Support for patient choice but it is not yet driving quality improvements, says new report

A new report published today by The King's Fund shows that having a choice of hospitals is valued by the majority of patients. However, it is not yet operating as intended and has not so far acted as a lever to improve quality and increase competition.

Since April 2008, patients in England have been able to choose treatment from any hospital in a national directory. The new report Patient choice: how patients choose and how providers respond, published jointly with the Picker Institute, RAND Europe and the Office of Health Economics, assesses how patient choice is operating based on research with patients, GPs and hospital providers. The research found that:

  • while 75 per cent of patients want to choose where they are treated, only around half recall being offered a choice by their GPs
  • only 8 per cent of those offered a choice recalled being offered the option of choosing a private provider
  • most patients remain loyal to their local hospital (69 per cent choose to be treated there)
  • previously having a bad experience of their local hospital is a major reason why patients choose to access care from an alternative provider 
  • few patients are making use of performance data to inform their choices - just 4 per cent of patients consulted the NHS Choices website - with most preferring to rely on their own experience or the advice of their GP
  • GPs said they were offering choice routinely but there was rarely a meaningful discussion of the options available.

While GPs broadly supported the idea of patient choice, many who took part in the research underestimated its importance to patients, distrusted comparative performance data and felt unable to advise patients on referrals outside their local area. They also strongly criticised Choose and Book, the electronic system for booking appointments for treatment, which despite technical improvements, GPs found difficult to use.

The report shows that choice is not yet acting as a sufficiently strong lever to improve quality or increase competition, as the policy intended. The main focus of competitive activity among providers is securing GP referrals rather than directly competing for patients, and this really occurs only at the boundaries of their catchment areas. Interviews with providers revealed that in many cases they are choosing to co-operate rather than compete with each other.

The research also debunks commonly held assumptions that only certain groups are interested in patient choice. Patients living in non-urban areas were more likely to be offered a choice and more likely to choose to travel beyond their local provider than those in urban areas. Older patients, those from mixed or non-white backgrounds and those with no qualifications were more likely to think having a choice is important.

However, while there were no apparent inequities among those who were offered a choice, older, more educated patients were more likely to choose a non-local provider. This suggests a potential risk that where local providers are providing poor-quality services, some patients may be 'left behind' while others exercise their right to choose to be treated elsewhere.

Anna Dixon, Director of Policy at The King's Fund and the report's lead author, said:

'Patients clearly value choice, even if in most cases they prefer to stay with their local provider. Choice does appear to be having an indirect effect on quality by motivating providers to maintain their reputation in order to avoid losing patients. But the reluctance to implement choice among GPs and little use of performance data by patients suggests there are still a number of significant challenges that need to be overcome if the policy is to be implemented as policy-makers originally envisaged.

'While it is still early days, we are some way from realising the vision of choice acting as a lever to improve quality, with informed patients choosing the highest performing providers in a competitive market.'

Read the final report: Patient choice: how patients choose and providers respond

Notes to editors: 

  1. For further information or interviews, please contact The King’s Fund media and public affairs office on 020 7307 2585. If you are calling out-of-hours, please ring 07584 146035. An ISDN line is available for interviews on 020 7637 0185.
  2. This research project was funded by the Department of Health and conducted by The King’s Fund in partnership with Picker Institute Europe, RAND Europe and the Office of Health Economics.
  3. The study was conducted in four local health economies in England between August 2008 and September 2009. It combined interviews with patients, GPs and senior executives from hospitals providers (including the private sector) with patient questionnaires.
  4. Patient responses: A postal questionnaire was sent to NHS patients who booked an outpatient appointment in January 2009 at five NHS trusts, six NHS foundation trusts and two independent sector treatment centres across the four case study areas. A total of 5,997 questionnaires were sent out between March and June 2009.The total number of responses was 2181. Nineteen patients who answered the questionnaire were then interviewed about their responses.
  5. Provider interviews: Interviews were conducted with 49 senior staff in participating NHS trusts and independent sector organisations between November 2008 and April 2009.
  6. GP interviews: Interviews were conducted over the telephone with 25 GPs practising in the four case study areas between February and April 2009.
  7. Government policy has been to promote choice as a mechanism for improving the quality and efficiency of the NHS in England. Since April 2008, all patients referred by their GP for a non-urgent hospital appointment have had the choice to be treated at any NHS hospital or registered independent sector provider listed in a national directory of services. Patients have had a choice of at least four providers at the point of referral since January 2006.
  8. The King’s Fund is a charity that seeks to understand how the health system in England can be improved. Using that insight, we help to shape policy, transform services and bring about behaviour change. Our work includes research, analysis, leadership development and service improvement. We also offer a wide range of resources to help everyone working in health to share knowledge, learning and ideas.
  9. Picker Institute Europe is a not-for-profit organisation that makes patients’ views count in health care.  It builds and uses evidence to champion the best possible patient-centred care and works with patients, professionals and policy makers to strive continuously for the highest standards of patient experience.
  10. The Office of Health Economics provides independent research, advisory and consultancy services on policy and economics issues within the pharmaceutical, health care and biotechnology sectors.
  11. RAND Europe is an independent not-for-profit research institute whose mission is to help improve policy and decision making through research and analysis. Our research aims to serve the public interest and is carried out on behalf of European governments and institutions, foundations, academic institutions, professional bodies, charitable organisations and private-sector clients with a need for quality-assured, impartial research and analysis.