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| How much choice do NHS patients really have? | How much choice do NHS patients really have? |
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| The days of “doctor knows best” when patients had to accept, unquestioningly, the decisions health professionals made for them are long gone. These days, the emphasis is on helping patients make informed decisions. But how much choice do patients really have? | The days of “doctor knows best” when patients had to accept, unquestioningly, the decisions health professionals made for them are long gone. These days, the emphasis is on helping patients make informed decisions. But how much choice do patients really have? |
| The idea of patient choice has started to gain traction in the past two decades, with the gradual introduction of options relating to place and time of appointments: one notable milestone was the launch in 2006 of the Choose and Book electronic appointment system, which enabled patients to make outpatient appointments by phone or over the internet. This was replaced by the NHS e-referral service in 2015. Reorganisation of the NHS extended patient choice further (pdf), to the extent of giving patients the ability to choose a GP anywhere in the country. | The idea of patient choice has started to gain traction in the past two decades, with the gradual introduction of options relating to place and time of appointments: one notable milestone was the launch in 2006 of the Choose and Book electronic appointment system, which enabled patients to make outpatient appointments by phone or over the internet. This was replaced by the NHS e-referral service in 2015. Reorganisation of the NHS extended patient choice further (pdf), to the extent of giving patients the ability to choose a GP anywhere in the country. |
| Provider choice is now well established. GPs have access to waiting times for outpatient appointments at different hospitals (including private ones) and a directory of services that enable them to show patients the options available. Julie Wood, chief executive of NHS Clinical Commissioners, says: “If we’re looking at episodic care, where you need to be referred to go and see a consultant, then patient choice is relatively easy to secure.” | Provider choice is now well established. GPs have access to waiting times for outpatient appointments at different hospitals (including private ones) and a directory of services that enable them to show patients the options available. Julie Wood, chief executive of NHS Clinical Commissioners, says: “If we’re looking at episodic care, where you need to be referred to go and see a consultant, then patient choice is relatively easy to secure.” |
| It’s usually a relatively easy choice for the patient too, says Stuart Sutton, a GP and member of Newham clinical commissioning group, who has found that what patients want is “a balance between something that’s local and the time they’re going to have to wait”. The other factor that comes into play, he says, is if a patient with complex needs wants to be treated by a particular specialist. | It’s usually a relatively easy choice for the patient too, says Stuart Sutton, a GP and member of Newham clinical commissioning group, who has found that what patients want is “a balance between something that’s local and the time they’re going to have to wait”. The other factor that comes into play, he says, is if a patient with complex needs wants to be treated by a particular specialist. |
| Even so, provider choice has limited value. Outside the big cities, there may be only one local hospital and, in practice, less than 40% of patients were offered a choice of hospital by their GP, according to a 2014 survey. And not all patients are aware of the choices available to them, though NHS England is undertaking a programme of work to make sure that patients are given information about NHS services in a format that is easy to understand and use. | Even so, provider choice has limited value. Outside the big cities, there may be only one local hospital and, in practice, less than 40% of patients were offered a choice of hospital by their GP, according to a 2014 survey. And not all patients are aware of the choices available to them, though NHS England is undertaking a programme of work to make sure that patients are given information about NHS services in a format that is easy to understand and use. |
| There are harder questions to be asked about choice, however. Charlotte Augst, partnerships manager at the Richmond Group of Charities, argues that the model needs to extended to offer patients more control over their own care so that they can be “partners in decisions about the best treatment they want and how they want to live their lives with the conditions they now have”. She cites as an example the fact that 73% of people with cancer would prefer to die at home but less than a third are able to do so. The reason in most cases is because of the lack of resources: “There is no 24-hour community nursing, no nurse who can visit and make sure you’re pain-free, that your breathing’s OK.” | There are harder questions to be asked about choice, however. Charlotte Augst, partnerships manager at the Richmond Group of Charities, argues that the model needs to extended to offer patients more control over their own care so that they can be “partners in decisions about the best treatment they want and how they want to live their lives with the conditions they now have”. She cites as an example the fact that 73% of people with cancer would prefer to die at home but less than a third are able to do so. The reason in most cases is because of the lack of resources: “There is no 24-hour community nursing, no nurse who can visit and make sure you’re pain-free, that your breathing’s OK.” |
| About £7 out of every £10 spent on health and social care is spent on people with long-term conditions, Augst points out, yet research suggests that many feel they lack choice: 50% of patients who had experienced a mini-stroke received little or no information about how they could prevent another one, while 60% of diabetes patients said they had not discussed their personal needs with a health professional. | About £7 out of every £10 spent on health and social care is spent on people with long-term conditions, Augst points out, yet research suggests that many feel they lack choice: 50% of patients who had experienced a mini-stroke received little or no information about how they could prevent another one, while 60% of diabetes patients said they had not discussed their personal needs with a health professional. |
