Choice is yours: A psychodynamic exploration of health policymaking and its consequences for the English National Health Service

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Abstract
Patient choice is at the forefront of the debate about the future of healthcare provision in many industrialized countries. It is argued that understanding the complexities and the multiple consequences involved in implementing individual patient choice in public health systems calls for an analytic framework extending beyond economic determinism and positivist social science paradigms. This study applies psychoanalytic concepts to illuminate policy dynamics and limitations, using the example of patient choice in the English NHS. It separates declared from unexpressed policy goals theorizing on the role of imaginary institutions and their defensive and less obvious functions in society, and reflects on the implications of policies that are formulated at a distance from operational reality on healthcare organizations. By focusing on the deeper primitive anxieties that are evoked and enacted in patient–doctor interactions, this article examines opportunities and limitations involved in developing individual patient choice.