第一部分 嘉宾主旨演讲 INVISIBLE LEVERS: DELIVERING PUBLIC SERVICES THROUGH CHOICE AND COMPETITION Julian Le Grand Richard Titmuss Professor of Social Policy London School of Economics Many publicly funded services such as health care and education face severe problems with their systems of care delivery. In many countries, public funding is often accompanied by public delivery: that is, by hospitals, schools and other facilities owned and operated by the state. Although on occasion such institutions can work successfully, in many other cases they do not. In fact typically they provide low quality service, are inefficient in their use of resources, and are unresponsive to the needs and wants of the people who use them. In addition, they are often monopolies with users having relatively little alternative sources of service – especially if they are poor and cannot afford whatever private facilities may be available. They are also often directly funded from government, with budgets that are determined historically and that bear little relationship to their performance or activities. Critics of these forms of public service delivery have linked the fact that such institutions perform poorly with their monopoly status and the budgetary system. They have argued that if users had more choice of where they could go for service, and if the money followed the choice, so that providers would only successfully obtain resources if they successfully attracted users, then the resultant competition would provide a powerful incentive for those providers to improve almost all aspects of the service they provide: their quality, their responsiveness and their efficiency. Such a 'quasi-market' system would also be more equitable, with choices that are currently reserved only for those can afford to use private services being extended to the less well off, and with the resultant rise in standards benefiting everyone. However, many would not accept these arguments. They would point to the problems that quasi-market systems of this kind of face, including the lack of genuine competition in the real world, the difficulty of providing information to users of a good enough quality to enable them make sensible choices, and the danger of cream-skimming (the selection by providers of easier or cheaper users to provide services to). All this, they would argue, would vitiate the alleged advantages of choice and competition and instead create a system encouraging exploitation and inequity. This paper addresses some of these issues. It begin with a discussion of alternative models for public service delivery, arguing that all have their merits and demerits, but pointing out that there are good theoretical arguments for preferring systems with a strong element of choice and competition in many situations. It then discusses some of the empirical evidence to see whether theory is born out in practice. Finally it draws together practice and theory to discuss how choice and competition policies in public services can be designed so as to benefit from their advantages without incurring too many of their disadvantages. MODELS OF PUBLIC SERVICE DELIVERY The basic reason why many publicly funded systems have experimented with quasi-markets in service delivery is because other models of delivery are perceived to have failed. Essentially, there are three other such models, all of which have been tried in one form or another within most countries. First, there is the Trust Model, where professionals and managers are trusted to know what is best for their users, and to deliver high quality services without interference from government or any other source. Then there is the Command and Control Model, where central management sets targets for providers, rewards them if they succeed in meeting those targets, and penalises them if they fail. And third is the Voice Model, where users express their dissatisfaction (or satisfaction) directly to providers. This can be through face–to-face c
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