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Freedom of choice

Is the NHS trying to feed patients and physicians something they don't actually want?

Baby_crying We are living in an age of unprecedented economic crises. Twelve months ago, I had never met anyone who had been made redundant; now I know plenty of people in that situation. On an administrative level, pressures on the Treasury mean government will have to look at its public spending across the board, which begs the question: what is the future for the NHS?

As the Reform think tank has highlighted, the NHS is facing a 'perfect storm' of an ageing population, expensive new technology and a more informed society. This will be a massive challenge for the NHS to confront and one that may prove even more difficult now that the high relative increases in central funding seem to be well and truly over. Despite the rapid growth of the NHS budget to around £100bn a year, as the recent report from the NHS Confederation anticipates, NHS funding is likely to be dramatically curtailed after 2011, regardless of whether a new government is in place or not. Given these great shifts in the market place, we can't just apply old ways of thinking or marketing models to the new environment.

Quality, patient choice and innovation are at the heart of NHS reform. Initiatives such as choose and book and giving patients the right to choose between GP practices and hospitals, along with the possibility of personal health budgets, have all placed patients at the forefront of healthcare provision. Health Secretary, Andy Burnham, said: "The vision for the future has to be that patients themselves become the pre-eminent force holding the NHS to account."

Patient choice has been high on the reform agenda, but what does choice actually mean in practice? As the focus increasingly moves towards patient choice, what will the impact be on the physician-patient relationship and for patients themselves?

At a very superficial level, this sounds like a move towards a more US-style healthcare system, with empowered patients asking for their brand of choice. This is ironic given that Obama recently held up the NHS as an ideal model for a healthcare structure.

Patient satisfaction
Concern among the general public about the NHS is at its lowest for decades; not surprisingly as most people are more concerned about the economy, crime, immigration and unemployment. The Perceptions of the NHS tracker by Ipsos MORI also reports the highest ever levels of satisfaction with the NHS. Those in the north of England are consistently more likely to be satisfied with the NHS than those in the South and East of the country. This trend is not unique to the NHS but matches attitudes to local government more generally. However, when it comes to the future of the NHS, the public are less certain. 30 per cent of people expect the NHS to get worse, 29 per cent better and the rest don't know. This lack of knowledge is also reflected in the level of knowledge about choice policies – 45 per cent of people claim to know nothing at all and 28 per cent know just a little.

When it comes to patient choice, it is all too easy to fall into the trap of thinking about empowered younger patients who have access to the internet to inform their views, however, the reality is the majority of patients are too vulnerable or ill to engage properly with a choice agenda. They will rely heavily on their physician to tell them what to do.

What is increasingly clear is that patients are wary of having too much responsibility in the treatment they receive. When we asked patients about whether or not they supported the idea of the government giving patients their own budget to allow them to choose various aspects of the help they receive from the NHS directly, 40 per cent opposed the idea.

Since the creation of the NHS, the physician-patient relationship has been defined by paternalism on the part of physicians, something that still resonates with many patients. For the 25th year running, doctors were named as the profession most trusted by the general public in one of our recent polls. Conducted 10 years after the Shipman case, the poll indicates that 92 per cent of adults in Britain believe doctors can be trusted to tell the truth. Clearly such negative events have not had an impact on the level of trust patients have in their physician.

When we look at what drives patient satisfaction with the service they receive from the NHS, objective measures such as spend per patient are poor predictors of patient ratings of their care. What matters most is being treated with dignity and respect, having good communication with their doctor and being involved in the decision making. What patients are really looking for is a true partnership with their physician, and an openness of discussion, not to make the choice of service for themselves. As Professor Ian Gilmore, President of the Royal College of Physicians, recently said, "The trust of patients in the modern world has to be earned and retained and we can do this only by reviewing the changing needs of patients in all aspects of their care. This will include the timely provision of information and the involvement of patients in a true partnership in decisions about their treatment."

GP-patient partnership
It would be wrong to think that this dynamic causes tension between patient and physicians – quite the opposite. As the majority of the general public (75 per cent) believe that treatment decisions should be made jointly between patient and healthcare professional, so the key motivation of NHS staff is to provide high quality patient care (74 per cent of over 9,000 NHS staff agree).

Qualitative research conducted by Ipsos MORI suggests that many physicians hark back to a rather more humane and idealised NHS ideal when patient care was the focus of all activity. By contrast, physicians do not see the modern NHS as reflecting this image. They perceive it as being run by, and using the language of, the commercial world.

For physicians, the NHS has – in recent years – become subject to constant change, operating to an agenda that appears to have been politicised and where fresh initiatives are imposed regularly. NHS staff give more praise to NHS values than to the NHS in its current state. 42 per cent would speak positively about what the organisation stands for, compared with one in five (22 per cent) who would speak critically.

Communication is also important within the NHS. The best performing Trusts are those where managers listen to their staff, allow staff input, give staff opportunities to show initiative and tell them how they're doing. Communication for physicians is of supreme importance and will become even more important in the future, within – but also outside – the NHS.

The future of the NHS will remain a hotly contested issue for all stakeholders with a part to play in shaping that future. Physicians are caught in a perpetually shifting landscape and it will be important for business intelligence to understand their role as change continues. Changes to the working patterns of physicians such as the imposition of extended GP surgery hours and the implementation of the European Working Time Directive, mean that now, more than ever before, physicians are being squeezed from many different angles.

Stakeholder engagement
The physician-patient relationship is one of 'partnership' rather than complete empowerment. Although patients will always be the central stakeholder, in order to drive positive change in the system, the healthcare service needs to look at all the stakeholders involved. The NHS aims to be a service that listens and responds to the needs of the people it serves, and physicians are still a vital part of the system, albeit strongly influenced by those above and below them. Marketers need to consider this broader landscape and not lose sight of the disparate influencing forces that may drive a choice of prescription or treatment option.

Physicians' influence on the NHS and the patients that it serves is not the same as it once was. Whether that is a good thing or a bad thing is open to debate. What is not debatable is that the reforms have increased the influence of other stakeholders and this will continue in one form or another, along with an increasingly demanding public.

The Author
Sarah Phillips is head of health at Ipsos MORI
To comment on this article, email

27th August 2009


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