Health

Patient choice: don't you just love it? The British government's buzzword for the National Health Service has such overarching smarminess that only the misguided or brave dare criticise it.

I hope I'm not misguided and I'm certainly not brave. I agree patient choice is a good thing. At the moment, however, there is not much point in debating what patient choice actually means because what is on offer is not so much patient choice as Patricia's choice, the Patricia being Ms Hewitt, our recently appointed health secretary.

Take the recent spat regarding flu vaccinations. Some patients in high-risk groups were going without vaccines as many areas had "run out" of them. Were GPs guilty of under-ordering their stock of vaccines? Were the government mismanaging a "crisis"? More interesting to me was the accusation levelled at GPs, that patients who were not entitled to a free NHS vaccine were getting one anyway.

It was claimed that patients were requesting a flu vaccine and paying for it and that doctors were complying with their request. This was using up the stocks of influenza vaccine and leaving those in greater clinical need without a jab. Whether or not this was an adequate explanation for the shortfall (and I very much doubt it), the government's reaction was fascinating. No, no, no, they said, slapping GPs firmly on the wrist, this won't do. The "worried well" are not to have the flu vaccine and doctors are very naughty for giving in to their patients' demands.

So that's one choice you don't have, at least not without incurring the wrath of the government. This pick and choose policy (pick and choose by the government, that is) goes on across the NHS. Take single-handed general practitioners: These are popular with patients. Lots of surveys prove that the high rates of satisfaction and accessibility they provide are much appreciated. There are also studies showing that the care provided by single-handed surgeries is as good as that found elsewhere.

But no, we are told that single-handed surgeries are not part of the NHS's future, which lies in large group practices and walk-in centres. A lot of people may be perfectly happy with changing to a larger group practice but some won't be. If staying with a solo GP was your "patient choice", it appears that on this matter the Department of Health is not terribly interested in your satisfaction.

There are more examples of the mishmash of choices you're allowed and those you're not. Five homeopathic hospitals are funded by the NHS and the Royal London Homeopathic Hospital underwent a £20m refurbishment in 2001. This is despite a lack of convincing evidence that homeopathic treatments are a good use of money. They are popular, though. Prince Charles sends GPs booklets on what complementary therapies have to offer and the Queen is the patron of the Royal London Homeopathic Hospital. It is a brave health secretary who would pull the plug on homeopathic hospitals. Hence, if you want to choose homeopathy on the NHS, you can have your prescription.

Yet should you want Aricept, the dementia drug, you'll be less lucky. The National Institute for Clinical Excellence (Nice) recently reviewed evidence and has decided, in preliminary new recommendations at least, that it was not to be prescribed by doctors on the NHS because it had been assessed and found not to be of overall benefit. Meanwhile, Patricia Hewitt has intervened over the prescription - or lack of prescription - of Herceptin, a breast cancer drug that has not yet been evaluated by Nice.

The availability of treatments should be based on evidence that they do or don't work. But it doesn't take a genius to see that there is a lack of consistency in the application of this particular principle. The choice being offered to patients is narrow and restricted to things that are politically, rather than clinically, expedient. For example, it was centrally decided that appointments with a GP were to be available within 48 hours. The result was that it often became impossible to book an appointment any further ahead than this. Was this an example of patient choice in action? It was certainly not a choice that worked. Doctors have always been obliged to see urgent cases as a priority - what now happens is that people have to spend time trying to get through on the telephone just to make a routine appointment.

So we have a bit of choice here but not very much there. Funding may be available for something proven to work but also for something unproven. Choice in the NHS has a political meaning rather than a clinical one. This is a great pity because more choice could be good thing for patients and doctors alike.

I suspect that the choice I would like to see - where doctors give unbiased information, tailored to individuals freely allowed to make their own choices - isn't really what the government has in mind. Then again, what I would really prefer is a government that was honest about its limited resources and which used them wisely by basing its health policies transparently on the evidence for maximum gain, rather than electoral popularity. But that's another choice not on offer.

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