Do patients want a choice and does it work?BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c4989 (Published 14 October 2010) Cite this as: BMJ 2010;341:c4989
- Angela Coulter, director of global initiatives
- Accepted 25 July 2010
“Nothing about me without me” was the guiding principle adopted by 64 participants from 29 countries at a 1998 Salzburg global seminar convened to develop ideas for improving the quality of health care by involving patients.1 The catchphrase has now resurfaced in the coalition government’s new plan for the NHS in England, which sees patient choice and shared decision making as key mechanisms to create a patient centred and quality focused NHS.2 The government wants to extend the offer of choice beyond what is currently available to include choice of specialist team, choice of general practice, and choice of treatment.
The introduction of choice and market competition into the NHS has been highly controversial. The debate about provider choice centres on its effect on quality, service development, equity, and patient empowerment (table⇓). Many people have argued passionately for and against the policy on the basis of their expectations of its effects, but research evidence to confirm or refute these assumptions is only now beginning to emerge.
In contrast, evidence about the effects of engaging patients in treatment choices has accumulated over some time, but the findings have been largely ignored. Although only a small minority of people want to switch providers, patient surveys show a large unmet demand for greater involvement in treatment decisions that has persisted over the past eight years (figure⇓). The government’s determination to introduce wider choice and shared decision making may be challenging to implement.
Choice of specialist
The right to choose where to receive specialist care is not a new idea for patients in England. After several pilot projects, choice at the point of referral was introduced from December 2005. Patients could choose where they were referred to, rather than an individual specialist, and a website, NHS Choices (www.nhs.uk), was set up to publish information on quality indicators to inform people’s choices. In 2008 the available choices were extended to include any hospital in the country, including private hospitals, and a legal right to choose was enshrined in the NHS constitution.3 The latest white paper promises that this will be extended to enable patients to choose the specialist clinical team that will provide their treatment.2
Pilot studies of patients offered a choice while on the waiting list for elective surgery showed that a choice of treatment location was popular and uptake was high. When patients waiting for cardiac surgery were offered the choice of going to another hospital with a shorter waiting list, half of them opted to do so, sometimes travelling long distances.4 Similarly, a high proportion (67%) of patients in London awaiting various elective surgical procedures opted for alternatives to their local hospital when given the choice, and there was no evidence of socioeconomic differences in uptake.5 One of the most startling findings from the London patient choice pilot study was that over two thirds (68%) of those eligible for the scheme were not offered the option of going to an alternative hospital, pointing to a reluctance on the part of clinicians or managers to encourage choice.
But government policy changed before the results of the pilot projects were published, and the hospital choice scheme that was rolled out in England differed from the pilot in many ways, not least in the much more limited availability of personal support and free transport and the fact that choice was to be offered to everyone at the point of referral, not to those already on the waiting list for elective surgery. Prices were fixed through the payment by results tariff system, and providers were expected to compete for patients by offering improved quality. This assumed that both general practitioners and patients would scan data on performance before making their referral decisions.
Regular surveys have monitored the scheme since its launch, and these show that patients’ awareness of the right to choose and general practitioners’ willingness to offer a choice have been slow to grow.6 Four years after the scheme was supposed to have been implemented nationally, only half of eligible patients were aware that they could choose a provider and less than half of those referred said they had been offered a choice. Recent evidence confirms the impression that most patients are keen on having a choice, even if they choose to remain at their local hospital, but many general practitioners remain ambivalent or antagonistic to the idea.7
The offer of choice seems to have intrinsic value to patients, even if they do not intend to switch providers. This is true for a majority of people in all social stratums, with older people, people with low educational qualifications, and those of mixed or non-white ethnic backgrounds being especially likely to value choice. Despite a widespread view among general practitioners and hospital managers that choice is relevant only in urban centres, a King’s Fund study found that patients living in rural areas were both more likely to be offered a choice and more likely to choose to travel to a non-local provider.7
In theory, choice should drive quality improvements if providers have a financial incentive to attract patients and patients make use of reliable performance data to inform their decisions. The government in England has promised “an NHS information revolution,” with the publication of more detailed information on patients’ experience, health outcomes, and safety indicators.2 In practice, most patients have tended to rely on informal information sources, such as the opinion of their general practitioner, family, and friends or their own experience, with fewer than 1 in 10 looking at officially published data on quality and performance. General practitioners also seem to prefer informal sources, with many indicating a distrust of official performance figures.7
Even in the United States, where choice and competition have been integral to health care for many years, there is little evidence that patients’ choices are influenced by published performance data.8 Nor is it evident that patient choice itself drives up quality standards, although the perception of competition between hospitals does seem to have had an effect.9 This finding was reinforced by three recent studies of the effect of the NHS reforms.10 11 12 These suggested that certain hospitals in areas where competition is more intense may have succeeded in attracting more patients, reducing preoperative lengths of stay, and reducing mortality, although the mechanisms by which the changes were achieved, and indeed whether there is any causative link between these indicators, remains unclear.
