Lord Darzi, in his next stage review, talks a lot about choice, and why not? Greater choice of healthcare provider is, undoubtedly, a good thing.
Reassuringly, we are told it is not just middle class professionals who want more choice. According to the British Social Attitudes Survey, 69 per cent of people with no formal educational qualifications want more choice, compared with 55 per cent of those with qualifications.
So far so good, but there's a danger in this - a danger that we will convince ourselves that by simply increasing choice and providing more and more information about providers we will increase competition, which will, in turn, drive up quality.
There is a danger in assuming that just because people say they want greater choice they will actually exercise it in the way we think they should.
Choose and book
As a GP, I was an early choose and book enthusiast. This was mainly because "book" was fantastic. Being able to send the patient out clutching their booked appointment meant they generally thought I was fantastic too. I religiously offered (and continue to offer) choice of provider to every patient I referred to hospital. Yet, in all this time, only one patient has chosen to go anywhere other than our local district general hospital, and no-one, not one single patient, has wanted any information at all about the quality of the services on offer at any of the providers available.
All these patients made their choice solely on the basis of location. Many of them even laughed at being offered choice at all, as though I was joking to even imagine they might wish to travel further than the nearest hospital.
I practise in an extremely deprived ward in one of the most deprived towns in the country. Residents have almost the worst life expectancy in the country, health inequalities are horrendous. For communities like this, choice isn't really an option. Travel is expensive and difficult, especially for the elderly and families without cars. Elderly people who need operations know they would have few visitors if they were to choose a hospital out of town.
Fortunately, our local district general hospital is excellent, and we have some of the lowest waiting times in the country, so everyone is happy.
Commissioning for quality
Yet, as a commissioner, it worries me that we may see choice as the means of driving quality - it can't be, not in all health communities. We, the commissioners, have to be the ones who use the increasing wealth of information available to ensure our local providers offer the highest quality care they possibly can to our patients.
We must ensure that contracts set out, in explicit terms, the outcomes and experience we expect for our patients. We must ask our patients what is important to them when they need to use health services - not decide what we think might be important to them.
More than anything, we need to use our clinicians to lead the commissioning process. Professional executive committees, practice-based commissioners and clinical leads all have front-line, day-to-day contact with patients and often have a wealth of knowledge about the experiences and outcomes of their patients. These clinicians also have the knowledge and understanding to set meaningful clinical outcome measures and the clinical credibility to engage their provider colleagues.
The NHS review doesn't only talk a lot about choice - it talks a lot about quality too. We need to make sure we harness the interest of clinical commissioners or we'll miss an opportunity to really drive up the quality of services.