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Patient Choice

6th March 2006

06032006_JellyBeans1.JPGWhat is the background to patient choice?

The idea of patient choice first emerged as a strategy for shortening waiting times, and to this end has been tried in a number of other European countries. It also aims to bring the NHS up to date with responding to a new type of consumer.  Today's consumer no longer wants a one-size-fits-all, paternalistic service; modern patients want choice and convenience. 

The power of the consumer is also a central element of the market model that lies at the heart of the Payment by Results funding system introduced on a trial basis by the Government in 2002, to which patient choice is intrinsically linked. In theory this provides a financial incentive for hospitals to attract patients through improved quality.

Patient choice is seen as one of several levers in the government's programme to modernise the NHS to create a more personalised, responsive and efficient health service. Consumers, it is argued, will choose hospitals that offer shorter waiting times or which they believe to offer a higher standard of care. Those hospitals losing business will have to improve or face closure.

Patient choice initiatives were initially piloted in 2001/2002 and have since been taken forward through a number of public consultation exercises and white papers, through the implementation of Choose and Book, the Connecting for Health initiative, and most recently taking patient choice into the community with 'Our Health, our Care, Our Say'. 

What have been the main initiatives in patient choice?

Pilot programmes began in 2001/2002 for heart and cardiac surgery with the National Coronary Heart Disease Choice scheme. In 2002 the London Patient Choice Project offered patients the chance of quicker treatment in areas such as orthopaedics, and  ear, nose and throat surgery.

In 2003 the Department of Health began a consultation exercise 'Choice, responsiveness and equity', culminating in December 2003 with ‘Building on the Best’ which looked to extend the concept of choice into primary care and pharmacy services as well. From summer 2004, all patients waiting six months for any form of elective surgery were to be able to choose at least one alternative hospital for treatment.

The policy drive to encompass patient choice was taken forward in the 'NHS Improvement Plan' of 2004 with the inception of  Connecting for Health, the move to a system of ‘Choose and Book’, and setting out further priorities for the NHS to be achieved by 2008.  The ‘Choosing Health’ white paper, also in 2004, expanded this to public health, emphasising the role of personal choices in the prevention of illness and promotion of well being. The information strategy to facilitate patient choice was set out in 'Better Information, Better Choices, Better Health' published in December 2004.

Two papers in 2005, 'Choosing a patient led NHS' and 'Commissioning a Patient Led NHS' spelt out in greater detail the reality of the implementation to keep patient choice central. The Department of Health set out how it intended to deliver the patient choice and public involvement in healthcare, promised in the NHS Improvement Plan.

From 1 January 2006, patients requiring a first outpatient appointment are required to be offered a choice of at least four hospitals for their treatment. These hospitals can be NHS trusts, NHS foundation trusts, treatment centres, private hospitals or practitioners with a special interest, operating in primary care; implementation has been dogged by delays in the NHS National Programme Connecting for Health and the implementation of e-booking systems, as well as inertia on the part of some  GPs.

The recent consultation exercise and publication of Our Health, Our Care, Our Say (February 2005) is set to take this into the community, including increased choice to be underpinned by a direct payment or care budget for people to pay for their own home help or residential care.

What are the potential benefits of the patient choice initiatives?

If successful, patient choice could deliver improved services and a rapid change in public perceptions of a service that has offered few choices in the past, with information empowering patients to make choices about their method and place of care. 

It has the potential to mean that healthcare will reflect patient’s priorities, that treatment is faster and that there will be less variation in standards of care.

It is hoped that for the NHS in general, allowing people to vote with their feet if they are unhappy with a service will galvanise the NHS into becoming more responsive to patients needs, reducing waiting times and raising standards of care.

Choice, and perception of choice, can be a means to establishing a sense of autonomy and trust in patients, crucial elements both for the public and for health professionals.

What are the risks involved in patient choice?

Aside from the delays experienced from the practical implementation of e-booking the biggest risk of patient choice may be its impact on the under-reported problem of healthcare inequalities.

There have been concerns that not every patient is able to make a choice in terms of location of care. Both the London Choice Pilot, and a recent report published by the Kings Fund 'Where the patient was king', examining the experiences of HIV patients, indicate that certain patients were more likely to exercise their right to choose their place of treatment than others. These included those who were better-educated, more vocal and more mobile.

In contrast to this however, a British Social Attitudes survey revealed that it found that older people and those on lower income were more pro-choice than those on higher incomes.  There was more enthusiasm for choice among those with lower or no educational attainment than those with higher qualifications.

If patients do begin to exercise choice, then those hospitals losing business may be forced to close the departments affected. Fewer hospitals mean less choice for patients - and it is the most vulnerable members of society, such as the elderly, who will suffer the most if they cannot access hospital services on their doorstep, leaving them with no real choice at all.

What of the future?

Further initiatives are anticipated to take forward patient choice in long term conditions, in maternity services and end of life care. A recent review of patients with long term conditions revealed strong preferences for involvement in choices about  diagnosis and treatment. 

From 2008, the Government promises to offer all patients the choice of any hospital, public or private, anywhere in the country which meet NHS standards at NHS costs.

If patient choice is to be a success then it is acknowledged that all patients, especially the vulnerable, must be enabled to exercise and take advantage of the extra benefits choice can bring. A key task is therefore to ensure that all patients have enough, and appropriately accessible, information with which to capitalize on the increased choice in healthcare offered.

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