The point of patient choice is that it demonstrates that we as doctors treat our patients with dignity and respect, as adults capable and willing to be involved in decisions made about their medical care.
Patient choice has an intrinsic value. By involving patients in their care and not merely caring for them, I am respecting their autonomy. The intrinsic value of patient choice lies not merely in the choice itself, but in the process by which the choice is made. This process involves exploring my patients’ stories, their ideas and values, hopes, fears and expectations, not only about what they want to do, but what they understand of their symptoms and their illness. It is a two-way process. Patients ask me questions, some of them very similar to my own, ‘what am I trying to achieve? What are my hopes, fears and expectations?’ This is how doctors and patients make sense of symptoms, deal with a disease and come up with a shared understanding and make a plan. With some patients (and some doctors) this is easier than others. My patients include many who don’t speak English and others who have cognitive impairments or overwhelming anxiety. Because they have difficulty expressing themselves, finding out what they want is difficult. Up to 50% of my patients’ symptoms defy medical explanation and in these cases it is helpful for doctors to think in terms of ‘medically unexamined stories’ and spend more time searching for clues.
The process of patients and doctors ‘getting to know’ eachother and working through frequently complicated and often uncertain healthcare choices is at the heart of medicine in general and general practice in particular. It depends on a relationship of trust which comes from continuity of care. It is a sophisticated process and it is now a significant part of postgraduate training for GPs. In the last 30 years the training of doctors has improved significantly, with increasing emphasis on patient autonomy as an ethical principle and communication skills as an essential clinical skill. At the same time the amount of information given and available to patients has increased and as a result, patients and doctors, now more than ever are co-producers of care.
When I fractured my scaphoid last year, the orthopedic surgeon recommended surgery, but I opted to wait and see. What mattered to me was that the surgeon respected my opinion even though we disagreed. Patient choice is not about making the best medical or surgical decision, but about respecting the patient’s wishes. Fortunately my fracture healed. But just because patients want to be listened to it doesn’t follow that they always want to make the final decision, many want the doctor to tell them what to do. (see this excellent article from the NY Times about doctors making decisions for their patients) There is a risk that patient choice, not properly understood as a process but as a goal leads us to abandon patients when they need us most.
Choice about where patients are treated has always been part of the NHS. Twenty years ago a GP could refer a patient to any NHS hospital. The reason this is no longer the case is that in the last 20 years an internal market has been introduced with expensive administrative barriers in the way. Attempts to extend patient choice within this system are hugely complicated and expensive. It is one of the main reasons that administration costs in the NHS have risen from approximately 5% to 14% of the budget. The absurdity of the purchaser-provider split that underpins this is explained in another blog post.
Patient choice is written through the NHS reforms like a stick of Brighton Rock, but it is not the patient choice I have described above. Proponents of NHS reform talk about patients choosing where they will get their care rather than why those decisions are important or how they are made. The NHS reforms are built upon the naive theory that patient choice will drive up quality because patients will choose the best quality healthcare providers, forcing lower quality providers to improve their care or go bust through lack of business.
There are several practical problems with this theory, best summarised in a blog by Ian Greener, What would the NHS have to look like for competition to work?
More profoundly, if my patient chooses to have her chemotherapy close to where her children live so that they can help look after her, she has every right to expect the same standards of care in Southend that she gets in Hackney, because she is still being cared for by the NHS. She does not, and should not expect that her choice might lead to substandard care. The responsibility for quality, ultimately rests with the Secretary of State, which is why the duty to provide and secure NHS services must remain there and not be delegated to less accountable bodies.
But there is an even more profound objection. Patient choice, understood in the terms of NHS reform does not have an intrinsic value, it has a ‘utility, or instrumental value’. Instead of being integral to patient dignity and autonomy, choice is being used as a tool for quality improvement and cost containment. The philosopher Emmanuel Kant defined human dignity as the intrinsic worth of a person. Respect for dignity means that one should “Act in such a way that you treat humanity, whether in your own person or in the person of any other, always at the same time as an end and never merely as a means to an end”.
This report from the NHS Competition and Cooperation Panel states,
The over-arching theme was the belief that choice and information were the key drivers of competition and innovation in healthcare markets, improving patient outcomes and efficiency in patient care.
The Secretary of State, Andrew Lansley said,
Of course, patient choice implies competition…there are areas where there is already strong demand for more choice – such as community services. This is where we will begin to introduce any qualified provider
The Kings Fund produced a report last year, Choosing a high-quality hospital, the role of nudges, score-card design and information. It explored tools to make sure patients chose the best quality hospital.
The decisions patients ultimately make about their care can have profound consequences, and may involve personal factors that have nothing to do with the actual or percieved quality of care.They must be free to make choices that may go against medical advice. Furthermore most of their choices are about factors other than hospital quailty; convenience, past experience, personal values and the recommendation of friends or professionals are more important for most patients than objective assessments or league tables. For these reasons, patient choice is a poor proxy for quality and an unsuitable tool for driving change.
Patient choices are integral to dignity and respect and are at the heart of medical ethical principles and the doctor-patient relationship. This is why doctors are so sensitive to criticism that we do not care about patient choice. The reason so many of us who care for patients every day object so strongly to the way that patient choice is framed in the NHS reforms, is that patients and their choices are not being treated as ends in themselves, but merely as means to an end; they are to become subservient to the goals of market based competitive healthcare.
Patient choice and narrative ethics. John Launer. Choice isn’t what you think it is.
Patient Choice: Can Consumers Direct Healthcare? Excellent, detailed (73page) report
Government claim that patient choice saves lives is based on flawed research. Allyson Pollock and others. Link to original Lancet article.
Patients may vary in their desire for involvement in decision making in consultations. Doctors need the skills, knowledge of their patients, and the time to determine on which occasions, with which illnesses, and at which level their patients wish to be involved in decision making. Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes. BMJ
Responses to ‘your views: Choice & competition’ May 27 See: 6.41 etc http://healthandcare.dh.gov.uk/your-views-choice-and-competition/
Some ‘choice’ Andrew Lansley quotes: http://www.bbc.co.uk/news/health-11566123
Shared Mind: Communication, Decision making and autonomy in serious illness Brilliant article exploring the issues I have discussed in more detail.
Having more choices, on the surface, appears to be a positive development; however it hides an underlying problem: faced with too many choices, consumers have trouble making optimal choices, and thus as a result can be indecisive, unhappy, and even refrain from making the choice. Overchoice.
The Tyranny of choice, Salecl: “The idea of choosing who we want to be and the imperative to ‘become yourself’ have begun to work against us, making us more anxious and more acquisitive rather than giving us more freedom”
In a society geared towards the individual, and dominated by consumerism and celebrity, we are constantly encouraged to choose a better life for ourselves. The weight of each choice and the super-abundance of options can cause crippling anxiety and we defer to others to make the right choices for us. When we do get what we want, fulfilment is swiftly replaced by dissatisfaction and desire for a better option.
Barry schwartz “…what seems to contribute most to happiness binds us rather than liberates us”
Sheena Lyengar Ted Talk
Hposital outcome data is too flawed for patients to use it to make choices. Academic Health Economists blog.
2007 NIHR/SDO Research document http://www.sdo.nihr.ac.uk/files/adhoc/80-research-summary.pdf evidence from the USA suggests that vulnerable patients, including those from black and other minority ethnic groups are increasingly excluded as a result of extending choice (Klassen, 2002). Increased inequity is a risk unless the choice policy includes a means of targeting disadvantaged groups, including older people, those who are less educated, those on low incomes and ethnic minority groups, to prevent such exclusion (Health Link, 2004; Which?, 2005).