SDHI Team Member, Deborah Baldie reports on findings from this study. For the full article, please see citation at the end as well as the links provided to the full publication.
A UK wide four country case study of patient choice of secondary care provider has recently been published in the Journal of Health Services Research. Researchers from SDHI worked with research teams across the UK to compare patients’ choices when referred to secondary care providers by their general practitioner (GP) to examine the changes that have resulted from the explicitly pro choice policy in England.
Interviews were conducted with providers of two high-volume surgical specialties, Ear, Nose and Throat and Orthopaedics, purchasers of these services and those responsible for referring to acute services.
Choice of provider
In England, patients had a choice of any provider, but in practice patients were only provided with a limited list of local providers. There was no national system for facilitating choice in the three other countries and therefore patients tended to be referred to the local provider and may have a choice of hospital sites managed by that provider. Referral further afield in all countries was very rare and only occurred in exceptional cases.
Choice of Specialist
Choice of specialists was reported to be available at the discretion of providers in England, Scotland and Wales but not Northern Ireland. The reason for restricting choice of specialist in all cases was reported to be the need to reduce or control waiting times. Most GPs in all cases were asked to refer to generic teams rather than individual consultants.
Choice of date and time of appointment
Choice of date and time of appointment was available to patients when they were referred to a provider in all cases through two key systems – partial and full booking. Data collected indicates that rather than enhance choice these systems operated primarily to manage waiting times.
Management of choice along the referral pathway
A range of triage systems to direct patients to appropriate secondary care services operated in orthopaedic services. They appeared to limit choice for patients, particularly in triage systems that had no access to the electronic booking system. GPs did however GPs often bypass the triage service if they felt this was clinically indicated.
Referrer’s communication of choices to patients
Interviewees’ understanding of the availability of choices was often confused and differed within sites. A common area of confusion concerned referral pathways and if triage systems existed and were mandatory or optional. Discussion of choice with patients tended to be very limited with GPs in England and most tended to limit choice to 5 local providers. In the three other countries discussion of choice was largely not commenced unless initiated by the patient. GPs indicated that lack of discussion of choice with patients was largely due to patients being confused by and not interested in choice.
Discussion
While the explicit patient choice policy in England would suggest greater possibilities for choice compared with Scotland, Wales and Northern Ireland, in practice differences were more nuanced. All countries had some degree of choice of provider, limited choice of specialist but restricted choice of date and time of appointment or admission. Choices were far more limited in Scotland, Wales and Northern Ireland. The limited range of choices made available in these countries were seen to be affected by geography and population spread however even in urban areas in England, GPs reported patients preferring stay close to home and this acted as a further limiting factor.
Choice of time and date of appointment were was viewed as a very useful tool for managing capacity. Confusion over referral pathways and choice of specialist was there at times amongst GPs in all four countries. Patient experience of choice was therefore dependant to some extent on GPs’ knowledge. GPs reported having similar conversations with patients about choice in all four countries and tended to be led by what they thought best suited the needs of individual patients and patients’ appetite for choice which was perceived by GPs in all cases to be small.
Lack of difference between countries may because free choice of any provider in England was still bedding down at the time of this study. Other factors more closely related to GPs perceptions and knowledge of choices available indicated however that overall, a longer term culture shift on the part of GPs is needed in all four countries if patients are to be made fully aware of choices available to them.
Citation:
Sanderson M , Allen P, Peckham S, Hughes D, Brown M, Kelly G, Baldie D, Mays N , Linyard A, Duguid A. Divergence of NHS choice policy in the UK: what difference has patient choice policy in England made?J Health Serv Res Policy 2013 18: 202 -208
Social Dimensions of Health Institute 