In Hackney another established practice has taken over a list from a failing practice that has suffered years of substandard care. Over the years many of the patients have chosen to register at other local practices. Due to the density of housing, practice boundaries often overlap in urban areas and this enables a limited choice. Typically there is a choice of 2-4 practices and patients usually choose by word of mouth or personal recommendation.
The patients who did not leave were disproportionately old, housebound, mentally ill, and suffering from long-term/ chronic diseases. They were too ill, disorganised, frail, uneducated or immobile to change GP. Some patients had been advised to change GP by their hospital specialists. One advantage of a local hospital (in contrast to the proposed model of multiple willing providers) is that once consultants have been in post for a while they know which practices take better care of their patients and they can (and not infrequently do) recommend patients change.
Choice is exercised according to your levels of motivation, education, flexibility and economic and social status. In fact the more our patients need to be looked after and the greater their health needs, the less empowered they are likely to be to make choices. Furthermore patients who are less empowered are more likely to say that they have not been offered the choices they want.
The downside of choice is that it risks widening health inequalities because of the Inverse Care Law. This states that: “The availability of good medical care tends to vary inversely with the need for it in the population served. This … operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.” (Hart, 1971).
A recent review of patient choice in the British Medical Journal concluded that choice of treatment was more important to patients than choice of provider. A typical GP consultation is full of choices about different treatment options, but provider choice is rarely necessary because even once patients are referred to the local hospital they expect to be able to discuss the treatment options again with the specialist. There is a world of difference between the treatment choices of patient-centred medicine and choice of provider as a market lever.
When Mary comes in to ask whether she should have a tube placed directly into her stomach so that she can be fed during another 7 cycles of radiotherapy for her throat cancer… when Alfred comes to tell me that he absolutely won’t take insulin for his diabetes and wants to know the alternatives… when Sally wants to discuss vaccinations because her neice almost died after an anaphylactic reaction… what my patients need is a doctor they know and trust, someone who is experienced and sufficiently qualified to help them make serious choices about their care.There are many ways in which doctors’ behaviour can be improved, but as the example above shows, simply widening provider choice will leave those who most need care without it.
Many doctors who object to the proposed NHS reforms have been criticised for denying patients choice. I do believe in patient choice. For all of my (now 15 year) career, I have involved patients as partners in discussions about their care. There is not doubt that this is what patients want. But what I also believe is that choice has risks as well as benefits. The risks of patient choice as a lever in healthcare markets is that those patients who are least able to exercise choice will be left with the worst care when they are the ones who need the best care, most of all.