The likely additional effect of allowing patients to choose between consultant led clinical teams is hard to gauge, although it will probably be popular with patients. The government wants other medical specialties to follow the lead set by cardiac surgeons and publish data on outcomes for individual named consultants. Each consultant surgeon’s survival rate for heart surgery is currently publicly available on the Care Quality Commission’s website (http://heartsurgery.cqc.org.uk/Survival.aspx).13 Publication of these data seems to have led to improved performance with no evidence that surgeons are being more selective about whom they treat.14 However, it seems likely that the effect of publication on clinical teams, rather than use of the data by patients, has driven the improvements. Since most patients don’t seem to use the information to shop around, it is unlikely that the improvements resulted from financial incentives. Professional pride and managerial targets may be the key, stimulated by a desire to maintain parity with benchmarks of best practice.
Choice of general practice
In March 2010 the Labour government launched a public consultation on extending choice in primary care by removing practice boundaries, with an intention to implement this nationally by April 2011.15 The coalition government has signalled its intention to proceed with these plans.2
NHS patients currently have the right to apply to register with a general practice of their choice, but practices can use their discretion about whether to accept a request. Refusals are usually because the patient lives outside the practice’s boundary area or because the practice has reached full capacity. In the new system the practice boundaries will be swept away, allowing patients to register with any practice of their choosing. Some people may want to register with practices near where they work, and some may want to join the lists of more than one practice, but since most patients value continuity and surveys suggest high levels of satisfaction with general practice care, it seems unlikely that many will want to switch.
For some years the Department of Health in England has been encouraging greater diversity and choice in primary care, but the effect of this on quality remains unclear. There are anecdotal accounts of service developments, including increased capacity in “under-doctored” areas, extended opening hours, new forms of provider such as general practitioner led companies and social enterprises, and innovative services such as polyclinics and clinics for specific disadvantaged groups—for example, travellers and homeless people.16 But it is not clear whether these developments can be reliably attributed to patients exercising choice or to other policy initiatives in play at the same time.
Choice of treatment
Although many people say they would like to be able to choose who to consult or where and when to be treated, provider choice is not at the top of most patients’ priorities.17 18 Most place greater value on involvement in choosing their treatment or care package. The government’s new commitment to shared decision making tackles this directly. Much more is known about the likely effect of this type of choice on patients’ experience and outcomes than about choice of provider because it has been extensively researched.
Shared decision making is a process in which patients are encouraged to participate in selecting appropriate treatments or management options. Not being properly informed about their illness and the options for treatment are the most common causes of patient dissatisfaction.19 Shared decision making is appropriate whenever there is more than one reasonable course of action and no single option is self evidently best for everyone. This situation is common because there are often different ways to treat a health problem, each of which may lead to different outcomes. These are known as “preference sensitive” decisions.20 In these cases, it is argued, the patient’s attitude to the likely benefits and risks should be a key factor in the decision.
The white paper promises patients access to decision aids to support informed choice of treatment.2 Use of evidence based decision aids has been shown to lead to improvements in patients’ knowledge, better understanding of treatment options, more accurate perception of risks, and reduced demand for elective procedures.21 The idea of shared decision making attracts broad support from patients, professionals, and policy makers, but UK patients rarely get effective support to make decisions.22 Clinicians have been slow to respond to the evidence that most patients want to participate in decisions about their care, citing concerns about time constraints and doubts about its relevance to their patients.23 The policy implies a challenge to entrenched attitudes and the need for big change in practice styles.
Choice has intrinsic value to patients. Most like the idea that they should be offered a choice of provider and, in particular, a choice of treatment. The evidence suggests that both can be beneficial, although there are risks. There are reasons to be concerned about the increasing complexity and fragmentation of healthcare delivery and the potential costs of providing greater diversity and choice. Nevertheless, the genie is out of the bottle and the expectation of choice will not go away. The task now is to develop effective means of engaging patients in healthcare decisions and of monitoring the outcomes.
Importantly, the availability of choice depends on the willingness of clinicians to offer it. They must ensure that patients understand the options and their likely consequences by pointing them to reliable information sources, eliciting their preferences, and facilitating their decisions. The evidence reviewed here suggests a reluctance on the part of general practitioners to play this supporting role, coupled with a gulf between what patients say they want and what general practitioners believe they want. This is worrying because the government’s plans assume that general practitioners understand patients’ preferences and will commission services accordingly. Implementation of the plans for extending choice will be a major test of the effectiveness of general practitioner led commissioning.
Cite this as: BMJ 2010;341:c4989
Competing interests: The author has completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from her) and declare no support from any organisation for the submitted work; she receives payment from the Foundation for Informed Medical Decision Making, a not-for-profit organisation that promotes patient involvement in treatment decisions; and no other relationships or activities that could appear to have influenced the submitted work.
An international Salzburg global seminar entitled “The greatest untapped resource in healthcare? informing and involving patients in decisions about their medical care” will take place on 12-17 December 2010, in Leopold Schloss, Salzburg, Austria. For more information see http://www.salzburgglobal.org/.
Provenance and peer review: Not commissioned; externally peer reviewed.