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NHS commissioning and quality

Dr Shane Gordon, co-lead of the NHS Alliance's GP Commissioning Federation, on what patient choice means for NHS commissioning

New Health StrategiesPatient choice has been enshrined in law since 2009 as part of the NHS Constitution. This includes rights to choose who delivers your healthcare, what information you get to help you choose and what treatments you choose with your healthcare professionals.

This has led to commissioning choices for elective care from independent sector hospitals. There is evidence that patients are starting to exercise that choice, with DH figures showing that NHS expenditure has risen from a mere £60m in 2008 to nearly £500m in 2010. From a clinical perspective, choice of provider appears to be reasonably well embedded in the referral process, with 54 per cent of GP outpatient referrals using the Choose and Book system in 2010.

“Choice” remains a prominent theme of the Health and Social Care Bill currently before Parliament and the expression of a strong desire for choice has been a theme of every recent consultation on health services. To support patients in making their choices we are promised an “information revolution” to make comparisons between providers easier. The outcome of this consultation is awaited. The policy of

“Any Qualified Provider” (AQP) is being rolled out this year to include community-based services, such as wheelchairs, leg ulcer treatment and back/neck pain services.

The intention is clear that with more choice and better information, patients will drive up the quality of services. However, in reality people are notoriously unable to make rational choices even with perfect information; evidence for this is neatly summarised in the 2008 book Nudge [4]. Indeed, even professionals struggle to make sense of familiar data; in a 2006 study only 34 per cent of gynaecologists were able to interpret correctly the risk of Down's Syndrome from screening blood tests.

Meanwhile there is some evidence that choice improves outcomes.

A 2009 Cochrane Review found that using decision aids (standardised information on the risks and benefits of treatments) not only increased patients' knowledge and confidence in their treatment decisions but also significantly reduced the number of patients choosing invasive surgery instead of conservative treatments. 

More recently Dr Zack Cooper at the London School of Economics found evidence that being close to several hospitals (and therefore having a choice between them) improved mortality compared to areas with less choice. However others, including Allyson Pollock, professor of public health research, University of London, dispute the validity of this study.

From the commissioning perspective, managing all this choice presents an interesting challenge. Each provider offering choice will require effort and therefore cost to manage their registration, contracts, billing and performance. This will rapidly eat into the running costs allowed for clinical commissioning groups and could easily consume more resources than managing a single large provider. Of more concern is the difficulty in assuring quality of these myriad providers. The Care Quality Commission has no current plans to assure this type of provider.

As a patient myself, I value having choices of treatment and provider, but I may need help judging the true quality of those choices.

Dr Shane Gordon is co-lead of the GP Commissioning Federation, NHS Alliance and CEO of NE Essex GP Commissioning Group a well-established GP consortium representing 44 practices and 320,000 patients in the East of England. He is a recognised authority on GP Commissioning appearing on national TV, radio and writing regularly in national health media

This article was first published in the Patient Choice issue of the New Health Strategies series. The interactive digital version of the issue features additional video content, links to an array of key documents and insights from all sides of the debate – to view or download it click here.

24th November 2011


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