Sugarman's commentary ^{Reference Sugarman1} strikes me as rather missing the point. I did not take Mynors-Wallis ^{Reference Mynors-Wallis2} to be criticising practitioners working outside of the National Health Service, but instead to be looking critically at the evidence that competition is the best mechanism for improving care. Sugarman makes much of the value of patient choice in improving services, although does not cite any evidence in favour of this assertion. In many mental health settings, this is also disingenuous. Our patients do not have any choice, instead it is the primary care trusts (PCTs) who make choices on their behalf. Even with the most benign possible view of these arrangements it is hard to believe that PCTs make their decisions on the basis of the wishes of the patients or their families as their primary concern. It may be that PCTs are, in fact, fantastically good at choosing the best, highest-quality, and most cost-efficient healthcare, but let us not pretend it is about patient choice.