Spoiling for choice

Choice, if Labour and the Tories are to be believed, is in danger of becoming like motherhood and apple pie: no right-thinking person could possibly be against it. If you raise questions about choice you are quickly condemned as a supporter of the old Stalinist-type "command and control" economy. Choice in public services is, however, a problematic concept.
August 2004

Market researcher Mori recently found that while people like the idea of choice, they did not mention the C word at all when they were asked what improvements they would like to see made to the NHS. For most people, it seems, choice does not feature as a moral good in and of itself.

Not so for politicians. The government and opposition are busy devising policies for public services as part of their campaigns for the next general election, and choice features prominently for both. In healthcare the Tories propose giving people the freedom to choose between being treated in the public or private sectors, with a subsidy to be given to those who choose private provision. The government, on the other hand, wants people to be able to choose between five hospitals.

Although Labour claims its proposals differ radically from those of the Tories (people will be offered a choice within the NHS and no money will change hands), it is clear that they will result in the private sector playing an increasingly significant role - especially in the cases of elective surgery and caring for people with long-term conditions. And ministers have said that in time patient choice may well be extended so that people will be able to choose from an unlimited range of hospitals. That would be very similar to the Tory approach.

Since its inception the NHS has been very good at providing the entire population with free healthcare - a huge accomplishment that is in danger of being forgotten in all the current talk about patient choice. In the past five years the government has been pumping a lot of money into the NHS with the aim of rebuilding it after decades of underinvestment. It has begun to extend capacity, increase the numbers of doctors and nurses being trained and cut waiting times; it has also made cancer care and treatment of heart disease major priorities, introduced NHS Direct and devised an ambitious set of targets for health improvement. However the NHS remains an extremely bureaucratic organisation that has been insufficiently attentive to diversity and individual patients. Now that the government has begun to build up capacity the NHS needs to address questions about the quality of the services it provides and their appropriateness to individuals.

But are the current proposals the only way of doing this? And are they the best way? The problem with both government and Tory proposals is that giving the patient the choice to go elsewhere is seen as a key driver of improvements in the quality of care. In place of a one-size-fits-all private economy of healthcare the Tories are proposing an equally one-sided individualistic economy. Labour will maintain targets that healthcare providers have to meet; so it will continue to provide a stronger element of central planning. But introducing patient choice alongside other measures like foundation hospitals and private fast-track surgery units means that Labour too is proposing to increase competition and significantly develop the internal market in the NHS.

Both Labour and Tory proposals on choice have received a great deal of criticism from doctors because it makes it impossible to predict how many people will choose a particular hospital for a particular procedure and to plan capacity accordingly. The new NHS Foundation Trusts, for example, are required to break even in their budgets, which require careful planning. But how can they possibly predict how many patients will be seeking, say, cancer care or hip replacements, and how much capacity they will need if the new model of patient choice becomes NHS policy?

The patient choice model is likely to be problematic for patients, too. We know from the state education system that when a school gets an excellent reputation it is inundated with applicants. Rationing by postcode happens, with affluent parents buying property within a school's catchment area. And if a school selects by ability, parents who have the means to do so purchase private tutoring for their children, thus giving them advantages over those who lack resources. Middle-class parents also know how education works and which are the good schools. Within education those who do not meet certain criteria may be turned away from the school of their choice.

If a hospital becomes very popular it will be faced with three choices. It can extend waiting lists for particular procedures, which would go against a key government target of further reducing waiting times. It can turn people away, but this would have very negative consequences for whichever government is in power - the bright new world of patient choice would become tarnished and the government would be faced with the problem of having raised expectations without being able to fulfil them. A third option is for a hospital to expand capacity, but in the short term this is virtually impossible. In a few areas capacity can be expanded through mergers or acquisitions, as has happened in London teaching hospitals like UCLH. Generally, however, it takes years to build a new hospital wing, and there may not be space to do so. Also you cannot increase the number of consultants and nurses or other professionals like physiotherapists or radiographers rapidly, especially in areas where it is hard to recruit and retain staff, and in specialisms where there is a shortage of trained personnel. Moreover, in expanding capacity you may transform a small or medium-sized hospital into a large one, thereby changing its character and culture and making it less attractive to patients. From the patient's point of view choice could become a chimera.

