PATIENT CHOICE Patient spotting

Published: 06/10/2005 Volume 115 No. 5976 Page 14 15

With just three months to go until choose and book becomes a reality, hospitals are having to work out how to attract patients. Strange times indeed, as Ian Lloyd reports

Choose a day. Choose a time. Choose hospital (a). Choose hospital (b).

Choose hospital (c), (d) or possibly (e). Choose free coffee or free tea.

Choose near or far. Choose shuttle bus or car. Choose and book.

A decade ago, when the 'choose life' opening credits to the film Trainspotting were echoing around cinemas in Britain, was the freshly appointed leader of the Labour Party listening especially closely? Google the words Tony Blair and choice and you will have almost 3 million pages to choose from.

'People demand quality, choice, high standards, ' the prime minister boomed at last week's Labour Party conference.

Choice in health is the centrepiece of the government's reforms: constantly promoted as a catalyst for continuous improvement and innovation. And in less than three months' time, the rhetoric becomes reality. From December, all patients will be able to plump for one of four or five healthcare providers.

But as acute and primary care trusts scramble to implement the IT system to support choose and book, something far more fundamental is going on behind the scenes.

Marketing machines at hospital trusts up and down the country are grinding into gear, attempting to fathom how patients can be ushered through their doors. Former health secretary John Reid and his successor, Patricia Hewitt, both said they would not shirk if it came to closing hospitals left empty as a consequence of choice. It is a threat that trusts cannot afford to ignore.

Forget Trainspotting; this is Patientspotting.

'Everyone is aware that marketing now becomes an area of much greater relevance and it is not a skill base that NHS management has substantial experience of - whereas private practice and doctors have been adept at marketing themselves, ' says Hammersmith Hospitals trust director of communications Nick Samuels.

Mr Samuels, who is also responsible for marketing, explains: 'Marketing needs to work alongside the trust's business strategy to ensure services are provided that the trust has the capacity to meet, and are financially beneficial.' Gimmicky marketing ploys, like offering patients free car-parking, appear to be off the agenda for trusts at this stage. But they have not been completely ruled out as a future means of enticing patients.

'Everyone is quickly realising that this is not going to be a big bang and you are not going to see lots of lurid advertisement hoardings out there. People will slowly find their way as to what level of marketing is appropriate and what patients would find acceptable and helpful. Remember, this is the provision of a public service - we are not creating EasyHospitals, ' says Mr Samuels.

Trusts appear to be opting for a more cost-effective route when it comes to selling themselves.

Newcastle Upon Tyne Hospitals trust business and development director Richard Barker says: 'We will be focusing on our clinical reputation and outcomes, and trying to communicate that to the public and GPs. But we have got to be able to guarantee shorter waiting times. No matter how good the product is, if you can't deliver it on time patients will go somewhere else.' Mr Barker admits there is a balancing act to perform between encouraging additional referrals and having the capacity to deal with them effectively.

'If we put a lot more effort into promotion and got a huge increase in referrals, we would have to be able to guarantee seeing all those referrals within 13 weeks and then deal with any inpatient consequences within six months, so we have got to be very careful. We are not going big on promotion just yet.' This direction of travel appears to be justified. The Patients Association believes people's choice of hospital will depend on two factors: waiting times and MRSA.

King's College Hospital trust head of corporate communications Sally Lingard says: 'People do not want to see hospitals spending a lot of money on advertisements. We have to make sure people have enough information to make an informed choice.

'I think it is highly unlikely we are going to be printing hundreds of thousands of leaflets, pushing them through people's doors saying: 'Are you sick? Come to our hospital.' I do not think It is going to work that way. We do not want to be seen to be aggressively marketing.' Instead King's College has chosen another route and built up a picture of what its reputation is among GPs by analysing 'which are good and which are not particularly good referrers'.

Ms Lingard argues that, specialist areas aside, trusts within a similar geographical area should expect a fairly equal split of GP referrals.

'If we found a GP practice which we would have thought from its location should be a regular referrer to King's and is not, we would approach them and say: 'You have obviously got a problem with us, can we tell you about our services?' 'In any marketing exercise you have got to find out the state of your market and how people feel about the things you do.' The government has argued that giving patients the choice of diversity of providers will drive up standards of care and become more tailored to the demands of local communities. Choice, Mr Blair would argue, is about social justice.

