I don’t want any more ‘patient choice’!

After intensively reviewing Britain’s National Health Service (NHS) over the past year, during which time his team of researchers interviewed 2,000 clinicians and 60,000 patients, the UK surgeon-minister Lord Darzi has finally delivered his plan for the future of the NHS (1). And what’s his big idea? Yet more ‘patient choice’ – that buzzphrase that has been repeated robotically by New Labour apparatchiks in every debate about health since May 1997.

Their continuous focus on ‘patient choice’ is revealing. It sounds radical, the idea that everyone should be able to choose between a line-up of doctors and to pick which hospital to be treated at (the cleanest, nicest and most wifi-friendly, please). Yet in reality, behind the government’s seemingly gracious desire to empower patients, there lurks a profound confusion about health provision, and a deep disdain for both medical practitioners and we citizens who occasionally must retreat for treatment into a hospital.

The rise and rise of ‘patient choice’ mirrors the decline of medical authority, and the denigration of the idea of choice – true choice – in contemporary society.

To the delight of many liberal commentators, who believe the NHS to be Britain’s most glorious historic achievement but who have always harboured a sneaking suspicion of the old-style, patrician doctor, Lord Darzi made ‘patient rights’ a major focus of his review (2). He proposes that patients’ views on the quality of their care should have an impact on the amount of funding a hospital or GP surgery receives: well-reviewed institutions will get financial ‘bonuses’; less well-reviewed ones will have to struggle by on the existing, paltry government funding.

He also suggests that information about the quality of an institution’s services should be published on the world wide web and on clinical ‘dashboards’ in hospitals and GP surgeries so that patients can make ‘informed choices’ about where to go for treatment. And he has written a draft NHS constitution which sets out the rights and responsibilities of both patients and staff in the NHS. One newspaper columnist says Darzi’s review – a ‘modest, wise and practical new direction that centres on what patients feel and on how doctors and nurses can best use their discretion’ – will ‘consolidate a golden age for the NHS’ (3).

Get real. The first notable thing about Darzi’s emphasis on patient choice is that it is a con; worse than that, it’s underpinned by Doublespeak. Although various patients’ groups and health rights activists have emerged in recent years, there is no ‘patient lobby’ that can exercise its ‘rights’ and use its ‘power’ to put pressure on local doctors and hospitals to improve their services. Rather, top-down proclamations about ‘patient choice’ are a rhetorical cover, a kind of weasel-worded camouflage, for the government’s own desire to shake up the NHS.

So under the guise of increasing choice for patients, Darzi and the government are keen to introduce polyclinics, or ‘super-surgeries’ as the health secretary Alan Johnson refers to them: large, centralised clinics that will offer GP services and also some hospital services, such as x-rays. These super-surgeries will possibly be funded by Tesco, Boots and other drug-selling private firms.

They’re already proving unpopular with patients, especially elderly people, who tend to visit the doctor more frequently than the rest of the population, and who are concerned that polyclinics will ruin their one-on-one relationship with their local GP and force them to walk further for a reassuring chat and a check-up. More than a million patients have signed petitions against Darzi’s polyclinic plans (4). And yet, in the name of ‘empowering patients’, Darzi is determined to bring them in. Here, spreading ‘patient choice’ is a cover for the officious reform, centralisation and privatisation of aspects of local health provision.

Another key plank of Darzi’s ‘patient choice’ agenda is the publication of more target-based information on hospitals and GP surgeries. So on the basis of surveys of patients, info about an institution’s quality of care, cleanliness and operation success rates will be made publicly available to web surfers and hospital-browsers (formerly known as ‘sick people’). And what’s more, actual, real-world funding – whether a surgery gets just enough to survive on or a little bit extra – will be determined by how well an institution ‘performs’ according to ‘patient feedback’.

