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What is NHS patient choice?

Real patient choice means freedom from institutionalisation, says Dr Nick Goodwin from The King's Fund

New Health StrategiesPatient choice is intrinsically attractive. Who would not, after all, benefit from making informed decisions about their care within a system that provides a range of accessible service options?

The evidence on how patients want to make choices backs this up. For example, recent research into patient choice in England concluded that the ability to make a choice about one's care and treatment is highly valued, particularly among older people. Nonetheless, the policy of patient choice is often criticised for two key reasons: firstly, for not necessarily providing the sorts of choices that patients really value, and secondly, for using choice as a mechanism to promote competition in the system, rather than as a tool to develop shared decision-making about care and treatment options.

Looking back, the policy of 'patient choice' that was introduced to the NHS in 2006 was designed as a mechanism for creating capacity, improving access and making services more responsive to patient demands. The policy had two key elements: first, patients waiting more than six months for an operation became entitled to choose an alternative place of treatment (a policy since made largely redundant as waiting times reduced dramatically), and second, 'Choose and Book' was introduced to offer patients needing hospital referral for elective treatment a choice of four or five providers (now extended to any accredited provider under the Free Choice Network).

Patient choice has also been used to define people's rights to choose the services they receive. The NHS Constitution, published in 2009 but recently updated, defines these as:

• The right to choose your GP practice, and to see the GP of your choice, and

• The right to receive information about, and to choose, outpatient treatment for mainly elective services at any accredited organisation that provides NHS care.

One of the key aspects of this choice policy is that it imposes a requirement on commissioners to enable people to access a choice of providers. This can cause problems for commissioners, however, when seeking to develop new forms of integrated care that bring together organisations across a community. A paradox develops in that the requirements of patient choice may begin to undermine the ability to devise a new way of working that patients might both desire and directly benefit from.

It is this key limitation to the interpretation of the current patient choice policy that the report of the NHS Future Forum Group sought to address in its recent listening exercise during the pause in the Health and Social Care Bill. As it concluded, much more needs to be done to deliver 'real choice' to patients (ie, not just of a provider), which in turn would require a more sophisticated interpretation of the policy.

As Sir Stephen Bubb, chair of the Choice and Competition stream of this work, put it: “Choice is much more than the ability to choose a different provider of elective surgery. It is also about the choice of care and treatment, the way care is provided and the ability to control budgets and self-manage conditions.”

The evidence shows that this different emphasis on what patient choice means is needed. In particular, patients (especially the elderly and vulnerable) are not adequately involved in making decisions about their care. A 'gulf' exists between what patients say they want and what care professionals believe should be provided.

Patient choice needs to transform this paternalistic attitude, since it currently supports a dependency culture on professionals and hospitals. Instead, patient choice policies need to focus on the promotion of shared decision-making, empowering individuals with the ability to self-care and helping to reduce the growing and ultimately unsustainable levels of demand on hospitals.

This policy needs to live up to the Government's commitment to patients of 'no decision about me without me' and focus on how care can become more personalised. After all, you cannot hope to have real patient choice without freedom from institutionalisation.

Dr Nick Goodwin is a senior fellow at The King's Fund, London. A social scientist specialising in research and policy analysis in healthcare, Nick's key research interests lie in the organisation and management of primary care, practice-based commissioning, integrated care systems and care networks, and international health management and development.

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.

11th November 2011

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