Bob Sang and Jane Keep On patient choice

Published: 30/09/2004, Volume II4, No. 5925 Page19

What does 'choice' really mean in healthcare? As political determination to push the patient choice agenda intensifies, the quasi-marketplace is diversifying. NHS trusts, foundation trusts and independent providers compete to 'pull' primary care trust business, alongside a parallel 'push' to provide choice for people with long-term conditions and disabilities.

However, many find the idea of choice 'uncomfortable', for two main reasons:

choosing service and treatment options can never be a risk-free process;

choices have consequences, for which all participants share responsibility and accountability.

The fact that the NHS improvement plan needs the subtitle Putting people at the heart of public services shows that We are still not there. National clinical director for patients and the public Harry Cayton's quietly challenging assertion: 'Trust me, I am a patient, ' reveals the deep cultural and behavioural changes we must all confront if choice is to work in any meaningful way.

The National Primary and Care Trust Development Programme held a series of workshops linking choice, risk and public accountability for primary care trusts, focused on PCT managers and staff, who will lead on choice.

Many managers felt that PCTs were not grasping their commissioning role in their relationships with the acute sector, and several also observed that PCTs often seemed worryingly uninformed about what they were buying.

It is hard to see how real patient choice can be achieved, if this lack of focus and clarity is combined with a low commitment to patient involvement.

Choice is no placebo. Unless both healthcare professionals and the patients associate a choice with a risk (of making the wrong choice; being the victim of error; being misinformed; getting bad data) and consider accountability (accepting the consequences of one's choice; understanding the use of resources; learning about the patient's or professional's needs), the result will be fake choice.

Risk can't be removed from healthcare while it is delivered by human beings. Nor can the 'choice, risk and accountability'matrix be limited to the GP surgery. The growing debate around lifestyles and health should lead PCTs to greater consideration of the nonhealthcare aspects of producing better health.

If the public and healthcare professionals both accept that choice involves uncertain consequences for which they must be accountable, we can begin a mature debate about choice, risk and accountability, among the public and their PCTs.

Bob Sang and Jane Keep are lead facilitators for the Engaging Communities Learning Network for PCTs, sponsored by the National Primary and Care Trust Development Programme.