Policies enabling patients’ freedom of choice of health provider (hereafter, freedom of choice policies) are increasingly common in Europe. For instance, between 2006 and 2008 the UK government extended patients’ right to freely choose their specialist doctor to the whole country, in both public and private hospitals [1,2]. Similarly, in 2016 the Portuguese National Health System (NHS) allowed patients to freely choose any hospital within or outside their referral area for outpatient consultations [3]. Similar reforms have also been implemented in Norway, Finland and Sweden [4].

Policies increasing freedom of choice are aimed at improving efficiency and quality by providing mechanisms for greater competition [1,5]. However, merely extending freedom of choice may not directly produce increased competition among health providers [6]. In addition, further actions could be necessary to achieve effective improvements in the health systems, such as implementing economic incentives linked to providers’ activities, expanding the capacity of the health system or providing performance-related information [1,4].

Previous studies about freedom of choice have mainly analysed the impact of policies seeking to increase competition among providers, focusing on areas such as the clinical quality of hospital care [7,8]. The majority of these studies have addressed the situation in the US and/or the UK [9]. The empirical evidence available on the effects of freedom of choice policies is mixed. In this respect, Dawson et al. and Ringard & Hagen found that greater freedom of choice in hospital care reduced average waiting times in London and Norway, respectively [10], [11], [12], while Moscelli et al. found that the reforms introduced in the English NHS in 2006 reduced mortality risks for hip fracture patients by 0.62% [13]. However, Simões et al. reported conflicting results in their study of a similar reform in Portugal [3]. As regards hospital quality, reforms extending the freedom of choice of hospital within the British NHS in 2006 were associated with decreased mortality rates for acute myocardial infarction for patients living in areas where stronger competition policies were implemented [1,14]. On the other hand, health care quality worsened in terms of emergency readmissions after hip and knee replacement [8].

By adopting a policy similar to the one implemented in the UK in 2006, in November 2009 the regional government of the Community of Madrid (Spain) enacted a law that extended the patients’ right to freely choose among any General Practitioner (GP), paediatrician or nurse available in the primary care service, and among any specialist at any hospital in the whole Community of Madrid [15], in the specialised care service, and not just among those professionals in their corresponding referral area. The Community of Madrid was the first, and to date the only, region in Spain to remove the main administrative barriers that prevented comprehensive freedom of choice of health providers by patients within its territory. Additional measures included proceedings to facilitate the choice of health provider, implementation of new information systems enabling patient to make more informed decisions and opening of new hospitals (see Table 1). In addition, a complementary measure of this reform provided a few hospitals in Madrid with strong economic incentives to attract patients as part of their receipts was based on the number of patients treated from other centres. While the new structure of the health system sought to develop citizens’ right to take part in health-related decision making, its primary aim was to improve healthcare quality [15]. To our knowledge, the only study investigating this reform has been conducted by Matías-Guiu et al. by considering a Neurology Department in the region of Madrid [16]. The results of the study show relevant inflows of patients to the Department from other health areas following this policy. Waiting times and doctor reputation appear as the main reasons for the choice of the Department

In this paper, we analyse the impact of the health system reform carried out in the region of Madrid in 2009 on the responsiveness of its primary and specialised care services. We address this goal by using cross-section microdata obtained from the Spanish Healthcare Barometer (SHB) survey for the period 2002-2016 and the synthetic control estimator as the main impact evaluation technique [17], [18], [19]. The Spanish health care setting is relevant to study freedom of choice reforms since its health care system is essentially universal coverage-wise, funded by taxation and provided free of charge at the point of delivery, like many other health systems which are currently implementing such reforms.

The World Health Organisation (WHO) has highlighted the desirability of measuring health system responsiveness as a valid component for evaluating health service performance [20]. This concept concerns how individuals are treated by the health system and the nature of the environment in which this interaction takes place [21]. Moreover, it is related to non-clinical health care factors, i.e. those which although not directly related to health outcomes may be relevant to the well-being of the population [21]. The WHO classified these aspects into eight domains, which can be categorised as respect-for-persons (dignity, autonomy, confidentiality and communication), and client-orientation (choice of care provider, prompt attention, quality of basic amenities and access to social support networks) [21,22]. In this paper, we study how extending the freedom of choice of health care providers in the Community of Madrid has affected patients’ healthcare experiences, with particular regard to the dignity, communication and prompt attention domains of responsiveness.

