Dr. Ian Greener Senior Lecturer in Public Policy and Management Manchester Business School

Introduction

One of the central elements of the government’s present reform programme is based around extending patient choice. But what do we know about what kind of decisions patients wish to make and how they are meant to make them? This paper examines these questions along with others to present recent academic scholarship in this important new area. It suggests that whereas patients might wish a greater say over when they are treated, they may neither want nor be able to make choices about where they are treated.

Summary

Patient choice is an area where considerable reform is taking place within the NHS. It makes sense to consider a series of questions asking who is meant to make choices as a result of the reforms, what kind of choices they are, and how they are meant to be made. It seems that each of these questions presents considerable difficulties for the reforms as we cannot assume they can be answered as straightforwardly as they can in other public services where choice has been widened. Patients may want greater choice over when they are treated, but not necessarily over where

Choice?

A commonsense approach to the consideration of choice suggests a number of inter-related questions we must ask of policies based around extending it. First, who is meant to be making the choices? Second, what choices is it they are meant to be making? Third, how are they meant to be making them? For a policy of increasing patient choice to successfully work it must have clear answers to each of these questions. Is this the case?

Who is meant to be choosing?

The answer to this question is not as straightforward as it might first appear. Surely a policy of patient choice is about getting patients to make decisions? There is certainly an element of truth in this, but this is far from a complete answer. This is because even in the field of health economics, several of whose members are amongst the strongest advocates of extending patient choice, there is a general acceptance that choices in healthcare are typically subject to the principle-agent problem 1. This is an acceptance that the specialist nature of healthcare decision-making means that patients (the principles) often have to rely upon medical experts (the agents) to make decisions on their behalf. As such, patients can hardly be expected to make choices alone. In the London patient choice pilot ‘patient choice advisors’ were specifically put in place to attempt to deal with this problem 2, but the finding of the pilot appear rather unrepresentative of the policy as implemented in the rest of the country because it is unclear whether GP surgeries, already hard-pressed because of the introduction of practice-based commissioning, would wish to take on the additional expense of appointing choice advisors 3. Even if this were the case, the logistics of moving patients between doctors and choice advisors are less than clear, and surely a potential source of patient dissatisfaction where it involves further waiting.

Instead, it would seem that the patient choice policy is about increasing the participation of patients in decision-making rather than directly giving them choices, and so the problem is about what support they need to make their decisions and from whom. Both of these are questions to which I will return below.

What choices are patients meant to be making?

Under the choose-and-book system, patients who require referrals will be given a selection of up to four possible providers for their care, and be asked to make a choice between them. Patients, then, are being given a choice of when they would like to be treated, and where. However, it is less than clear that they actually want this full range of choices 4. It seems relatively uncontentious to assume that patients would like a greater say about when they are treated. This is the aspect of choice most frequently cited as providing evidence for the choice agenda in government publications 5. Even this question, however, has considerable implications for the resourcing and delivery of care as it would probably result in already over-stretched NHS facilities having to be open to receive patients at both evenings and weekends.

The where question is even more difficult to resolve. This is because of what sociologists call the ’embedded’ nature of healthcare 6. Healthcare exists in a specific social context in which any referral which involves staying away from home is likely to lead to patients wanting visitors, and this means they will tend to prefer locations which are close to home. Equally, patients without their own transport may exert a strong preference for care providers near public transport links (a factor very prevalent in already existing patient choice leaflets 7). What all of this means is that the healthcare decision is also a social one, based not just on which provider is rationally the best to treat my clinical symptoms, but also the one that fits in with my personal background and requirements for visiting and transport.

An additional complicating factor appears to come from research that examines prospective choice versus what we might term concurrent choice. Work in the US by Barry Schwarz 8 shows that, when asked prospectively if they would like a choice were they to be diagnose with cancer, the majority of patients answer that they would. However, upon actually being diagnosed, the percentages reverse and only a relatively small group still wish to choose. This is because healthcare is not an abstract, cold decision, but often an emotional one we ask patients to make at moments of their lives when they may be feeling less than well. As such, assuming that patients always want to make choices is not always a good starting for policy to make in this area.

In sum, even if we wish to make a choice as to where we go for care, our decision may be rather less about the care we expect to receive, and more about factors not really related to it at all. This becomes even clearer when we consider how patient choices are meant to be made.

