Published: 16/09/2004, Volume II4, No. 5923 Page 10 11 12

The first implementation deadline for choice, a lynchpin of the modernisation agenda and destined to play a major part in the pre-election health debate, has arrived.The scale of the achievement is significant:75,000 six-month waiters are now being offered the option of an alternative provider.

An even bigger step will be taken in four months, when choice at the point of referral is offered to cataract patients.The programme is due to cover most specialties by December 2005.But while the political rhetoric has been about patient power and consumerism, for those charged with the implementation of choice it is about planning, capacity - and funding. In this four-page special, Daloni Carlisle talks to those on the front line who have made choice a reality


At the end of last month, the NHS appeared to have more or less successfully implemented its first national, comprehensive choice programme.

Despite the politicised nature of the debate over choice, the deadline came and went with barely a whisper. As ever, a positive news story about the NHS proved eminently resistible to the media pack busy topping up their tans or chasing the latest superbug 'scandal'.

The last day of August marked the completion of the NHS's drive to offer choice to all patients waiting more than six months for an elective operation.

Beginning in April this year, the NHS was asked to identify patients in all specialties bar ear, nose and throat or orthopaedics and give them the option of treatment by at least one alternative provider that could offer a faster service. ENT joined the list in June and by 31 August orthopaedics came on board, a staggered start which recognised the latter as the specialty with the longest waiting lists.

By now all six-month waiters - around 75,000 at the latest count - should be included in the programme. The government estimates that around 23 per cent of these patients will exercise their option to be treated elsewhere. If this estimate is correct, approximately 17,000 NHS patients may soon be on the move.

Just over two weeks after the deadline, the common consensus is that the programme is working well.According to the Department of Health, all health economies are on track to implement choice at six months in full, although it is unable to report how many patients are taking up the offer of being treated elsewhere.

A DoH spokesperson says: 'The policy is likely to achieve its primary objectives - namely helping to reduce maximum inpatient waiting times to six months and offering the opportunity of faster treatment to those patients who need it.'

By and large, strategic health authorities and primary care and acute trusts confirm this view.

They have been able to identify a range of alternative providers, largely in the independent sector.

PCTs, meanwhile, have been able to control the financial implications of choice by working collaboratively to increase buying power and keep costs under control.

The mix of providers includes using capacity made available under national contracts with established private providers Nuffield and Capio, negotiating locally with independent providers and using newly established independent treatment centres. Some trusts have set themselves up as 'receiving trusts', offering their spare capacity to those whose lengthy waiting lists mean they have to 'export' patients.

Local health systems have also set up the mechanisms to identify patients waiting six months, offer them choice and guide them through the choice system.

Dorset and Somerset SHA has just over 500 six-month waiters.

Choice lead

Eric Gatling says: 'In terms of the additional capacity we have been able to identify it is a completely different environment to 12 months ago. We have been able to buy the required number of operations from the independent sector or, in some cases, NHS trusts, then use an SHA-wide referral centre to match that capacity to patients.'

In west Essex, Denise Walters is associate director of commissioning acting on behalf of three PCTs - Epping Forest, Harlow and Uttlesford. She has negotiated a deal with Aston Healthcare which is seeing about 40 patients a month treated at the private Holly House Hospital.

Negotiating the contract has meant making service-level agreements and setting out patient care pathways.

She says: 'Choice is supposed to be cost-neutral and We have been able to negotiate a good financial deal with prices just above the NHS tariff.'

In fact, she says that the 'deal' with Holly House is proving less expensive than sending patients to trusts in London, some of which are charging 28 per cent market forces factor on top of national tariffs.

Holly House Hospital manager Jackie Row adds: 'It is fantastic compared with the old way of working.Our previous experience has been: 'Can you do 20 hips by next Tuesday?' This is very carefully considered, with patients contacted well in advance.

Across England, managers put some of the success down to the cuts already achieved in waiting lists. The number of six-month waiters has fallen from 135,000 and 13.8 per cent of the overall waiting list in June 2003 to 75,000 or 8.5 per cent of the total waiting list in June 2004.