| Providing choice for patients who receive their care in the community is challenging for commissioners. When procedures are not dependent on other areas of the healthcare system, offering patient choice is quite straightforward, says Sutton. But when co-dependencies exist, it’s much harder. There is a tension, says Sutton, between the Five Year Forward View’s push towards breaking down the silos between primary, community and acute care, with “an integrated provider covering all the different parts of the patient journey or a patient’s pathway” and enabling patients to choose to go anywhere they like for care. | Providing choice for patients who receive their care in the community is challenging for commissioners. When procedures are not dependent on other areas of the healthcare system, offering patient choice is quite straightforward, says Sutton. But when co-dependencies exist, it’s much harder. There is a tension, says Sutton, between the Five Year Forward View’s push towards breaking down the silos between primary, community and acute care, with “an integrated provider covering all the different parts of the patient journey or a patient’s pathway” and enabling patients to choose to go anywhere they like for care. |
| Mental health patients are particularly vulnerable, but one Mental Health Taskforce report found that while mental health patients wanted to have more control over their own care, in practice “health professionals did not systematically listen to them or take their concerns seriously”. Naomi Good, regional development and research manager for the National Survivor User Network for mental health, argues that community-based options, such as support groups, that could boost people’s mental health, have often been cut back in favour of medication: “That bill can be a lot higher for those kinds of medicines, and yet people are being prescribed medication that can cut your life short and have severe physical consequences.” This kind of shift can, she argues, lead to increased isolation and a decline in mental wellness. | Mental health patients are particularly vulnerable, but one Mental Health Taskforce report found that while mental health patients wanted to have more control over their own care, in practice “health professionals did not systematically listen to them or take their concerns seriously”. Naomi Good, regional development and research manager for the National Survivor User Network for mental health, argues that community-based options, such as support groups, that could boost people’s mental health, have often been cut back in favour of medication: “That bill can be a lot higher for those kinds of medicines, and yet people are being prescribed medication that can cut your life short and have severe physical consequences.” This kind of shift can, she argues, lead to increased isolation and a decline in mental wellness. |
| One innovation that does provide grounds for optimism is that of personal health budgets, rolled out in some areas of England in 2015. Aimed initially at people with long-term health conditions, they enable patients to work with health professionals to choose their own care from a variety of options – not just medicines, but equipment or activities. Pilots in 2008 and 2009 had a positive impact on patients’ quality of life. | One innovation that does provide grounds for optimism is that of personal health budgets, rolled out in some areas of England in 2015. Aimed initially at people with long-term health conditions, they enable patients to work with health professionals to choose their own care from a variety of options – not just medicines, but equipment or activities. Pilots in 2008 and 2009 had a positive impact on patients’ quality of life. |
| A similar scheme could be set up for pregnant women after a national maternity review recommended that women should each have a personal maternity care budget to be spent on the NHS care they choose – whether they give birth in a midwife-run unit, a hospital or at home. | A similar scheme could be set up for pregnant women after a national maternity review recommended that women should each have a personal maternity care budget to be spent on the NHS care they choose – whether they give birth in a midwife-run unit, a hospital or at home. |
| Sarah Hutchinson, policy adviser at National Voices, welcomes personal health budgets as a way of helping patients discuss their particular needs with their caregivers. She explains: “Instead of coming in monthly for blood pressure checks, it might be going and doing some exercise classes or starting a walking group or something that helps you manage in a way that is less invasive but still gets you to the same point you need to be in a way that makes life a bit more fulfilling.” | Sarah Hutchinson, policy adviser at National Voices, welcomes personal health budgets as a way of helping patients discuss their particular needs with their caregivers. She explains: “Instead of coming in monthly for blood pressure checks, it might be going and doing some exercise classes or starting a walking group or something that helps you manage in a way that is less invasive but still gets you to the same point you need to be in a way that makes life a bit more fulfilling.” |
| Although the NHS is beginning to recognise the importance of giving patients a say in their care, there is still a long way to go. As Augst says: “It should be about making them partners in decisions about the treatment they want, and how they want to live their lives with the conditions they have.” | Although the NHS is beginning to recognise the importance of giving patients a say in their care, there is still a long way to go. As Augst says: “It should be about making them partners in decisions about the treatment they want, and how they want to live their lives with the conditions they have.” |
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