Posts Tagged 'choice'

TripAdvisor helps us choose hotels and restaurants – so why not where we end our days?

Originally published by The Conversation on August 1st 2017. 

Tony Walter

My 91-year-old mother was deeply unhappy at the geriatric hospital in which she found herself after breaking her ankle.

But we knew little of the alternatives. Official inspection ratings offer impersonal information. So how were we, her children, supposed to gauge the quality of other establishments offering care?

Our saviour turned out to be Alison – my mother’s hairdresser. As a specialist in older, housebound clients, she had continued to do her customers’ hair as they moved to various hospitals or care homes.

Alison gave us the names of three places nearby that our mother might prefer, and we arranged her transfer within 36 hours. It was a move which transformed the quality of her last few months of life.

Unlike formal inspectors, Alison was an unthreatening, secret observer of each of the institutions she visited. She proved to be a knowledgeable and reliable guide. Without her, my mother’s life could have ended very differently.

The trouble is, not every family is lucky enough to know an Alison.

In the UK, people are expected to make their own choices about their own care in the final months and years of life. But how can people become well informed about different care providers, especially when a crisis forces decisions to be made at short notice? Alison revealed the importance of informal contacts and social networks in allowing individuals and families to make good choices.

How could her role be made available to all families seeking similar information? Care settings for those nearing the end of life are, in terms of inspection, a bit like restaurants. Technical medical and nursing procedures, like a restaurant’s kitchen, need inspecting by technical inspectors. But most of the care provided at the end of a person’s life is not of the technical kind. It involves hard to measure factors like respect, a sense of belonging, and relationships with staff. It is in many ways like assessing a restaurant’s ambience. In the hospitality trade, this is something best considered by mystery customers who collectively author good food guides, or by informal online ratings like on TripAdvisor.

Such assessments rightly abandon the myth of objectivity embedded in formal inspections. Potential consumers perusing TripAdvisor ratings understand them as subjective experiences to be taken on balance.

So collective, honestly subjective, online ratings should be available for families to make informed choices about different care settings. For well-being over the course of life, we need to be able to read about customer experiences of health and care agencies just as much as we need to read about experiences of restaurants, hotels and holidays.

A great example of what is needed is carehome.co.uk, which gathers and publishes reviews of care homes, along with other information provided by the home. Many of the care homes listed, however, have no reviews. Care at home is reviewed by the online database homecare.co.uk, although the vast majority of organisations that look after people in their own homes have no reviews.

Those two websites are funded by industry subscriptions. Proposed reviews are authenticated and vetted before publication, and reviewers are advised not to publish complaints but send them direct to the agency. These safeguards should eradicate vexatious reviews, although they may also present an unrealistically positive overall view of user experience. The sites are, however, a step in the right direction.

Of course, TripAdvisor-style ratings for the “last journey” tend to come not from the actual service-user or patient. Most reviews are from family and friends, which could be an issue. Complex family dynamics – such as guilt at putting parents into care, or anxiety that care costs are eating up the inheritance – can mean families are rarely the baggage-free observers that Alison was.

Reviewing the situation

Of more concern is that even the most loving, attentive and observant family member may know little about the person’s experiences at the hands of their paid carers. This might only be achieved by CCTV cameras, but do we really want care homes, hospital wards and (in the case of home care) even the person’s own home to become zones of electronic surveillance?

No way of monitoring or collecting information will be perfect. And we should acknowledge that the trajectory of frail elderly dying is always uncertain. No one can predict how they will feel as bodies and minds fail, so all choices will entail a degree of guesswork.

Rigorous formal inspection – and public enquiries when things go dramatically wrong – are of course essential. But if people nearing the end of life (or their families) are to adopt the prescribed role of informed consumer, comprehensive collations of user experiences are vital.

End of life care is more important than booking a restaurant or the next holiday – so information needs to be just as good, or better.

What death means now by Tony Walter is available with 20% discount on the Policy Press website.  Order here for just £7.99.

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Choice, markets and welfare

Paul Spicker

Paul Spicker

by Paul Spicker, author of Reclaiming individualism, published today

Having ‘choice’ is assumed to be part of welfare, but when people write about it they may be referring to very different things. Part of the arguments for ‘choice’ are arguments for self-determination and freedom of action; those may not be enough to be sure of people’s welfare, but they are certainly important. In economic theory, however, choice is about something quite different – the selection of preferred options from a limited basket of goods. Choice in the second sense tells us very little about choice in the first.

Markets offer some choice, but they only go so far. In the first place, things that are being chosen have to be capable of being treated as commodities. Second, because commodities are scarce, people have to decide what they are ready to forego, as well as what they want. Third, producers have choices, too. They can decide what to provide, and who to provide it to. Producers compete, and they become ‘efficient’, because they are selective. There is often ‘adverse selection’; people who are isolated, poor or who have particular needs may not be served. The argument that markets provide choices, and that choices guarantee well-being, is contingent at best, and this is not always good enough to protect the situation of individuals. Markets might work, and they might not.

Individualisation and personalisation, similarly, are not necessarily good ways to improve individual welfare. There are some circumstances where policies ought to be tailored to the individual, usually after more general services and facilities are put in place. There are others where people need a common foundation of services and facilities, such as schools and hospitals. Where there is no road, the answer is not to issue everyone with boots.

Where governments claim to work for people as individuals, they need to engage with a wide range of activity promoting and safeguarding their welfare. Markets are not enough. Reclaiming individualism makes the case for taking individualism as a focus for actions to protect rights, extending basic security and empowering people as citizens.

Reclaiming individualism is available with 20% discount at www.policypress.co.uk

Challenging choice in society

Following the recent discussion on the Today programme about choice in society (listen again here), Michael Clarke, author of the forthcoming Challenging choices, writes:

Choices proliferate in every corner of our lives, not just in the supermarket, the clothing shop and online, but in the knowledge, techniques and drugs available in medicine, in the options for savings and investments, in building our short or long term relationships, in how we bring up our children. Compared to those suffering poverty, authoritarian government and patriarchal family life we are surely privileged and have achieved mighty progress over the past centuries. Choice is central to our way of life and empowers and enables us.

So can we never have too much choice? Is it always a benefit? At some point each of us will be overwhelmed at having to choose between too many alternatives, or at having to make too many choices in sequence. We routinise, have habits, have favourite brands, leave it up to others, to alleviate these problems, but the issue returns.

Not all choices are easy: try choosing a pension arrangement unless there is a good occupational scheme available to you. The consequences of a choice may be severe and yet the responsibility rests firmly with the chooser. And choice does not always work. Do we really have a choice of train operators, or merely regional monopoly, high prices and ticketing confusion? Surely there are other ways? But is that not in itself a bit of a contradiction: other and better ways than choice?

What do you think? Is more choice always better? What are the alternatives and are they necessarily any better? We’d love to hear your views, so please add your comments to the discussion.


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