The reasoning was something like this: those units with the best reputations and the best outcomes would attract the most patients and thus the most funding. Conversely, those departments that were ‘not up to scratch' would either have to improve or cease to exist.
Of course, investing in quality and efficiency requires funds, so hospital managers have found themselves in something of a quandary over ensuring patient throughput to in turn ensure funding levels are maintained.
And given the emphasis put on learning from the private sector in the modern NHS, the answer was obvious - increased marketing and even advertising efforts.
So next week the DoH will publish a guide to advertising NHS services in a move that could see rival secondary care trusts battling like Sainsbury and Tesco in the local papers.
Already some trusts have started sending out glossy pamphlets explaining their services to GPs. Others have invested in software that tells them which local practices are not referring patients to their departments and have started cold calling those GPs to find out what they can do to ensure more referrals. Loyalty cards perhaps?
But this forgets that it is supposedly patients and not GPs who now make the choice of referrals. So what next, can we expect local hospitals to mailshot patients with two-for-the-price-of-one special offers? Or perhaps there is a new market for the call centre industry: ‘Good evening, madam. Our records indicate that you have expressed interest in a hip replacement. No, well we also have a very good range of cancer treatments available...'
And what funds this marketing effort? Money that could be spent on patient care.
Before ‘choice' and PbR - and in fact still in the rest of the UK outside England - we had a simple system for ensuring referrals went to the right place. It was called clinicians' knowledge.
For decades, GPs have had an expert knowledge of what services are available from what hospital, how long patients have to wait and the reputations of different clinics and consultants.
But in the era of choice, it seems that the profession cannot be relied on to continue to gather the information vital to the treatment of their patients, and so valuable NHS funds may be diverted to marketing efforts. This is an example of how the push to ‘modernise' can forget the basics.