More problems with patient choice

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.

6 responses to “More problems with patient choice

  1. Hi Jonathan

    are you happy about having a BUPA ad on your blog? Was this google imposing on you or are you demonstrating the illusory nature of choice of provider?!



  2. I’m a policy wonk too (I was once told that anyway). Agree entirely with inverse care law and complete disregard of policymakers in dealing with it. My question is (and I hope you know me well enough by now to know this is in good faith), given that 80% of interactions with health professionals occur in GP surgeries, should there be greater competition between them?

    • If I was to answer yes, it would have to be because I thought that competition improved quality and/ or efficiency of care. I don’t know of any evidence to support this hypothesis.
      What I do know is that in Hackney (and elsewhere throughout the UK, France, Germany, Switzerland, Holland, India, Nepal, Afghanistan. America -places I have spoken to experienced doctors and/or read research) there is already competition and yet there is considerable variation between the quality of different GPs, even (and especially) where competition is most intense, i.e. where they are working in close proximity in inner-city areas. There isn’t (to my knowledge) any system of care in the world that has solved the problem of GPs of different quality working alongside eachother. The reasons include:

      1. demand for care outstripping the supply of GPs, 2. the inablity and unwillingness of people/patients to travel, especially if they are elderly, immobile, disabled, with young children, mentally ill, etc. 3. the importance patients place on continuity of care, patients overwelmingly want ‘their own doctor’, very few research their GP 4. The lack of comparative data between practices -even if/ when this is available, you may find a practice that has excellent diabetic outcomes, but how are you to know if the outcomes are to do with highly skilled nurses or motivated patients or a practice that refuses to register alcoholics with diabetes? 5. The Inverse Care Law which I have described above, competition leads to a widening of variability

      Our catchment area, like most urban practices overlaps 2-4 other neighbouring practices. We don’t accept patients from outside our catchment area becasue we do not have capacity and we do not have time to visit patients who live further away. Because of overlapping catchment areas in dnesely populated areas patients typically have a choice of 2 to 4 practices. A few patients move around, usually becuause of a disagreement/ argument/ complaint or because of personal recommendation. I do think that patients ought to be able to change GP if they have had problems with their own GP, and they can at present do so. But this is not the solution for the problem of underperforming practices.

      We are compeitive with other practices in Hackney in so far as every 6-12 months we are given data comparing treatment for blood pressure, diabetes, cholesterol, new patient health checks, child immunisations etc. We are also given comparative data for hospital admissions, referrals according to different speciality etc. All the GPs I know are competitive -we want to be the best, but we do not (so far as I am aware) compete for patients, but to improve the quality of care for our patients. Mostly though, we are collaborative. After we look at the data, instead of trying to attract patients from other practices we get together with them and work out ways to for us all to improve. For example, I looked at headache referrals in City and Hackney, arranged teaching sessions with the highest referring practices and reduced their unecessary referrals by 25-100%.

      By collaborating we can improve care for everyone in Hackney, but by competing for patients, we will leave practices and their patients, like those described above, to suffer.

      Competition in healthcare is the moral bankruptcy at the heart of the NHS reforms. It is being advocated without evidence or consideration of the consequences.

  3. Interesting. However, whilst I agree that a patient who thinks he knows it all is a bad thing, it doesn’t get away from the fact that patients want to be involved in the decision making process, and for that they need information. I do agree that simply googling a condition and then thinking you know more than the doctor is silly, but the way to cure it is by having accurate information on outcomes for treatments not less information, so that a two way conversation can happen rather than the one way street of referral writing that currently exists.

  4. Interesting responses. In the Midlands town where I live there are two practices with surgeries within 100m of each other. When we moved here 15 years ago there was no criteria we could use to choose between them and chose more or less at random. However, since then, talking to neighbours, we found that the *other* practice was more popular a few years before because it had women doctors (the practice we are registered at had women doctors when we moved to the town). So there are some “competition” aspects, and aspects where “competition” can improve competing practices. But do I read the QOF figures of the two practices (does any patient?) and switch to the one with the better values (like people do with their electricity suppliers)? Of course not. Unless my GP does something appalling to offend me I am likely to remain registered with him until he retires (or I move away or die).

    One thing that Jonathon didn’t mention is the doctorpreneurs. Back in the fundholding days I moved house and registered at a GP who told me that I could not attend the diabetic clinic at the local hospital because their practice had a clinic. At the first clinic I attended the doctor (who I had been told was the “diabetic expert”) told me that he had just been on a course but since I had had type 1 diabetes for 17 years he said that I “probably know more about my condition than he did” (yes, I know this was most likely in jest). I am all for care closer to the patient, but “have a go” doctorpreneurs do not instil confidence in me, and its worse when – literally – my life is at stake. When it comes to medicine far more important than what the doctor knows, is whether they know what they don’t know; doctorpreneurs appear to assume that they have no limits, and that worries me.

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