Feature

How will greater ‘consumer choice’ impact on the NHS?

‘Choice and consumer power as the route to social justice not social division’, says the prime minister of the government’s new approach to public services. But how likely is this? healthmatters went in search of reactions

Fiona Campbell

Co-ordinator, Democratic Health Network

It is interesting that we talk of “consumers” rather than citizens. There is a general (and, in my view, unpleasant and divisive) trend to encourage people to think of themselves only as individuals with individual “rights” and “choices”, and not as part of a wider society.

The concept of “choice” is also problematical. At the moment, the only “choice” that is being offered to patients is between waiting over six months to have an operation at their local hospital, or going somewhere else, possibly even overseas, to have it sooner. Is this what we mean by real choice?

I attended a so-called consultation meeting run by the Department of Health on the Choice, Responsiveness and Equity paper, currently in circulation. The ‘consultation’ consisted of asking those present to imagine that they were patients using different services: maternity services, services for people with long-term conditions, etc. We had to say what choices we would like to be able to make. There was no discussion of scarce resources or rationing or the potential effects of “choice” on these. Even more importantly, there was no discussion of the effects of choice on equity and the trade-offs that would be required.

In a situation of scarce resources, where the government is not prepared to increase taxes to improve healthcare, offering choices to some people will inevitably mean restricting choice for others and will lead to greater inequality. We cannot even provide decent local health services in clean and welcoming surroundings, where people are treated with respect. There are enormous imperatives in public health and preventive measures to tackle health inequalities. Why are we talking about extending choice when we know that any real choices going will be exercised by those who least need support? Answer: because those who make policy for our public services can now only think in terms of markets and consumers where choice is a sacred word.

Rosamund Stock

Social psychologist, London School of Economics

What the future holds, with the introduction of ‘consumer choice’ into the NHS, needs to be seen in the context of a whole system. It is not merely a matter of the choice already being offered to people under the Patient Choice initiative, or the availability of private options, it is the fact that the system will encourage individual decisions as the primary organising principle for the health service.

Such a system will create an outlook in which everyone will see their own concerns as more important and -- this is the real crunch -- legitimate. They may not consciously see their own needs as more important than others: too often they simply will not think of others at all. But even when they do, their own welfare and that of their families will simply come to take legitimate priority over the claims of others. Look no further than the school system to see the result: people recognising that the system is unfair, but saying they must do the best for ‘their child’. More than education, such as change in the NHS will have a deeply corrosive effect on our attitudes to the health service and to society as a whole.

Carol Orchard

Public Health Specialist, Hampshire & Isle of Wight Strategic Health Authority

Introducing elements of consumer choice is fine if it’s an attempt to adjust the old-style NHS culture, but as a public health manager I wouldn’t like to see it go too far -- or we are in danger of ending up with consumerist and fragmented health services instead of an integrated system aimed at responding to population needs.

Ron Singer

North London general practitioner, and president of the Medical Practitioners Union

Choice is a beguiling word. My patients in urban Edmonton could chose to buy a Ferrari or private schools if they had the money. They would chose not to wait six months for an outpatient appointment, an operation or a scan. Being offered a choice of three hospitals to wait at - a choice they already have - is no choice at all. If the quality was good in every NHS hospital patients would not need choice, only access.

Soon they will be able to chose North Middlesex or the new treatment centre run by Bloggs plc where local surgeons will have ‘found’ the time to do more operations. It is no surprise that increasing NHS capacity results in shorter waiting times -- for decades we have been saying that the NHS is under-resourced.

Paradoxically, patients have less choice of a GP as practices close their doors to new patients, trying to cope with the ones they already have. GP vacancies are high, particularly in areas of greatest need.

If choice does mean increasing capacity, then unmet need will be revealed and could easily soak up the extra capacity. The NHS will then have ‘failed’, and no doubt the private sector will take over and will have to reduce choice and levels of service to preserve profits.

