The current colloquy over patient choice in the UK can be seen as part of a fundamentally changed European debate about the objective of health sector reform generally. What initially took form in the mid-1980s as a highly charged, ideological struggle between Thatcherite market liberals against neo-Marxist social democrats has now evolved into a practical, almost technical discussion about tools and mechanisms. From Olympian thunderbolts about Truth and Human Rights, there is now a quite civil discussion about what works and what does not, and how to improve outcomes – clinical, fiscal, and administrative. In countries like Sweden and Norway in the Nordic region, and Spain, Portugal, and Italy in Southern Europe, as well as The Netherlands and Switzerland among social health insurance funded countries, the political premium has shifted from the purity of beliefs to practical measures of implementation and evaluation. In short, European health care systems have entered a new period, less ideological and more pragmatic, but also more complex and demanding in their structure, organization, management, evaluation, and accountability.

A key element in this emerging complexity has been an altered approach to the longstanding welfare state debate about the appropriate roles of state and market and/or public versus private in the health sector. In Europe, this debate dates back to the early 1980s, with the publication of Gordon McLachlan and Alan Maynard’s The Public–Private Mix for Health in 1982, and the first European Health Policy Forum on the topic in 1984 in Brussels – which broke up after 10 minutes, with participants hurling invective and, reportedly, chairs.

The fact that the presentations on individual choice at the London School of Economics (LSE) and the discussion that followed were considerably better mannered reflects the essential change in the character of the debate over the intervening 25 years. In the early 1980s, any question of public or private decision-making in health care systems was seen to be an all-or-nothing, black-or-white proposition. Either you were in favor of markets in health care or you were against them. Either you favored competition and market-derived efficiencies in health care or you supported expert planning and equity for vulnerable populations.

Today, more than two decades later, the debate on this topic has a different character in five fundamental respects.

First, it is focused on the relative role of public and private in specific sub-sectors of the health care system. Many of those across Europe who favor choice and competition among a diversity of providers, for example, frequently favor a continued uniform public sector role in the funding of health services. Similarly, in Central and Eastern Europe, policymakers have transformed first contact, and now general practitioner (GP)-led primary care into private competitive markets, yet kept hospital ownership and management within the public sector.

Second, the present-day debate is, in many parts of Europe, focused on pragmatic tools and mechanisms that can achieve specific ends, rather than on ideologically generated statements grounded in philosophical belief systems. Can transforming hospitals into public firms (as has been done in England, Norway, Estonia and in parts of Spain, Italy, and Portugal) improve outcomes or not? Can re-structuring incentives for GPs, from salary to a mixed payment model (as in the UK and Finland), produce greater responsiveness to patients or not?

Third, policymakers recognize that market mechanisms can be adopted inside the public sector as well as in private parts of health care systems. Hospitals in the above-noted countries compete in a variety of publicly designed markets, yet none of these hospitals have been privatized. Similarly, in the 1993 ADEL Reform in Sweden, market mechanisms were introduced that linked together two separate public budgets – (local) municipality and (regional) county council – to create more clinically appropriate and more fiscally efficient care for the sick elderly, without accountability being transferred to the private sector.

Fourth, issues of greater choice for patients have become as important as those of greater efficiency for health economists. As countries have become wealthier, the importance of meeting citizen expectations has grown considerably, and questions of responsiveness and satisfaction now share the top of the policymaking agenda. Managerially, choice of public provider can create market-like signals about performance that can lead to improvements in fiscal and quality outcomes in public as in private markets.

Fifth, policymaking has become more nuanced, reflecting efforts to mix public and private roles, to balance state planning and regulatory instruments with the standard range of market mechanisms including contracts and patient sovereignty. Policy is also more flexible regarding the selected melting of public/private boundaries, as witnessed by the growth of public–private-partnerships, private finance initiatives, and similar cross-boundary mechanisms.

As these points all demonstrate, the public/private debate in Europe has not disappeared. However, in most policymaking circles, the nature and focus of that debate has shifted rather dramatically. The previous, ideologically charged debate about state ‘versus’ market models of health care have largely been superceded by a spirited but highly pragmatic discussion on how to ‘combine’ state and market in the health sector, and through what mix of mechanisms. In England as well, as the presentations at the LSE about expanded patient choice of provider highlight, pragmatism appears to have largely gained the upper hand. Thus, while the debate lives on, it is now a transformed and largely practical debate that can help steer the future of publicly accountable health care systems in Europe in a considerably more effective manner than could its absolutist predecessor.