Intended for healthcare professionals


Do patients want a choice and does it work?

BMJ 2010; 341 doi: (Published 14 October 2010) Cite this as: BMJ 2010;341:c4989
  1. Angela Coulter, director of global initiatives
  1. 1Foundation for Informed Medical Decision Making, Boston, MA 02108, USA
  1. acoulter{at}
  • Accepted 25 July 2010

The government in England wants to give patients more choice about their health care. But Angela Coulter argues that treatment choice is more popular with patients than provider choice, with much greater evidence of benefit

“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.

View this table:

Arguments for and against provider choice

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.

Proportion of respondents in NHS inpatient surveys who wanted more involvement in treatment decisions ( …

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