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From buzzword to contract clause, choice rises again

GPs now have a legal duty to provide choice - with minister set on giving fresh impetus to the DH's patient choice plans. By Steve Nowottny investigates.

By Steve Nowottny

GPs now have a legal duty to provide choice - with minister set on giving fresh impetus to the DH's patient choice plans. By Steve Nowottny investigates.

If access was the buzzword of 2007 and polyclinics the term of 2008, then in 2009 it is all about choice.

Choice has been around since Tony Blair's time of course, but it is back to the top of the agenda with a vengeance, with a raft of new announcements already this year.

For GPs, choice offering is no longer optional, with the NHS Constitution guaranteeing all patients a legal right to choose both their hospital and GP practice.

Yet the gap between that aspiration and reality is still considerable, as the latest National Patient Choice Survey showed last week.

In September 2008 - the latest figures available - just 46% of patients recalled being offered a choice of hospital for their first outpatient appointment, a figure which has remained struck in the mire for the past two years - and is actually down from 48% in March 2007.

Department of Health sources admit the figure has ‘flatlined', and to alter that, it has published details of plans to reinvigorate the policy.

Under the constitution, PCTs will have a ‘duty' to promote choice - and although it will be up to them how they do so, even the best case scenario is likely to cost an estimated £5.2m, or £33,000 per PCT.

This scenario would see printed literature distributed to GP surgeries, and practice nurses would show NHS Choices information to patients unable to access the internet.

A minute on choice

But under another proposed model – which at an estimated £31.9m could prove prohibitively expensive - GPs would spend a minute's consultation time talking through options on NHS Choices in person with every patient they refer.

Dr Paul Williams, a GP from Wisbech in Norfolk, tries to make every referral through Choose and Book and does discuss options with patients in person – but it takes longer than a minute, he warns.

‘A minute is probably an underestimate,' he says. ‘Some practices have a member of staff who do all that. I personally do it with them.'

But if GPs are unlikely to be delighted by rules on how they should run their appointments, it would be even more controversial if the DH were to put away the carrot and take out a big stick.

Some reports suggested last week that the Government may be planning to insert choice into the core GP contract in the next round of negotiations.

David Stout, director of the NHS Confederation's PCT Network, says he doesn't know if the reports are true, and believes there may be ‘other ways of achieving the same objective'.

But making choice a contractual requirement – with PCTs able to impose financial penalties on GPs who fail to offer it – has a certain logic, he concedes.

‘The truth is nowhere in the GP contract is it stated that they have to offer choice, so that's where there's a slight disconnect between the legal rights of the patient and no obligation on the practice,' he says.

‘You can see why there might be an argument for tidying that up and including it.'

Dr Williams, however, fears that if choice entered the core contract, the LES he is currently paid to offer choice would disappear.

‘I'd be disappointed if by making it a core requirement we lost the extra funding we get for spending the time doing it.'

Real choice

The GPC response is blunter still. Deputy chair Dr Richard Vautrey says: ‘We support true patient choice rather than choice with a big C.'

He adds: ‘They've not mentioned [a contract change] to us yet so we'll wait for that. [But] using mechanisms like surveys to assess this is not useful.'

Do patients really want choice? It's hard to find anyone – politician, manager, doctor or patient – who's against the concept in principle. But how it is defined varies considerably depending on who you talk to.

DH planners have actually put a figure on choice, claiming they free choice should mean between 5% and 30% of patients ‘choosing a hospital more aligned to their needs'.

But so far the Department has refused to say what progress has been made against that target.

Patients groups argue patients will only be able to exercise real choice when relevant information is made easily accessible.

Katherine Murphy of the Patients' Association says the deciding factor for most patients is currently hospital infection rates, which the National Patient Choice Survey lists as an important factor for three in four patients choosing a hospital.

‘Until patients have information on hospitals, the clinician, doctor, infection rates, how good the person looking after them is, the individual doesn't have the right information to make that choice,' she says.

‘That information is not really available. It is available if you dig and dig – but average members of the public won't have time.'

One telling statistic buried in the Government's impact assessment bears this argument out.

In November 2008, the NHS Choices website, set up to spearhead the Government's choice initiative, received more than four million visits.

But just 85,000 of these were to the provider ‘scorecard' section of the site – a figure the report admits is ‘very low'.

Getting information to patients is clearly key, but putting increasing amounts of information online may not necessarily be the answer.

Of the 9.6 million referrals to which choice could apply each year, 2.9 million are for patients without internet access at all.

And among the wider population, a COI/MORI survey last September found just 12% were aware of NHS Choices, and just 3% had used it.

The other danger is that patients could go from having too little information to too much. A range of initiatives this year will see a blizzard of data made available for patients to pick through.

Just before New Year, ministers announced patients were to be given the opportunity to use the NHS Choices website to rate their GP and comment on their performance.

The Government has also announced that school-report style ‘balanced scorecards' will be published to help patients choose between practices, and enable them to switch practice online at the click of a button.

Patient survey results, QOF data and even practice accreditation status may all also be made available to help patients choose.

Outcome measures

Last week, the Department of Health unveiled plans for Patient Reported Outcome Measures. All licensed providers of hip replacements, knee replacements, groin hernia surgery and varicose vein surgery will be expected to take part from April 2009, while research is underway to identify ‘other areas where PROMs may be feasible.' 250,000 patients are expected to fill out a questionnaire next year.

Health Minister Lord Darzi is in no doubt about the significance of the initiative. ‘This programme is the first of its kind in the world and the information collected will empower patients to choose a hospital that achieves the best results for the operation they need.'

But unsurprisingly, some fear patients will be left overwhelmed, uninformed and confused. And it is here that the Conservative party – staunch advocates of expanding information available to patients – suggest GPs could have a role to play.

Speaking at the BMA last month Shadow Health Secretary Andrew Lansley caused outrage among GPs when he suggested they would be held partly responsible if patients they referred were caught up in infection outbreaks in hospital.

Explaining the remarks last week, a party spokesperson told Pulse that under a Conservative Government, GPs would be asked to take on a key role in informing patient choice.

‘GPs should be guiding patients every step of the way,' he said. ‘Patients are only going to be able to make a choice if they've been informed by someone in the know.'

Patients may have the right to choose – but it seems GPs' knowledge and experience are not entirely redundant just yet.

FAQs: Patient choice

What's the history of patient choice?
Patient choice was originally set out in the NHS Plan 2000, as part of a wider cross-departmental emphasis on individual choice launched under Tony Blair. From January 2006, patients were offered a choice from a list of four or more providers, and from April 2008, the free choice initiative meant patients were free to choose any hospital in England.

Why the renewed effort now?
Ministers see choice as a key lever in the drive to improve standards, both in hospitals and also GP practices. Forcing NHS providers to compete for patients will focus their minds on achieving the quality improvements demanded by the NHS Next Stage Review, they believe.

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