Ruth Thorlby King’s Fund Presentation at our conference March 2006

Why introduce more choice in the NHS?

  • Offering choice: a policy objective in its own right
  • Choice as a mechanism for levering up quality
  • Choice as means to make the NHS a more equitable service

What are the equity problems in the NHS?

  • Choice to go private to get faster/better treatment
  • No evidence of bias on decisions to treat within NHS waiting lists
  • Lower intervention rates + higher prevalence amongst poorer groups

Examples of Inequities

  • Unemployed, and individuals with low income and poor educational qualifications use health services less relative to need than the employed, the rich and the better educated.
  • Intervention rates of Coronary Artery Bypass Grafts (CABG) or angiography following heart attack (AMI) were 30% lower in lowest socio-economic groups than the highest.
  • Hip replacements were 20% lower among lower socio-economic groups despite roughly 30% higher need.

(from Julian Le Grand’s LSE lecture)

What choices have been made available in the NHS?

  • Choice of hospital, for elective outpatient appointment, once a GP has decided to refer
  • Not maternity, cancer and selected others
  • Choice of hospital outpatient: designed as a tactic to reduce waiting times

No imminent, realistic choice of GP

Direct payments: social care

How could choice fix these inequities?

  • Current patient choice policy: not designed to make any impact on these inequities
  • Will require investment in advocacy and information to avoid creating a new dimension of inequity
  • Information: to be made aware of choice (equal opportunity to choose)
  • Information: allows creation of appropriate services

Choice theory

  • Movement of patients sends a “signal” to providers to change
  • Patients need information relevant to their needs
  • Providers: need to know why patients are choosing them or choosing to avoid them (market research)

Study of HIV units and choice

People with HIV: can refer themselves to unit of their choice

Money followed patient (roughly)

Five units in London: qualitative interviews

Why did patients move? With what information?

Any effect on providers?


  • Some moved- a minority
  • In search of anonymity, but also better quality care-considerable distances
  • Used internet, written information
  • Word of mouth, especially peer groups and support groups trusted the most
  • No comparable Trust data

Did providers care if patients left?

For a while, amongst senior staff

Focused minds on waiting rooms, politeness of staff, extra services, timing of services

Clinical quality?

Other factors: resources, autonomy, HIV a special case . During the period in question cash for HIV services was plentiful

HIV Allocations by region

The economics of HIV services has changed since the period of the research:

HIV diagnoses and deaths

Choice: the ideal?

“I can remember seven, eight years ago, if a patient transferred to another unit you would get b*llcked from a dizzy height- how dare you, what did you do wrong, why did that patient transfer? I mean all hell broke loose, what were you doing wrong that meant the patient was unhappy? Senior doctor Trust C

Choice: the dream

“There have been times when I’ve had to send my patients to a consultant outside the HIV unit and there have been times when those consultants have been off-hand with my patients. I’ve had to phone them and explain that if I behaved like that with my patients, I wouldn’t have any patients” Consultant Trust E

Choice in HIV: reality

  • Perception: educated (white, gay) men more inclined to move
  • Small units: less evidence of patient movement
  • Two big units: patients travel from all over England
  • Quality? No evidence of difference
  • Differentiation of services

Can more choice mean more equity?

  • Current patient choice policy: limited impact on big inequities
  • Advocacy and information is expensive: where are the incentives?
  • Good quality information: will consumers use it?
  • Skewed investment into “peripherals”?

What do you think?

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