What price choice

Patient choice is being enthusiastically promoted by politicians as a means of gaining public support for healthcare reform, but the idea has created antibodies in some quarters. While some claim that choice and equity are fully compatible,1 others disagree.2 They argue that the new emphasis on patient choice panders to a middle class consumerist agenda that has little to offer people whose opportunities are severely constrained by low incomes, poor living conditions or multiple health problems. Critics of the current emphasis on patient choice see it as a distraction from the much more important task of tackling health inequalities and shifting the focus from health care to prevention. But there is no doubt that choice is a popular concept. Many people feel they should be able to choose who to consult or where to be treated and there is considerable demand for more involvement in treatment choices.3 A recent survey carried out among random population samples in eight European countries found strong support for the notion of free choice of provider: 92% wanted to be able to choose their primary care doctor, 85% wanted to be able to choose which specialist to see, and 86% wanted a free choice of hospital.4 Three of four respondents (74%) said they wanted to be involved in treatment decisions. There were considerable international differences in people's views on the possibility of choice in their country, with 73% of Spanish respondents and 70% of Swiss saying they were satisfied with the opportunities to make health-care choices in their country, as against only 30% of respondents from Slovenia and the UK and only 15% of those from Poland. Proponents of choice hope that it will encourage greater responsibility and self-care, and also provide an incentive for providers to improve the quality of their services because of the need to attract patients. A recent review of future funding needs for the health service carried out on behalf of the UK Treasury Department called for a new focus on moderating demand by encouraging patient and public engagement.5 They concluded that the ‘fully engaged’ scenario offered the best and most cost-effective means of matching demand to supply of health care in the long-term. By providing information to ensure that patients can make informed choices and by encouraging effective shared decision-making and self-management, the treasury team hoped that demand for doctors’ services would decline. Meanwhile, the government's economic advisors want to encourage greater competition among providers, with patient choice acting as the ‘grit in the oyster’ to drive up quality standards.6 It is clear that patient engagement and increased choice is now seen as a key element in healthcare reform, and many readers of Health Expectations will welcome this. But what about the downside? Does the emphasis on choice indicate a shift to a more individualistic and market-orientated system and, if so, will it inevitably increase inequalities between the haves and the have-nots? What will be the consequences for neighbourhood care and continuity? Will giving individuals more choice encourage greater responsibility and self-reliance or will it lead to more commercialization of health care, fostering increases in demand and greater dependency on health professionals? What will be the consequences for public health and prevention? The debate on choice in health care tends to be highly ideological, but there is a great need for well-conducted research in this area. We need to know more about the benefits and harms in relation to patient experience, public expectations and the consequences for health systems more generally. Health Expectations welcomes submissions on this topic, especially those which cut through the ideological arguments to shed light on the reality for patients and public health

Economics · Environmental health · Health care · Inequality · Patient choice · Political science · Population · Public relations · Health Services Management and Policy · Health Systems, Economic Evaluations, Quality of Life · Healthcare Policy and Management · Law · Medicine · Psychology

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  Paul Bate, Glenn Robert•Policy & Politics•2006

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• Trust, choice and obligation

  Open Access•P Ward, Cushla Coffey et al.•Sociology of Health & Illness•2015

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