Public policy and inequalities of choice and autonomy

Choice by service users has been promoted in social policy across many developed welfare states, often on the grounds that it will incentivize providers to enhance quality and efficiency. But this instrumental motivation for the promotion of choice overlooks the possibility that choice, understood in the deeper sense of autonomy, has intrinsic value, as suggested by egalitarian and capability-based theories of social justice. This article argues that the narrow motivation of choice policies leads to a focus on services rather than outcomes for individuals and fails to address deep-seated inequalities in the opportunities people have for real autonomy. We test this concept using newly collected data for the UK. Our empirical findings indicate that disabled people are more likely to experience constrained autonomy in all respects, while being from a low socio-economic group and/or lacking educational qualifications is a risk factor across several components. We conclude that improving the ‘choice’ agenda for policy requires: (1) adopting a more sophisticated concept of ‘choice’ such as the conceptualization of ‘choice as autonomy’ outlined here; (2) developing a better understanding of existing inequalities in autonomy, such as we begin to explore in our empirical results; and (3) tackling these inequalities through, for example, the removal of obstacles to active decision-making by providing effective support and advocacy, especially for disabled people, and addressing the major structural barriers – poverty, ill health and geographical inequality – which place significant restrictions on the autonomy of those who are already disadvantaged