Julian Le Grand: This unhealthy opposition to patient choice

Nobody likes competition when it threatens a lucrative private practice

The British Medical Association is holding its key policy meeting today in Belfast, where the leadership is likely to be attacked for failing to oppose the Government's health reforms, especially patient choice and the use of NHS funds to pay for patients to go to private treatment centres. It will be told that patients don't want choice, that those unfortunates who have chosen to be treated in the independent centres are suffering in the hands of incompetent foreign doctors, and that the whole process of reform is part of an underhand government plot to privatise the NHS.

None of this is true. Whatever BMA-commissioned surveys may indicate, patients do want choice. The independent British Social Attitudes Survey found that 63 per cent of respondents wanted a choice of hospital and 53 per cent a choice of appointment time.

Evidence from the pilot experiments in the NHS on patient choice showed that choice is popular with patients who have tried it: 86 per cent of patients taking part in the Coronary Heart Disease Choice Pilot said they would recommend it to another patient. A report on the London Choice project found that 97 per cent of the patients who opted to go to an alternative hospital said they would recommend the scheme to others.

Significantly, the Social Attitudes Survey found that support for choice was highest among poorer groups and the less educated: an indication that the desire for choice is not just a middle-class obsession.Moreover, most people do not mind if their choice includes the option of going to independent treatment centres. When Mori told people in the Black Country that the NHS would now pay for patients to have their operations in private hospitals and asked them whether they were happy about this, 71 per cent said they were, compared with just 11 per cent who said they were unhappy.

And the majority are right to be happy. There is no evidence whatsoever that the new treatment centres are providing care of a lower quality than other NHS hospitals. Indeed, such evidence as exists shows quite the reverse. Patient satisfaction (at 97 per cent) is higher than for NHS trusts as a whole (91 per cent), re-admission rates for the treatment centres are lower, they have not reported a single case of hospital-acquired MRSA infection.

It is true that, when patients are asked if they want choice or a good local service, they will opt for the local service. But that is a nonsensical question. Anyone asked if they would prefer a perfect television set or a choice of television sets would prefer the perfect television. The real issue is how to get a good local service. Is the best way to compel people to go to their local hospital, regardless of the time of appointment or the standard of treatment? Or is it to give them a choice, with the money following the choice, so that if the local hospital is providing a poor service, it has a strong incentive to improve?

In fact, there is some evidence that the incentive pressure from choice is beginning to work. Staff at the independent treatment centres are 60 per cent more productive than similar staff in NHS trusts. Theatre utilisation in the centres is up to one-third higher than in comparable NHS acute trusts. The average surgical duration for a knee replacement across a number of centres was 24 per cent shorter than the typical NHS time.

These improvements are beginning to spread into the NHS. In the West Country, local Trusts have begun to replicate some of their independent sector competitors' methods, improving rehabilitation, providing better discharge planning and using more day-case surgery and local anaesthetics. In York, faced with competition from a local independent treatment centre, the local trust has re-organised its facilities to minimise staff and patient movements, and sharply increased its rate of theatre utilisation.

Of course, much of the doctors' unhappiness is understandable. Nobody likes being subject to competition - especially when, as with some consultants, it threatens not only their traditional ways of doing things, but also a highly lucrative private practice. However, the recent dramatic increases in doctors' pay should help soften that blow. And the new quasi-market will offer greater freedoms than the old, target- driven regime; a change that medical professionals, demoralised and demotivated by continually being told what to do by minister and civil servants, should welcome.

The real motive behind the Government's reforms is not to privatise the NHS, but to give it greater freedom to innovate and - importantly - to provide it with the incentives to do so. Patient empowerment and incentivisation are the key to the reforms - unlovely expressions, but no more so than privatisation, and a great deal more accurate.

The writer is Richard Titmuss Professor of Health Policy at the LSE and a former Downing Street health policy adviser