Patient choice and equity in the British National Health Service: towards developing an alternative framework

Choice and competition have been phased into many public health systems with the aim of achieving various and potentially exclusive goals such as improving efficiency, quality and responsiveness to users' needs. Yet their use to promote equity of access as evidenced recently in the British National Health Service (the NHS) is unprecedented. Giving users the power of exit over unresponsive providers is meant to address the failures of previous policies. This paper shows that there is a potential conflict between choice and equity, in terms of both the values and the outcomes each policy is likely to produce. Using a multidisciplinary and multidimensional framework, drawn from Bourdieusian sociology, feminist theory and economics, the study highlights the implications of the simplistic and one-sided conception of individual patient choice in relation to equity. It also uses the existing evidence on the impact of market competition and choice, in the UK and elsewhere, to emphasise the importance of socio-economic and psycho-social factors, which are left out of current policy considerations.