Policy responses and statements
- Name of organisation:
- Department of Health
- Name of policy document:
- Liberating the NHS: greater choice and control - A consultation
on proposals
- Deadline for response:
- 14 January 2011
Background: The Government's White Paper,
Equity and Excellence: liberating the NHS sets out proposals which
envisage a presumption of greater choice and control over care and
treatment, choice of treatment and healthcare provider becoming the
reality in the vast majority of NHS-funded services.
This consultation explains the proposals in more details and seeks
the views of patients, the wider public, healthcare professionals and
the NHS on:
- Proposals for offering more choice for patients and service users
- How shared decision making can become the norm
- How it can happen: information, 'any willing provider' and other
tools
- Making safe and sustainable choices
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.
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[14 January 2011]
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