Published: 17/11/2005 Volume 115 No. 5982 Page 23

Joe Farrington-Douglas of the IPPR wants choice in the NHS - but not as we know it

Patient choice in primary care could hold the key to delivering better outcomes and reducing inequality.

The government invested its first two terms in expanding secondary care and developing choice of hospitals. Despite computer failures and professional scepticism, choice is here to stay.

The current shift of policy focus towards care outside hospitals is welcome, but the role of choice in primary care is unclear. Will it simply be a mechanism for competition between GPs and a Trojan horse for more private providers? Or could it improve healthcare and reduce inequalities?

Healthcare inequality starts in primary care. Fifteen per cent of patients live in areas with closed lists where access, let alone choice, is difficult. Poorer areas have fewer health professionals, and people living in areas with higher levels of illness are more likely to spend more than 50 hours per week doing unpaid care.

Socially excluded groups, including homeless people, gypsies and asylum seekers, are often excluded by the registration system. Work and care commitments and lack of transport prevent poorer groups from accessing GP appointments. Middle class patients have longer consultations and achieve more referrals, despite lower need.

'Free choice', by abandoning GP registration altogether, would - apart from undermining the financial structure of the NHS, and preventing practice-based commissioning - remove the existing motives for health management and prevention. Continuity of care, gatekeeping and co-ordination are efficient and popular functions that should be strengthened.

However, we do need to free patients from practice boundary rationing that locks poor people into under-provision and prevents innovation. Broadening the range of surgeries that people can access means practices could specialise for a particular demographic or group.

New freedoms would allow practices to commission or provide traditionally hospital-based services in the community. This would improve access and allow earlier interventions to keep patients out of hospital.

The key to primary care effectiveness and equity is to ensure appropriate, targeted services meet personal needs.

This means the end of a one-size-fits-all model of general practice that feeds the secondary care beast with referrals for conditions that could be more effectively managed at home or in the community. Family medicine should become a specialism rather than a generic, medically led model that diverse patients have to fit around.

Allowing patients to choose their practice could help improve quality and patient-centredness. Practices attracting patients with extended hours or better outcomes for heart disease would be rewarded. Networks of practices would pool their budgets so patients could be referred to a neighbouring clinic rather than hospital. Doctors, nurses and allied health professionals would be gateways to co-ordinated care.

We are now a long way from this vision. Quality information for choice in primary care is inaccessible.

Disadvantaged groups need advice, support and advocacy to access choice fairly. Hospital choice was supported by an injection of extra capacity that is badly needed in primary care.

The white paper on care outside hospitals aims to create a primary careled health service. Choice should not be introduced to serve a market that patients do not want. Choice should empower patients to improve health and tackle health inequalities.

Joe Farrington-Douglas is a research fellow at the Institute for Public Policy Research, and co-author of Equitable Choices for Health, published yesterday.

www. ippr. org