Choice on the sickbed

New Labour's new Patient Choice initiative suggests it doesn't know the meaning of the c-word

You may be part of the 80 per cent of the British public who didn't know this, but as of 1 January this year we Brits have the right to choose between at least four hospitals for non-emergency treatment.

Under health secretary Patricia Hewitt's Patient Choice initiative, which she modestly describes as a 'revolution', you will no longer have to put up with treatment at your run-down, resources-challenged local hospital - you can choose a different run-down, resources-challenged hospital in your Strategic Local Authority instead. The only problem is, a Mori poll carried out for the Department of Health found that of 1,276 people surveyed 41 per cent knew 'nothing at all' about the new policy and 39 per cent said they knew 'just a little'. Only four per cent said they knew a 'great deal'. And given that the NHS is one of the biggest employers in Europe, that four per cent may well be its own staff.

Welcome to Britain 2006, where a 'revolution' can occur without anybody noticing and where you can have apparently brilliant brand new choices without even knowing it; where the government's idea of overhauling the NHS is to let us pick between hospitals rather than to rethink the hospitals themselves. Nothing better captures the government's degraded view of choice than the 'empowering patients' debate. Under New Labour choice has come to mean, not active citizens making decisions about big issues, but sick people deciding whether they want their injections or stitches from Dr Patel or Dr Jones in hospital A or B (or C or D, to be fair). It says a lot about the government's view of citizens that it only seems able to conceive of us as choice-makers when we're dilapidated, and temporarily removed from public life to get something fixed.

Government ministers present choice-in-health as something that patients are crying out for and which they are graciously providing. According to Hewitt, 'Every survey shows people want more choice and control over healthcare. We found the majority welcome being offered a choice and use that choice.' In truth, patient choice is an entirely top-down initiative; it's a political invention. How many people do you know who when they get sick think to themselves: Right, I must flick through the catalogues and go on a tour of hospitals in and around my area to find out which has the best resources and doctors? When we're ill we want to be made un-ill as quickly as possible, preferably in a local hospital that does things competently. For most people, hospital treatment is a technical thing rather than a life-changing choice: we want to be made better so that we can get on with the important things in life.

Indeed, choice in healthcare is something of a misnomer. Most of us are not in a position to make serious choices about the treatment we receive because we don't know enough. As Barry Schwartz, author of The Paradox of Choice, argues, 'individuals are not in a position to accept responsibility for their medical treatment' because we generally do not know 'the ins and outs' of such matters. It is precisely when we're sick or injured that we are most willing to absolve ourselves of decision-making and hand our bodies over to the experts. We trust doctors to choose what treatment we need because they know better than us. One satire website summed up the absurdity of too much choice in healthcare with the headline 'New NHS reform allows patients to choose own diagnoses..'

Something that we could take responsibility for is rethinking how the NHS is run - but if this isn't really a personal choice over treatment then neither is it a political debate about healthcare. 'Patient choice' never refers to making choices about how public healthcare is organised and distributed; instead it's limited to choosing between different hospitals within an already-defined healthcare system. Indeed, the government's emphasis on patient choice seems designed to avoid having any kind of proper debate. By making choice of hospitals the priority Hewitt and co are really saying: 'Yes, we know some local hospitals are crap. But there isn't much we can do about it, so from now on you can choose a different hospital instead.' Giving us more choice over which hospital to have our kidney op in is another way of limiting the debate about hospitals and healthcare more broadly. Instead of having a say in how the healthcare system might be reshaped, we're given leeway to wander around the current healthcare system a bit more than we could before.

Hewitt's revolution really amounts to a choice between venues. We will receive much the same treatment for the same ailment, but in one of four buildings of our choice. This is choice in the consumerist rather than the political sense. Our medical treatment is necessarily a set course of action, and it seems that political decision-making about the NHS is off the agenda, so our choice is only over where that action should take place. Like consumers in the supermarket we can pick already-made products off the shelf; how those products got to be made and put on the shelves is something for other people to concern themselves with, apparently. I prefer the late social theorist C Wright Mills' definition of choice: 'Freedom is not merely the opportunity to do as one pleases; neither is it merely the opportunity to choose between set alternatives. Freedom is, first of all, the chance to formulate the available choices, to argue over them - and then, the opportunity to choose.'

Hewitt's Patient Choice initiative is really an attempt to tart up the NHS with some positive-sounding words (or 'Hooray Words' as Jamie Whyte calls them in his book A Load of Blair). Bereft of ideas for how to improve the NHS the government simply plays around with its presentation. This could end up making things worse by increasing the bureaucracy. As one doctor said when asked for his response to the choice revolution: 'At the present time we're still, to be honest, pretty short of doctors, nurses and other health professionals to run a high-quality 21st-century health service.' (5) Maybe the government should put its thinking cap on about those problems instead of giving us bogus choices we never asked for in the first place.

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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