Choice drive ignites in cities but leaves the country cold
Urban areas are starting to take to Government's choice agenda - but marketing, not quality, is driving factor
By Steve Nowottny
Urban areas are starting to take to Government's choice agenda - but marketing, not quality, is driving factor
Choice was a Tony Blair buzzword, and has been at the heart of Government health policy since the NHS Plan nine years ago.
The policy has created a purpose-built multi-million pound IT system. It has been advertised across England in newspapers and on billboards and is enshrined this year as a patient's legal right in the new NHS Constitution.
But shockingly – until now – nobody has quite known if it was actually happening, let alone working in driving up quality.
A Pulse investigation this week reveals for the first time the impact of the drive for GPs to offer patients a choice of hospital.
It shows that the choice agenda, roundly derided by many GPs as political rhetoric, is having a real effect, with the number of patients attending hospitals outside their own area more than doubling since 2004.
But our findings also raise serious questions about the future of the policy, with evidence uptake of choice remains a rarity rather than the rule, and is hugely skewed to large conurbations with major hospitals.
Could it be that patients exercising choice are drawn not to the best hospitals, but the ones who say they are the best?
Previous evidence on patient choice has been sketchy at best. The Department of Health has commissioned the King's Fund, Picker Institute and the RAND Corporation to produce a definitive report into the impact of patient choice – but this research is still very much under way, and not due to report until spring next year.
In the meantime, an analysis of hospital episode statistic data by the Health Service Journal and the Picker Institute published earlier this month suggested some movement among patients, with 11 of 66 PCTs seeing a swing of 10% or more in the proportion of GP referrals going to a trust's local hospital since 2006/7. But such evidence was limited in scope, with commissioners explaining the changes could be due to a variety of factors.
When Pulse asked the DH earlier this year what evidence it had on the subject, a spokesman said changes to referral patterns could be hard to attribute to choice alone, but added: ‘In principle, routinely collected administrative data could be analysed to assess how referral patterns are changing.'
So we did just that. Pulse submitted a Freedom of Information request to every hospital trust in England, asking for information on referral patterns over the past five years, and details on what steps they were taking to promote choice. The analysis of data from the 84 trusts who replied reveals some startling findings.
The good news, for the Government at least, is that years spent badgering GPs to offer patients choice have not been in vain.
On average, 6.4% of referrals received by trusts last year were for ‘out-of-area' patients. In trusts able to supply complete figures, this represented a striking 114% increase since 2004/5.
While trusts sometimes differed over the exact definition of an ‘out-of-area' patient, the conclusion is clear – an increasing proportion of patients are taking an active role in choosing a hospital right for them even if they have to travel.
University Birmingham Hospitals NHS Foundation Trust, for example, reported 1,069 patients had travelled more than 100 miles for treatment last year – up from 576 in 2004/5.
The big caveat, however, is that this dramatic increase was often from a very low base. Tameside Hospital NHS Foundation Trust, for instance, recorded a 1003% rise in the proportion of out-of-area referrals. But in practice, just 304 of its patients last year were from outside its catchment area.
Nigel Edwards, policy director of the NHS Confederation, sees the findings as encouraging – and insists even low levels of switching show choice is having some success.
‘If 20% of people started shifting in one direction, hospitals would completely fall over,' he says. ‘Choice doesn't need too many people to switch to have the effect it's intended to have, which is to encourage providers to become more responsive.'
DH insiders also believe the findings are ‘encouraging'.
‘It fits quite well into an emerging picture,' one senior official told Pulse this week.
But our investigation is not entirely good news for ministers.
It found where a patient lives largely determines whether they exercise choice. GPs in rural areas – or anywhere outside the biggest cities – have long complained choice is meaningless when patients can only afford to travel to one hospital. Until now there have never been the figures to prove it.
Pulse's investigation found a clear and striking geographical divide, with hospitals in urban areas three times as likely to draw patients from further afield.
Last year 9.1% of patients in urban hospitals were out-of-area, compared with just 3.5% of those in the country. Hospitals in urban areas also saw a 29.6% rise in total referrals since 2004/5 – the equivalent figure for rural hospitals was just 12.0%.
Choice, then, is largely irrelevant in rural areas – and Dr Gavin Jamie, a GP in Swindon, warns if anything Pulse's figures could understate the divide.
‘It is probably only the very biggest towns with multiple hospitals that get real choice,' he says. ‘Although we are a bit urban here in Swindon, as there is only one DGH we see very, very few people moving out of area.'
‘The nearest DGHs would be Cheltenham, Gloucester, Oxford or Bristol – none is less than 45 minutes away.'
Rural hospitals seem to be aware of patients' reluctance to travel. When asked about the impact of patient choice, York Hospitals NHS Foundation Trust, which has seen a 29% fall in the proportion of patients from further afield, gave a disarmingly off-message response.
‘The hospital is geographically quite isolated and so choosing another hospital would cause patients considerable inconvenience,' it said.
With the introduction of free choice in April 2008, the Department of Health relaxed rules on advertising of services to encourage hospitals to do more to attract patients.
While many trusts have yet to dip more than a toe in the marketing pool, there are signs they are beginning to do more to sell themselves to patients and GPs.
