Published in Tribune 7 July 2006

Increasing patient choice in the health service must not mean increasing healthcare inequality, writes Suresh Pushpananthan

The NHS has undergone a huge amount of change under our Labour government. Despite the controversial nature of many recent reforms there is no denying that some, such as centrally-issued directives coupled with strong arm performance management, have been highly effective in decreasing waiting times and improving hospital facilities.

The most recent clutch of reforms have focused on introducing market-style incentives to encourage improvement. Competition (or contestability), regulation and commissioning have all been relied upon to improve performance. The government is facilitating this development through the choice agenda that is currently being rolled out for patients across England. These changes are underpinned by a new system – essentially a cost per case mechanism – of financial flows around the NHS. Patients are now being offered a referral to a specialist in at least four centres and any of the 32 foundation trusts and some independent treatment centres across the country. These choices are intended to enhance the patient experience and to ensure that the NHS is more responsive to the individual needs of the patient.

The introduction of choice, in particular the system of Choose and Book, has been widely criticised as being likely to introduce greater inequality into the healthcare arena. The most disadvantaged members of society are potentially prevented from making informed healthcare choices by lack of information, knowledge, language problems and inadequate access to transport. The risk of not getting this policy right is that the middle classes, who are already able to successfully manipulate systems in education and other areas of healthcare, will gain greater leverage from the introduction of increased choice within the NHS.

Choice should be about more than just introducing greater competition into the NHS – although this is undeniably one of the government’s key aims. Choice should also aim to enrich the patient experience, especially for those who rely upon the NHS the most. The Black Report identified the greatest users of healthcare as the poor and disadvantaged more than 25 years ago, and sadly this situation remains unchanged today. An important component of narrowing health inequalities has to be improving the way people interface with public services. Choice should be a tool to combat the corrosive nature of inequality in a decent and civilised society.

Choice in public services has always proven to be popular among many of the most economically deprived groups in society. This has been proven in the USA and in Canada amongst others. In the UK, the only real healthcare choices that existed previously were for the wealthiest members of society, who were able to choose to pay for private healthcare. With the introduction of Choose and Book, patients are now able to choose between four or five centres including from the private sector to have their elective treatment.

There are, however, many problems with the current choice agenda which risk exaggerating inequalities in health. Part of this is the flawed Choose and Book system itself – the flagship of the NHS choice agenda. The system is already unpopular with general practitioners, due to the length of time taken to navigate the online software. The expensive software that underpins the Choose and Book system also limits the potential for real choice. For example, when GPs traverse the online software, the hospitals and consultants with the longest waiting lists do not flash up on the screen as an available option. The software programme currently chooses four or five centres with the shortest waiting lists to offer the patient as a choice. Quality of care is not a parameter in the software programme’s protocol. This offers the patient little more than a sham choice.

Many of the best specialists have the longest waiting lists. However, those that know how to ‘work’ the system still manage to get on the waiting lists of the very best specialists. There should be a mechanism to ensure that those less able to navigate the complex medical systems have the ability to be treated by the very best doctors. One of the unique achievements of the NHS, compared to nearly all other countries, is that every person has access, if needed, to the very best specialists based on need and regardless of ability to pay. This is a crucial element of the fairness upon which the NHS was formed and it must be preserved.

Patients also need more than just a waiting time estimate and a global star rating in order to make an appropriate choice. Many NHS Trusts are huge organisations with large and varied hospitals, departments and specialities. A global star rating for a Trust may not represent an under-performing orthopaedic surgery department, or may not do justice to an exemplary cardiology service. Choice in the NHS is currently about waiting times, geographic location and global star ratings rather than league tables and the performance of individual specialists.

The most valuable choices that any patient can make are not between distant hospitals, but by being directly involved in the decision making process with their GP. A good doctor/patient consultation should involve a joint decision-making process, and an explanation of the situation by a doctor who in reality influences choice through superior medical and technical knowledge. Giving already over-burdened GPs the task of online booking within their 5 minute consultation slot, will only diminish this important role. Real empowerment of patients will be jeopardised by Choose and Book under the current system.

The Choose and Book system risks negating those efforts that are currently being made to tackle health inequalities. The choice agenda has to be monitored, and must be consciously amended to ensure that it works for all sectors of society and all individuals, rather than those who are healthier, wealthier and more demanding.

Suresh Pushpananthan is a specialist registrar neurosurgeon, lecturer in neurosurgery and member of the Central Council of the Socialist Health Association.

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