Increasing Patient Choice

The NHS White Paper, Liberating the NHS, sets out the government’s intention to give patients ‘more fundamental control’ over their care and treatment, including a choice of any willing provider and named consultant-led team for elective care. 1

This builds on previous work to extend choice within the English NHS, including the introduction of market-based reforms aimed at increasing efficiency and quality.

Patients requiring a specialist referral have been entitled to a choice of provider since January 2006, and should be able to choose from any hospital listed in a national directory of services, including NHS and independent sector providers 2

Evidence of the possible benefits

The evidence base for this approach is dominated by early pilot data, which related specifically to choice of provider hospital. The results of the pilot suggest that choice could result in improved patient satisfaction and contribute to reductions in waiting times.3

Evidence of the possible risks

There is little evidence that choice will itself improve efficiency or care quality> 4. Although patients may value being able to choose, in one study most patients chose their local service provider and were reluctant to travel further 2. Another study found that provider choice is not a high priority for the public, except where local services are poor, and patients rely on a trusted clinician to choose their treatment 4.

Indeed, most GPs report making choices on their patients’ behalf, unless the patient expresses a preference 5. In making a decision, patients value aspects of quality, including the cleanliness of the hospital and the standard of facilities, but rely heavily on their own experience, that of friends and family, or the advice of their GP, rather than published information about hospital performance. 2

Concerns have been raised that not all individuals have the same capacity to make health care choices.7 Choice may negatively impact equity of access, for example better educated populations are more likely to exercise choice. 4 If choice in health services is not equitable there is the potential that increasing patient choice may exacerbate existing inequalities in health outcomes.

However, a recent study found that there were no significant differences in whether different population groups were offered a choice of provider by their GP, suggesting that the opportunity to choose is reasonably equitable. Gender and ethnicity also made no significant impact on whether a patient took up the offer of choice, and chose a non-local provider. However, older, more educated individuals were more likely to choose an alternative provider, whilst those reliant on public transport were less likely to be willing to travel to another hospital 2. A more detailed analysis of the impact of patient choice on equity is due to be published shortly. 8

Although some have suggested that increasing patient choice may increase health care costs without improving efficiency, [4] there is limited evidence available about the impact of patient choice on the cost-effectiveness of services. 3

Implications for health and well-being

This review focuses on the uptake of patient choice. Many people have argued passionately for and against the introduction of choice into the English NHS on the basis of their expectations about its effects, but research evidence is only now beginning to emerge. 9 A recent Kings Fund report concludes that, even if relatively few patients choose to attend a non-local provider, there is intrinsic value in giving patients the ability to choose. 2

There is, however, still limited evidence about whether choice improves quality, or the likely impact of the White Paper proposals 1, as well as concerns about the potential costs of providing greater choice. 9 Effectively engaging patients will also depend on the willingness of clinicians to point patients to reliable information, elicit their preferences, and facilitate their decisions. 9

Author: Dr Helen Barratt MSc, Wellcome Trust Research Training Fellow, Department of Epidemiology & Public Health, University College London

UK area affected: England only

Further reading:

Coulter A. Do patients want a choice and does it work? BMJ 2010; 341:c4989

Dixon A, Robertson R, Appleby J, Burge P, Devlin N, Magee H. Patient choice: how patients choose and how providers respond. London: King’s Fund, 2010.

References:

1 Department of Health. Equity and excellence: Liberating the NHS. London: The Stationery Office, 2010.
2 Dixon A, Robertson R, Appleby J, Burge P, Devlin N, Magee H. Patient choice: how patients choose and how providers respond. London: King’s Fund, 2010.
3 Jones L, Mays N. Systematic review of the impact of patient choice of provider in the English NHS. London: London School of Hygiene and Tropical Medicine, 2009.
4 Fotaki M, Roland M, Boyd A, McDonald R, Scheaff R, Smith L. What benefits will choice bring to patients? Literature review and assessment of implications. J Health Serv Res Policy. 2008; 13(3):178-84.
5 Rosen R, Florin D, Hutt R. An Anatomy of GP Referral Decisions: A qualitative study of GPs’ views on their role in supporting patient choice. London: The King’s Fund, 2007.
6 Appleby J, Harrison A, Devlin A. What is the Real Cost of More Patient Choice? London: King’s Fund, 2003..
7 Thorlby R, Robertson R. Briefing Paper: Patient choice. London: King’s Fund, 2008
8 http://www.sdo.nihr.ac.uk/projdetails.php?ref=08-1710-164 (Accessed 18 April 2011)
9 Coulter A. Do patients want a choice and does it work? BMJ 2010;341:c4989