Patient choice in the NHS

In the run up to the next general election greater choice for patients over where to be treated is emerging as the big political idea. Ironically, while choice is being promoted in health care, there seems to be very little to choose between the two main political parties on this aspect of health policy. Last week the secretary of state for health, John Reid, announced an expansion of the Labour government's choice programme—and his Conservative opposite number, Andrew Lansley, did the same.¹,² However, look closely and some differences start to emerge. But will the power to choose really improve health outcomes for all?

By 2008, the government says that every patient who needs to be referred by their general practitioner (such gatekeeping is to be retained) for a specialist outpatient consultation will have the choice of any NHS or private provider, or any one of the new treatment centres that are often run as public-private enterprises.³ The Conservatives' choice policy is remarkably similar. The difference emerges over how patients' choices are to be funded and, in particular, how private providers are to be paid for treating NHS patients.

The government has said that private providers treating NHS patients will be paid the same fees as NHS hospitals—based on a “money following patient” system of fixed national tariffs.⁴ Such a payment system effectively challenges the private sector to reduce its costs if it wants to do business with the NHS.

But the Conservatives are offering to pay private hospitals half the national tariff, with patients picking up the rest of the private fee. This reduces the price to patients and may prove attractive for many people who have not previously been able to afford private care. But it will also provide a (partially) free ride for those who would use private care anyway—an estimated cost to the Exchequer of around £1.2bn⁵ and equivalent to treating around one million inpatients in the NHS. Of course, the offer will not benefit people who cannot afford the difference between the subsidy and the full fee. Nor will it provide an incentive to the private sector to reduce its costs. At the extreme it could simply encourage price rises, up to the point where the subsidy is absorbed by private providers.

Such differences aside, how either version of patient choice is to work in practice remains hazy. Choosing your outpatient department is not necessarily the same as choosing your inpatient care, for example. Whether patients are to get a further opportunity to choose once they know they need to be admitted is not clear. It is also unclear how patients (and their general practitioners) will decide on their hospital. Waiting times were the only criterion in choice pilots such as the London Patients Choice Project.⁶ But as waiting times decrease (and given both parties' pledge for a maximum wait of 18 weeks from referral to admission), other factors will increasingly loom large—not least the quality of care. But where is the information patients need to judge quality?

Uncertainties exist too about how powerful an incentive mechanism patient choice is to be allowed to be.⁷ Will hospitals that lose patients beyond some critical point be allowed to go to the wall? How will we know whether those patients who choose not to choose are not doing so because they are, for example, unhappy about travelling? How is equality of opportunity of choice to be ensured or defined? And how are popular hospitals to ration their services given short term restrictions on capacity?

Choice is largely instrumental—a means to the end of good quality care. But to what extent can choice really lever up quality? For both parties money following patients should, in theory, prompt providers of acute care to improve the quality of service. For the Conservatives, this will be the major force for improving performance, and targets will no longer be needed. Put simply, free the hospitals and give the public choice and the market will do the rest. But Labour are less sanguine about such market mechanisms and will continue to rely on other ways to improve performance such as central standards and targets, continued investment (funds and staff in particular), more effective regulation, and a different mix of incentives.¹,⁸

Overall, much of the debate and the political rhetoric about choice has been narrowly focused; couched in terms of competition or the threat of competition (contestability), markets (of a sort), and supply side incentives.⁸ What is missing is a broader view of choice⁹,¹⁰: to most NHS patients, choice of hospital is not always relevant—for example, those with chronic conditions¹¹ or needing acute emergency care or those who cannot travel far. Choice also needs to encompass ideas of patient empowerment and a more collaborative approach between patients and professionals when it comes to making often difficult clinical decisions.