Who wants patient choice?

John Appleby, Arturo Alvarez-Rosete

John Appleby and Arturo Alvarez-Rosete say that the latest British Social Attitudes survey reveals some interesting – and perhaps surprising – views about choice in health care.

Publication:  Society Guardian

This is a longer version of an article appearing in Society Guardian on 14 December 2005.

Tony Blair is adamant that the public are keen to have more choice in the NHS - but are they? The latest British Social Attitudes survey reveals some interesting - and perhaps surprising – views about choice in health care.

The survey of 3,200 people, conducted last year and published this week, tells us the characteristics of those who are most enthusiastic about choice. And importantly for a government keen to improve the public’s overall rating of the NHS, the survey also gives us a handle on the relationship between the public’s views about choice and their overall satisfaction with the NHS.

The headline figures appear to support the government’s enthusiasm for choice. They show that around two-thirds of those taking part in the survey thought that patients should have 'a great deal or quite a lot' of choice over which hospital they go to for inpatient treatment and the kind of treatment they receive. Just over half thought that patients should have choice over the date and time of their outpatient appointments

However, relatively few – between 9 per cent and 17 per cent – thought the NHS currently offered much choice in these areas. The key message is that there was a significant gap between what people say they want and what the NHS is currently delivering. This too will suggest to ministers that their choice-driven modernisation policies are on the right track.

Wider discussions about choice have identified concerns that rather than improving equity in the NHS – as the Prime Minister has claimed – choice could widen the access (and health) gap as the healthy and wealthy young, the middle classes and the better educated exploit the opportunities that choice offers.

On this basis, and out of self-interest, we might expect these groups to be more pro-choice than the old, the less wealthy and those with lower educational attainments. But our analysis of the British Social Attitudes BSA survey have produced some counter-intuitive results.

Analysis that isolates the most significant factors in explaining views on choice of hospital shows that the groups who are significantly pro-choice are women, those aged 55 to 64 years, and those with lower or no educational qualifications.

On the other hand, men, the young, the better educated and those without recent experience of inpatient care are significantly less enthusiastic about choice.

What explains these differences? One possible common factor is the propensity to use the NHS: those more in favour of choice (women, the elderly) tend to be heavier users than the less enthusiastic (men, the young). All this, too, would seem to provide some encouragement to current choice policy.

But there is, inevitably, a health warning. As choice of outpatient department rolls out across England next year it could well be that those most in favour of choice in the abstract find their expectations not matched in reality.

Choice may bring benefits, but it will also bring costs - waiting times may increase at popular hospitals and the existence of some hospitals may be threatened for the majority of patients even if only a small number choose alternative hospitals.

And if the government was hoping that greater choice will help improve satisfaction with the NHS overall, it may be disappointed. We found that views about choice had little or no impact on overall satisfaction ratings for the NHS.

Prof. John Appleby is chief economist and Dr Arturo Alvarez is a health policy researcher at the King's Fund. They have written the chapter on health in British Social Attitudes: the 22nd report 'Two terms of New Labour: the public's reaction'. Edited by Park, A, Curtice, J, Thomson, K. Bromley, C, Phillips, M and Johnson, M. Published by Sage on 13 December 2005.

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