Clinical quality matters most to patients but concerns raised over health inequalities, survey reveals

Patients value clinical quality the most when choosing a hospital to be treated at but there are concerns that the government's flagship health reform of offering patients greater choice risks widening health inequalities.

These are the main findings from a joint study by RAND Europe, The King's Fund and City University, which is based on focus groups and a survey of 1,000 people across England with experience of being referred to a hospital for elective treatment in the previous five years.

The study reveals that patients with formal educational qualifications were more likely to choose to be treated at hospitals with higher standards of clinical performance. But patients without formal educational qualifications placed significantly less importance on increases in clinical quality above an 'average' level.

Peter Burge, Senior Analyst at RAND Europe, said:

'Many patients want and value more choice in health services, but this study exposes real differences in the choices that patients with different levels of education are likely to make. It raises uncomfortable questions about how best to provide a health service that promotes equal access to the best performing hospitals for those in equal need.'

Other key findings from the study are:

  • Reductions in waiting times below 10 weeks (from GP referral to treatment if needed) were not valued by respondents and exerted no influence over the choice of hospital.
  • The advice of a family doctor over which hospital to choose was found to be important, but did not override other information, such as that about the performance of hospitals or travel times.
  • Although higher quality hospitals will tend to be chosen more often than others, there are on average diminishing returns to all aspects of a hospital’s performance improvement. In making their choices, patients surveyed attached less importance to successive increases in hospital performance.

Report co-author Professor John Appleby, The King's Fund chief economist, said:

'The fact that clinical quality was the most important factor influencing choice of hospital begs the question of what information patients can use to make their choice. There is a dearth of the sort of quality data that patients say will influence their choices.

'Choice has the potential to better match what patients want with what’s on offer. But this report is also a reminder that we need to be careful to ensure there are safeguards in place to provide people with the information and support they need to take advantage of greater choice.'

The report, Understanding Patients' Choices at the Point of Referral, attempts to provide an understanding of the factors patients are likely to take into account when choosing between hospitals and, in particular, to examine the choices patients make when they are faced with trade-offs between those factors. Examining these choices and trade-offs provides insights into the relative value patients place on particular characteristics of hospitals, such as waiting times, various aspects of hospital quality and performance and proximity to patients' homes.

With some further development this work can also show how patient demand for different hospitals can change as hospital performance changes. Professor Nancy Devlin, City University, joint researcher on the study, said:

'As patient choice rolls out, and with hospital payments following those choices, it will become increasingly vital for hospitals to understand what drives patients' choice of hospital; their income will depend on this sort of market analysis.'

Notes to editors: 

  1. The report, Understanding Patients’ Choices at the Point of Referral, by Peter Burge, Nancy Devlin, John Appleby, Federico Gallo, Edward Nason and Tom Ling, is available to download from the RAND website
  2. This research was commissioned in March 2005 by the Corporate Analytic Team at the Department of Health from a joint research team from RAND Europe, the King’s Fund and City University. The main body of the research employed Discrete Choice Experiments (DCEs) which asked a sample of over 1,000 people across England, with experience of being referred for elective treatment in the previous five years, to respond to a series of hypothetical choice scenarios. The sample were invited to participate in a discrete choice experiment, which asked them to state the choices they would make if they were in the position of being advised by their GP that they needed to be referred for a specialist consultation in a hospital outpatient department. Participants were presented with sets of providers and asked to indicate which they would choose. Respondents were also given the option of seeking treatment outside of the NHS or not taking up their referral. Informing the structure of the DCE questionnaire were two sets of focus groups that took place in Norwich and London.
  3. The King’s Fund is an independent charitable foundation working for better health, especially in London. We carry out research, policy analysis and development activities, working on our own, in partnerships, and through funding. We are a major resource to people working in health and social care, offering leadership development programmes; seminars and workshops; publications; information and library services; and conference and meeting facilities.

    RAND Europe is an independent not-for-profit policy research organisation that serves the public interest by improving policymaking and informing public debate. Our clients are European governments, institutions, and companies with a need for rigorous, impartial, multidisciplinary analysis.

    City University, London, is "The University for the business and the professions". City offers postgraduate programmes in economic evaluation and health economics. The City Health Economics Centre aims to provide innovative and policy relevant health economics research.
  4. For further information or interviews, please contact the King's Fund media and public relations office on 020 7307 2632 or 020 7307 2581; or Peter Burge, lead RAND Europe author, on 01223 353329.