Peter Crome

Professor of geriatric medicine and honorary consultant geriatrician, North Staffordshire Combined Healthcare NHS Trust

Reflecting on the various changes that have taken place in the NHS, I sometimes wonder whether any one change has made a real difference. I suspect that for my practice in geriatric medicine -- working in memory clinics, a community hospital and a stroke ward -- there will not be much change.

Jill Manthorpe

Social Care Workforce Research Unit, King’s College London

Social care is an area where ‘choice’ has been a major policy aim for over a decade, for politicians of all parties. So it may be helpful to see if this experience casts any light on choice in health services.

A ‘Positive Choice’, as the Wagner committee on residential care reported in 1988, would provide people with the necessary information and support to make decisions about one of the most important moves in later life: the giving up of one’s own home and much independence. This was based on a vision of a wide range of options and support for people making decisions at difficult times.

Has this happened? Over the past decade people have been able to choose between residential homes, but their quality is highly variable and there are great differences in availability at local level. The extent of their choice may be limited and, since most care is publicly funded, strict limits exist on the funding to pay for these services. Small-sized homes are closing or being taken over by large corporations. These are often the homes with greater local links and higher quality of care. Homes may close as costs rise. Some try to balance their books by cutting costs or raising prices. Despite the greater range of social care services, these too are often restricted by geography, and their reliability and quality can also vary.

A market in social care has undoubtedly led to more flexible services that can provide help with problems related to illness and disability. More people are able to stay at home, particularly if they have a high level of disability. But in reality there is often little choice – and many people find their circumstances are not ‘bad enough’ for care of any type. Development of direct payments may produce wider choices for disabled people and carers, and here social care will have much to show health services. But the lessons may be about the limits of choice, as well as its benefits.

Linda Patterson, Medical Director

Commission for Health Improvement

Organisations which involve patients and the public in developing services, and which really listen to the issues raised by stories of individual patients, will be more likely to deliver responsive care. This is particularly important for those who are traditionally marginalised -- such as older people, people with learning disabilities and those with mental health problems.

Innovative solutions for reducing waiting times, offering a choice of a shorter wait if you are prepared to travel, may help with elective surgical problems, but far more people are being managed for chronic disease problems. They require an assurance that their local service is providing the quality they need.

The big issue with the planned diversity of providers is quality assurance. That must be set in contracting, in performance management and in regulating services. The public needs information about the quality of services in both the public and private sector, from the regulators in a form which makes sense to them. The paucity of clinical information systems and a culture which is still not measuring for improvement, only for accountability (e.g. targets) and judgement (e.g. Star ratings ) means that information about quality of clinical care is still very poor. If meaningful comparison between providers - and individual clinicians – is currently impossible, can there be a meaningful ‘choice’?

Roger Seifert

Professor of industrial relations, Keele University

The notion of giving patients and their families more ‘choice’ health care providers is both a sham in reality and a dangerous move to create an increasingly large non-public health sector. The idea that so-called ‘consumer choice’ is a good thing is rooted in old fashioned and idealistic beliefs about the efficacy of free market operations: namely, that the more choice from those demanding goods or services, the more pressure on those supplying them to be more efficient and effective.

In theory this is perverse, since patients are not consumers of the NHS (they do not pay for use) but are users, while the government is the customer. Furthermore the theory of perfect competition requires perfect knowledge as well as a large number of suppliers, with profit as the incentive to respond to customer demands. But in practice none of this actually works, since it ignores pre-existing social and economic inequalities in society, and it assumes consumer demand is the same as need, that one person’s decision has no impact on those of others, and that there is an endless supply of the service.

The government’s NHS reforms in general, and foundation hospitals in particular, over-concentrate on supply side economics, and treat the demand for health care as a matter for the individual. The reforms are part of a wider trend towards a neo-liberal political economy, in which all aspects of welfare are to be shifted onto individuals and families and away from collective state provision. They are pursuing the myth that market freedom for everyone and for everything are better than collective state provision of health, education, protection and welfare.