Magazine article Public Finance

Spoilt for Choice

Magazine article Public Finance

Spoilt for Choice

Article excerpt

I am not an opponent of choice: I am more than happy to live in a capitalist democracy and to exercise my rights to choose a government through the ballot box and to choose the things I consume through the market.

But I am also aware of the limits and failings of choice. I can vote, but the party I vote for doesn't always get into power. And I can go to any one of hundreds of car mechanics - but did my car really need all its shock absorbers replaced?

A key question, therefore, is not the simplistic one - choice: good or bad? Rather, it is whether the costs and not just the financial ones justify the benefits. Another way of framing this question is whether Patient Choice is not just an effective, but a cost-effective, way of achieving the benefits.

The latter, according to Julian Le Grand's recent Public Finance article 1A better class of choice', March 31-April 6 - include, in theory at least, more equitable access to quality health care services across social groups and an 'embedded' incentive mechanism to pressure providers to improve the efficiency and quality of their services.

But we need to be even more specific. Too often in debates about Patient Choice, what is being chosen and the necessary limits to choice, are left indeterminate. While NHS patients do not face the financial consequences of their choices, the NHS does: it has a finite budget. So, regardless of the demands of patients, a choice of an unlicensed high-cost drug of dubious effectiveness is not the sort of choice that should be on offer.

Indeed, the current policy on choice at the point of GP referral is in many ways highly restrictive. It is a choice - from a limited set of hospitals - of outpatient department. It is not a choice of surgeon, or of treatment, or of any of the myriad possible choices that could be imagined along a patient's pathway of care. Further, hospitals that look likely to miss their waiting times targets due to their popularity among patients will be removed from the choice 'menu'.

Le Grand builds a case for choice based partly on a description of a failing NHS, with long waiting times, haughty professionals and dastardly monopolistic practices. But it is too easy to slip into hyperbole, exaggerating the decrepitness of the current situation, when you have a new policy solution to promote.

This is an over-reaction to what Karl Popper termed 'solutioneering': the jumping to a solution without properly setting out the problem the solution is meant to address. Perhaps we need a new term to describe this: 'problemeering'?

It is, of course, not true to say that there has never been choice in the NHS - its very creation opened up access to health care for millions of people who were previously unable to afford even the basics. …

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