In a society like ours with huge inequalities in wealth and income, education and know-how, it is likely to be the more affluent, the better educated and those who are fluent in English and have good local knowledge who will be able to exercise choice. Many of the poor, the socially excluded, those with poor health who cannot travel far and those whose English is inadequate or whose local savvy is limited will end up going to the hospitals which are undersubscribed. It is also worth noting that exercising choice in the way that some government advisers advocate is an exhausting and time-consuming business. Those who may be perfectly capable of getting good quality information about different hospitals and consultants from the internet or personal networks may not wish to spend their precious leisure time in this way, and those who are old or have poor health may have the time to do so but not the energy.

All models of public services have to strike a balance between equity and fairness on the one hand and flexibility and diversity on the other. Both the government and the Tory choice models for the NHS would shift the balance dramatically from a system with reasonable equity but insufficient choice to one with greater choice for some but far less equity. But there is another way. First, resources should be concentrated on making all local hospitals as good as possible, so that for most people their local hospital is a place they are happy to use most of the time. This would involve establishing high standards of clinical care, patient-centred appointment systems and, for many places, a radical transformation in staff culture and attitudes. Second, a flexible system should be introduced that would allow patients to attend other hospitals if they wish to be near family or friends or to be treated in a particular way (e.g., with complementary medicine), or they want a second opinion or the expertise of a specialist with a research interest in a particular condition. Third, where local hospitals do not have sufficient expertise (e.g., in treating complex cancer cases or poorly understood conditions like ME) there must be routes to appropriate specialist care. This is already happening where clinical networks have been set up, as is the case with cancer care.

There is a further dimension that is largely missing from the current debate about patient choice. This concerns the quality of care people receive and their experience as patients within the NHS. The government has a whole range of targets that are designed to improve care. These include cutting waiting lists and ending postcode provision, and new institutions like the Commission for Health Improvement and the National Institute for Clinical Excellence have been created to help attain these goals. It has also argued, quite rightly, that the patient experience should be central to NHS provision, but this has somehow got lost in the recent debate about choice, which has tended to focus on the structure of the NHS rather than on its culture and relationships.

One of the things that is most important to patients is that doctors and other healthcare professionals work in partnership with them, treating them respectfully and understanding their specific circumstances. People want to be listened to and have their perception of their illness taken seriously and not invalidated. They want doctors to have the time and communication skills to be able to explain potential treatments and drugs to them thoroughly and to answer their questions. They want to be treated holistically, so that when they attend, say, an orthopaedic clinic but also have another condition the doctor is interested in their overall wellbeing and not just their arthritic hip or broken knee. They want their doctors to have some understanding of their domestic situation, so that it is not automatically assumed that people have somebody at home to look after them after an operation or a programme of in-patient treatment. They want recognition that if they are from an ethnic minority or are a refugee they will receive equal treatment that is sensitive to their cultural background, and that discussion of their illness takes place in a language they can understand. People want flexibility as to when they see their GP or have a hospital appointment. If they are disabled or find it hard to get around they want staff to be available and willing to give them a helping hand instead of having to wait hours for a porter.

Some of these things would involve small changes in attitudes and etiquette that could easily be implemented: asking people how they would like to be addressed, for example, or encouraging GP receptionists to be more friendly towards their patients. Some, like the electronic booking system that is designed to enable patients to make appointments at times that are convenient to them, are already in the pipeline. Some would involve changing medical education and training so that doctors improve their communication skills and become more aware about disability and diversity. And some would involve joined-up thinking, so that health and social care services are better integrated and people's needs for convenient and efficient transport are taken into account.

Underlying many of these issues are questions about the culture of the NHS and the attitudes of those who work in it towards their patients. In many areas these need radical transformation. Some GPs, primary care trust services and hospital departments are brilliant. They are responsive to their patients, flexible in how they operate, and make huge efforts to work in partnership with their patients. Some are mediocre, and others are appalling. The culture of an institution cannot be changed through centrally imposed targets. Such changes require enlightened management, good channels of communication between managers, staff and patients, and active (not token) patient and public involvement.

The fallacy in both Labour and Tory thinking is to assume that innovation and improved care can only be produced through allowing individuals to vote with their feet so they can go anywhere for treatment. It is perfectly possible to provide excellence, diversity, patient-centred care and a reasonable amount of choice within the NHS without introducing the inequalities, uncertainties and hassles that would inevitably accompany an ideologically-driven mode of patient choice. This is the task that both government and opposition should focus on.


 

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