NHS choice may benefit a few but will harm many

FOR patients in England, choosing where to have their first outpatient appointment and subsequent treatment if they need it is slowly becoming a reality. But is Scotland also choosing choice?

In England, from 1 January, anyone who needed a referral for a consultation could choose from four or five local hospitals. And from this month, the choice has widened to include any one of the 32 foundation trusts across England, or some of the new specialist, independent treatment centres.

For some, this flagship policy is but a further nail in the marketisation-shaped coffin for the NHS. Ministers hail choice as a breakthrough for those who have traditionally been denied the opportunity to choose that the rich have always enjoyed. But others worry about the viability of those local hospitals that will inevitably lose patients and the possibility that, as with choice in education, it will be the middle classes who will be most successful in playing the system.

But surveys of the public suggest that the idea of choice is very popular - and not just in England. The latest British Social Attitudes Survey (BSAS) carried out in 2004 revealed that in England 62 per cent of the sample felt they should have a great deal or quite a lot of say over which hospital to go to. The same proportion of Scots also indicated their support for choice. The vote was even higher in Wales, at 73 per cent.

What's not to like about choice? Try turning the question round: would you like less choice of hospitals?

And contrary to choice sceptics, the BSAS also suggests that those with higher educational qualifications and those in higher social classes are less likely to be in favour of more choice than others. The differences are small, but statistically significant.

Choice is appealing to politicians. Rather than ministers micro-managing the NHS, choice is seen as an alternative, more "automatic" mechanism for putting pressure on hospitals to improve their services.

With hospitals in England now paid only for the patients they actually treat, taking your business elsewhere carries a financial incentive for hospitals to retain (and attract) patients.

And for patients, the policy can be sold on the promise that they will be empowered, that their voice will not just be listened to, but also acted upon.

As any economist will be quick to point out, there are never benefits without costs, however. But as England acts as a test-bed for choice for the rest of the UK, the problem is the dearth of evidence to either back or refute claims about the impact of patient choice.

To be fair, it is still very early days, but there have been some experiments and evaluations of choice over the past few years that provide some insights into its costs and benefits.

Research by the King's Fund, RAND Europe and City University, London, suggests that choice might exacerbate health inequalities.

When asked to choose between hospitals, this study found that those with formal education placed a higher value on hospitals that had an above-average impact on their health than others. If true, this could mean that this group could gravitate to better- performing hospitals, with the prospect of those without formal educational qualifications being left at hospitals with poorer performance.

The problem here is that the choices of a minority of patients could affect the choices of others.

On the upside, the study found that clinical quality was a key driver of the choices people said they would make in real life. On the downside, however, while there is a lot of information available to patients to help them choose, there is very little about quality, and none is available at the level patients need to make meaningful choices - the clinician or clinical team.

With six out of ten Scots saying they would like more choice of hospitals, is it time for Scotland to go down the English route?

In fact, as with the origins of choice in England, choice in Scotland is already one of the strategies being used to reduce waiting times.

The waiting times guarantee entitles patients to choose another hospital, if their local hospital cannot meet the prevailing waiting times target. Scotland is also rolling out a computerised outpatient booking system - patient-focused booking - similar to the English choose-and-book system.

And, what's more, Scotland is now rolling out a money-follows-the-patient system of paying hospitals, which looks almost identical to the English payment-by-results system.

A case of what London does today, Edinburgh does tomorrow (and the rest of the UK the day after).

• Professor John Appleby is chief economist with the King's Fund, an independent charitable foundation working for better health. It carries out research, policy analysis and development activities