thinkers on this important alternative to the current social security system. It seems to me that basic income and personal budgets are both innovations to advance citizenship - giving citizens rights and securities which they can use, not just to make a better life for themselves, but a better life for all of us.

It is great that Finland is exploring both basic income and personal budgets. I hope we can see this interest turn into a real commitment to active citizenship and creative communities.

This article has been translated into Finnish and is available to read on KVPS's website here.

The publisher is the Centre for Welfare Reform.

The Difference Between Choice and Control © Simon Duffy 2016.

All Rights Reserved. No part of this paper may be reproduced in any form without permission from the publisher except for the quotation of brief passages in reviews.

Article | 13.03.16

politics, social care, Finland, Article

Also see