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Patient choice ‘destabilising secondary care’

Exclusive: Evidence is emerging that the Government’s patient choice agenda is destabilising secondary care, with inflated waiting lists and warnings that spare capacity could force hospital closures.

CCG leaders say patients are increasingly exercising their choice, with influxes of out-of-area patients causing spikes in activity and longer waiting times at hospitals for local patients.

The choice agenda, first introduced by Labour in 2004 and due to be expanded into new areas by the current Government, encourages GPs to offer patients a choice of provider when referring them for treatment.

A Pulse investigation back in 2009 cast doubt on the effect of the policy, showing that just 6.4% of referrals that year were for patients travelling from outside hospitals’ normal catchment areas.

But board papers from several CCGs reveal real concern in many parts of the country that patient choice is proving unsustainable as NHS budgets tighten.

Harrow CCG in North West London said an audit of antenatal care at the Northwick Park Hospital showed over 40% of local patients were not seen within the set time due to an increase in out-of-area patients, with 27% not receiving an appointment within the set time.

In South east London, Lewisham Healthcare NHS Trust said it had experienced demand above the projected level in maternity and outpatient services in the past year due to patient choice.

A spokesperson explained: ‘The Trust’s market share for maternity service users in Lewisham has increased by 6% in the last two years. With patient choice, many women from outside of the borough choose to birth in Lewisham.’

Councillors are warning in other areas of the country that patient choice is leading to ‘capacity issues’ and the threat of closure in other hospitals.

Earlier this year, neighbouring Bexley CCG reported concerns from Councillor Eileen Pallen that local patients were ‘experiencing long waits for appointments’.  Board papers from the CCG said ‘capacity issues at hospitals resulted from patient choice’.

The NHS South West London cluster, which is currently reconfiguring its hospital services, also had warnings from a local councillor that the St Helier Hospital in Carshalton was ‘likely to close’ as a result of ‘the anticipated adverse impact of patient choice’.

Dr Chaand Nagpaul, GPC negotiator and a GP in Harrow, said: ‘A full choice agenda makes it impossible for local hospitals to plan and make provision for local patients whilst at the same time being available to patients from other areas.

‘It is not appropriate to the choice agenda to be applied in certain clinical areas, such as maternity. There are tensions that need to be addressed. The notion of unfettered choice is a flawed one that does meet the needs or the ethos of the NHS.’

Dr Kamran Ahmed, a GP in Wolverhampton and board member of Wolverhampton CCG, said it was important that choice was used sensibly to keep a lid on demand.

‘There are lots of factors causing change. Obviously if you are a secondary care provider, increasing activity is important to your business. As a commissioner, getting a grip of the activity that’s already there and trying to manage future activity is important to us.’

A spokesperson for NHS South West London attempted to allay concerns over the sustainability of St Helier hospital. They said: ‘No decisions have made yet, but the proposals put forward by local clinicians included a commitment to four sustainable hospitals. The modelling we have carried out on expected patient flows supports that.

The spokesperson added: ‘St Helier was recommended as the location of a new planned care centre for the whole of south west London and that planned care centre is central to the Better Service Better Value proposals.’


Choice puts pressure on services

  • Royal Wolverhampton Hospitals NHS Trust - received more referrals than expected
  • Lewisham Healthcare NHS Trust  - experiencing demand above the projected level in maternity and outpatient services
  • Harrow CCG - audit of antenatal care at the Northwick Park hospital shows 40% of local patients had not been seen within the set time
  • Bexley CCG - long waits for appointments reported
  • NHS South West London cluster – warnings hospital could close


Readers' comments (11)

  • Genuinely interested in understanding whether the policy is truly at fault here, versus planning and preparedness. A couple of items jump out to my (admittedly uninformed) eyes:
    * the policy seems to have been around since 2004, allowing 8 years to work through impact
    * some of the quoted increases seem quite small (6% over two years)

    Pointers to any longform articles, blogs etc. critiquing the policy agenda much appreciated.

    And if St Helier is 'likely to close', I gather from the wording because patients are choosing not to go there (?), why is that? Given this is a story about patient choice it would be nice to have an idea of the patient perspectives on this issue.

