The Question of Choice

One of the cornerstones of government health policy is the agenda of patient choice, but does the aim to introduce so much choice conflict with the efficiency and sustainability of the NHS?

The patient choice agenda has two main functions.  The first is to engage the patient more in their own care, allowing them to work in partnership with the clinician and feel more in control of their own care. The second aim of patient choice is to introduce greater competition between healthcare providers.

At 2020health we strongly support the first aim of greater patient engagement.  This will facilitate a movement towards better patient self-care, allowing patients to take more responsibility for their own health, and hopefully decrease the reliance on an already stretched healthcare system.  This aim could be further strengthened by better patient education about their condition.

However in terms of competition, we feel that patient choice is not the best way to introduce competition between providers.  Instead competition between providers should be through competing for contracts with the commissioning bodies.  It is the responsibility of commissioning bodies to draw up the optimum care pathway, and encourage patients to follow that care pathway.  Providers may compete for contracts  to deliver all, or part of, a pathway of care.  Whilst the feedback of patients on the quality of their care provided is important, this feedback should be taken into account by commissioners rather than through patient choices themselves.

The important choice for the patient is the choice of what care they should receive.  If there is a meaningful choice between several alternative treatments, with different outcomes, then of course the patient should be involved.  It may be that there are also relevant choices of treatment which are too expensive (not cost-effective enough) to be offered on the NHS, in which case it may be appropriate to offer the patient the option to pay a top-up to access these treatments.

For the older population in particular sometimes the choices offered can be overwhelming and confusing.  In a recent roundtable run by 2020health to discuss the Health Bill, it was reported that some patients felt that the offer of all these choices was due to the doctor “not doing their job properly” or being “too lazy to write a letter”.  Patients used to the old system of being told what care they should receive and when and where they should go to receive it, continue to expect this kind of service.

As this example clearly shows, there is a need to manage patient expectations.  Currently the conflicts between the policy on choice and the degree of choice available on the ground are likely to raise expectations high above what is deliverable in practice.

The best way to organise an efficient, cost-effective and fair NHS is the development of  standardised care pathways for a population, based on NICE guidelines. There will always be limits on the funding for NHS care, so determination of what care should be made available will always be a balancing act between the cost-effectiveness of different treatments. In general this is the current expectation of the NHS – but if we lead people to believe that they should be able to access any treatment, in any way they choose, the problem of rationing could quickly become very difficult.


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