Although choice may be seen as an end in itself, the papers included in this special issue of Health Economics, Policy and Law, examine choice policies in European systems of health care, which aim to be effective instruments for ameliorating the systemic pressures from the iron triangle of equity, efficiency, and cost. Three papers consider the nature of differences between and within countries following the Beveridge and Bismarck models of financing and organising the delivery of care, and how choices are changing within different systems. Within countries following the Beveridge model, current policies in England, Denmark and Sweden emphasise increasing patient choice of provider. Within countries following the Bismarck model, current policies in France and Germany seek to restrict choice of specialists by introducing ‘soft’ gatekeeping; and in the Netherlands there is a system of managed competition with choice of insurer that, in principle, allows insurers to contract selectively with providers. A fourth paper considers how government policies that seek to restrict choice within systems of universal coverage have been subject to challenges in the courts. A commentary explores the implications of the fraught and complex nature of choices between insurers and providers of health care for designing effective choice policies.

Industrialised countries face similar challenges for improving the performance of their health system. Nevertheless, the nature and intensity of the reforms required are largely determined by each country’s basic social security model. Most reforms in Beveridge-type systems have sought to increase choice and reduce waiting times while those in major Bismarck-type systems have focused on cost control by constraining the choice of providers. This paper looks at the main differences in performance of five countries and reviews their recent reform experience, focusing on three questions: Are there systematic differences in performance of Beveridge and Bismarck-type systems? What are the key parameters of healthcare system, which underlie these differences? Have recent reforms been effective?

Our results do not suggest that one system-type performs consistently better than the other. In part, this may be explained by the heterogeneity in organisational design and governance both within and across these systems. Insufficient attention to those structural differences may explain the limited success of a number of recent reforms. Thus, while countries may share similar problems in terms of improving healthcare performance, adopting a ‘copy-and-paste’ approach to healthcare reform is likely to be ineffective.

The implementation of choice for patients over where and when they are seen by specialists in hospital outpatient clinics has been supported by electronic referral systems in England and the Netherlands. This paper compares the implementation of ‘Choose and Book’ in England and ‘ZorgDomein’ in a region of the Netherlands. For England the analysis draws on national data and published studies on ‘Choose and Book’, national patient surveys, and qualitative data based on general practitioner (GP) focus groups. For the Netherlands the analysis draws on qualitative data collected during observational study as well as survey data among patients, GPs and medical specialists. We find that despite significant differences in the genesis and design of the policy, similar challenges have been faced. The electronic referral systems have forced changes to the process of care at the interface between primary and secondary care and standardisation between practices. Although these changes have the potential to generate improvements and benefits, for example, convenience, certainty and choice for patients and efficiency gains through for example reduced do not attend rates, repeat consultations and duplicative diagnostic tests; they have also generated problems during implementation including GP resistance. Policy ambitions for patient choice may not be realised if the implementation of the booking system is not carefully designed and evaluated.

Choice is often touted as a means for change within health care systems. Yet ‘choice’, in this context, takes at least three distinct forms: choice between providers within a publicly funded health care system; choice between competing insurers within a universal plan; and, lastly, choice as between privately financed health care and universal public coverage. In Canada, it is this last form of choice that is under active debate; particularly in light of the Supreme Court of Canada’s decision in Chaoulli, which found a regulation banning private health insurance for medically necessary care was unconstitutional. The argument is frequently made that Canada is an outlier from other countries in having regulation that effectively precludes this kind of choice. This issue is likely to become of concern again in upcoming constitutional challenges where applicants are looking to overturn through judicial challenges Canada’s medicare system. This article tests that argument of whether Canada truly is ‘odd’ from a comparative policy perspective by exploring regulation of choice of privately financed health care in several European countries – the Netherlands, Germany, Sweden, England and France. We highlight commonalities as well as differences, showing the extent to which these countries employ regulation to fetter growth of a large privately financed sector. The article’s thesis is that Canada, in employing more intrusive forms of regulation, is not an outlier per se but at one point in a regulatory spectrum.

In the 1990s, countries experimented with two models of health care reforms based on choice of provider and insurer. The governments of the UK, Italy, Sweden and New Zealand introduced relatively quickly ‘internal market’ models into their single-payer systems, to transform hierarchies into markets by separating ‘purchasers’ from ‘providers’, and enabling ‘purchasers’ to contract selectively with competing public and private providers so that ‘money followed the patient’. This model has largely been abandoned where it has been tried. England, however, has implemented a modified ‘internal market’ model emphasising patient choice, which has so far had disappointing results. In the Netherlands, it took nearly 20 years to implement successfully the model in which enrollees choose among multiple insurers; but these insurers have so far only realised in part their potential to contract selectively with competing providers. The paper discusses the difficulties of implementing these different models and what England and the Netherlands can learn from each other. This includes exploration, as a thought experiment, of how choice of purchaser might be introduced into the English National Health Service based on lessons from the Netherlands.

In this commentary I explore several ways in which the psychology of individual decision-making shapes consumers’ choices in medical settings and the potential for choice-based policies to improve the performance of the health care system. This analysis draws some crucial distinctions among the various pathways though which policymakers expect choice to improve outcomes and the various forms of support that might enhance patients’ engagement with choice. I also consider how choice-promoting policies interact with other strategies for patient empowerment and depend crucially on the ways in which individual patients develop the capacity to make sense of their experiences with medical care. Drawing largely on data and studies from medical consumerism in the US, I identify a number of choice ‘pathologies’ that might compromise the influence or beneficial effects of choice-promoting initiatives. Though these limitations are unlikely to turn public officials away from their consumerist policy aspirations, identifying the realistic limitations of such initiatives makes clear the need to complement them with other strategies for enhancing patients’ well being and encouraging a more responsive health care system.