What has the number of patients treated in non-NHS hospitals got to do with patient choice?

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Patient choice has been a priority for successive governments since 2002. The recently published Operating Framework reinforced the coalition government's intention to extend choice further. However, I was left puzzled by a new indicator of choice based on 'the volume of patients being treated at non-NHS hospitals'.

This indicator is only measuring the growth in the use of private sector providers. While it may capture some patients' preferences, it is certainly not a measure of choice.

Let's take a step back and start with the basic question 'what is patient choice'?

After a series of pilots launched by the previous Labour government, from January 2006 patients requiring referral to a specialist were able to choose between four or five providers, and, from 2008 they could choose any provider in England – both NHS and non-NHS. The main goal was to tackle long waiting times and improve access. Patient choice is also being used to promote shared decision-making – 'the process in which clinicians and patients work together…with the aim of reaching mutual agreement on the best course of action' (Coulter, Making shared decision-making a reality, 2011). This link between choice and the empowerment of patients has been explicitly embraced in the 2012/13 Operating Framework, where choices include treatment, consultant and tests, mental health services, and care for long-term conditions.

Against this background, there are at least three evident drawbacks in using this new measurement as an indicator of choice. The first, and most obvious limitation, is the focus on non-NHS providers. Patients have a choice of a wide range of providers within the NHS as well as between the public and private providers. An active decision to go to an NHS hospital is a valid choice. The indicator is capturing some choices, but not others.

Second, the measure focuses on the choice of where a patient is treated but not what the treatment comprises. The Operating Framework promotes choice of treatment, diagnostic tests, and consultant, but the proposed measure does not provide any account of whether these choices are being offered. Choice is about making an active decision about treatment, and empowering patients to engage in their own care, so a measure of patient movement across the system is superficial and potentially misleading.

The third limitation is the indicator's focus on patient flows. These are just as likely to result from a professional decision to refer as they are from patients making an informed choice. Our recent research on patient choice (Dixon et al, 2010) shows that many patients continue to rely on professionals to make decisions about where they receive treatment.

So, on what basis should the government measure patient choice? A more nuanced approach is needed that recognises the complexity of the dimensions of patient choice. In this respect, the framework adopted in The King's Fund report, How patient choose and how providers respond, might represent a good starting point as it clearly identifies the various dimensions of the choice process. First, there must be awareness and understanding of choice among everyone involved – including patients, GPs providers and commissioners. Second, information must be available, accessible, relevant, and accurate. Third, GPs must offer support and advice, and patients must be genuinely involved in decisions. Finally, choice must be supported  by efficient IT systems.

If the government wants to know whether its objectives on patient choice are being met, it needs to develop a more meaningful approach that relies on multiple source of information to assess these various dimensions of choice. For example it could ask patients whether they have been sufficiently informed and supported to make shared decisions with care providers, and to make choices about their care and treatment options. It seems likely this measure is more about checking whether primary care trusts or GPs are restricting access to the private sector than it is about whether patients are getting the choices they want.


Dr Paul Worthington

Chief Officer,
Cwm Taf CHC
Comment date
19 December 2011
Francesca is wholly correct - the measure in the Operating Framework doesn't by any stretch of the imagination demonstrate the amount of choice. It's a very limited indicator driven by a limited and very unimaginative view of the world. If a large number of patients choose to use NHS services, is that supposed to measure failure ?

The Kings Fund Report provides a much richer and more useful set of possibilities. Similarly, there are already opportunities through effective individual care planning approaches and even personal budget pilots which can demonstrate how patient choice is exercised. These won't necessarily produce big or especially sexy numbers, but they would shift the emphasis away from a solely acute focus and provide potentially more meaningful data.

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