Choice as proxy for efficiency

Rather than just the opportunity to choose a GP there is considerably more evidence that patients wish to be involved in individual treatment decisions²⁹⁸ and have

293 cf Department of Health, Operational Guidance to the NHS: Extending Patient Choice of Provider (2011) 4 <www.dh.gov.uk/publications> accessed 1 September 2012 referring to the policy of the current coalition government aimed at increasing the numbers of such providers by extending patient choice from April 2013 to ‘any qualified provider’ in the NHS that meets NHS requirements for service quality. Providers of musculo-skeletal services for back and neck pain are considered for potential inclusion. If these are not salaried NHS employees a cost reduction for the NHS is possible.

294 Choice of GP had at least in theory been available since 1948, see I Greener, ‘Towards a History of Choice in UK Health Policy’ (2009) 31 Sociology of Health and Illness 309, 313; R Robertson,

‘Patient Choice’ (The King’s Fund 2008) 1 <www.kingsfund.org.uk/document.rm%3Fid%3D7356>

accessed 15 July 2011.

295 M Fotaki and others, Patient Choice and the Organisation and Delivery of Health Services: Scoping Review. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO 2006) 67.

296 A Coulter, ‘Do Patients Want a Choice and Does It Work?’ (2010) 341 BMJ 973, 974; I Greener,

‘Are the Assumptions Underlying Patient Choice Realistic?: A Review of the Evidence’ (2007) British Medical Bulletin 1, 5.

297 J Le Grand, ‘Choice and Competition in Publicly Funded Healthcare’ [2009] Health Economics, Policy and Law 479, 486; see also Royal College of General Practitioners ‘It’s Your Practice, a Patient Guide to GP Services’ (2011)

<www.nhs.uk/choiceintheNHS/Yourchoices/GPchoice/Documents/rcgp_iyp_full_booklet_web_versi on.pdf> accessed 5 March 2012; NHS Choices, ‘GP Choice’ (2012)

<www.nhs.uk/choiceintheNHS/Yourchoices/GPchoice/Pages/ChoosingaGP.aspx> accessed 5 March 2012.

298 M Fotaki and others, ‘What Benefits Will Choice Bring To Patients? Literature Review and Assessment of Implications’ (2008) J Health Serv Res Policy 178, 181.

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information about available treatment options.²⁹⁹ Most patients place greater value on involvement in choosing their treatment or treatment package.³⁰⁰ As will be shown below, a choice of treatment in the primary care sector may, however, not lead to a reduction in cost or greater efficiency.

To be able to make a treatment choice, patients require information about the variety of possible treatments and their different risks and outcomes. While choice of treatment is likely to be less important for patients in acute and life-threatening medical situations, where the patient is particularly vulnerable and dependent on the expertise of the physician,³⁰¹ much more of the time in general practice is spent on patients with chronic, not time-limited conditions,³⁰² where recovery is impossible or at least unlikely in the near future and requires ongoing management over a period of years.³⁰³ In order to exercise treatment choice the information requirements of these patients, often affected by several co-existing chronic health problems, will be extensive. However, there is often insufficient evidence available about the

competing advantages and drawbacks of treatments for multiple conditions.³⁰⁴ Studies among patients in general practice have shown that patients are not

299 M Fotaki and others, Patient Choice and the Organisation and Delivery of Health Services: Scoping Review. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO 2006) 101.

300 A Coulter, ‘Do Patients Want a Choice and Does It Work?’ (2010) 341 BMJ 973, 974; see also E Nolte and M McKee, ‘Caring for People with Chronic Conditions: An Introduction’ in E Nolte and M McKee (eds), Caring for People with Chronic Conditions: A Health System Perspective (Open University Press 2008) 3–4 stating that patients with chronic, long-term conditions are particularly likely to value treatment choice because of the lasting impact of the illness or illnesses on their physical, psychological and social functioning, requiring them to alter their behaviour and engage in activities promoting their physical and psychological well-being.

301 S Watt, ‘Clinical Decision-making in the Context of Chronic Illness’ [2000] Health Expectations 6, 6.

302 E Nolte and M McKee, ‘Caring for People with Chronic Conditions: An Introduction’ in E Nolte and M McKee (eds), Caring for People with Chronic Conditions: A Health System Perspective (Open University Press 2008) 3 where the authors refer to T Wilson and others, ‘Rising to the Challenge:

Will the NHS Support People with Long-Term Conditions?’ (2005) 330 BMJ 657 stating that people with chronic illness account for 80% of general practice consultations in England.

303 S Watt, ‘Clinical Decision-making in the Context of Chronic Illness’ [2000] Health Expectations 6, 9 suggesting that treatment expectations are usually remission or control of symptoms, a delay in the progression of the disease or a prevention of secondary complications and rarely curative so that patients will want to make trade-offs regarding the different adverse effects of different treatments and the impact on their life.

304 ibid 10.

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sufficiently informed to make choices,³⁰⁵ and this is one of the most common causes of dissatisfaction of patients.³⁰⁶

While patients are likely to benefit from being given information enabling them to make choices, the provision of this information is likely to add considerable costs.

