Patient choice: two decades on and in need of reform

One of the early indications of the ideological approach of Wes Streeting’s health and social care team will be what they decide to do about patient choice. Introduced by the last Labour administration in 2002, the principle – that patients with non-urgent conditions should have a choice of where and by whom they are treated – has remained fundamental to the NHS’s approach to referral.

But scratch the surface, and competing visions quickly emerge. And these arguments have been simmering away for years.

For some, the benefits of patient choice are clearer than ever. Writing in its Time to Choose report in 2022, the Patients Association’s CEO Rachel Power concludes that every individual consultation should have shared decision-making “at the heart”, which must include clear communication on how a patient can “choose where they can access the treatment they need to live their lives well”.

Ms Power writes that making waiting times more equitable between different areas and different providers will “help to restore patients’ confidence” that the NHS is functioning as it should – “an important step given disruption to the relationship between patients and the NHS over the last couple of years”.

A competing view argues that, simply put, giving patients choice can be incompatible with efficient demand management and cost control within the NHS. “Money is leaching from NHS due to patient choice policy,” was one HSJ headline in 2023, in an article by a CEO of an integrated care system.

Angela Coulter, writing in the BMJ as far back as 2010, challenged the coalition government’s aim at the time to give patients more choice about their healthcare, with Coulter arguing that “treatment choice” was more popular with patients than “provider choice,” and had “much greater evidence of benefit”.

Polls and focus group data have shown that the public is enthusiastic about patient choice, especially when alternative provider care could potentially reduce waiting times

Ben Burton, president of the Royal College of Ophthalmologists, mused publicly about whether the idea of patient choice should take priority over patient safety at his organisation’s annual conference this year, and he has made similar arguments in The Guardian.

Of course, the choice debate is not merely theoretical; it has a real impact on real patients.

The Time to choose report, for example, found significant variations in waiting times across the country – from the South West of England, where the difference between the providers with the best and worst waits was more than 18 weeks, to London, where patients were waiting for more than two months in the poorest performing providers.

Polling and focus group data revealed that the public was enthusiastic about patient choice, when accessing care through an alternative provider had the potential to reduce waiting times.

Devon ICB’s case study

A specific case study is now playing out in eye care with the integrated care board in Devon. The ICB’s position on patient choice is not clear – the policy document displayed on its website is not theirs but that of the neighbouring Cornwall ICB.

But recently, Devon ICB has used the results of what it called an “audit of referrals” from local optometrists to claim it has found a pattern of differential referrals, leading it to put pressure on providers to reduce the number of referrals that were being sent to private providers in the area.

Looked at from that point of view, having patients choose alternative provisions is viewed as a “waste.” It may not be unrelated that the area the ICB administers contains a newly-built Nightingale Hospital, which appears to be underutilised.

Its just food for thought

First, there is a disconnect between the data and a rational reaction to it in Devon. The results of an audit that are being claimed to represent compelling evidence that patient choice is being subverted (the Getting It Right First Time team in particular has been quick to adopt this stance) have not yet been made available for inspection and analysis.

Strikingly, when a sample of the 100 or so most egregious examples were shared with local providers, the analysis showed little more than some examples of poor patient interaction recording. Certainly, there is nothing to substantiate the claimed conclusion that patients are deliberately being directed away from NHS hospitals.

Take away the ICB’s claims, and one is left merely with a handful of anecdotes – nothing to require eye care providers to rush to action, and nothing to justify the intervention of agencies such as GIRFT who are supposed to be the exemplars of evidence-based practice.

Second, the ICB’s claims of differential referral have been seized on by those whose agenda is not to attack patient choice per se, but rather the use of private providers in secondary care. We have been hearing unsubstantiated claims of private providers “bribing” community optometrists to refer patients, particularly cataract patients, their way, leaving NHS hospitals to deal with more complex and expensive cases.

The reality is, we are talking about contracts to provide assessment and aftercare services; contracts that are common across independent sector providers. Not to mention that when faced with the choice between a three-month wait for an NHS procedure and a two-week wait at a private hospital, patients are “choosing” the latter.

The importance of patient choice cannot be overstated, and it is crucial to protect against the risk of compromising this principle for the sake of profit

That said, there is certainly an issue here to address. Patient choice is important, and we need to guard against the possibility of the principle being subverted in the name of profit. This means we need to be putting in place structures and systems to support proper patient choice. That may take different forms in different parts of the system.

In eye care, for example, the current NHS contract (which pays optometrists £23 for an eye examination but costs more than double that to perform) does not allow for any such interaction (optometrists could, if they choose, merely refer all patients with signs of eye disease to their GP).

In eye care, therefore, either that contract could be amended to recognise the additional time and recording this part of the service requires, or – less satisfactory in our view, but something which is being actively canvassed by some secondary care providers – an intermediate stage between diagnosis and treatment will need to be introduced, the so-called “single point of access” (which is an ironic title, since it would, in fact, represent an additional, third hurdle for a patient to negotiate).

Whichever solution is chosen, action is clearly necessary. If patient choice is going to last for another 20 years, we have to apply the principle more effectively than we are currently doing.