This essay investigates how patient choice in the NHS has been developed by New Labour and coalition government. I will do this by first defining the term ‘choice’ and then providing some background information on the emergence of choice agenda under the 1979-1990 government of Margaret Thatcher. . I will then go on to discuss how patient choice has been developed under the New Labour and coalition governments that followed by discussing the reforms that both have implemented in relation to the patient choice agenda. Finally, I will examine the uptake of patient choice agenda. This is likely to include patient travel distances in order to access better and faster healthcare, as well as the performance ratings of hospitals, which are published online and so available to the public to use. However, people that live in certain areas in the UK tend to have a somewhat limited choice of medical care providers. Overall, choice empowers the general public, offering them the ability to make autonomous decisions about their health-care providers and likely to improve the health outcomes of the British people.
The patient choice agenda outlined above relates to offering patients a choice among various types of service providers in the NHS analogous to that of the private healthcare market . Central to it is the notion that without competition, there is no real choice, and therefore a choice among competing options is offered which is intended to improve quality and efficiency. This market discipline will motivate less competitive healthcare providers to upgrade their services to attract customers while giving customers a wider range of options (Le Grant, 2007). Thatcher Government (1970-1990) developed patient choice in order to create a dynamic market-orientated system in the NHS. She intended to introduce this form of internal market as a means of increasing efficiency and to develop the NHS into a more business-type model (Driver and Martell, 1998).Thatcher’s administration intended to achieve these changes though the adoption of a privatisation scheme focused on providers and purchasers. The idea of patient choice derived from the fact that GPs exercised choice on behalf of patients.
Extending the choice agenda aims to eliminate or minimise the healthcare inequalities faced by less affluent patients, to whom it offers equal opportunities of services (Dixon and Le Grand, 2006). In 2005, MORI reported that 50 percent of the general public preferred to select healthcare providers outside of their local areas, which was something that the NHS had not provided for in its original manifestation (Popper, Wilson and Burgess, 2005). Thus, a large proportion of the general public clearly favours the idea of being able to select alterative healthcare providers.
However, merely increasing patient choice may “not successfully eliminate inequities” (Oliver and Evans, 2005, p. 68). Certainly, offering choice to the general public is less likely to improve inequity if non-existent varieties exist within the uptake of choice. Wealthy patients have resources to opt for private healthcare providers if they believe that their local providers offer poor quality of services and low rating (Davies, Tavakoli, Malek, 2001). Therefore, the idea of equal access for meeting the equal needs of all people has failed.
New Labour accepted the neoliberal model that had been developed by Thatcher’s administration during the 1980s and further developed by the Major government of the early-mid 1990s. In 1997, with New Labour’s ascent to power, patient choice was increased with some important reforms that promoted the patient choice agenda, including the establishment of Foundation Trusts (FTs) and the rating system (Driver and Martell, 1998). These reforms aimed to produce cheaper, better quality services by incentivising healthcare providers to compete for funding that equated to the number of patients they treated (Peck, 2003). Another reform introduced was ‘Payment by Results’, which pays secondary care providers using a standard fee tariff linked with the amount of patients treated. This reform enabled patient choice upon referral from GPs. Thus, this conception of the choice agenda served to improve waiting list times and the quality of services offered. Lastly, the government put in place a targets system that measured the uptake of choice. The government also shifted the focus from competition while continuing to promote the business model by promoting partnerships between healthcare providers (Peck, 2003).
In order to promote real choice, the market is obliged to offer alternative providers of goods and services (Smith, 2005). Private healthcare providers have operated within the internal market since 1948, providing their services at a standard tariff (Peck, 2003). The internal market that was operated under New Labour was less focused on competition, but rather towards promoting the efficiency and quality of services. Davies, Tavakoli, Malek (2001) argue that patients opt for private healthcare providers over public healthcare providers when they are able to because private providers offer good service quality. In general, patient choice tends to enhance competition among providers, who strive to attract customers in the way that any other private firms do.
Private healthcare providers generally cover limited, mainly non-emergency services and as private businesses, are primarily focused on making profits. Therefore, private providers cost more than services offered by the NHS and hence this market attracts wealthier competitive patients (Le Grant, 2007). Middle class patients are likely to select private providers because material resources are not an issue.
In the 2010 White Paper, Equity and Excellence: Liberating the NHS, the coalition government set out to promote patient choice by introducing a commissioning board to the NHS. The Commissioning Board monitors the performance of primary care providers to ensure that high standards of service care are offered and that patients are involved in decision making as much as possible. The Commissioning Board is also responsible for improving equity within healthcare. Finally, the government seeks to promote patient choice though increasing competition among medical providers. Under the Foundation Trusts obtained the role as regulators that supervise tariff costs and encourages efficiency.
Despite these developments, the fact remains that choice is not real possibly for patients living in certain areas of the UK (Spiers, 2008). People that live in rural area are likely to be excluded from selecting their healthcare providers. One of the reasons for this is that less affluent patients are less motivated to travel greater distances due to car ownership being lower among disadvantaged groups (Appleby and Dixon, 2004). Some people in low-paid employment are also unable to take time off from work to seek medical attention, preventing them from further exercising choice. Additionally, people travelling long distances tend to have poor attendance records for primary care appointments. A study conducted by RAND in 2008 also shows that age, gender and social class differences can serve as obstacles to people in exercising choice, while people over the age of 60, housewives and the working class tend to limit their travelling distances for providers (both primary and secondary care (Powell, 2008). Hence, gender, social class and age are found to be important factors that determine the uptake of choice for healthcare providers.
