Introduction

The neoliberalism of Margaret Thatcher and her successors has had a profound effect on conceptualisations of the relationship between those who provide health and social care services and those who use them. The reinvention of clients and patients as welfare consumers was intended as one way of subjecting public services to the assumed discipline of the market. If people behaved more like active consumers than passive clients, then, it was argued, this would force services to become more responsive. Politically, the Left was found wanting in terms of its capacity to resist the power of this consumerist rhetoric, not least because welfare services were also under critique from very different quarters for their unresponsiveness and paternalism (Deakin and Wright, 1990). It was not possible simply to defend the existing state of affairs, and consumerism came to be linked with the empowerment of public service users. The mantra of choice appeared to unite those who wanted to dismantle public provision and replace it with the private sector, and service users who were angry and frustrated by their inability to receive services of the type they wanted when they wanted.

The embracing of consumerism by New Labour – albeit in hybrid form along with other projects such as the crafting of more responsible citizens (Clarke et al, 2007; Clarke and Newman, 2007) – indicates the strength of the Thatcher legacy and the extent to which, in practice, relationships between producers and consumers of welfare have shifted. But this does not mean that consumerism offers the most appropriate way of understanding the identities of those who use health and social care services, or the solution to paternalistic welfare provision. I argued against this in 1990 (Barnes et al, 1990) and I see little reason to change my mind. In this chapter I revisit and develop my arguments.

Revisiting choice

The equation of consumerism with the ‘empowerment’ of service users underpins the strength of the consumerist discourse. It is a claim that continues to be made in the context of the ‘personalisation’ agenda and the introduction of individual budgets as the preferred model for the delivery of social care (and other) services (Leadbeater et al, 2008).