Choice and responsiveness in the English NHS

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments Issue 3

Abstract

The government is seeking to introduce greater choice and responsiveness into the English NHS. The official report Building on the best: choice, responsiveness and equity in the NHS (December, 2003) sets out progess to date and plans for the future.

Purpose of health policy or idea

The NHS Plan (2000) set out proposals for extending user choice and making the NHS more responsive to user needs. The official paper, Delivering the NHS Plan (2002).described how this policy would be pursued. The main focus was on offering more choice over when and where hospital treatment is delivered. Interestingly, from an international perspective, Sweden and Denmark were cited as countries with tax-funded systems that offered more choice.

In December 2003, the Department of Health published another official report, Building the Best: Choice, Responsiveness and Equity in the NHS. This report sets out progress to date and plans for the future.

The Secretary of State for Health has argued that major increases in investment in the NHS are creating (and will create in the future) extra capacity enabling more choice. The 2003 report identifies key areas for more choice; these are, more choice over how people are treated through patient participation in decision-making; access to a wider range of services in primary care; increased choice about when, where and how medicine prescriptions are obtained; more choice over hospitals for patients and the introduction of booked appointment schemes; more choice over treatment patterns in maternity care and end-of-life care; improvements in information provided to patients on the basis of which they can make choices.

It is intended that programmes for offering more choice will be underpinned by a clear system of incentives, regulation and inspection. One of the major incentives  will be the new payment system for hospitals - "payment by results" - whereby they will receive income related to the number of patients they treat, and thereby have an incentive to respond to patient preferences in order to attract them. Regulation through inspection will still take place, however, through the newly established Commission for Audit and Inspection.

Main points

Main objectives

To offer more choice to NHS patients over where, when and how they are treated.

Type of incentives

Providers (hospitals) income will depend upon the numbers of patients they treat and, hence, are expected to respond to patient preferences. A system of regulation and inspection will also be used as a means of top-down performance management.

Groups affected

Patients, providers

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Political and economic background

The NHS has not traditionally attached much importance to patient choice. As a large state bureaucracy it has seen its role as providing services for users rather than responding to their wants, needs and preferences. However, the reforms of the 1990s, centring around the internal market and the production of a Patients' Charter (under the previous Conservative government) started to change this culture.

The present government has continued and strengthened this trend. As part of the 'modernisation' of the NHS it has made it clear that the old-style 'take-it-or-leave-attitude' of a large-scale state bureaucracy is no longer appropriate or acceptable.

The overall aims of the plans for more choice and responsiveness were set out in the National Plan (2000) and have subsequently been elaborated in the reports referred to above. This is a national initiative, and not prompted by any EU or other international official influences, although the experiences of other European countries have been cited as examples of countries with apparently greater choice, to which England should aspire as NHS funding levels increase to mainstream Western European levels.

Change based on an overall national health policy statement

NHS Plan

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

As explained above, the aim of introducing more choice and responsiveness can be traced back to the reforms of 1991 onwards, although the present government is pursuing them through its 'modernisation' programme with renewed vigour.

Specific elements of the programme include:

Healthspace. From next year patients will have access to a secure personal health organiser on the internet, where information will be recorded and they will be able to record preferences as a means of facilitating better shared decision making.

Better access to primary care. This will be achieved by providing more and varied capacity, e.g. NHS Direct online(an extension of the existing telephone advice line, expansion of walk-in clinics (presently there are 42 that have dealt with approximately 4 million attendances since 2000), more nurse-led clinics, expansion of independent sector treatment centres.

Choice of time and place of hospital treatment. In July 2002 a national pilot programme was launched offering more choice to patients who had been waiting over 6 months for heart surgery. Around 50% of patients chose to go elsewhere for faster treatment. The government intends to offer these choices to all patients waiting for surgery by August 2004, and by December 2005 offer all patients who require surgery the choice between 4-5 hospitals.

These plans are due to be implemented by top-down performance management, i.e. expectations are built into performance targets, supported by the so-called modernisation agency, although financial incentives are meant to bolster hospital performance.

Stakeholder positions

The policy of seeking to increase choice is not a controversial one leading to major disagreements between different stakeholders and actors. Some criticism of the policy from health policy experts has centred on the perceived trade-off between choice and equity. These criticisms maintain that certain deprived groups are less able to take advantage of the increased choice on offer and, as a result, increased choice will lead to increased inequality. The government disputes this claim and argues that equity will actually be improved by offering choice to all NHS groups, in contrast to the present situation where only those higher income groups who receive private health care have discernable choice. (Note: the government rejoinder does not address the claim that there will be more inequality within the NHS).

From the government's point of view the main aim has been to develop a policy that reflects patients' wishes regarding choice. To this end a national consultation exercise was carried out. This had four main elements: 8 national expert task groups, local consultations that engaged 33,000 people, a survey conducted by MORI covering 2500 patients and wide engagement covering 220 patient, voluntary groups, etc. The Department of Health estimates that over 110,000 people were reached by the consultation process. The choice and responsive strategy was informed by the views obtained through this process.

Influences in policy making and legislation

The Duty of the NHS to consult and involve patients was set out in section 11 of the Health and Social Care Act 2001 and was implemented on 1 January 2003. Current initiatives are an extension of these provisions and do not require further legislation. The proposals are uncontroversial.

Adoption and implementation

The government has announced that policy on choice and responsiveness will be built into the new planning framework for the NHS, covering the period 2005-06 to 2007-08, to be issued in July 2004. As explained previously many of the components of the programme will be implemented by local organisations as part of their planning strategies approved by Strategic Health Authorities. Implementation will be monitored by the Commission for HealthCare Audit and Inspection (recently renamed the HealthCare Commission). This is in essence a continuation of top-down management.

Certain milestones for progress were set in the Building on the Best paper. These include:

• August 2004: choice of hospital for all patients who have waited more than six months for care.
• December 2004: patients able to pick up repeat medical prescriptions from a pharmacy of their choice.
• January 2005: choice of hospital at point of referral for cataract patients.
• December 2005: 4 or 5 choices of hospitals for all other elective surgery at the point of referral, and ability to book choice.

Monitoring and evaluation

The National Audit Office is planning a review of the various policies on choice but I am not aware of any plans for a formal research-based evaluation.

Expected outcome

Given the increase in resources being devoted to the NHS there is reason to believe that greater choice cannot be offered to patients. Initiatives such as NHS Direct (the telephone advice line), walk-in centres, GPs with special interests and polyclinics are already expanding the choice available to patients in primary care. Offering more  choice to patients in secondary care started through pilot schemes and is being extended. It is however - in my view - questionable how far choice can be extended at the local level in a system that will rely primarily on top-down regulation for progress, rather than personal incentives. There is also an unresolved question about whether more choice will reduce equity within the NHS. Ministerial denials of this possibility rely on political obfuscation rather than clear logic.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

Impossible to know at this stage.

References

Sources of Information

Secretary of State for Health (2003) Building on the best: choice, responsiveness and equity in the NHS. (Cm 6079) The Stationery Office: London.

Author/s and/or contributors to this survey

Ray Robinson, London School of Economics and Political Science

Suggested citation for this online article

Ray Robinson, London School of Economics and Political Science. "Choice and responsiveness in the English NHS". Health Policy Monitor, 04/04. Available at http://www.hpm.org/survey/uk/a3/3