1. Choice and
Health Inequalities
Frances Blunden
Principal Policy Adviser, Which?
Socialist Health Association
28 February 2006

2. Choice: panacea or death knell
• Arguments in favour of increased choice
— Fundamental to a patient-centred NHS
— Modernising the NHS
— Driving up standards in the NHS
— Providing more flexible and personalised healthcare
— Empowering patients and increasing autonomy
— Guaranteeing support for NHS from all sections of society
— Reducing inequalities
— Encouraging a more active role in healthcare
• Arguments against increased choice
— Privatisation of the NHS by stealth
— Increasing inequalities
— Choice is irrelevant
— Unwanted burden at a time of stress
28 February 2006

3. Choice and healthcare
• Choice fundamental to healthcare
— Informed consent is the legal and ethical basis for any treatment
— Health is deeply personal
— Our reactions to ill-health and our health needs are particular
— We want to retain some control over our healthcare
• Choice in healthcare is not new
• Health needs are unpredictable
• Huge information asymmetries
• Impact of choices significant
• Consumers lack the confidence to make many healthcare choices
• Choice has to be about more than just elective care
— Choice of GP, treatments, appointment times
28 February 2006

4. Government proposals for choice
• Increased choice in elective acute care
— Patient choice pilots 2002 for patients waiting longer than 6 months
— “Choose and Book” December 2005
• Increased choice in primary care
— Choice of GP and GP practices
— Widening range of primary services eg Walk in clinics, minor injuries
units and expanded NHS Direct
— Enhanced roles for existing health professionals
— New services and new professionals in primary care
• Increased choice about medicines
— Reclassification of medicines
— New prescribers
— New ways of dispensing medicines
• Increased choices about treatment
28 February 2006

5. Proposals associated with increased choice
• Diversity of providers
— Increased capacity
— New providers
— Increased use of the private sector
— New roles for health professionals
• Contestability between providers
• New systems of funding NHS care
— ‘Payment by Results’ fixed national tariffs for NHS funded care with
the funding following the patient
— Practice based commissioning
28 February 2006

6. Consumers and healthcare choices
• Attitudes to choices about healthcare vary significantly
between individuals and different circumstances
— Not all consumers have the same capacity or desire to make choices
— Consumers want some choices and not others
— Consumers want choice sometimes and not at others
— The desire for choice may be modified in reality
• Not all consumers have the same opportunities for choice
• Not all consumers have the same ability to make choices
— Access to information and support vital
— Tailor to the needs of particular groups
• Not all consumers have the same ability to take up choices
— Rural areas
— Low income consumers
28 February 2006

7. Do consumers want choice?
• Demand for some sorts of choices, particularly to give:
— Convenience
— Control
— Continuity
— Flexibility
• Prompt diagnosis and treatment is more important than choice
• Proximity is key
• Quality and safety are assumed as given
• Consumers find it difficult to conceptualise what is meant by ‘patient
choice’
• Consumers lack confidence and experience in making some choices
28 February 2006

8. Existing experiences of healthcare choices
• Existing experiences of choices about healthcare are limited
— Previously few opportunities for choice
— Choice of GP practice most common
— Only 12% had a choice of different hospitals
• Little awareness of government proposals to increase
opportunities for patient choice
— Limited knowledge of ‘Choose & Book’
— Patchy knowledge of new facilities and services
— Limited understanding of enhanced roles for nurses and pharmacists
in primary care
• Health professionals can facilitate or frustrate choice
28 February 2006

9. Impact of choice on health inequalities
Both positive and negative:
• Access to choice for some for the first time
• May exacerbate existing inequalities in health & access to care
• Potential to create new health inequalities as a result of:
— Inequalities in service provision and quality
— Choice not offered equally for all services & conditions
— Opportunities to make and take up choices are unequal:
— Patients with significant healthcare needs
— Conditions & treatment needs
— Rural areas
— Patients who choose not to choose
— Patients whose GP does not offer choice
• Higher costs of choice for some communities
28 February 2006

10. Payment by Results – access and equity
• Incentives to cherry-pick
• Providing care to the tariff
• Providers chosen by more complex patients
• Providers serving deprived communities
• Providers with higher costs
28 February 2006

11. What’s needed to make choice work?
• Choice must be part of a wider, strategic policy framework
— Market-based approach not enough
— Priority must be given to clinical need
— Limitations of the private sector
• The right choices must be in place
• Sufficient resources and capacity in the right places
— Market mechanisms will not generate capacity to meet all needs
• Measures to guarantee safe and effective services
• More fine-tuned system of funding care
— Recognition of cost variations for different patients & providers
— Financial safety net
• Information and support
• Targeted measures to address inequalities
28 February 2006

12. Information and Support
• Improved range of information and at the right level of detail
— What services are available? When? How to access?
— Quality of services including waiting times, outcome data
— Relative risks of treatment
— Qualitative data
• Improved quality of information and how it’s presented
— Up to date
— Tailored to needs
— Different formats
— There is more than just the Internet
28 February 2006

13. Measures to address inequalities
• Choice must be offered equally and consistently to all
• Priority based on clinical need
• Positive measures and resources to guide consumers unused to
making choices through the process
• Support vital for many people to make and take up choices
— Patient Care Advisers
— Time with GPs and primary care professionals
— Help with travel
• Safeguards for consumers who choose not to choose
• Guidelines to achieve greater consistency in GP referrals
• More positive engagement of GPs & other primary care
professionals in the process
28 February 2006