'Offering choice at six months is not really a big issue for us, ' says one choice manager at a large, urban hospital in the Midlands.

'We have very low waiting times, with only a few patients in some small specialties waiting more than six months. We are in the process of going through the database to identify patients with no dates [for their operation] and of getting agreements on treating them.We are working closely with our PCTs but we do not anticipate a huge shift of patients.'

Another factor cited as a reason for successful implementation of choice at six months is that the NHS appears to have benefited from the six pilot projects that preceded this national choice programme.

Trent access and choice project lead Sue Wallace says: 'We had one of the pilot projects here and it enabled us to set up the process by which we offer choice to patients, in terms of the information we give them and identifying where our alternative providers are.'

Similarly, the hugely successful London patient choice project has left its mark. King's Fund chief economist Professor John Appleby evaluated the project last year and says: 'The rhetoric is about choice and freedom, patient power and consumerism. In fact, the London patient choice project was seen to be an exercise in extreme planning and capacity management.

'It was done with almost military precision. They looked at how many patients were waiting and bought [the necessary] beds. Then they went to hospitals and demanded data on who was waiting and wrote to the patients.

They were acting almost as a BUPA purchaser with one goal and one bottom line: to match patients to beds.'

While this was a one-off, Professor Appleby says PCTs and SHAs in the capital will carry on working in this sort of co-ordinated fashion.

The DoH says it will be some months before it can report on how many patients have taken up the choice to move. But HSJ's enquiries have unearthed some wide variations, ranging from an unconfirmed 10-15 per cent uptake in one SHA to 80 per cent in another.

In Cumbria and Lancashire the uptake has been lower than expected. Collaborative commissioning lead Sue Thompson says: 'We are waiting for confirmation of our figures but it is well below the national average [of 23 per cent].'

The reason, as cited by patients, is that there is not enough benefit to warrant the move, especially as waiting lists are now falling.

'You are talking about having your operation maybe six weeks earlier, after a six-month wait' says Ms Thompson. 'Patients already know their consultant and have started to set up a rapport with them.'

But in Greater Manchester things are very different. SHA spokesman Ian Rhodes says: 'We have 4,160 people waiting more than six months. So far we have offered choice to 2,770 and over 80 per cent of them have taken it.'

He is not sure why, although a survey of over 1,000 patients indicates that the alternative provider - three local BMI Healthcare hospitals - may have something to do with it. 'People say they like the idea of trying the private sector, ' says Mr Rhodes.

At this point, managers are optimistic that choice at six months will lead to real inroads into waiting lists. Not only will an estimated 17,000 people get their operations quicker but their moving will free capacity to treat patients lower down the list.

The independent sector's view

The independent sector has welcomed choice at six months with open arms - as well it might.

With waiting lists on their way down they are likely to see a dramatic drop in income from individual patients and from spot purchasing under waiting-list initiatives.

Choice offers an alternative income flow with longer-term contracts if they can meet NHS tariffs.

And the sector has jumped at the opportunity.Capio chief executive and Independent Healthcare Forum chair Tim Elsigood says choice is already having a 'significant impact'on the sector.'It offers a huge potential boost to the independent sector, 'he says.

BUPA has been active in the cardiac choice project that ran nationally over the last two years; It is now involved in choice at six months projects in Yorkshire and Hertfordshire.

BUPA commercial director Richard Jones says: 'It is early days but I would say It is going well.We are seeing commissioners come directly to the independent sector and negotiating more long-term contracts.'

Losers, weepers: the cost of losing patients

While the NHS as a whole appears to be taking choice at six months in its stride, some parts are struggling.Where waiting lists are longer, some trusts fear they may lose large numbers of patients and could run the risk of financial destabilisation as a result, since payment by results would mean they would lose payment for these patients.

'A number of our trusts are really very nervous about this, ' says one PCT commissioner in the South East.'Some of them face losing a significant number of orthopaedic patients and that could seriously threaten their financial stability.'

If they lose enough patients they could end up with unused capacity.

The commissioner added: 'Obviously we have no interest in seeing that happen and the discussion at the moment is around the extent to which they could become receiving trusts, taking on patients from other trusts under the choice programme as it expands next year.'