Feature

Diversity, inequality, inefficiency

New ‘patient choice’ proposals suggest that the rush to create a market in the NHS is gathering pace, warns Steve Iliffe

Fearing that ‘the public believe the NHS is no better’ because services are ‘too indifferent’ to the needs of patients, Alan Milburn, the health secretary, has spoken out about the need for ‘patient choice’. He believes that public confidence demands ‘not just a change in structure [in the NHS] but a change in culture too.’

New Labour wants to put this right through a top-down programme of service monitoring and investment, but the pace of change is too slow and there is too much resistance to modernisation.

What the government has learned is that investment ‘cannot be used to ossify the system [but] must be used to change it.’ If this does not happen more citizens will use their rising disposable income to join commercial insurance schemes, enlarging the commercial sector beyond its present seven million members and allowing it to broaden its range of services. The political objective, therefore, is to retain the allegiance of the middle classes.

The aim of the ‘patient choice’ policy is to increase competition between the NHS and the commercial sector, particularly in the affluent south where the commercial sector is strongest and the NHS least flexible. The NHS will retain its virtual monopoly of GP services, maternity care and psychiatric and long-term treatments but challenge the commercial sector in the lucrative area of surgery.

The government wants to avoid the vote-losing situation in which people have to choose between waiting (potentially a long time) for necessary surgery and spending their savings – or their family’s – on a quicker operation in the commercial sector. Typically these operations are for hip and knee joint replacement or cataract extraction, but the menu will grow over a relatively short period of time.

For example, offering choices of where cataract surgery can be done is designed to reduce waiting times to six months by 2004 and three months by 2005. And from mid-2004 all patients waiting for any elective operation will be able to choose at least one, and normally four, alternative hospitals – private or public. By 2005 the choice will be made at referral, not after six months wait. To service this diversity new diagnostic and treatment centres, some run by commercial organisations, will be created to concentrate on non-urgent surgery, with a target of treating 250,000 patients by 2005.

This is a huge, high-risk gamble on the ability of the NHS to change and of the professions to co-operate. The government’s encounter with consultants over their new contract demonstrated that the specialists would forego substantial pay increases to avoid being more managed and more ‘flexible’. We do not yet know if general practitioners will accept a similarly substantial offer in return for co-operation with the planned reforms. But we do know that professionals can sabotage attempts at change, especially when lucrative private practice is under threat.

There is comfort in the successes of NHS walk-in centres in demolishing their commercial rivals, and in the dominance of NHS out-of-hours co-operatives over commercial deputising services, but these are small changes compared with the ‘patient choice’ plans.

It is not clear which agency will act as broker for choice, drawing up the list of alternative hospitals and offering it to the patients awaiting surgery, but it is certain who will not be allowed that role. Giving patients themselves a free choice, rather than a restricted range, would be too destabilising – and the fundholding debacle showed that letting GPs control choices would be similarly burdensome. Presumably primary care trusts would intercept referrals and act as the brokers, checking waiting times, cost and quality like financial advisors assess mortgage offers or stock options. Whether they have the capacity to do this must be doubtful.

Hospital managers are likely to be galvanised by ‘patient choice’, because each operation will attract an NHS fee. In effect, this policy will make all NHS hospitals sub-contractors to the public sector. Many commercial hospitals could take the same role, becoming subject to the same regulatory processes.

The hospital sector would then become a franchised network, using local expertise and knowledge to shape the quality of care, deploying a variety of local, national or even multinational resources to modernise and expand buildings, while trading under the NHS ‘brand’. Commercial hospitals may buy into this franchise because their throughput and cash flow could increase smoothly – and once in the system will find ways to raise their prices.

Opportunity costs are bound to arise as attention, time and resources are focussed on re-engineering surgical services. No prizes for guessing that long-term care, particularly for frail older people, will be the loser, along with the other Cinderella services for mental health and disability.

A policy initiative around expanding social care, increasing the number and accessibility of psychologists or creating a network of rapid-response disability prevention and treatment centres might have enormous benefits for some, but has little political appeal. Nor would it act as a counter-attack on the commercial sector, which as a whole does not offer much outside physiotherapy for sports injures and some limited psychiatric care for the seriously affluent. In fact, the commercial sector may prefer such a policy, which would allow it to concentrate on ‘complementing’ the provisions of the NHS.

The ‘patient choice’ policy has some merit and many associated risks, but perhaps more important it has no competition. If the fundamental argument that ‘public confidence’ in the NHS has to be restored is correct, then Milburn has no rivals to his left, because there is as yet no coherent alternative strategy for the NHS emerging from the trade unions and those who campaign against the private finance initiative and foundation hospitals.

Milburn’s argument may be false, of course, and reflect the ability of a conservative fraction of the population to dominate the political agenda, even if it cannot elect its own party to government office, but this is no consolation. ‘Public confidence’ may be Milburn-speak for the Daily Mail’s opinion, but even so it is still a threat to a public health service.