What happened to patient choice?
The debate on competition in the NHS continues to be a source of ongoing controversy. Recently there has been a lot of focus on the impact of competitive tendering in increasing the role of alternative providers. While some commentators have argued that the Health and Social Care Act meant the NHS have been forced to put all services out to tender, as a BMJ analysis demonstrated only 6 per cent of contracts in 2013/14 were subject to competitive tender. Yet the ambition of the Coalition’s reforms was not necessarily to increase “competition for the market” through tendering but to increase “competition in the market” through patient choice.
From one perspective the number of patients exercising choice for elective care appears to be increasing. Since 2010 the volume of activity undertaken by non-NHS providers has continued to grow. Under the last Government, reforms were introduced to give patients more choice on where they receive elective care and in 2009 the right to choose was enshrined in the NHS constitution. The latest quarterly hospital activity data shows that the volume of GP referrals to private providers has increased from 4 per cent to 6 per cent between 2011 and 2014. Yet the role of the private sector is greater in certain service lines. For example, orthopaedic and trauma (O&T) services represent 38 per cent of all privately provided hospital activity to the NHS. According to monthly waiting time data in December 2014 the independent sector provided over 10,000 O&T procedures to the NHS, a 56 per cent increase since December 2011. The independent sector’s market share of O&T procedures has increased from 15 per cent to over 20 per cent during this period.
In choosing to use a non-NHS provider patients could be considering a range of factors, such as perceptions of quality and patient experience. In an analysis of Patient Reported Outcome Measures data by Chris Cook for the BBC it was found that patients receiving a hip or knee replacement are more likely to experience better care from private providers as opposed to NHS ones. However in most cases patients make shorter waiting times a key priority when choosing their healthcare provider. Certainly independent providers have continued to outperform NHS providers against 18 week targets for treatments and patients could be exercising their choice to receive care with providers that offer the shortest waits.
But from other perspectives the record on patient choice this Parliament is more mixed. Since the National Patient Choice Survey was cancelled in 2010 it has been very hard to assess the state of the choice in the NHS. The last survey found that 54 per cent of patients were aware of their right to choose where they receive their first outpatient appointment, while 49 per cent recall being offered choice by their GP. By contrast in the first survey in 2006 only 30 per cent of patients were aware of their right to choose and 29 per cent recall being offered a choice. With choice being measured it was unsurprising that the NHS felt incentivised to work with GPs to ensure patients were being allowed to choose. In the new NHS there is a clear commitment to embed a patient’s right to choose at a national level, yet there is no longer a regular assessment of where choice exists. A small survey commissioned by NHS England in 2014 found that while the awareness of choice had plateaued since 2010, the number of patients that recall being offered choice had fallen to 38 per cent.
The availability of other choices appears to be more mixed. As well as choosing where they have their first outpatient appointment patients also have the right to choose another provider if they have to wait longer than 18 weeks. Yet this right is something of a black hole in the NHS and no data exists on how many patients are offered a choice if they have to wait too long. Given the growing number of people waiting to receive care in NHS hospitals many could possibly benefit from the opportunity to “choose again”. Yet with the small number of patients transferring to the independent sector (one analysis found that private providers cared for 8 per cent of patients waiting longer than 18 weeks in Q2 2014) it is likely that awareness of this right to choose is very low. Since 2012 patients have also had greater choice over some community services such as hearing care. However a recent Monitor report found that 90 per cent of patients did not recall being offered a choice of hearing care provider. Fewer than one in four patients were aware that choice might be available. Monitor also found that GPs were often unaware of the ability for patients to choose provider, had limited knowledge of the options available or felt confident in making the choice on behalf of the patient.
So why do so few patients get offered a choice? While the NHS Mandate and Monitor’s competition rules set requirements for commissioners to allow patients to choose, in practice it is up to commissioners to promote choice among patients. Monitor has suggested various mechanisms CCGs can use to promote choice such as patient choice surveys, monitoring referral data, providing information to GPs on the different providers available or publishing information on which GPs routinely offer choice. Yet the appetite and approach to using choice can be quite mixed. A recent investigation of patient choice in Blackpool and Fylde and Wyre found that these commissioners were not doing enough to promote choice but it is far from clear if other CCGs have taken more effective steps. Certainly, there is evidence of a mixed appetite among commissioners to promoting choice. Some CCGs have claimed to be anxious of the effect choice has on equity of services, the sustainability of local providers or on overall costs if choice creates extra demand. While Monitor’s “case by case” approach to investigating choice in different parts of the country is highlighting specific problems, what is needed is a strategic assessment of how all commissioners have gone about promoting choice to identify the recurring barriers and opportunities.
The recent Five Year Forward View stated the desire to “make good on the NHS’ longstanding promise to give patients choice over where and how they receive care.” Patient surveys for elective and community care showed that large numbers of patients of all age groups value their right to choose where and how they receive NHS care. Monitor’s report on hearing care also demonstrated that choice allowed new providers to enter the market, potentially delivering treatment at 25 per cent of the cost of incumbent providers. Reintroducing the National Patient Choice Survey would help the Department of Health and Monitor more closely performance manage the extent to which choice is offered. A further survey could also assess how many patients are offered a choice of an alternative provider if they wait longer than 18 weeks. As well as more effective measurement of where choice exists in the NHS, Monitor and NHS England could set more demanding requirements on CCGs to produce plans on how they will promote choice locally. While some CCGs have launched campaigns to promote choice, many have not.
In recent months the debate on competition has become narrowly focused on the headline figure on the total value of private sector activity in the NHS. But without hard numbers on how many patients are offered choice it is hard to have a more meaningful discussion on the role of competition in the NHS. In the next Parliament policymakers should not seek to actively manage the volume of private sector activity, but the extent to which patients are offered a choice in the first place.