Given the difficulty often encountered in obtaining objective indicators to measure the responsiveness of the health system concerning some of these domains [21], patients’ opinions about their own experiences are usually used in research studies as a proxy of the true level of responsiveness. According to the literature, self-reported measures of responsiveness can be considered as valid predictors of more objective measures of this variable and are useful tools for evaluating the performance of health systems’ secondary care [23]. In view of these considerations, the present study uses patient-reported measures to quantify the level of responsiveness of the domains addressed.

This study contributes to the literature on freedom of choice policies in the health field in several ways. Firstly, to our knowledge, this is the first study providing empirical evidence about the effects of such policies on some of the responsiveness domains proposed by the WHO as a means of evaluating healthcare systems. Although previous studies have explored the impact of competition reforms on quality from the patients’ point of view, they mainly focus on broader measures of patient satisfaction, as opposed to responsiveness [24]. Secondly, unlike much previous research, our study analyses and compares the effects of the freedom of choice reform on both primary and specialised health care [24,25]. Finally, we measure the effect of the policy on prompt attention by using objective and subjective indicators of waiting times and provide further support to previous literature by revealing a strong correlation between the two types of measures.

Under the Spanish NHS, health cover is essentially universal, funded by taxation and provided free of charge at the point of delivery. To a large extent, health services are publicly provided (the public sector accounted for 70.8% of total health spending in 2019) [26].

The Spanish health system is highly decentralised, since responsibility for budget management and territorial organisation has been fully devolved to the regional governments since 2002. Health care funding is regulated by an agreement by which the central government devolves tax and funds revenues to the regions on the basis of a needs-based weighted formula. Hospitals are paid on the basis of prospective budgets based on volume and some quality indicators, while primary care health professionals are - with very few exceptions - salaried workers [27]. In some cases, when the provision is delivered by private providers –mostly in secondary care–, procedures are paid via a fee-for-service mechanism [27].

From the healthcare management stand point, the country is divided into Regions, and the territory of each Region is divided into Health Areas. Each Health Area is composed of several Basic Health Zones, the smallest units of the organisational structure. Each Basic Zone is composed of one or more health centres, staffed by primary care teams, who exercise the gatekeeper function. Each regional government is responsible for the organisation of this territorial structure within its region. Citizens are assigned the primary care team which is closest to their place of residence. Therefore, their referral Health Area is that where the assigned primary care team works. Hospital departments are responsible for the provision of specialised care, in addition to inpatient care.

In Spain, patients can choose among GPs/specialists in health centres/hospitals within their referral Health Area. However, the regions have the right to modify the national legislation regarding freedom of choice within their territories. In November 2009, under a regional regulation, the former eleven Health Areas in the region of Madrid were replaced by a unified Single Health Area. This reform removed the main administrative barrier preventing patients from choosing health providers within the entire region. In summary, this reform extended patients’ freedom of choice by allowing them to freely choose among all the healthcare professionals working in the region, in both primary and specialised care, and not just among those in their referral Health Area. To date, the Community of Madrid is the only region in Spain which has adopted a Single Health Area.

The regional health authority of the Community of Madrid adopted several measures to facilitate patient choice. Under the new system in primary care, patients need only communicate their choice of doctor to the health centre where the GP in question delivers the service. In specialised care, after being referred by their GP, patients can make an appointment by internet, mobile application, by means of digital facilities located within the health centre or via the Appointment Management Centre (a call centre which since 2010 has been helping users make appointments with specialists and informing them of waiting lists and alternative providers). Furthermore, since 2014 the health authority has published indicators of the performance and speciality-specific waiting lists for hospitals in the region, in order to facilitate the decision making process [28]. Since the law came into effect, the number of patients who have exercised their freedom of choice has progressively increased. The most recent data show that, in 2018, the citizens in this region made 2,292 changes of specialist doctor per 100,000 consultations, 83% more than in 2011 [29] (see supplementary material 1). In parallel to the reform some new hospitals have been inaugurated in the Community of Madrid, under a Public-Private Initiative (PPI) funded on a fee-for-service basis and whose concession contracts include financial incentives to attract patients from other hospitals (see the Discussion section).