The illusion of choice

James Gubb, 17 August 2007

The DH sent out a press release today entitled ‘Statistical press notice: Patient choice survey and A&E statistics’. The content’s as bland as the headline; the section on the patient choice survey merely reads: ‘Report on the National Patient Choice Survey, March 2007 England and provisional headline results of the May 2007 Survey’. Yet these are often the ones that are the most interesting; the ones that aren’t spun. You’d better your bottom dollar that if the results had been worth shouting about, the release would’ve been much juicier and, at the very least, actually contained some of the statistics. The fact of the matter is that those on patient choice are a cause for concern.

Yes, the results of the March survey show that ‘the percentages of patients aware of choice, offered choice and offered the [DH’s] Choice booklet continues to rise’. But the problem is that the rise is only a marginal improvement on those in the January survey and – most worryingly – the May survey actually shows a fall on both the March and January figures. Just 44 per cent of patients recalled being offered a choice of hospital for their first outpatient appointment in May, compared with 45% in January and 48% in March. Similarly, in the May survey, only 63% of patients who were aware they were entitled to choice of hospital recalled actually being offered that choice, compared with 64% in January.
The only consolation is that more patients are becoming aware that they have a choice; 38% in the May survey as opposed to 37% in March and 31% in January. But, overall, the picture of choice is one of stagnation; true, if more patients are becoming aware they have a choice, you would expect more of them to demand it, but if the choice is not forthcoming in the first place then the awareness of there being a choice is likely to level off or even fall. It’s a catch-22 situation, which in many ways embodies the feeling of drift in the NHS at present. Patient awareness and exercise of choice, at least according to the series of surveys cited above, increased fairly rapidly from May 2006 – when the lists of choices available to patients were extended from local options to include all Foundation Trusts and ISTCs – until January this year. For example, the number of patients that recalled being offered a choice of hospital for their first outpatient appointment increased by 15%.
But, to borrow the title of a recent report by the think-tank Reform, the NHS ‘empire’ has since struck back and patient choice is falling away. Yet this trend, unless checked, will be incredibly damaging to the ‘reform package’ that, at least on paper, should be introducing some kind of competition into the NHS to drive up standards. Why? Because choice is vital to competition; it is the ability of patients to compliment, complain and ultimately take their ‘business’ elsewhere that will drive the providers of health care to improve.
A part of the problem is of course that even if patients have a choice, they still have little ability to exercise it because the supply side is, as yet, still dominated by a monopoly of NHS providers. What diversification that has taken place is apparently being scaled back – witness the announcement by Alan Johnson that there will be no new wave of ISTCs – and rhetoric of competition is being replaced once again by that of ‘contestability’. The inadequacy of information is also a problem – without decent information of various aspects of a hospital’s care for a given condition, it is near impossible for any informed choices to be made. There is the ‘illusion of choice’ as Julian Le Grand puts it, which can be ‘worse than none at all’.
But, on the other hand, data quality is improving through instruments of comparability such as NHS Choices, Dr Foster and patientchoice.org.uk, and by 2008 patients should at least in theory have free choice for all elective care between NHS Trusts, Foundation Trusts and all independent providers that can meet the NHS tariff and core standards of care. BUPA is already advertising for NHS patients.
The deeper problem is probably the inertia in the system. Ultimately, unless patients go to their GP demanding choice, it lies with the GPs to offer it, which there appears massive resistance to do. With the lack of an adequate failure regime in place, GPs still feel responsible for propping up any failing local hospital by referring patients to it. They don’t want to be seen as the source of instability in the local health economy. This needs to change – it is not that instability is good, but the threat and reality of entry and exit. PCTs (and ideally not the DH) should start driving the patient choice agenda as a matter of urgency as part of their commissioning function, to hold providers to account, focus on quality and outcome evaluation, and ‘make the unpalatable decisions about exiting providers from the local market’ (Health Policy Forum). Only if this is done can we ever hope to move away from inefficient ‘monopoly-like’ provision to one which can provide a competitive environment in which world-class health care can flourish.