Published 15 June 2009, doi:10.1136/bmj.b2423
Cite this as: BMJ 2009;338:b2423

Letters

US healthcare reform

Choice and equality in health

The US aversion to a single payer system highlights a fundamental difference in mentality between the United States and the United Kingdom that the US government would do well to remember.¹ To many Americans the term single payer represents socialised medicine and government bureaucracy, while in the NHS it represents a noble ideal of use according to need but contribution according to the ability to pay. The US healthcare system is driven by the desire for choice whereas the NHS is driven by the desire for equality.

In moving to empower NHS patients with choice, the UK government is in danger of sacrificing the principle of equality on which the service was founded, for choice and equality necessarily conflict. If choice is possible then, by definition, differences exist in the quality of care being provided in the NHS and some are receiving a substandard service that an informed patient would not choose. Allowing patient choice by publicly reporting outcomes is likely to exacerbate inequality as some are better positioned to exercise choice²—most likely rich and well educated people.

These people are more likely to be politically active, and thus promoting choice seems an effective way of scoring political points in the guise of making the NHS fairer. The fairest approach is to foster a system in which choice is not needed by dealing with those whom no informed patient would choose.

Cite this as: BMJ 2009;338:b2423

¹ Harvard University, Cambridge, MA 02138, USA

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Competing interests: None declared.

References

1. Roehr B. Senate finance chairman sees progress on US healthcare reform. BMJ 2009;338:b2134. (26 May.)[Free Full Text]
2. Werner RM, Asch DA, Polsky D. Racial profiling: the unintended consequences of coronary artery bypass graft report cards. Circulation 2005;111:1257-63.[Abstract/Free Full Text]

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