Public 1, Labour's Choice Agenda 0?

The NHS Next Steps Review, under the leadership of Lord Darzi of Denham, is emphasising that patient choice is a key driver. Now I freely admit that I am generally supportive of choice, although not so enthusiastic that I am blinded to the genuine problems that arise in offering real choice.

Firstly, choice must be real rather than notional, especially if your intention is to use choice as a means of driving up standards. It must be an informed choice, which requires information to be available in an accessible and approachable manner, and available to all. Otherwise, it merely enhances the advantages that the middle and upper classes have over the poorer, more needy members of our society.

In most public services, choice is somewhat of an urban obsession, as I have noted in the past. If you can walk to eight schools within a mile, you have realistic choice. If your nearest school is five miles away, and it's another six to the next, you don't really have choice. And so it is with the NHS. But don't believe me, here's what the Kings Fund has to say...

" Patient choice is currently limited by a number of factors: the lack of information on quality, and particularly on outcomes; the difficulties patients have in interpreting outcome and quality data, even when it is available; the relatively small proportion of care over which choice can be exercised (at present limited to initial outpatient appointment, with perhaps the possibility thereafter to choose another provider for an operation); and the lack of feedback to providers about why patients may choose to go elsewhere."

However, the biggest hurdle is that of persuading the public. We're used to having a facility nearby and, whilst quality is important, many prefer to be closer to home. This desire tends to protect a weaker local facility from the 'threat' presented by a better, but more distant, facility. In addition, in rural areas, the nearest facility may already be some distance away, making alternatives effectively unviable as an option.

Indeed, choice implies that there is spare capacity for, without it, weak facilities will operate at full capacity and have little or no incentive to improve and, worse still, become the likely option most utilised by the poorer, less educated elements of society, the very groups most reliant on the NHS.

Worse still, from a political perspective, success will probably mean the closure of facilities, and we all know exactly how popular that is. How will that process be managed, especially where geographical and access issues complicate matters? Do you close a hospital in, say Norwich, if it is weak, but not as weak as Ipswich, if closing Ipswich removes capacity from a wider, or more heavily populated area?

I fully accept that the idea that we can provide high-quality, local facilties everywhere is a fantasy. It has never been done, and rationing of healthcare makes it unlikely that it ever can be, but persuading the public that such a yearning is against their interests is going to be a very tough sell. And frankly, I don't believe that this government is up to the task...