Two thirds told Pulse they have started actively promoting themselves. In many cases, activity is low-level, such as sending out newsletters to GPs or responding to patients' comments on NHS Choices, but some are taking a more direct approach.
Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust paid £9,000 for a series of radio adverts. In Barnsley, the hospital trust spent £1,545 advertising itself on local buses. Liverpool Women's NHS Foundation Trust has almost doubled its total marketing budget for the coming year, and expects to spend £232,000.
There is evidence even tentative steps in this direction may be paying dividends. Hospitals doing any kind of promotion saw their proportion of out-of-area patients rise almost three times as fast as those that are not, while trusts rated ‘Excellent' in ‘Use of Resources' by the Healthcare Commission last year have the highest proportion of out-of-area patients by a clear margin.
It's a link which worries Dr Michael Dixon, chair of the NHS Alliance and a GP in Cullompton, Devon.
‘Do you believe the marketing of the local trust in a cynical world?' he asks. ‘Perhaps the only constant in a changing world is the relationship of trust between patients and GPs. Well-advised choice in this context is more likely to lead to patients accessing higher-quality services than anything else.'
So what of quality, supposedly the driving force behind patient choice?
Pulse compared uptake of choice with quality of hospital trusts, as recorded in the Healthcare Commission's annual health check last year – and found little or no correlation.
On average, trusts rated ‘Weak' or ‘Fair' had seen a slightly lower rise in referrals since 2004/5, but there was no apparent link at all with out-of-area referrals.
Anecdotally, the picture is even more confused. Despite its now-widely publicised service failures and above average mortality rate, Mid Staffordshire NHS Foundation Trust saw a 121% rise in its proportion of out-of-area patients since 2004/5.
Nigel Edwards, director of policy at the NHS Confederation, says patients who do exercise choice often do so more on the basis of selective clinical factors such as MRSA rates, or non-clinical factors such as travel time, reputation or even sentiment.
‘My favourite example is when St Albans maternity unit closed, the transport modelling suggested people would go to Hemel Hempstead,' he says. ‘But if you're in St Albans, you don't want Hemel Hempstead on your child's birth certificate.
You'd much rather go to Welwyn Garden City even though it's a bit further.'
Regardless of the findings of Pulse's investigation, which provides ammunition for both choice's supporters and critics, it remains a policy which is here to stay.
The NHS Constitution is making choice a legal right and, as Pulse revealed in February, ministers are looking at how an obligation to offer patients choice could become part of the GP contract. Should the Conservatives win the next general election, choice will if anything be ramped up, with GPs taking on a more prominent role in guiding patients' choice of hospital.
GPs, though, remain sceptical. Dr Kailash Chand, GPC member and a GP in Ashton-under-Lyne in Lancashire, says: ‘Asking people if they want more choice is like asking whether they want more peace. Of course they will say yes.
‘Patients are more interested in having a say in the kind of treatment they receive than where they receive it. So far this reform has been costly, unworkable and illogical.'
Until now there has been little evidence on choice to support the critics or the Government. Pulse's investigation shows some progress - but whether the results justify the costs is another matter.
Exponents of choice have a long way to go before they prove they made the right one.Troubling lack of correlation between hospital quality ratings and patients' choices Troubling lack of correlation between hospital quality ratings and patients' choices Dr Kailash Chand Dr Kailash Chand
So far this reform has been costly, unworkable and illogicalChoice in the city
Trusts serving predominantly urban populations have seen a much bigger rise in out-of-area referrals, suggesting they are successfully attracting patients from further afield as patient choice becomes a reality.
Trafford Healthcare NHS Trust in Manchester has seen its out-of-area referrals increase dramatically since 2006/7, from 8.51% to 14.58% last year.
The trust received a ‘Good' Quality of Service rating in the Healthcare Commission's last annual health check, but the rise also follows a range of promotional activities aimed at both GP and patient.
The Trust responds to patient comments left on websites such as NHS Choices and Patient Opinion, has upgraded its own website and developed an Extranet for GP practices to use, if they are seeking referral advice or consultant contact details.
A GP liaison manager has been hired to improve communication with local GP practices and a newsletter aimed at GPs highlights the steps the trust has taken to reduce infection and waiting times.
Choice in the country
Practices have been targeted because they are likely to advise patients on where to attend, the trust said. But it adds: ‘Ultimately it should be the patient who makes the choice.'
Trusts in rural areas have seen far less of a rise in out-of-area patients, with many patients unwilling to travel further distances.
Hospitals in the newly-created Western Sussex Hospitals NHS Trust – formed by the merger of the Royal West Sussex and Worthing & Southlands Hospitals NHS Trusts last month – saw just 177 out-of-area patients last year, and the proportion out-of-area decline by more than 50% since 2004/5.
The trust says it already responds to patient comments on NHS Choices and has established communication channels with GPs, and the new trust is planning to develop a marketing strategy which may see it take a more proactive approach.
But Sefton LMC chair Dr Andrew Mimnagh that rural hospitals will face increasing financial pressures if the choice agenda takes off.
‘Think greengrocers versus supermarkets,' he says. ‘The end point is clearly predictable – a few urban super-hospitals around the country and the death of the local DGH, except in very isolated rural areas.'