Choice

‘Users should be provided with an improved range of choice in service provision. The expression of that choice needs to be equitable, informed and to provide genuine options in who delivers care, and where and when it is delivered.’1

Under the Labour government the rhetoric of modernisation and reform has disguised a return to the past: first to voluntary (‘foundation’) hospitals, and now to fund-holding (‘practice-based commissioning’). Next stop — the workhouse? The proclamations of choice that now accompany every ministerial speech or policy statement signal the further intrusion of consumerism into health care. But it was the inadequacy of market relations in medicine that led to emergence of a medical profession tied to an ethos of public service.2 The mantra of choice now accompanies measures that threaten to return medical practice to the 19th century.

Choice is inimical to equity. Many of our patients are incapable, because of immaturity, or mental or physical impairment, of exercising choice. The capacity of many more is limited by the simple fact that they are ill, either acutely or chronically, physically or psychologically. Choice in matters of health is restricted to those who are well, well educated and well off — that is to say, those whose need for health care is least, but whose influence weighs most heavily in the concerns of this government.

The choices made by those articulate consumers whose votes the government most covets are as likely to be misinformed as informed. When I summoned an ambulance last week for a young professional with a high fever, who had just returned from West Africa, his partner told me that, after consulting the Internet about the risks of malaria prophylaxis and the disease itself, ‘it was his choice’ not to take the tablets. Another patient recently told me that, on the authority of an almost unbelievably asinine newspaper article — widely available on the Internet — she had decided against giving her baby the new ‘five-in-one’ immunisation.3 The cost of encouraging such choices, in human lives as well as financial terms, is likely to be considerable. But, as we must now acknowledge, ‘the customer is always right’.

We are now supposed to offer our patients the choice of several local hospitals. But we know that at each of them they are likely to be kept waiting for hours, they are unlikely to see the same doctor twice, their notes are equally likely to get lost, and the toilets will be filthy. We can offer them the option of the private sector, where the staff may be more civil and the facilities more congenial, but the quality of clinical care may be less reliable.

For the government, patient choice is ‘a driver for quality and empowerment’.4 But this is nonsense. As the patients of the former GP Harold Shipman, who protested in disbelief at his suspension, can testify, patients are often ill-equipped to judge the quality of their doctors. One definition of a quack is a practitioner who tries to please his/her patients rather than satisfy colleagues' authoritative judgement of his/her professional standards.5 The simple truth is that, in every area of medical practice, the quest for quality has been driven by doctors, not by patients, and least of all by politicians.6

Contrary to the prejudice assiduously promoted by the government, it is not doctors who ‘disempower’ patients, but disease itself. It is the increasingly successful treatment of disease by doctors that restores patients' powers, and enables them to continue to make unhealthy choices, should they choose to do so. This is why patients willingly surrender a degree of autonomy to their doctors as a precondition for recovery from illness. This relationship, well understood and appreciated by generations of doctors and patients, is now jeopardised by the philistine dogma of the market.

• © British Journal of General Practice, 2004.