Andreas Whittam Smith: The myth of patient choice

What is true and good about the White Paper is that it heralds a big improvement in the sensitivity of the NHS to patients' needs and views
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I visit my local hospital once or twice a year for an examination by a senior consultant. When I arrive, I often glance at my watch to see how long I shall have to wait before I am seen – not because the process is usually slow but because it is amazingly quick. What would I do if my esteemed consultant were to leave? According to the White Paper on reforming the National Health Service published earlier this week, from April next year I shall personally be able to choose a "named consultant-led team" where "clinically appropriate".

It is not always easy, however, to compare one product or service with another. Financial plans are an example. Few people can make informed decisions as to, say, which pensions arrangement or life assurance policy best suits their needs. Even past performance is an unreliable guide. I don't believe it would be any easier to choose between different providers of medical services. I would prefer the Government to say – "look, choice is difficult so far as health services are concerned, but we think we can make it work" rather than just repeat the mantra "choice is good".

In any case, do not worry, says Mr Lansley, the new Secretary of State, the Government is going to provide lots of relevant information. It will amount to an "NHS information revolution". In the hypothetical circumstances I describe above, what would I need to know in order to choose a "named consultant-led team"? I should have to decide whether to accept whoever takes my consultant's place or to move to another hospital. Under Mr Lansley's plans, I should be able to read a report that would describe how patients and families had rated departments according to the quality of care they had received. I should also be able to study a risk-adjusted assessment of the performance of my local team against its peers. However, this "risk-adjusted" assessment might conceal a trap. Supposing a rival hospital did as well as it could with outdated equipment. The "risk adjustment" would take account of this difficulty and would give the team a good mark. Yet I would never know that the equipment needed updating.

Faced with similar complexity in other walks of life, recourse is often had to an agent or to a professional adviser. In financial services that might be an insurance broker or a stockbroker, or in other circumstances, it might be a solicitor. In health services, isn't my family doctor the agent or advisor I require? I turn again to this week's White Paper.

There I read "consortia of GP practices, working with other health and care professionals, and in partnership with local communities and local authorities, will commission the great majority of NHS services for their patients". Every GP practice will have to be a member of a consortium. These will have huge budgets, calculated practice by practice. Rather than agents or advisors, my GP practice and the others to which it is joined in a consortium will more resemble another form of business, which is wholesaling. For the consortia, Mr Lansley's information revolution is essential.

Nonetheless, a later passage in the White Paper suggests that the Government has limited faith in the GP consortia. For it will allow them to hollow themselves out. They will be able "to decide what commissioning activities they undertake for themselves and for what activities (such as demographic analysis, contract negotiation, performance monitoring and aspects of financial management) they may choose to buy in from external organisations, including local authorities, private and voluntary sector bodies". Actually, there isn't much left to the business of being a buying consortium if you don't negotiate contracts, monitor performance or manage your own financial situation.

Let us go back to my problem. If my trusted consultant were to move elsewhere and I decided to use my freedom of choice to find a replacement, how exactly would it work? I would most likely carefully study the new material on the performance of individual consultants and hospitals that is to be made available. But I strongly suspect that I should doubt my judgement. I should like to have some experienced advice. But when I turn to my family doctor I would find that the practice has become part of a buying consortium that may or may not have put out most of the work to third parties.

So I imagine going down the road to see my GP. My doctor has no experience of bulk buying, though he now bears some responsibility for the activity. He doesn't know what it means to be an agent who carries out business on behalf of his client. He is just an ordinary family doctor who does the work for which he has been trained as conscientiously as he can. I enter his room. He has far too many patients to remember anything about my circumstances and he starts to glance at the file to refresh his memory as I sit down. I tell him that I wish to exercise my right of choice but that I require some help. I am relying on a further passage in the White Paper: "GP consortia will have a duty of public and patient involvement, and will need to engage patients and the public in their neighbourhoods in the commissioning process."



'Ah, yes", I think he would say, "that is true, but what it means is that the consortium itself carries out local surveys of patients' needs and experiences, and that is what it relies on. We are not involved in any of that in this surgery. And as the consortium to which we belong is bulk buying, it cannot reflect individual requests. I am sorry but I cannot help you. The consortium is purchasing the service you require from Hospital X and that is where you should go."

I should have no choice. Nonetheless, what I think is true and good about the White Paper is that it heralds a big improvement in the sensitivity of the NHS to patients' needs and views. There will be some validity in the assertion that the headquarters of the NHS will be in the consulting room and clinic rather than in the Department of Health. On the other hand, I strongly suspect that choice in the sense of individual patient choice will prove to be a myth. The Government won't be able to make it work and I hope I don't have to discover that for myself.

a.whittamsmith@independent.co.uk

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