Choice and Health Inequalities
Frances Blunden, Principal Policy Adviser, Which? Presentation at Choice, Markets, Competition in the NHS Socialist Health Association seminar 28 February 2006
Choice: panacea or death knell
Arguments in favour of increased choice
- Fundamental to a patient-centred NHS Modernising the NHS
- Driving up standards in the NHS
- Providing more flexible and personalised healthcare
- Empowering patients and increasing autonomy
- Guaranteeing support for NHS from all sections of society
- Reducing inequalities
- Encouraging a more active role in healthcare
Arguments against increased choice
- Privatisation of the NHS by stealth
- Increasing inequalities
- Choice is irrelevant
- Unwanted burden at a time of stress
Choice and healthcare
- Choice fundamental to healthcare:
- Informed consent is the legal and ethical basis for any treatment
- Health is deeply personal
- Our reactions to ill-health and our health needs are particular
- We want to retain some control over our healthcare
- Choice in healthcare is not new
- Health needs are unpredictable
- Huge information asymmetries
- Impact of choices significant
- Consumers lack the confidence to make many healthcare choices
- Choice has to be about more than just elective care
- Choice of GP, treatments, appointment times
Government proposals for choice
- Increased choice in elective acute care
- Patient choice pilots 2002 for patients waiting longer than 6 months
- “Choose and Book” December 2005
- Increased choice in primary care
- Choice of GP and GP practices
- Widening range of primary services eg Walk in clinics, minor injuries units and expanded NHS Direct
- Enhanced roles for existing health professionals
- New services and new professionals in primary care
- Increased choice about medicines
- Reclassification of medicines
- New prescribers
- New ways of dispensing medicines
- Increased choices about treatment
Proposals associated with increased choice
- Diversity of providers
- Increased capacity
- New providers
- Increased use of the private sector
- New roles for health professionals
- Contestability between providers
- New systems of funding NHS care
- ‘Payment by Results’ fixed national tariffs for NHS funded care with the funding following the patient
- Practice based commissioning
Consumers and healthcare choices
- Attitudes to choices about healthcare vary significantly between individuals and different circumstances
- Not all consumers have the same capacity or desire to make choices
- Consumers want some choices and not others
- Consumers want choice sometimes and not at others
- The desire for choice may be modified in reality
- Not all consumers have the same opportunities for choice
- Not all consumers have the same ability to make choices
- Access to information and support vital
- Tailor to the needs of particular groups
- Not all consumers have the same ability to take up choices
- Rural areas
- Low income consumers
Do consumers want choice?
Demand for some sorts of choices, particularly to give:
- Convenience
- Control
- Continuity
- Flexibility
Prompt diagnosis and treatment is more important than choice
Proximity is key
Quality and safety are assumed as given
Consumers find it difficult to conceptualise what is meant by ‘patient choice’
Consumers lack confidence and experience in making some choices
Existing experiences of healthcare choices
- Existing experiences of choices about healthcare are limited
- Previously few opportunities for choice
- Choice of GP practice most common
- Only 12% had a choice of different hospitals
- Little awareness of government proposals to increase opportunities for patient choice
- Limited knowledge of ‘Choose & Book’
- Patchy knowledge of new facilities and services
- Limited understanding of enhanced roles for nurses and pharmacists in primary care
- Health professionals can facilitate or frustrate choice
Impact of choice on health inequalities
Both positive and negative:
- Access to choice for some for the first time
- May exacerbate existing inequalities in health & access to care
Potential to create new health inequalities as a result of:
- Inequalities in service provision and quality
- Choice not offered equally for all services & conditions
Opportunities to make and take up choices are unequal:
- Patients with significant healthcare needs
- Conditions & treatment needs
- Rural areas
- Patients who choose not to choose
- Patients whose GP does not offer choice
- Higher costs of choice for some communities
Payment by Results – access and equity
- Incentives to cherry-pick
- Providing care to the tariff
- Providers chosen by more complex patients
- Providers serving deprived communities
- Providers with higher costs
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What’s needed to make choice work?
- Choice must be part of a wider, strategic policy framework
- Market-based approach not enough
- Priority must be given to clinical need
- Limitations of the private sector
- The right choices must be in place
- Sufficient resources and capacity in the right places
- Market mechanisms will not generate capacity to meet all needs
- Measures to guarantee safe and effective services
- More fine-tuned system of funding care
- Recognition of cost variations for different patients & providers
- Financial safety net
- Information and support
- Targeted measures to address inequalities
Information and Support
- Improved range of information and at the right level of detail
- What services are available? When? How to access?
- Quality of services including waiting times, outcome data
- Relative risks of treatment
- Qualitative data
- Improved quality of information and how it’s presented
- Up to date
- Tailored to needs
- Different formats
- There is more than just the Internet
Measures to address inequalities
- Choice must be offered equally and consistently to all
- Priority based on clinical need
- Positive measures and resources to guide consumers unused to making choices through the process
- Support vital for many people to make and take up choices
- Patient Care Advisers
- Time with GPs and primary care professionals
- Help with travel
- Safeguards for consumers who choose not to choose
- Guidelines to achieve greater consistency in GP referrals
- More positive engagement of GPs & other primary care professionals in the process