The illusion of choice - they are at it again

It is time to re-visit “choice” again. “Choice” within the NHS or, as most doctors would say, the illusion of choice.

First, some simple facts. In 1997, until New Labour took over, I could refer my patients to any NHS hospital in the country. At that time, theoretically, I could refer them to any hospital within the EC, although I never tested the hypothesis. Over 90% of my patients went to local hospital by choice. They were not interested in going elsewhere. Occasionally, one would give a gentle steer to a hospital further afield. For example, there was one consultant who we knew was not performing well, who had matrimonial and alcohol problems, and who has now taken early retirement. His normally high standards were slipping. Nothing that would show in a league table, but we knew what was going on.

One of the first “improvements” New Labour made to healthcare was to remove this choice and restrict our patients to the local hospital. If I wanted to refer “out of area” I had to convince a committee of over-promoted, non-medically qualified pilonidal typists that the service my patient needed was not available locally. And it was no good me saying that Mr Jones, the local urologist (or whatever), was the worst and most dangerous surgeon in the country. A service is service. We are not talking quality here. This new restriction bothered the family doctors but, let’s be honest, it did not bother the patients. Most of them did not notice. They continued to go locally as they had always done.

Now, “choice” has been restored. We have “choose and book”. Most patients are not interested and are exasperated by the bureaucracy. They still want to go locally but preferably without the new paperwork. Sadly, a number of them, particularly the elderly, are unable to get though the Choose and Book bureaucracy (currently 25% of our patients fail to make an appointment). Of those that do make an appointment, over 95% choose one of the two local hospitals. As they always did.

It saddens me to see that the new Tory policy is jumping on the bandwagon of the illusion of choice. Hospital league tables are close to meaningless. OK, well, the unfortunate hospital right at the bottom is best avoided, but most hospitals are clumped together in the middle, and the difference between, say, 78% and 82% means nothing.

This does not mean that I am against choice. Far from it. Choice is essential. But the exercise of choice must have consequences for the hospital. We need a system where the money follows the patient. Real choice and real consequencies.

The government is as detached from reality as ever. It its last desperate dying days, it is going to introduce a NHS Constitution which will embody the illusion of choice. Details are awaited but it seems that:

It will not, however, determine what services, drugs, operations and treatments the NHS will provide. Many had hoped the constitution would free the health service from political control so that it can be run by an independent board in the same way as the BBC, but it is understood that this has been discounted.

Along with the rights will come a list of patient responsibilities such as keeping appointments, treating minor ailments at home and not being abusive or violent towards NHS staff. There will be a new focus on preventive care and emphasising what patients can do to keep themselves healthy by directing them to websites such as NHS Direct and NHS Choices.  Source

Read the final part of the last sentence again:

…emphasising what patients can do to keep themselves healthy by directing them to websites such as NHS Direct and NHS Choices.

Most of my patients who need medical care are over the age of sixty. Many are frail and vulnerable. They do not use computers. They do not understand websites. Take a look at the NHS Choices front page.

I cannot be bothered with it, and I know how to use websites. How many £millions did this site cost? How many cataract operations or hip replacements would those £millions have bought? Ask yourself this. How many elderly women with poor eyesight and painful hips are going to be able to use this site to exercise their right to make an informed choice? They won't bother. They will ask me for advice and usually they will prefer to go to one of the two local hospitals.

It is time to move on from this obsession with process, and this endless promulgation of the illusion of choice.