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Who is choosing 'choice'?

Updated Friday, 25th July 2008

Will patient choice result in long waiting lists at some hospitals and no demand at others?

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Everywhere these days the mantra of ‘choice’ rings in our ears. No politician can speak about education or health without choice being a key part of the message.

But, what is less often discussed is the question of who is choosing choice. It does seem that we are simply to take for granted that this idea, one that is driving change and reform across the public sector, will lead us to better public services. For in the name of this idea, we are promised enhanced ‘transparency’, openness and democracy. On the face of it, it’s difficult to see why anyone could question that all these things are simply good things.

Medical notes
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However, I wonder just what capacities we need in order to exercise choice in the first place. Exercising ‘choice’ is not just a case of being able to access ‘raw’ facts, after all. Facts always have a surrounding context in which we understand their importance and their meaning. Choice means that we take some care in selecting, that we use judgement or skill to distinguish what is to be preferred, which leads to being able to discriminate. Those advocating choice often seem to assume that exercising choice is a straightforward and uncomplicated matter. But if many of us nowadays find choosing a can of beans, or a electricity company a time-consuming and often ultimately inconclusive activity, how much more burdensome and challenging is it to have to constantly choose between doctors and hospitals for this or that treatment?

Just as has already happened with school ‘league tables’, and after a year-long review of the health service in England by the surgeon-minister, Lord Darzi, an announcement came in early July that hospitals would be required to publish "quality accounts" alongside the financial balance sheet. They will reveal information ranging from the death rates of surgeons to the relative satisfaction of patients during and after a course of treatment. NHS hospitals will be eligible for bonuses worth billions of pounds if they can demonstrate top quality clinical performance, the government said. Whereas a ‘poorer’ performer would lose patients to rival establishments with better clinical outcomes.

Understandably, potential patients want to know in advance about poor survival rate in particular hospitals. Who would not want to go somewhere safe, and with ‘better outcomes’ than elsewhere? Who would choose to ignore that information, if it was available.

But that’s the rub, because the language of choice assumes there is a simple and direct relationship between this desire to reduce risk (to avoid unsafe doctors and hospitals and ultimately to avoid harm or death) and the solution, of successfully identifying doctors and hospitals that are less risky. It seems to me that the language of choice relies on an appeal to primitive desires in the population (‘I want to know if I’m less likely to die if I go to X hospital). But the solution it proposes is highly cognitively complex. Context and presentation are key elements and citizen-consumers would need to be educated in the social science of statistical interpretation before being able to fully take part; are these capacities equally available to everyone?

For, for example, mortality is not the only guide to the standard of treatment. A hospital that picked ‘bread and butter’ cases, turning away difficult operations, would score well. Another unit might have a higher mortality rate, by dint of having hugely expert surgeons prepared to take on complicated cases. How is a patient with a serious condition to ‘choose’, for emotionally s/he’d be drawn towards the ‘low mortality’ unit, perhaps against his/her interests. How does one judge which is ‘better’?

Another development in this armoury of consumer choice is that of a new website,, which will let patients rate and review every medic who has treated them. This follows hot on the heels of sites for customers of hotels, restaurants, books, travel companies to name a few, to record, praise or deride their experiences. Internet democracy is one way in which customer ‘choice’ is manifesting itself. The doctor behind the site claims that letting the public give medics individual reviews and rate their performance will help to bring about higher standards of care and to ‘choose’ which doctor to go and see.

Lord Darzi said: ‘For the first time, patients' own assessments of the success of their treatment and the quality of their experiences will have a direct impact on the way hospitals are funded.’ This may end up with a ‘social Darwinist’ survival of the fittest, which deals in primitive and absolute divisions between the bad and the good: the ‘bad’ (hospitals) go to the wall, and the ‘good’ are rewarded. Presumably then, the poorer performers, already punished with less income, will still have to treat patients, who will get worse treatment. Similar things have happened in education: parents are told they may ‘choose’ a school; in reality what are deemed ‘good’ schools are oversubscribed (and indeed become 'good' schools because wealthier parents are able to move into expensive catchment areas) and so not all parents may in fact be able to ‘choose’ those good schools. I have visions of ‘popular’ doctors on the website being in so much demand that there are long waiting lists at certain hospitals and no demand at others. How is this practicable, on the scale of a national health system?

The ‘choice’ agenda is part of a wider Labour government move away from a ‘one size fits all’ idea of public services towards a personalised system based around the ‘user’. But how many people really want a government to put so much energy into pursuing an ideology that, even if sounds ideal, has so many unintended consequences and assumes so much about the capacities of citizens?

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