How are patient choice decisions meant to be made?

The crux of the problem is, given a choice, how is a patient meant to choose between the possible providers of care? Reading the speeches of successful Secretaries of State, the answer most frequently given is that patients will read the relevant information and make their choice based upon it 9. However, this again, is an over-simplification. This is because studies of decision making processes suggest that choice is only one part of how we make decisions, we also need a framework for understanding how that choice is meant to be made 10 and for that framework to then structure the information into a form that allows us to understand what is relevant and what not, before we can then choose between the alternatives 11. In other areas of welfare reform the choices before particular groups can be argued to meet these criteria.

When choosing a primary school for example, parents can inspect league tables, go on school visits, read OFSTED reports and then work out from all that information the factors relevant to them, as they have some notion of what the notion of a good school means to them, and then make their choice. Assuming places are available at the school, the process is what cognitive scientists would call programmable, an answer can be reached through a rational process. In healthcare, however, this may not be the case 12. This is because the information we have is often about hospital performance as a whole, and the specific area of treatment we are to be receiving may not be at all represented by it 13. Equally, school information gives data on what the average expected achievement for a student might be, but hospital information gives us no such clues as to what we, as individuals, are likely to experience. We cannot really visit the ward or clinic first, and inspection reports may tell us nothing relevant to the decision before us. Finally, the treatment we might expect to receive might well be a one-off or infrequent experience, whereas if we get our school choice wrong there is always the option of taking a child out of that school and sending them somewhere else.

As such, health decisions are not only more complex than decisions in other areas of welfare, but also tend to have less available relevant information available about them. This means that patients may tend to make decisions on non-clinical factors instead, such as the availability of car parking spaces or public transport links; both factors are surely relevant, but neither of which are particularly designed to improve patient care, which is surely the goal of this reform.

Conclusion

In all then, it appears that patient choice reforms have a number of difficulties. Can the policy be retrieved? We have already noted above that it is relatively uncontentious that patients would like greater say over when they are treated. Making strides in this area will certainly cause pain for already over-worked doctors, but would be an inevitable consequence of recognising the need for greater patient choice. However, it makes sense to question whether choices of where patients might wish to be treated are really necessary, or even whether patients want to make them, when the view often expressed in research is that, above else, what they would really like is good local services they can access within a reasonable period of time 14.

References

1. Mooney G. Economics, Medicine and Healthcare. London: FT Prentice Hall, 2003.

2. Coulter A, le Maistre N, Henderson L. Patients’ experience of choosing where to undergo surgical treatment: Evaluation of London Patient Choice Scheme. Oxford: Picker Institute, 2005.

3. Greener I, Mannion R. What can the evidence from GP Fundholding tell us about the prospects for Practice-Based Commissioning? British Medical Journal 2006, forthcoming.

4. Fotaki M, Boyd A, Smith L, McDonald R, Roland M, Sheaff R, et al. Patient Choice and the Organization and Delivery of Health Services: Scoping Review. London: NCCSDO, 2005.

5. Secretary of State for Health. The NHS Plan: A Plan for Investment, A Plan for Reform. London: HMSO, 2000.

6. Granovetter M. Economic Action and Social Structure: The Problem of Embeddedness. American Journal of Sociology 1985;91(3):481-510.

7. Easington Primary Care Trust. Choosing your hospital. Peterlee: Easington Primary Care Trust, 2006.

8. Schwartz B. The Paradox of Choice: Why Less is More. New York: Harper Collins, 2004.

9. Reid J. Managing new realities – integrating the care landscape. Speech given on 11th March 2004.

10. Callon M. Introduction: the embeddedness of economic markets in economies. In: Callon M, editor. The Laws of the Markets. Oxford: Blackwell, 1998:1-57.

11. Simon H. New Science of Management Decision. New York: Harper and Row, 1960.

12. Greener I. Agency, social theory and social policy. Critical Social Policy 2002;22(73):688-706.

13. Greener I. Performance in the NHS: insistence of measurement and confusion of content. Public Performance and Management Review 2003;26(3):237-250.

14. Clarke J, Smith N, Vidler E. The Indeterminacy of Choice: Political, Policy and Organisational Implications. Social Policy and Society 2006;5(3):327-336.

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