Quality's the new measure ...

Health service performance indicators have long concentrated on hospitals - but all this is about to change. Primary care trusts (PCTs), now the main budget-holders of the NHS, will have to subject themselves and their GP commissioners to greater scrutiny to ensure quality of care - rather than throughput - becomes the driving force of the new NHS market.

So far, the measures have been simple: waiting lists for surgery, or waiting times in accident and emergency. While these are vitally important to patients, many in the NHS believe they have led to distortion of their professional priorities.

Measuring quality of health outcomes and patient experience is complex and difficult. If PCTs are to be held accountable for the services they fund, patients need to be presented with real choices that are easy to understand.

In the new market, PCTs are the counterweight to hospitals fighting for their cash. Hospitals need high levels of routine operations to bring the funds that can finance more specialist work. That means hospital trusts may be tempted to treat more patients at a time when the government plainly wants fewer people to go into hospital. Its strategy is that prevention is better than cure - and what cannot be prevented may often be treated more cheaply, and more to the patient's satisfaction, in the community.

There is no point in blaming hospitals for poor health outcomes if the organisation paying the piper is not calling the tune. And soon family doctors will be required to offer patients four or five choices of elective treatment, with both hospitals and PCTs carrying the financial can for the judgments made in GP surgeries. Hospitals that fail to attract preferences may go the wall, while PCTs will have to cover any "excessive" use of certain procedures through patients' decisions.

Since national tariffs rule out much differentiation of service by cost - not likely to be a factor in NHS patients' minds anyway - differentiation will be by quality: not just on life-or-death consequences of surgery, but on whether there are suitable back-up services.

But do most patients see much difference between competing hospitals? We are not, the government promises, going to live in a world where hospitals advertise on buses that they kill fewer patients, but they will soon be targeting GPs - advertising success in heart treatments, for instance.

Consider a GP's discussion with a patient about a routine operation. Hospital A may have an average stay of six days for this procedure, compared with 10 days at hospital B. But is that more important a marker than the fact B has a far lower rate of MRSA bloodstream infection? Or hospital C may actually have even longer in-patient stays, but far better rehabilitation services. Patients will want to be able to assess that sort of information for themselves rather than be handed a fistful of leaflets from competing service providers.

Roger Taylor, director of research at Dr Foster, talks of a "virtuous triangle" of payment-by-results, GP commissioning and patient choice. For the triangle to work, he says, there has to be some tension in the system. The suspicion is that it's not there yet. The PCTs, still youthful organisations, do not appear to have flexed much financial muscle by making new choices of how they commission acute services.

"There are signs a real market can be there - there is the faintest creaking sound of it getting into gear," says Taylor. "But we are only just getting the ball rolling and we don't yet know what the real competition rules are.

"At the moment, how many PCTs are actually having conversations with their hospitals over the quality of outcomes they are delivering in terms of their population? Zero, probably. It is about trying to switch the balance of power so that the people receiving the services - and paying for them - actually start arguing about the quality of them."

But what happens if, as the market develops, PCTs don't prevent GPs from forming cosy relationships with hospitals, and patient choice does not provide grit in the oyster to make the system work? Much will hinge on how ministers manage the market. Will they let 1,000 roses bloom, irrespective of patient choice, or will they intervene to ensure it?