The UK government’s “patient choice” initiative may be actually worsening health inequalities across the nation, the British Medical Association (BMA) has warned Parliament, and the doctors’ group has also suggested that the Minister of Public Health should perhaps be located at the Treasury, rather than operating within the Department of Health.

Recent research shows that patients with formal education qualifications are more likely to choose to be treated in hospitals with higher standards of clinical performance, while those without such qualifications placed significantly less importance on increases in clinical quality above an average level, according to Dr Hamish Meldrum, chairman of council at the BMA. In effect, this research suggests that offering patients greater choice risks widening health inequalities, Dr Meldrum told the House of Commons Health Select Committee’s inquiry into health inequalities last week.

His concerns were echoed by Professor Martin Roland, director of the National Primary Care Research and Development Centre, who told Members of Parliament that deprived areas need more and different types of services, as well as more staff. However, he added that the problem of “choice” benefiting only the more affluent patients can be mitigated, studies have shown; these include the London Patient Choice Project, which provided advisers to help patients make choices of hospital and supplied transport to more distant hospitals.

Dr Meldrum also told the MPs of the BMA’s concern at the DoH’s “insistence” on the setting up of so many new general practices under the new Alternative Provider Medical Services (APMS) route, through which Primary Care Trusts (PCTs) can contract to deliver primary care services locally from a range of providers, including those in the commercial sector. According to the DoH, the APMS route has “enhanced considerably PCTs’ abilities to develop services to offer greater patient choice, improved access and greater responsiveness to local needs.”

However, Dr Meldrum pointed out to the MPs that private organisations holding APMS contracts employ a salaried or locum staffing model, similar to that of the existing Primary Care Trust Medical Services (PCTMS) practices where the turnover of employed doctors is often high and the running costs are greater than for those run under the traditional General Medical Services (GMS) or Personal Medical Services (PMS) route. Also, their Quality and Outcome Framework (QOF) scores are lower. "As we believe that, in general, GMS and PMS practices offer the best option for all patients, not just those in better-off areas of towns and cities, we remain very concerned that these new APMS practices may end up delivering a potentially second-class service to areas of the country that already have significant health inequalities,” says the BMA.

The doctors’ group is also calling for all local authorities and PCTs to be required to have a Director of Public Health, and is highly critical of the DoH’s interpretation of the role of the Minister of Public Health as being primarily directed towards medical interventions for prevention. “This must change, if the DoH is to continue to fulfil the lead role on the health of the people,” says the BMA, which is calling for “much greater joined-up thinking” in government and for consideration to be given to appointing a minister at cabinet level with responsibility for public health and who would oversee work in every government department to facilitate this.

One option could be to make health a major element of Public Service Agreements (PSAs), and locate the Minister of Public Health in the Treasury, the BMA suggests. However, it adds, whichever route is chosen, there needs to be “an overarching commitment to health” which is led from the top, by the Prime Minister.