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BMJ. Dec 24, 2005; 331(7531): 1488–1489.
PMCID: PMC1322235


More can mean less
Paul Bate, chair of health services management
Royal Free and University College Medical School, London N19 5LW
Glenn Robert, senior research fellow

For the NHS, 2006 might well be the year of choice. The UK government's plans for “empowering patients to play a bigger role in choosing where and who provides them with their health service” are finally to become reality.1,2 These plans will be supported by the twin pillars of competition, and plurality of provision. To be pro-choice is clearly to be on the side of the angels, or at least the politicians. Spare a thought this Christmas, therefore, for a small group of people who insist there is another side to the argument.

In a recent bestselling business book, psychologist Barry Schwartz argues that the amount of choice on offer in life exceeds our ability to effectively exercise that choice, or even to enjoy it.3 The debilitating effects of choice overload may be bewilderment and high levels of anxiety and stress. When a brush with illness in the United States caused health economist Rhiannon Tudor Edwards to question the value of choice in health care, she concluded that having less choice in health care is a price well worth paying for universal coverage.4 The UK Public Administration Select Committee wisely advises caution, calling on the government to be more realistic about the role and limitations of choice.5 The paradox of choice is that more can sometimes mean less.

Support for the concept of choice is neither universal nor unconditional. The London Patient Choice Project showed that, although choice of provider was indeed popular among those waiting for elective treatment, less than a third of patients eligible for the scheme were offered a choice of hospital. Two thirds of those offered the opportunity to go to an alternative hospital chose to do so.6 And 89% of respondents surveyed by the consumer magazine Which? agreed that access to a good local hospital was more important than having more hospitals to choose between.7

Research on NHS treatment centres indicates that recent reductions in waiting times may have limited the number of patients motivated to choose faster treatment.8 Indeed, staying with the local hospital might well be a patient's way of dealing with choice overload. Such a scenario is probably highly specific to the condition, however. In the choice scheme for coronary heart disease, half of the patients who had been waiting six months or more for heart surgery chose to go to a different hospital to avoid a longer wait.9

Even when patients are willing to seek treatment from another hospital, exercising choice may not be practical for all of them.10 Will greater choice of providers by primary care services be worth having if it undermines the foundations of a system that works reasonably well at present?11 Might increased choice be harmful or dysfunctional for certain people or groups? Certainly, unmediated choice will increase inequity because it will favour patients with access to information and transport.12 This inequity will be magnified if patients in lower socioeconomic groups have lower expectations and less ability—real or perceived—to deal with the choices on offer.

How are patients to judge whether hospital or consultant A is better than consultant or hospital B, and by how much, if they do not have the necessary information? And too much information can be as debilitating as too little. Increasingly, patients have “to cope both with the blessing and burden of receiving a super-abundance of information, often several treatment options, and the right to choose among them.”13 Furthermore, choice does not depend only on having information. It also relies on the skill of understanding and choosing between options whose probable consequences cannot be measured or even known.14 The knowledge that they might be making the wrong decision exposes patients to additional stress.

Patients do not have a choice about choice. Current political dogma assumes that choice is inherently good, but patients may soon begin to disagree vociferously if this ideology forces their local hospital to close or disrupts established NHS services.15 It is time to open up both sides of the choice equation to wider debate and action, recognising that both the upsides and downsides need to be managed.

The NHS should shift the focus to assisted or facilitated choice, providing experts and tools to help narrow down the possibilities to a manageable number and to offer support to those least able to negotiate their way around the service. In the early pilot projects on choice in the NHS, patient care advisers—independent of any particular provider—provided a single point of contact and helped patients through the process of choosing where to get care. Patients found this very helpful.6 The paradox of choice needs to be managed carefully.


Competing interests: PB's post is partly funded by University College London Hospitals NHS Trust.


1. Department of Health. Building on the best. Choice, responsiveness and equity in the NHS. London: Stationery Office, 2003. [PubMed]
2. Reid J. Limits of the market, constraints of the state: an NHS fair to us all and personal to each of us. 31 January 2005. www.smf.co.uk/modules.php?op=modload&name=News&file=article&sid=72 (accessed 7 Dec 2005).
3. Schwartz B. The paradox of choice. Why more is less. New York: Harper Collins, 2004.
4. Tudor Edwards R. Blind faith and choice. Health Affairs 2005;24: 1624-8. [PubMed]
5. Public Administration Select Committee. Choice, voice and public services. Fourth report of session 2004-05. London: Stationery Office, 2005. (HC 49-I.)
6. Coulter A, Le Maistre N, Henderson I. Patients' experience of choosing where to undergo surgical treatment. Evaluation of London Patient Choice scheme. Oxford: Picker Institute Europe, 2005.
7. Which choice? Health. London: Which?, August 2005.
8. Bate SP, Robert G. “Build it and they will come”—or will they? Choice, policy paradoxes and NHS Treatment Centres. Policy & Politics (in press).
9. Le Maistre N, Reeves R, Coulter A. Patients' experience of CHD choice. Oxford: Picker Institute Europe, 2003.
10. Damiani M, Propper C, Dixon J. Mapping choice in the NHS: cross sectional study of routinely collected data. BMJ 2005;330: 284. [PMC free article] [PubMed]
11. Coulter A. What do patients and the public want from primary care? BMJ 2005;331: 1199-200. [PMC free article] [PubMed]
12. Farringdon-Douglas J, Allen J. Equitable choices for health. London: Institute for Public Policy Research, 2005.
13. Hoffman J. Awash in information, patients face a lonely, uncertain road. New York Times 14 Aug 2005. [PubMed]
14. Hastie R, Dawes R. Rational choice in an uncertain world: the psychology of decision making. London: Sage, 2001.
15. Timmins N. Challenges of private provision in the NHS. BMJ 2005;331: 1193-5. [PMC free article] [PubMed]

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