Not only is it likely to necessitate extending the allocated consultation time in the GP practice, it may also require patient choice advisors ³⁰⁷ and decision aids to improve the patients’ understanding of, and help them with, their treatment

options.³⁰⁸ It might require a complete re-designing of the consultation process, with patients having to be referred to patient choice advisors and GPs having to incur additional costs to employ more staff.³⁰⁹ Providing information and support to patients to enable them to arrive at sensible choices about their healthcare is

therefore likely to lead to a significant increase in resources rather than enabling cost containment.

Whether patient choice really leads to efficiency gains in the primary healthcare sector is therefore far from clear,³¹⁰ unless efficiency gains could possibly be

305 M Fotaki and others, Patient Choice and the Organisation and Delivery of Health Services: Scoping Review. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO 2006) 101; M Fotaki and others, ‘What Benefits Will Choice Bring to Patients? Literature Review and Assessment of Implications’ (2008) J Health Serv Res Policy 178, 181.

306 A Coulter, ‘Do Patients Want a Choice and Does It Work?’ (2010) 341 BMJ 973, 974; see also J Ovretveit, ’Values in European Health Care Markets’ (1994) 4 European Journal of Public Health 294, 298 suggesting that it may also be one of the reasons why patients turn to CAM, because they are dissatisfied with losing control over decisions about their care in the conventional health setting.

307 I Greener, ‘Are the Assumptions Underlying Patient Choice Realistic?: A Review of the Evidence’

(2007) British Medical Bulletin 1, 6; J Le Grand, ‘Choice and Competition in Publicly Funded

Healthcare’ [2009] Health Economics, Policy and Law 479, 484; M Fotaki and others, ‘What Benefits Will Choice Bring to Patients? Literature Review and Assessment of Implications’ (2008) J Health Serv Res Policy 178, 182.

308 M Fotaki and others, Patient Choice and the Organisation and Delivery of Health Services: Scoping Review. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO 2006) 122.

309 I Greener, ‘Are the Assumptions Underlying Patient Choice Realistic?: A Review of the Evidence’

(2007) British Medical Bulletin 1, 6.

310 M Fotaki and others, Patient Choice and the Organisation and Delivery of Health Services: Scoping Review. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO 2006) 115 arguing that efficiency gains of new patient choice schemes are difficult to assess because they may be accompanied by increased NHS funding.

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achieved by moving some of the costs of treatment to the patient³¹¹ by, for example, enabling access to CAM services through the primary care sector on the

understanding that the patient will have to bear the costs of these services.³¹² The concern with patient choice as proxy for marketisation policies is of course the concern that market reform will lead to privatisation or quasi-privatisation³¹³ where efficiency will become the driving force, leading to conflict and tension with the traditional values of the NHS, particularly the value of equity.³¹⁴ However, policy-makers have tended to justify their policies as supportive of the original

settlement.³¹⁵ In this light, the antagonism towards patient choice in the English NHS as leading to inequity and therefore undermining one of its core values also needs to be scrutinised.

311 ibid 117.

312 Thus supporting patient choice of CAM could also be used as a covert strategy to curtail costs, although such a solution would favour the better-off. Given that the holistic healthcare model of CAM favours individual responsibility for health, such a strategy might well be compatible with the views of government health policy-makers, see HA Baer, ‘Why Is the Australian Government Interested in Complementary Medicine? A Case Study of Economic Rationalism’ (2007) 12 Complementary Health Practice Review 167, 168 arguing that the growing legitimation of CAM in Australia is a strategy to curtail costs and parallels the advent of a policy of economic rationalism.

313 J Clarke and others, ‘The Antagonisms of Choice: New Labour and the Reform of Public Services’

(2008) Social Policy and Society 245, 250.

314 Efficiency might conflict with equity, defined as equal geographical access, as it is likely to be more expensive to treat people living in remote rural areas and to enable them to have access to the same package of healthcare as city dwellers. Efficiency might also affect equity, defined as unequal shares of healthcare depending on need, because the very ‘needy’ such as the elderly or disabled are likely to use a much larger share of the overall health budget. If the most ‘needy’ are considered to be those who are most at risk of immediate death, an efficient use of resources might encourage letting the most seriously ill die in order to stop the drain on resources and improve the aggregate health of the less ill; see J Harris, ‘The Case Against: What the Principal Objective of the NHS Should Really Be’ (1997) BMJ 667, 669-672 and M Fotaki, ‘Patient Choice and Equity in the British National Health Service: Towards Developing an Alternative Framework’ (2010) 32 Sociology of Health and Illness 898, 901; cf B New, A Good Enough Service – Values Trade-offs and the NHS (Institute for Public Policy Research 1999) 16 arguing that equal access to healthcare, both in terms of geographical equality of access to the same package of healthcare and also according to the various understandings of need, can only be achieved in a utopian world of unlimited resources; see also generally B Rumbold and others, Rationing Health Care (Nuffield Trust 2012)

<www.nuffieldtrust.org.uk/publications/rationing-health-care> accessed 20 October 2012.

315 A Oliver, ‘The English National Health Service: 1979–2005’ (2005) Health Economics 575, 576 suggesting that this may well be because of the value placed by the public on the principles underlying the NHS.

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