Here, ‘patient choice’ is a cover for the government’s desire to whip the health service into shape by introducing more and more externally imposed, soul-destroying, managerial targets (5). It’s also a justification for government stinginess when it comes to funding real and necessary health provision around the country. In place of a genuine and generous vision for improving the efficiency of the health service across the board, Darzi wants to use the ‘views of patients’ to increase the power of the NHS’s management consultants – people like himself – to hector hospital staff and withhold funding as and when they please. Throughout the Darzi review, patients appear as little more than a stage army for officialdom’s plans for the NHS.

Away from this cynical exploitation of The Patient, the emphasis on ‘patient choice’ over the past 10 years also reveals a great deal about the authorities’ view of the medical profession, and the rest of us. In essence, ‘patient choice’ is a misnomer. Most of us are not in a position to make ‘informed choices’ about our healthcare. Yes, we know for certain that we want to be treated in a clean, efficient and friendly hospital – and every hospital should be like that – but such is the average man in the street’s deficit of medical expertise that he is in no position to make wise choices about treatment, medication or recovery.

Instead, the rise of the idea of ‘patient choice’ mirrors the demise in recent years of medical authority. As a result of a crisis of confidence in the medical establishment, one that has frequently been worsened and even exploited by government officials, the old view of doctors as wise, authoritative figures has waned, to be replaced by a relativistic view of health practitioners as the ‘facilitators’ of patient choice.

As Barry Schwartz argues in his book The Paradox of Choice: Why More Is Less: ‘The tenor of medical practice has shifted from one in which the all-knowing, paternalistic doctor tells the patient what must be done – or just does it – to one in which the doctor arrays the possibilities before the patient, along with the likely plusses and minuses of each, and the patient makes a choice.’ (6)

Here, the use of the word ‘choice’ effectively adds a lick of positive gloss to official doubt and indecision; confusion at the top of society about the virtues of old-style medical wisdom is sexed-up and reposed as ‘patient empowerment’. Yet as Schwartz argues, not only does this promiscuous use of the c-word to disguise ‘real doubt about the authority-imposed course of action’ fail to address the reason why the medical establishment seems in disarray; it also places an intolerable burden on patients who do not have the expertise to ‘take responsibility for their medical treatment’ (7).

Indeed, the view of patients as ‘choice-makers’ reflects the government’s decadent and degenerate view of choice more broadly today. Pretty much the only time the government gets excited about the idea of ‘choice’ is when it talks about healthcare and health reform, yet few of us want to exercise real choice when we’re being treated for an illness or looked after by a nurse.

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. Hospital treatment is a technical thing for most people, rather than a life-changing choice; we simply want to be made un-ill as quickly as possible, so that we can return to our public or private lives and get on with the important business of living and working.

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 sick, dazed and dilapidated, and have temporarily removed ourselves from the public sphere in order to get something fixed. This is when the government feels it is safe to ‘empower’ people and give us more and more ‘rights’ and ‘choices’ – at a time when we’re weak, possibly confused, and sometimes even ensconced in an institution. The only time the government trusts us with ‘power’ is when we are little more than bodies that need an MOT rather than active, thinking subjects. Most of us would prefer some real choice in the real world, thanks very much, and some clearer decisions made on our behalf by experts in the medical world.

The Darzi review is no herald of a new ‘golden age’ of medicine – it shows that there is a sickness at the heart of government, in terms of its view of health provision, its view of doctors, and its view of choice.

Brendan O’Neill is editor of spiked. Visit his website here.

(1) Darzi review: at a glance, BBC News, 30 June 2008

(2) For all the hyperbole, Bevan would have approved of this, Guardian, 1 July 2008

(3) For all the hyperbole, Bevan would have approved of this, Guardian, 1 July 2008

(4) Doctors’ leaders claim patients will suffer from polyclinics plan, The Times (London), 12 June 2008

(5) Reactions to review of NHS, Reuters, 30 June 2008

(6) See The politics of pick’n’mix, by Brendan O’Neill

(7) See The politics of pick’n’mix, by Brendan O’Neill