Liberating the NHS: greater choice and control - A consultation on proposals

COMMENTS ON DEPARTMENT OF HEALTH
LIBERATING THE NHS: GREATER CHOICE AND CONTROL: A CONSULTATION ON PROPOSALS

The Royal College of Physicians of Edinburgh is pleased to respond to this consultation on the important issue of generating improved choice and control for patients. Comments are referenced to the consultation questions and are largely restricted to the perspective of physicians on the services they provide within the acute care sector.

General Comments

The College supports the direction of travel in terms of patient understanding of and participation in their health care, but believes that the balance should be more heavily weighted to control than choice. The College is particularly concerned that the public may misunderstand that choice will not be readily achievable for emergency care for most patients.

The College has significant reservations about the ability of the NHS at this time to implement increased choice and strongly advises a tempering of expectations in this regard. Clearly the direction of travel has much merit but if poorly implemented will, at best, damage patient confidence in the NHS and may result in yet greater disparity between areas of England, adding to the postcode lottery so resented by patients generally.

Offering choice based on a range of (as yet) poorly defined performance and outcome measures increases false competition into the NHS. Whilst weaker teams would do well to learn from their more successful colleagues, competition between providers is risky when local services should be developed on a co-operative basis for the long term benefit of patients. Where, for example, will the future of managed clinical networks rest if patients have the option to chose freely and to change their choice midway through the diagnostic/care process?

Piloting the key changes will be essential in advance of whole scale adoption to evaluate the real impact on patient care of increasing choice in the ways proposed. The College also recommends that the very full agenda outlined in this consultation paper is prioritised, as the reforms signalled in the White Paper have great potential to destabilise the NHS and damage patient care through overloading the service with change at a time of financial pressure.

Points relating to consultation questions

Greater Choice and Control

Q.1:It would seem important for any patient to be able to access a menu or list of options with regard to choice and control over their care. This list will differ with local conditions or healthcare needs, and will also depend on whether these are initiated by primary care or secondary care. It will be challenging to offer the same treatment choices across England given that services can only be delivered in the same way in similar environments, namely urban versus rural areas, or where patients may live close to a choice of many hospitals or perhaps just even one hospital. Choose and Book has not yet provided equity of choice as expected across the country. For example, within one NHS Trust, there may be two or more hospitals where an initial out-patient consultation could take place. However, because this comes under the umbrella of one Trust, it is often difficult for the patient to choose the hospital nearest to them.

The College is anxious that choice could extend to prescription medicines on the basis of incomplete or misunderstood information and could drive up prescribing costs significantly if generic drugs are perceived as inferior by patients.

Choice of any willing provider

Q.2: The main priority for introducing choice would be choice of location for initial out-patient consultations and thereafter, routine elective care. This should extend to choice of location for planned longer term care eg renal dialysis.

Q.4: We can only help people have more choice if we supply them with information on waiting times, quality of care indicators and access to patient comments/reviews of care. Information will need to be presented in an appropriate and accessible format, designed to support understanding of performance and quality statistics, particularly the implications of comparable performance indicators eg the often quoted 50% of hospitals are below average. The risks of patient choice being influenced inappropriately by misinformation or mistaken interpretation of information are considerable. This is the subject of a twin consultation, to which the College has also responded.

Choice of diagnostic tests and measurements

Q.7: & Q.8: Patients should have a greater choice of location for diagnostic tests at all stages of their treatment, and this could include moving some diagnostic testing into primary care. However, healthcare providers must ensure that the quality of the test for a given patient meets that required for diagnostic purposes eg the correct size MRI magnet to diagnose a problem, which would avoid duplication of tests where insufficient data is gathered because the wrong machine is used at the location chosen by the patient. Inappropriate choices will add to costs and introduce diagnostic delay.

Equally important will be the time turnaround for test results and the need for secure information systems to ensure results are made available to the correct referring doctor. Greater choice of location risks loss of test results and delayed reporting, causing inefficiency and inconvenience later at outpatient clinics or other follow up.

Choice of consultant

Q.9: If patients wish to choose a named consultant lead for their care, health professionals need to review what information is made available to them to make that choice and be sure that this is accurate. If there is an imbalance of popularity of consultant-led provider, waiting list times will rise with the risk of other teams being potentially under-employed. Should this result in the reduction or removal of a team, the knock-on impact to other services must be considered lest it restrict patient choice further.

The question asks about choice after diagnosis and there is a risk of duplication of diagnostic tests if a patient selects a consultant-led team at a different provider, where preferred practice and/or availability of diagnostic tests may differ. Until such time as a clear national patient record system is well established, movement of patients between providers during episodes of care may be compromised by delayed or missing patient information. Similarly, encouraging choice to swap provider for follow-up care may be professionally complicated (however convenient for individual patients), particularly in cases of unexpected clinical complications.

End of life decisions

Q.13: This sensitive issue needs to balance patient choice with effective, appropriate clinical care, particularly in resuscitation decisions. Doctors are given very specific professional guidance from the General Medical Council in this regard and patient choice may, on occasion, conflict with this position and require consideration; for example if admission to an ITU has been refused on clinical grounds.

