I’ve written a great deal in this blog about the problems with patient choice (for example, http://t1ber1us.wordpress.com/2011/07/19/the-trouble-with-healthcare-choice/), but thought it necessary to make it clear that I’m only against certain kinds of patient choice, and that’s only because I don’t think they work.
It seems to me that the present reforms, despite claims otherwise in the White Paper, are making the same mistake as Labour made in focusing too narrowly on choice of provider when being referred by GP. It is possible that they also want to be concerned (again, as were Labour) with getting patients to choose GPs more carefully too.
This is a pretty narrow conception of choice – it is trying to get secondary providers and GPs to raise their game by being threatened by what Hirschman referred to as ‘exit’ (http://www.amazon.co.uk/Exit-Voice-Loyalty-Responses-Organizations/dp/0674276604/ref=sr_1_1?ie=UTF8&qid=1314132333&sr=8-1). When faced with a market-like situation, we have three options according to Hirschman – exit, voice and loyalty. Exit is what happens when you go somewhere else (choose another GP or secondary provider), voice is when you try and get them to change their ways, often by threatening to leave or complaining, and loyalty (which he was admittedly a bit vague on) is when you decide to stick with your present provider.
Hirschman suggested there are considerable dangers in situations where choice is strong and voice is weak, as those that can easily move will do, and those that are left don’t exercise voice to improve things. I can imagine poor health providers being in a situation where the vocal middle classes don’t want to go to them, or to complain when they can easily move somewhere else. I know of schools that are a bit like this.
There are other problems specific to healthcare. Can you imagine threatening a GP with exit? Or you hospital consultant? Seems pretty anachronistic to me. I think most GPs and consultants are trying to do a good job and treating them in a transactional way isn’t going to help. This is made all the more silly because most GPs aren’t exactly short of patients, and most hospitals hardly short of demand for their services – an individual patient making threats isn’t going to cut much ice.
Voice tends to work better – you explain what the problem is and give the clinician a chance to fix things. This feels intrinsically more possible, but let’s be honest, the NHS has a terrible track record on complaints especially. This is an area where the NHS needs to do much better – but it’s not as if private healthcare is much better at dealing with complaints either so I’m not sure there is much to be learned there. But the NHS does need to improve in terms of voice mechanism, and wasn’t helped by Labour changing the way this was supposed to happen every couple of years (http://www.sdo.nihr.ac.uk/projdetails.php?ref=08-1808-245), or by the confusion over this in the present reforms.
Loyalty is about sticking with a relationship, and ideally a long-term commitment from both parties to get it to work. That seems more what I’d like my relationship with clinicians to be like. However, there are issues in terms of continuity of care even in GP surgeries, and both sides have to be making an effort for it to work out. But fragmenting services and putting them on a transactional basis favouring threats of exit, as the present reforms seem to want to, isn’t going to achieve this.
However, we can achieve loyalty by thinking about the way clinicians interact with patients. I wrote yesterday that what we can learn from CAM is that giving patients time and space can lead to good outcomes even if they underlying treatment doesn’t have much merit (http://t1ber1us.wordpress.com/2011/08/22/complementary-and-alternative-medicine-and-the-nhs/). How much better if we can be more patient focused and have solid treatment to back it up?
Taking a bit more time and care is also the way choice can be offered in a positive way. People want to understand their treatment options, to be consulted and for their wishes to be considered, even if they take the GP or consultant’s word about what it best at the end. It isn’t choice of provider that people want, it’s to be consulted, reassured and to be sure they are getting the best treatment.
So perhaps choice is the wrong word here. Choice is now to associated with provider choice, when it works best when being placed in a respectful and caring consultation. Good GPs and consultants know that already, and get the loyalty they deserve. Trying to put relationships like that on an exit-based, transactional level misunderstands the nature of healthcare.