With choice comes responsibility

Choice shows no sign of slipping down the policy agenda. GPs now routinely offer patients choice when they book outpatient appointments, and patients will increasingly be able to choose between providers.

However, there are a number of questions surrounding this issue: will increased choice improve care? Do patients want choice? What effect will choice have on quality of care? Will it drive down costs? And what impact will choice have on health inequalities?

Competitive attitude

Few would argue that choice of quicker treatment is not going to be popular if waiting lists are very long. But is it needed in the NHS of 2007, where very long waiting lists are largely a thing of the past? In pilots in Manchester, patients were pleased to be offered choice of hospital, even in a context of shorter waits.

Choice can be seen as a good thing in its own right, having potential to empower users of public services.

The alternative view is that the main point of offering choice is to make providers sit up and improve their services. If that is the case, then it does not matter if only small numbers of patients actually choose an alternative hospital.

The threat of choice will produce benefits for all patients by stimulating the market.

There is little evidence that patients would choose alternative providers if they could be sure their local hospital would provide a good and prompt service. The main benefits of choice will be seen from the impact it has on providers, driving up standards by providing competition.

At the moment we do not know what would happen if patients had more choice of primary care. In some areas, patients have virtually none as so many GPs' lists are closed. It would be better if patients could change doctors more easily - with more practices to choose between.

There is a consistent message from research into choice in education and social services that affluent and educated patients are more able to exercise choices than those from deprived areas. So if the affluent take advantage of being able to choose between providers, choice might actually increase inequalities.

Specific measures are needed to make sure people who might be disadvantaged, such as the elderly or those with poor literacy or language skills, can actually make use of the choices offered.

In the London patient choice project travel costs were paid for, so poorer people were not put off choosing distant hospitals for financial reasons.

In contrast to the sparse literature on whether patients want to choose their hospital, there are many papers on patients' involvement in individual treatment decisions.

Here patients are often not well-enough informed about treatments to make choices. But they would like to participate in these decisions. They want better information about choice of treatment and they would like to have a doctor who discusses treatment options with them openly.

Although choice may produce benefits, it is far from clear that it will improve quality, efficiency or equality in the NHS.

We need choice to be introduced carefully to make sure the benefits are realised and the potential problems minimised.

There are several key questions for policy-makers and managers:

• How much can the NHS afford increases in capacity?

• Increasing patient choice may increase inequalities. What measures are needed to protect the interests of disadvantaged groups?

• If additional providers are brought in to improve choice, are there adequate checks on training standards and quality of care?

• Is information being provided effectively? How can the information be made available to a wide range of population groups?

• What steps are being taken to improve choice within consultations in order to ensure patient choice becomes a reality?