Affluent patients often have resources to purchase houses in areas near to good-quality healthcare providers. However, Popper, Wilson and Burgess (2005) argue young, affluent patients and those living in inner city areas of London are likely to opt for alternative healthcare providers, whereas disadvantaged patients with low levels of education are found to opt for alternative medical providers the least. Certainly the uptake of choice among less well-off patients would be more likely to improve if subsidised transport were offered to people and covering additional transport funding incurred by people who are not located close to alternative providers. Thus, an effort to improve these issues may encourage poor patients to travel longer distances to have their treatments.
Another factor is the lack of available information, which can prevent patients from exercising choice over medical providers (Fotaki, Roland, Boyd et al., 2008). It is believed that some people require additional support in their choice of healthcare providers. Often, less well-off patients, those with low levels of education and the elderly require supplementary assistance in order to be able to make effective choices (Powell, 2008). These types of groups are less likely to have access to the internet and friends working as medical professionals in the NHS to help them navigate the system. However, making use of internet sources have been criticised for being resource-intensive and a real problem for those who are not computer literature.
Published data is a key element for choice and outlines the performance of various healthcare providers. Making use of this type of data can serve to make patients more autonomous and responsible for their own health (Davies, Tavakoli and Malek, 2001). In general, healthcare providers’ services are rated using ranking systems. With their reputations at stake, medical providers are motivated to improve the quality of their services in order to remain in business. Often, disadvantaged groups use performance data more than middle class people to make healthcare choice (Collins, Britten, and Ruusuvuori, 2007). A lack of available data though is a major factor preventing them from exercising their choices.
The patient choice agenda aims to lead to inequality in the medical system. Appleby and Dixon (2004) claim patient choice agenda in healthcare is far more complex rather than just focusing solely on resources. Poor people tend to lack the self-confidence and knowledge to converse with healthcare providers in a medical vocabulary
. Oliver and Evans (2005) state patient’s poor abilities of expression create imperfect freedom of choice in decision-making amongst individuals. Hence, these issues lead to an “unequal ability to navigate the system” (Mandelstam, 2007, p. 109)
Providing people with choice rather than voice to express tend to be more effective for less well-off patients (Barr and Fenton, 2008). The patient choice agenda offers disadvantaged groups the opportunity to be heard and promotes the necessary self-confidence to exercise choices, in parallel. Thus, choice empowers patients who are the least knowledgeable about how to use the system to their advantage. Middle class people, on the other hand, have the educational capacities, resources and skills to manipulate the system in a way that suites their interests (Spiers, 2008). Certainly, affluent patients are more proactive than less-well of patients in relation to the uptake of choice. Hence, privileged patients are more articulate, confident and persistent, which means that the system in its current form suites privileged patients over poor people.
The impact of patient choice on health service delivery provides mixed views. Patient choice may improve the quality of services offered in the internal market in response to waiting list times, which it may also markedly reduce (Le Grant, 2007). GP fund-holders can improve waiting list times upon referral to hospitals and may also reduce prescription costs. An example that illustrates this capacity is found in a study conducted by the London Patient Choice Project during 2006 (Dixon and Le Grand, 2006). This study states that patients are inclined chooses for alternative providers in order to reduce waiting list times. Certainly, competition, along with large numbers of healthcare providers, may further reduce waiting list times.
However, patients dissatisfied with services offered by medical providers can opt to search for alternative medical providers that meet their needs. Under the internal market, money dictates the choices that patients make, meaning that hospitals lose money if patients choose alternative medical providers (Dixon and Le Grand, 2006). Thus, healthcare providers must be responsive to consumer demands in order to remain in business, unless they are likely to face closure.
Patients often empower medical experts to decide on their treatments because of the generally held view that the “doctor knows best” (Burge, Devlin, Appley, et al., 2004, p. 190) Often, patients shift choice into the hands of doctors, particularly in life-threatening situations. In such serious situations, medical staff are likely to decide on treatments on behalf of patients. Therefore, the choice agenda in this case is not taken into account. However, Popper, Wilson and Burgess (2005) suggest that seven out of ten patients prefer to relocate treatment choices to primary care providers. This example tells us that people like the idea of having an input in relation to deciding on medical providers.
In reality, GPs are seen as the “gatekeepers” for making medical choices (Powell, 2008, p. 77). They act as agents for the patients, and are often empowered to select treatments on their behalf, thus undermining the ability of patients to exercise choice. This happens because of people tend to have limited skills and access to information that could otherwise inform them of the various treatment options available. As mentioned above, middle class people are often also better informed of premium treatments options, usually having better access to the internet and sources such as books and journals that inform them of the various treatments available. People with lower levels of education do not generally have access to journals and books which would allow them to make meaningful choices. The London Patient Choice Pilot study (in 2008) on the other hand, contradicts this view. This study claims that the up-take of choice among people with various levels of education has little significance, with only a two percent difference between people with various levels of education with regard to looking for hospitals that provide treatment (Spiers, 2008).
In conclusion, middle class people benefit from the choice agenda to a far greater degree than the working class. Middle class groups have higher levels of income, which allow them to purchase houses near good-quality medical providers. In addition, the middle classes have access to information and money that enables them to travel further in order to have access to the best services. It must also be questioned as to whether patients want choice rather than just high overall quality, as most patients like the idea of a good local medical provider (both primary and secondary providers), rather than travelling longer distances to have their treatment.
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