Patient-centred healthcare: the right to choose?

The Coalition government’s July 2010 White Paper Equity and excellence: Liberating the NHS, promises that ‘patients will be at the heart of everything we do’. They will have ‘choice of any provider, choice of consultant-led team, choice of GP practice and choice of treatment.’

So patients will now have even more “choice” than ever before. This is a development from the “choice” first offered in 2006, revised in 2008 and, a year later, formalised as a right in the NHS constitution. So why is the “choice” agenda becoming so central to the NHS? And, equally, why do so many people remain sceptical of it?

Some suggest it’s about the government fashioning an environment in which the private sector can thrive, forcing hospitals to compete for patients and improving care standards as a result. However I suspect the “choice” on offer is more illusory than real. Top-down proclamations like this instead serve as a rhetorical cover for the government’s own desire to both shake up the NHS and keep health professionals in check. More importantly, it shifts the responsibility for the provision of decent healthcare away from politicians and onto vulnerable people. That demonstrates political cowardice and an abdication of responsibility, not leadership.

Re-branding patients as consumers, a trend that has been gathering pace for some time in the NHS, is also ideologically important here. It’s justified by the need for cultural change, to shift patients from thinking of themselves as passive users to active consumers. Consumers expect to be able to exercise choice, decide which services to use and vote with their feet when they don’t suit. And, equally, staff are forced to see patients in a different light: as citizens with entitlements, who are able to select from a menu of “choices”.

Ironically however, public health is an arena where “choice” won’t be on offer. Blaming people for their behaviour and spotting problem people was institutionalised under New Labour and will continue under the Coalition government.  In a recent speech to the UK Faculty of Public Health Andrew Lansley said, ‘So often the treatment that is delivered in the NHS is compromised by patients’ poor diet, lack of exercise, and alcohol or drug abuse or use of tobacco.’ So people will be expected to make the “right” choice. Damaging or wrong choices will not be tolerated.

So “choice” is promoted predominantly to sick people:  at a time when most do not want to have to exercise it, nor to make decisions about their care.  Patients should be absolved of that responsibility, confident that they can trust health care professionals to care for them until they are well again.  Indeed one of the impacts of the “choice agenda” is to undermine the trust that patients have in health professionals: the implication being that if you don’t make the right choice, you could end up with a lower level standard of treatment.

The beneficiaries of this development, as usual, will be the most articulate and demanding – the people who traditionally have got the best services despite the fact that this orientation is supposed to ensure that ‘everyone, whatever their need or background, benefits from these arrangements.’

If excellent services were provided everywhere, something that is entirely possible considering the amount of money poured into the NHS annually, then the “choice” agenda would be consigned to the dustbin of history where it belongs.

First published here Oct 2010