Taking responsibility for choices

Q.17: This is a wide ranging issue, and the College understands that drawing the attention of the general public to responsible use of the NHS and their personal responsibility for their own health has been attempted before in such projects as Patients’ Charters. Offering and delivering increased patient choice may encourage compliance and greater awareness of lifestyle choices, but supporting evidence is scarce and piloting would be advisable. Requiring a patient signature for a test and/or course of treatment may help reinforce their decision and obligations, particularly as expanded choice will begin in elective care.

Q.44: The development of patient budgets has the potential to increase personal responsibility for choice but the implications of exhausting these budgets must be considered and made clear to patients and their clinical advisers. The position of this question within the consultation paper implies this option will be available for selected (probably community based) care only in the first instance and should be evaluated carefully before extension.

Delivering more personalised choices

Q.18, Q.19 & Q.20: A central issue when considering the ability to promote greater dialogue and discussion with patients to ensure care reflects ethnic, religious or other background is consultation time. If healthcare professionals are to respond to complex issues with regard to choice and involvement of carers and families, they need more time in the consultation process. Both primary and secondary care consultations are still in many places rushed affairs. Although some of these issues could be absorbed in the jobs of other health care professionals, the main load is still likely to fall upon doctors and the Department of Health needs to recognise the increased cost in terms of consultant hours in the system.

Q.21, Q.22 & Q.27: Many clinicians are already very skilled in gauging how much involvement their patients wish to have in their healthcare. However, to support this development, in addition to consultation time, an educational support system would need to be put into place, to re-skill healthcare professionals in supporting the choices of their patients and engaging their patients in decision making as the norm. The design and content of such a programme will need careful consideration. and the College would be keen to participate in further discussions to support to the current cohort of consultants and speciality doctors and to review the curricula for trainees.

Q.23: Where a doctor disagrees with a patient over their choices, it may be difficult for a constructive relationship to continue, and both may benefit from referral to another team. To require a doctor to continue to support a patient after a fundamental disagreement over an important aspect of care could be counter-productive.

Decision Aids

Q.35: Decision aids can be helpful for some patients, but Fellows report that the example given is very simple, and many patients will be faced with much more complex circumstances and require additional information to address their needs beyond what may be easily included within a decision aid. Generic information providing context as produced by voluntary sector support groups can also be useful.

Information about research studies

Q.36: The College is strongly supportive of efforts to encourage patients to agree to participate in ethically approved and well run research studies. Patients need to be aware at the Choose and Book stage of the general level of research activity of their preferred provider, allowing patients who would prefer not to participate to avoid such providers. Providers should also promote the benefits to the general population and to individual patients of participation in research.

Choose and Book

Q.37 & Q.40: Many Fellows of the College have significant reservations about the benefits for patients of the current system. Clearly, the availability of real choice varies with area and in central London Choose and Book has greater potential than in other parts of England where there may be only a single provider within reasonable geographic distance. This presumes that patients will continue to focus on location as a major determinant of choice, as has been the case previously.

The College understands that many GPs prefer the option to refer to a named team rather than a service, accepting the need to match style and approach in addition to outcomes and waiting times. However, the management teams at provider units will struggle to deliver waiting time guarantees if there is limited opportunity to (re) allocate referrals between teams.

Getting the right urgent care

The consultation document appears to announce the decision to establish a new emergency number (111) as an option for patients seeking urgent but not life threatening care. There are mixed views on this issue with some believing this to be a retrograde step, introducing further confusion into the system for patients at an anxious time and potential delay in accessing the emergency services for life threatening conditions. Others, however, are aware of evidence from other healthcare systems that demonstrates the benefit of another easily remembered number. A helpline for patients requiring advice on how to access a GP or the out-of-hours service in their area may be a useful alternative.

Extending patient choice to unplanned/urgent care is a logical next step but will require extensive piloting and may not be deliverable in many areas of England, particularly in the more rural parts of the country.

Implementing choice fairly

Q.45: The question of travelling and accommodation expenses for more distant choices will influence equity of opportunity – patients may opt for their local provider for convenience and cost reasons, and those on higher incomes or eligible for travel reimbursement through the benefits system may have a greater choice.

Commissioning for Patient Choice

Q.41-Q.43: This is a particularly difficult area, in terms of balancing the needs of new GP consortia to commission services for their patients and delivering choice well beyond their known catchment area. In larger urban conurbations where choice may be more feasible there may be more demand from patients, but the College has to question the added value of requiring all willing providers irrespective of size and location to register detailed information on a central directory to support commissioning. Is such information intended to be in the public domain, offering unlimited choice to individual patients and binding the commissioning strategies of consortia? The creation of appeal bodies for patients who believe they have been denied choice will be necessary and will further add to the administrative burden on commissioning consortia. Individualised care and choice is aspirational and will bring significant administrative workloads at a time when government is planning to reduce management and administrative layers within planned efficiency savings.

Financial affordability and risk

Q.47 & Q.54: The College is concerned about duplication and inefficiency through inappropriate referrals, poor information systems and changes to provider mid-way through care. All are current problem areas, and increasing choice and mobility of patients will add to this risk in the absence of significantly improved information systems and administrative resources. Choice cannot become a reality without significant investment in information systems and creating the time for healthcare professionals to support patients in understanding their options fully and the consequences of the choices they make.

Also, as stated previously, open choice will inevitably lead to less popular teams becoming under-employed and less financially viable which, in turn, will reduce choice both within that service and potentially in other linked areas of care. It is difficult to understand how the Department of Health can prevent this, especially if the right to choice becomes enshrined in legislation.