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Published: 17/04/2003, Volume II3, No. 5851 Page 14 15

When the great and the good met to discuss choice, the consensus was that patients'growing knowledge of their conditions would have far-reaching repercussions.Alastair McLellan heard the debate An event that can boast an audience numbering future Commission for Healthcare Audit and Inspection chair Professor Sir Ian Kennedy, emergency care czar Professor Sir George Alberti, recently departed junior health minister Lord Hunt and Department of Health director of strategy Professor Chris Ham, as well as many more of the NHS intelligentsia, is clearly tackling a weighty subject.

And by the end of the King's Fund seminar on patient choice, there was a clear consensus that the policy could have a huge impact far beyond the easing of elective waiting lists.

In fact, the meeting soon concluded that 'choice' fell into two camps: the 'when' and 'where' and the 'what' and 'how'. As healthcare provision diversifies, there is greater variety in when and where treatment takes place. But at the same time, as patients understand more about their conditions and the care they need they will have greater influence on what treatment they receive and how it is provided.While the first type of choice is obviously currently collecting most of the headlines, there was a general consensus that the second would have just as great an impact in the long term.

King's Fund chief economist John Appleby set the scene.He pointed out that all healthcare systems constrain choice in some form, from access to drugs to the speed of service, and from patient safety measures to the regulation of the medical profession.He said some restrictions were necessary 'to protect the vulnerable and the ignorant', but others were the product of a desire to 'justify professional power' or of the cost and difficulty of producing the information needed to help patients make informed choices.

However patient choice was developed, a line would have to be drawn somewhere, concluded Mr Appleby.

The longest-running patient choice schemes already in existence - within London and coronary heart diseases services - focus on offering a range of providers to speed up treatment. It is an approach being extended to a wider range of services and region. Dorset and Somerset strategic health authority performance manager Jeremy Martin sketched out how this would have significant repercussions in many health economies.

For primary care trusts, the introduction of patient choice would require ownership of waiting lists and put them in a position in which they buy capacity up front rather than activity when it is needed.As a result, acute trusts would then manage capacity, rather than activity - making sure they could respond to the demands of commissioners. Trusts that cannot meet them obviously stand to lose referrals, but Mr Martin argued that this could give organisations 'head room' to work on raising their game.

SHAs, he claimed, would be the 'market managers', setting the framework for choice, planning the necessary capacity and then encouraging PCTs to offer it.

They could also 'control the worst aspects' of competition that choice could engender between trusts.

The impact of patient choice on those with chronic health problems was the focus of the contribution from Cliff Prior, chief executive of severe mental illness charity Rethink.

'The public experience of the NHS is 58 million anecdotes, ' he declared before telling how the care given to his terminally ill father was blighted by an approach which offered him very little choice.

This was no longer tenable, claimed Mr Prior. As improved healthcare and greater longevity produced an increase in those living with chronic conditions, the resulting rise in wellinformed patients with longterm conditions would create 'huge, bottom-up pressure' for greater choice. The NHS was already in a position where it needed to 'catch up'with public expectations.

Mr Prior stressed he was not discussing the 'supermarket consumerism' that is being developed in elective care - which was 'of some, but limited, use'. Instead he suggested that 'relationship consumerism' which prioritised 'listening to and respecting' the views of patients was 'much more important'.

He said the NHS needed to learn how to inform patients, engage with their views and respond to their wishes.He warned that doctors should move from being 'high priests' to guides and advisers.

William Butler, chief executive of charity Arthritis Care, said the NHS needed to question 'the choice of the professional to say no' to patients.While Patient Partnership chair Dr Simon Fradd said patients schooled in self-care would, through the correct use of drugs for example, produce huge financial savings for the NHS.

Mr Prior said public rights should drive choice as they did in other areas of public service, such as housing, and there were signs that this approach was being followed.

The National Institute for Clinical Excellence decision on atypical anti-psychotic drugs, which recommended that treatment should be negotiated between patient and doctor, and the increasing practice of copying doctors' letters to patients were just two examples. But there was much further to go.

Mr Martin perhaps best encapsulated the main conclusion of the debate.

'Choice, ' he said, is a powerful 'lever for change' and 'once patients had experienced an increase in choice, they would only want more'.