Three blog posts have caught my attention today: this from Lib Dem Voice, this from Cicero and this from John Hemming MP. All are on the subject of the National Health Service.

First up, Grace Goodlad's post at LDV. She rightly attacks the government's PFI schemes - a wasteful, poorly designed approach to funding any project, let alone something as important as healthcare. But rather than identify mismanagement, lack of proper structures and lack of critical oversight as the cause of the problems in the NHS, she identifies choice as being to blame. This is, to my mind, most odd, especially as she correctly states that:

As good Liberals we should all be backing the concept of choice in public services – patients should be allowed to choose appropriate treatments that are accessible and convenient to them.

I think that's a rather minimal case for choice, but it makes sense and ticks all of the liberal boxes - freedom, diversity, empowerment. Freedom to be treated where you prefer, diversity of options to choose from, and empowerment for patients to demand better services. But she quickly amends this statement by saying:

Fine – I agree with all that, but what price choice?

This question goes to the very heart of not just the debate on health, but the debate on government in its entirety.

It's at this point that I must return to the earlier point - that Goodlad's case for choice is incomplete. It's not simply the case that choice makes people feel a little better about their circumstances; that by choosing where to be treated they might feel as though they're getting a bit more control over things. This is important, but it's the consequences of choice that really matter.

To explain the issue further, I turn to John Hemming's recent post. In it, he recounts the tale of an NHS doctor who, disillusioned with the management of the service, went public with his observations via a blog entitled 'Angry NHS Doctor'. Or rather, he did so until the management uncovered his identity and ordered him to stop posting or lose his job. Now, to be fair, it has to be said that most of what was posted was an angry, even offensive, rant. But it certainly throws a different light on the view that the NHS is having its 'best ever year'. The one interesting revelation was his casual assertion that NHS waiting list figures are, seemingly, routinely fiddled:

8 year old kid from school. Fell over grazed his knee. Played football for 30 mins after injury. School not happy to take responsibility to wash graze and give him a Paracetemol. Poor kid - waited 4 and 1/2 hours – (3 hours 59 mins Mrs. Hewitt - don’t worry we fiddled the figures so that we had a 100% target figures).

This is where choice matters. You, and I, and the Health Secretary cannot see what goes on in every hospital in the land at all times. It's especially bad for the Health Secretary, who is the first and only democratically-elected person in the NHS chain of command. Believing in central change management, the government has, for most of the last nine years, pursued a policy of central control, informed by statistics and reports emerging from the NHS bureaucracy below. This is often referred to as 'target culture'. If a hospital is failing, your best hope for that failure being addressed is to hope that a) that failure is recorded and b) that someone, somewhere on the NHS chain of command notices that failure and does something about it.

The problem, as should be apparent to anyone who has ever worked in an organisation which uses inspections, targets or statistics as its primary means of identifying success or failure, is that getting good figures has relatively little to do with treating patients well. Figures can be fiddled, statistics can be massaged and inspection reports can only show what the inspectors saw. No wonder Patricia Hewitt thought that the NHS was doing so well - it's probably exactly what she was told.

Choice does two things. Firstly, it short-cuts the process for individuals; if your present hospital is failing, you can go elsewhere. Secondly, it provides an alternative means of measuring hospital performance. 'Target culture' tries to gather information about the NHS through statistics which, supposedly, reflect some objective measure of performance. Leaving aside the question of their inaccuracy, it's not even clear that what one person regards as 'objective' criteria will be regarded as similarly objective by another. 'Choice culture', on the other hand, says that each individual's assessment of performance matters. Rather than using statistics and bureaucrats to measure performance, choice turns this power over to individuals who actually use the service - the only people with no incentive to lie about their opinions. Indeed, people who are using a hospital have every incentive to be critical about failings in that hospital - their life may depend on it.

If the hospital treating you has a problem with MRSA, would you be comforted by being told that, overall, the hospital has good statistics for the last five years? I doubt it. Would you turn a blind eye to dirty wards, long waiting times or overworked staff? No, you wouldn't. Choice gives people more than just a way of choosing about their own treatment; choice gives people a way of improving the system for everyone by voting with their feet and rejecting substandard service. To say that restricting choice might somehow solve these problems is an act of incredible faith in a bureaucratic system that has shown no signs of being capable of tackling them in the last ten years.

Furthermore, as liberals it is our first duty to be on the side of the people against overmighty institutions, be they governments or true corporate monopolies. The NHS is the largest employer in Britain, a tax-funded service with considerable resources at its disposal, representation at the highest levels of government and a vast bureaucratic machinery. It is also the beneficiary of considerable public goodwill - we want the NHS to succeed. But for precisely that reason, it needs to be exposed to greater choice, greater accountability and greater scrutiny. The centralised mess that is the Department of Health needs to give way to a decentralised system, more responsive to people's needs and delegating greater authority to people with real expertise - the doctors and nurses on the wards. We need to cut out the middleman and allow patients and doctors to engage more directly, instead of being shuffled around like pieces on a board to satisfy government PR criteria. In my opinion, these arguments are in favour of more choice, not less.