25 July 2003
Need a cataract operation, a hip replacement or a heart by-pass? Don't fancy the interminable wait at your local hospital? Fear not.
Within two years, according to plans announced last week by Health Secretary John Reid, everyone will be offered the choice of at least four hospitals – NHS, private or overseas – when a GP refers them for treatment. Theoretically, patients will be able to choose the one with the shortest waiting list, not to mention the cleanest toilets.
In a speech to the New Health Network, Reid attacked the 'two-tier health service' that allows only the wealthy to queue-jump and exercise choice. Instead, in a move clearly designed to outflank Conservative plans for private health care, he said: 'We will empower patients by giving them individual choices about where, when and by whom they are treated.'
The Patient Choice scheme, due to be rolled out in six-month stages, will eventually be extended from secondary care to primary care and other services, with local primary care trusts picking up the tab.
The proposals and accompanying NHS guidance have been broadly welcomed by health service managers and patient organisations. But a number of tricky questions remain unanswered.
First, how exactly are patients meant to make an informed choice? Most people find it hard to get three minutes of their GP's time, let alone a detailed consultation about which hospital to choose. The government says it intends to recruit an army of 'patient care advisers' to help patients access the necessary information. One of the pilot schemes that have been successfully trialling Patient Choice employed senior nurses for this role.
But as John Appleby, chief economist at the King's Fund and an evaluator for the London pilot, told Public Finance: 'The patients loved them. But they don't come cheap. If all the advisers were recruited in this way we'd use up all the nurses in the country.'
Other, less desirable, options – such as using call-centre staff – are being considered.
Second, it is not at all clear that the information on which patient choice will be based – the hospital star-rating system – is adequate for the purpose. The promotions and demotions in this year's ratings illustrate the problem, says Appleby.
'Star ratings can be a useful management tool, but are a poor guide for patients. Plus, appalling NHS IT systems mean that many health-care professionals don't have the right information to help patients make an informed choice.'
The Liberal Democrat health spokesman, Evan Harris, shares this view. 'Reid's version of patient choice is glib, and based on misinformation. There's not a shred of evidence that star ratings lead to better clinical outcomes,' he said.
Harris adds that, given very limited NHS capacity, patient choice will lead to more, not less, inequality. 'The poor, the elderly, people with limited access to the NHS or unable easily to travel will lose out. Choice for the few will threaten equity for the many.'
This third issue – the role of the market in the NHS – goes to the heart of the patient choice debate. As Trade and Industry Secretary Patricia Hewitt recently reminded her Cabinet colleagues, 'The public services must not be reduced to the language of customer service. You can't deliver health care or education as if you're delivering pizzas.' Yet the Patient Choice plans seem to suggest just that.
The result, given a fixed tariff system where NHS funding increasingly follows the patient, is that some hospitals' income is likely to fall. 'The weaker ones could be "selected" out of the system, even though this runs counter to the Modernisation Agency's role of helping weaker hospitals,' says Appleby.
No-one at the DoH was available for comment, but one insider told Public Finance: 'The department is quite relaxed about letting market forces take their course.'
There are other issues: how will social services and health liaise on aftercare with patients dispersed round the country; how will specialists share complex clinical information; who will pay for patients' and relatives' travel costs?
So far, there are few answers, and it remains unclear whether Patient Choice is a serious proposition or just an attractive political gimmick. In the meantime, anyone for a single hospital room with en suite facilities, and extra topping?
PFjul2003