But a report published in June by consumer watchdog Which? (formerly the Consumers' Association) claims the government has a long way to go if choice is not to create more problems than it solves.

Nine out of ten respondents to the Which? survey supported the key argument of those opposed to choice: essentially patients want good local services which 'obviate the need for choices'.

The danger of exacerbating health inequalities because of the variation in people's ability to access information was also highlighted.

Most importantly, the study found that the information trusts hope to provide to help patients choose is not yet out there. In fact, many patients are still blissfully unaware that choice is even being rolled out.

'It is true to say that many people are not fully informed that they have choice, ' says Patients Association chair Michael Summers.

'A lot of younger people who have access to computers and the internet are better informed because they have those advantages. But many people from the older population may not be computer literate.

'There is also the danger of increasing health inequalities and that is something we need to avoid.

We need better information so everyone knows, come the end of the year, that they do not necessarily need to be palmed off to the hospital near their home - there are options further afield.' Dr Foster business manager for patient choice Steve Mackenney also stresses the importance of information. 'Trusts need to understand the clinical quality of the services they provide - not just in terms of efficiencies but in the patient experience.

'To do that, they need intelligent management information and they need to be able to track the outcomes of their clinical interventions.

'This is strongly becoming an information economy where GPs need the information about their communities to commission well, and trusts need the information about services to demonstrate good quality. Patients need access to good information to make choices - that is the driver.' Dr Foster has just reported its initial findings to the DoH after being commissioned to run a set of national pilots to establish how to engage GPs and practice staff in the choice agenda.

The apathy of GPs towards choice is well documented. NHS Alliance chair Dr Michael Dixon says they resented having choose and book imposed upon them as a fait accompli. 'It was rather dramatic that they wanted to offer five providers, ' he adds.

Mr Mackenney explains that GPs not only assumed their patients did not want choice, but that their perceptions of choose and book were affected by the problems of the£6.2bn national IT programme, headed by Richard Granger.

But he says Dr Foster's work suggests they are now more willing to jump on board. 'Our preliminary findings are around people not being aware that choice is available, but when you tell patients a little bit about it they feel strongly that choice is what they want.

'When we tell GPs this, they become more willing to engage because they realise choice is bigger than just booking.

As we move into this new era, GPs will wield an enormous amount of power. Many patients will simply ask them to choose on their behalf.

But with power comes a responsibility to commission intelligently, not govern patient choice by their own preferences and prejudices, and manage the potential problems of foundation trusts monopolising the market.

'There is a fear that foundation trusts will go out and advertise - strongly marketeer - to populations and try to cherry-pick certain services. You may well get some of the more well-informed population going to foundation trusts, filling those places up, and reducing choice for others, ' says Mr Mackenney.

To ensure a mixed economy where patients choose a range of providers, it is essential for GPs to map their referral patterns and understand the choices their patients are making.

'If GPs understand who the providers are in their area, and what each one does best, they can commission different services from different providers.

'But the power should lie with patients. That is the benefit of choice - patients can drive quality improvements in providers by choosing to go elsewhere, ' says Mr Mackenney.

'All the attention has been on foundation trusts and the power has been with them because they have got the big budgets and are already established. The next step is to give GPs and patients enough information to balance that out.' If you were visiting Bristol's Broadmead shopping centre last month, you may have bumped into business development manager Mary-Anne Cooke staffing a stand for United Bristol Healthcare trust.

While the trust does not see it as a long-term marketing strategy, the stand was a useful tool in publicising services to potential patients.

'It was about trying to encourage people to get involved with the trust.

I get involved with the patient and public involvement forums. It is about making sure that the patient's voice is raised in people's awareness.

The more we can get them involved, the better patients will be served because they will be able to choose a service that suits them.' There is no doubt that choice is here to stay. West Yorkshire strategic health authority chief executive Mike Farrar, who is heading work on contestability in primary care, says:

'It appears the direction of travel is set fair - and my understanding is that not only is it set fair with this prime minister, but it would survive a change of leadership and probably a change of government.

'A variety of people from all walks of the political spectrum are promulgating its merits. It has almost become like world peace, an Ashes victory or a Manchester United defeat - something which is almost universally acclaimed.' .