exo : blah

Apropos of the recent NHS White paper (CMS geeks check the URL) I was thinking about choice. Mostly I wonder about how much people actually want choice in their healthcare and if it does any good.

So I did something I've never done before and read the white paper. It's fairly clear, not too long and reasonably free of jargon which was a pleasant surprise. It also answered some of my questions in that it says in footnote 22 that

The 2009 British Social Attitudes Survey shows that over 95% of people think that there should be at least some choice over which hospital a patient attends and what kind of treatment they receive

Sadly the 2009 British Social Attitudes Survey appears not to be online and I can't find the same question in the 2008 edition. That may just be me not being able to navigate the rather old school website.

It also pointed at a few papers that show positive results for patient outcomes when the patient is involved in choosing their care. Impressively in section 2.3 we have one footnoted study which says in the abstract that "Patient-centeredness was associated with better outcomes and higher cost" followed shortly afterwards by the claim that involving patients in their care "can also bring significant reductions in cost, as highlighted in the Wanless Report". I point this out more as evidence that anything involving healthcare is complex and likely to involve conflicting evidence. There's clearly some evidence for the notion that choice can be a good thing though. I'm not even close to being well versed enough in such matters to know how to reach a conclusion if there's more evidence for or against though. Probably I should read the Wanless report but one government document a day is my limit.

Still, it seems there is some indication that people want choice and that is might be a good thing. It's certainly reasonably hard to argue against the notion that providing people with information about their care and getting them involved is a bad thing.

Of course the issue with choice is that it's pretty useless unless you understand the choice you are making. In order to get round this there's a reasonably chunk of the paper which talks about providing more information to people so they can make an informed choice - see section 2.10. The problem I see here is that with these kind of statistics it's all going to be about the context and educating people about what they mean and how to use them. Outcomes from medical treatments are dependant on a huge range of factors not all of which are going to be under the control of those administering the treatment and unless these are factored out or minimised in the statistics it's likely to be hard for the lay person to make meaningful comparisons.

Of course as one of the main changes in the white paper is that GPs will be doing the commissioning it's likely to be the GPs that are explaining the choices and hence the stats so that should help. I do wonder about the burden this places on the GPs to research and understand all of this. I can see that for routine treatments this works well but given the increasing specialisation of modern medicine it seems less tenable for more complex conditions. It makes me wonder how well choice will work in these cases.

Two things are a bit unclear to me about this though. The first is how this helps in areas with only one feasible provider. A core notion in the white paper is that choice will mean that the good/efficient providers will be picked and hence will get paid and the rest will be forced into improving in order to win business. If there is only one provider in an area how does this work? ( Also, to improve you need to invest so where does money for that investment come from? )

The second aspect that's unclear is how this effects scheduling and resourcing. Surely the more popular providers will become over-subscribed?

It's the notion of setting up hospitals and doctors in competition with each other for business that disturbs me most about this. Surely you want them to work together to improve care everywhere?