As ‘free choice’ is extended to all patients, minister Ben Bradshaw tells primary care trusts they must undergo a cultural change to make it work - with consequences if they fail. Rebecca Evans met him

On 1 April “free choice” came into force, allowing patients to decide where they want to be treated.

The Department of Health is spending£600,000 on a publicity drive to promote choice to patients, and healthcare providers that are trying to attract patients can now advertise their services. The ideological aim is that patients will be empowered to choose the best healthcare and those services that are most popular will be rewarded with greater funding - the money will follow the patient.

Much of the information on which patients are expected to base their decisions will be available through the NHS Choices website. A brochure published by the DH last week boldly says the site will be “at the heart of a new relationship between commissioners, providers and the communities they serve” and will be people’s “personal health and well-being partner throughout their lives”.

Health minister Ben Bradshaw acknowledges that the website is some way from providing the perfect information essential for perfect competition. In an exclusive interview with HSJabout the launch of free choice, he says the DH has “made great strides” with NHS Choices, but it will have to constantly improve the amount and the quality of information available, and its user-friendliness.

“There’s more information on there than there’s ever been; there’s new information on the 18-week target, there’s new information on MRSA for electives - two things that the public are really concerned about.”

The website will soon contain some mortality data and comparable information on the quality of hospital food, for example. But detailed information on clinical quality will have to come later, he says. “We do have to be quite careful that we’re happy the data is robust and accurate and comparable across the piece.”

NHS medical director Sir Bruce Keogh - an internationally recognised expert on clinical outcomes data - is working with the DH choice team to come up with a new generation of clinical quality and safety indicators, not just for the public but for GPs, who will be referring patients and guiding them through the options available.

Meaningful data

Over the next few weeks, the DH plans to increase information on independent sector providers. At present it is only possible to compare the performance of NHS with independent providers on waiting times and MRSA rates. In other areas the independent sector and NHS use different measures. Measurement must be brought into line and validated before it can be put on the website.

Mr Bradshaw says: “I’ve given the department a real push to get some of this data in the independent sector on there, because until there’s some meaningful data to compare like with like, I accept that there’s not as much information as I would like there to be now.”

The minister is passionate about the potential benefits of choice, but admits there are obstacles to overcome, not least tackling low public awareness of their new options. “Far too few people are aware they have a choice,” he says.

Provisional results from the most recent DH survey on choice found 44 per cent of patients recalled being offered a choice of hospital for their first outpatient appointment for elective care.

The next priority is giving the 15 million people with long-term conditions greater control. Over the next two years, primary care trusts will be expected to introduce choice of treatment and of the setting for that treatment, working with local branches of organisations such as Diabetes UK or Asthma UK to develop the options.

Mr Bradshaw is impatient for more, quizzing the civil servant present on why choice in maternity is not available until the end of 2009 and bringing up the prospect of choice in mental health, even though the government has not committed itself to a date for its introduction. For people with long-term conditions, choice is likely to be augmented with the introduction of individual budgets for some areas of treatment. Mr Bradshaw says, “the logic is inescapable”.

“You could imagine a situation quite clearly where someone with multiple sclerosis or motor neurone disease, who’s very knowledgeable in managing their own condition, could be given a lot of freedom in where they commission their care and services - that they are in a better position to know, with complex needs like that, than any practitioner.”

It is not policy yet, but is being scoped out as part of junior health minister Lord Darzi’s review of the NHS. Pilot versions are likely to follow. Individual budgets have been successful in social care and their extension into health services was alluded to by prime minister Gordon Brown when he set out his vision for a personal health service in which patients take greater control over their own health.

Mr Bradshaw says patients want choice, and it will not be just “middle class people with the biggest elbows” who take advantage of it. “If you look at the opinion polling, it’s actually people in the most deprived areas who value choice more because they tend to be the people who have the lowest quality of public services.”

He stresses that the government is aware not everyone has internet access at home so it has trained staff in public libraries to give people help navigating the system.

Of course, the political ideology, where money follows the patient, only works if choices are made on the basis of quality of services. But evidence shows that given a choice, people will often go for the closest hospital rather than the best one.

“I don’t think that’s necessarily a bad thing,” Mr Bradshaw says. “That would signal to me that people are a lot more confident in their local hospital in general than sometimes the media would have us believe.” But he hopes that as more information becomes available, people will begin to take more notice of clinical outcomes and quality.

Pre-empting any questions about whether good hospitals will be “overwhelmed” while others are forced to close, the minister says “a certain balancing element” is inevitable.

“It’s very likely, until the good hospitals that are getting a lot more patients can get the extra capacity in, waits there are going to be longer.” But he argues this puts greater power in patients’ hands: they can weigh up the importance of speed of treatment against quality. “For a patient for whom time is much more important than [an] extra star, they will be able to make that decision.”

Primary movers

Mr Bradshaw has tough words for PCTs, saying there needs to be cultural change in the way they think about choice and its consequences. They may not want to destabilise their local health economy or they might feel uncomfortable about the fallout from proposals to withdraw local services, but they have got to take the bull by the horns.

“I don’t think it should be at all difficult for a well-run PCT which has got its communications right to be able to explain to local people why a particular service in the local hospital has to be reduced or even closed because it hasn’t been up to standard because the public who pay for this have decided they want to be treated somewhere else where the quality is higher. I would think forward-looking and good trusts would welcome and relish this as an extra lever to drive up quality.

“PCTs need to see themselves as the champions of patient choice, not the champions of maintaining an existing provider structure that is not delivering for the public.”

Any reluctance to push for greater choice will be met with a firm response: “Get your act together and be aware that the Healthcare Commission will come down on you like a ton of bricks. This will be a very important part of the Healthcare Commission’s ranking of trust performance. And PCTs failing to champion this will be named and shamed.”

In time, the dual commissioning and provider role of PCTs may not be sustainable either: “There are very big questions in the long term about that, but our feeling is that for the time being we can manage it as long as there are clear dividing lines and this system of appeal to the independent co-operation and competition panel.”

The DH intends to get the panel up and running by October, with “a good, strong, independent membership from the private sector and the legal profession so it’s not dominated by NHS interests”.

It will be an advisory body, but the minister makes clear it would be “very embarrassing” for a strategic health authority not to follow its recommendations. “It’s a bit like we don’t say no to the independent reconfiguration panel, do we?”

Doctors also need to do their bit. In last year’s annual health check, the Healthcare Commission was most critical about patients not being offered choice by their GPs - it was the worst area of performance against the national standards.

Despite the caveats, Mr Bradshaw is optimistic about the changes choice can bring - all part of changing the NHS from an illness service to a wellness service.

“I think this is a really exciting and important development in the health service, which started its life as a service that gave people something they were made to feel they should be grateful for, to shifting the balance of power in the service into the hands of the public.”