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  • I agree with comment by claire. I think CCGs need to think deeply (as commissioners) on why patients are going to different providers. Providers need to address these issues, if patients are Not happy with local services and choosing to go elsewhere, then they need to address quality concerns. This also applies to commissioners too. Simply saying patient choice is the cause does not address the core issues. Easy to blame patients for choosing to go to places with better quality of care, much harder for commissioners and providers to question variation in quality of care and work together to improve services.

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  • Couldn't have put it better myself - why are patients choosing not to go to St Helier. How about St Helier learning from the places people do choose to go to? We should be happy to offer people choices rather than the previous Stalinist model.

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  • This is exactly what the policy was supposed to do. Those providers loosing patients need to either up their game and provide a quality of service or accept the consequences, and downsizing, of not doing so.

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  • It is really difficult for patients to judge clinical quality as they have nothing to compare it to-even as aGP im not sure I could judge the clinical qualty of one department versus another

    so choice based on car parks and restaurants and advertising are what we are basing the lottery of NHS funding on.

    so the best place to keep you alive may close. This is the result

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  • I think people are forgetting NHS is not a private sector company. Many people may choose & be able to travel to hospital of their choice. Many others may not be able to do this due to their physical or financial situation.

    Hence closing a local hospital will have devastating effect for the local population. We'll also have to remember the hospital cannot "expand" their business as private sectors can - funding for new project will have to be agreed with CCG (unless you are foundation), and it cannot suddenly generate an income even if a service did improve. It can't improve it's service without money, and there for it goes into a down ward spiral.

    Home many people would be happy to see their local hospital shut, as poor as it may be?

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  • Vinci Ho

    'Choice' simply has exposed the variation in standards and performances amongst hospitals . Of course , patients want to choose their 'best' ones. But reasons and causes behind the discrepancies are for more complex and have not been dealt with constructively .
    As more people will choose one hospital more than another , the waiting time gets longer for the former .
    Your question to your patients will be ,' Yes , are you prepared to wait longer to be seen in this ''better'' hospital ?'

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  • And "better" cannot be measured easily either.

    My neighbouring hospital has x3 ore colorectal specialist nurses then my local hospital. But if you look at cancer mortality/recurrence rates, its no different. So if you are purely looking at the numbers one might argue there is no different.

    As a GP I wont pretend to even know how many specialist nurses there are in each department, let alone length of waiting lists, how many individual cubicles, re-admission rates for each condition, knee op failure rates (which, by the way gets published nationally) etc etc. In fact, I'm not really interested in it as most of my patient wants to goto local hospital (and my limited brain capacity wont allow me to remember these on top of 7 guideline that gets pushed to GPs every day - as per previous pulse article).

    And "choice" costs money folks. Starting with C&B IT costs...........

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  • I thought that maternity and mental health were the two areas where there was no guaranteed choice? Until women vote with their feet nothing will change for them. And of course with all the maternity hospital mergers, closures of birth centres and pressure on community midwifery time, maternal choice will become even more restricted. Maternity is not a one side fits all specialty.

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  • There appears to be a real lack of understanding among clinicians on why/how patients may exercise choice. With regards maternal services is it surprising mothers-to-be actively seek out information on services, they talk to each other and share experiences. This has become much easier these days via internet (mumsnet etc.) and social media - news travels faster and further. Information gathered in this way may not be easy to measure, except on the outcomes - some services been preferred over the others. If one thinks patients make choice decisions based solely on car parking or restaurant, then you really need to think again. News of good or poor quality services travels faster and influences patients much more than clinicians would like to admit. Both commissioners and providers need to take these changes into account.
    Naturally there is concern that the NHS is moving to actually offering less choice by focusing on reconfigurations based on bigger-is-better. Patients, where they can are voting with there feet. However, access to less able patients is an issue. But patient choice can/should be used as a driver for improving service quality NOT for closing front line services. Commissioners/patients should look to question providers on why their service is not attracting or retaining patients. Then build on making it better, which does not necessary cost a lot of money, usually it is about changing the culture of an organisation, putting patients first rather than other competing needs. How much does it cost to change culture, a lot less than reconfiguring hospitals and services.

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