The unhealthy choice

Once the National Health Service put equality first.

I am imagining, aptly for a man of my age and lifestyle, that I need coronary artery bypass surgery. From this month, I can choose any suitable NHS hospital in the country to carry out this and other non-emergency procedures. I can also choose from private units that now offer NHS services.

How do I proceed? I go to the official website NHS Choices ( Aboutpatientchoice.aspx) where, having identified the required treatment, I am invited to enter my postcode. I am then offered five nearby hospitals, two of them private. (I can get details for hospitals further afield, but can display only five comparisons at a time.) There is no data for either private hospital and the Department of Health admits only 15 of 160 on its website offer useful information. More importantly, only one of the five hospitals shows data for waiting times.

I can, however, make some comparisons between the three NHS hospitals.

St George's, Tooting, presents the greatest risk of my catching MRSA and of being readmitted within a month of discharge. On the other hand, it offers the greatest chance of my being treated with respect, which is perhaps a comfort if I'm going to be struck down by a superbug or have to keep going back. It also has the highest consumer rating, which looks impressive until I find this is based on seven responses and there are none at all for the others.

Well, NHS Choices is a work in progress. The information will no doubt improve. One is bound to ask, though, whether it is worth the £90m cost. Ministers assume choice is self-evidently good. Competition will spur hospitals to improve performance, they say. Moreover, it's what the public wants, and figures from the British Social Attitudes Survey prove it. But ask people if they would like a choice and - whether it's hospitals, vegetables or methods of execution - they nearly always say yes. Why wouldn't they? Whether choice will give them the service they want is another matter.

There are genuine choices in health care, perhaps more than in education. I may prefer a hospital that doesn't have a particularly good clinical record because it can do my bypass quickly. Or I may prefer running the increased risks of MRSA to being treated in a mixed-sex ward. Unfortunately, the "tyranny of small choices" (a term invented by the economist Fred Hirsch) can lead to consequences that neither I nor anyone else intends. For example, with money following the patient, a hospital that fails to attract customers may close. So if I reject my local hospital for a prostate treatment I run the risk of losing my local A&E.

If ministers think more choice will increase patient satisfaction, and therefore their re-election chances, they may be mistaken.

Choice raises expectations and, given these will almost certainly run ahead of improvements in provision, the outcome will be disappointment. In The Paradox of Choice (2004), the American sociologist Barry Schwartz argues that the people who are keenest on choice - the sort who will spend hours on the NHS website, comparing every hospital from Sunderland to Southampton - are those most likely to be dissatisfied by their decision. They fear they've missed out on something better and, any psychologist will tell you, since loss is felt more keenly than gain, they will be miserable and probably blame the government.

They will be right. The NHS once embodied values distinct from those of the commercial sector. It stood for equity, social solidarity and communal culture rather than for individual gratification and competitive advantage. In shops, affluent folk could wave chequebooks; in NHS hospitals and GPs' surgeries, there was a kind of rough equality, with everyone kept hanging around and being treated like an idiot by brusque bureaucrats and professionals. It wasn't pretty, but there are unpretty things about many commercial firms. Most people, including many Tories, accepted it. On the first day of the NHS in 1948, some doctors barricaded themselves in their surgeries expecting a rush for free treatment. The patients just formed an orderly queue, recognising the basic economic law that if a scarce resource isn't rationed by price, it must be rationed by something else, such as willingness to wait.

Some time in the 1980s, politicians decided people wouldn't put up with it any more. I was never convinced. It may be true now that people expect choice and treatment at their convenience, but only because politicians have told them to expect it, as in the Conservatives' ridiculous slogan "The patient will see you now, doctor". (Are they really going to pay doctors to hang around like dockers waiting for a boat to come in?) The British used to be prouder of the NHS than of anything. Perhaps ministers should find out what once made it work so well before they move on to the next new wheeze.

Peter Wilby was editor of the Independent on Sunday from 1995 to 1996 and of the New Statesman from 1998 to 2005. He writes the weekly First Thoughts column for the NS.

This article first appeared in the 07 April 2008 issue of the New Statesman, British jihad