Rising patient choice fails to improve NHS quality standards

HSJ and the Picker Institute analysed hospital episode statistic data supplied by the NHS Information Centre for the first three quarters of 2008-09 and for all of 2006-07 for 66 primary care trusts.

Of the PCT results scrutinised, 11 had recorded a greater than 10 per cent change in the percentage of GP referrals going to their local hospital.

“There is as yet no strong evidence that reputation affects choice of provider in large numbers”

In more than half of PCT areas, local hospitals continued to see referral rates of 75 per cent or above across the period.

Of the PCTs where less than three quarters of patients are treated at a single hospital, 80 per cent seemed to be referring in a broadly similar way to their pattern for 2006-07.

By comparison, 15-20 per cent of energy customers switch accounts each year, according to energy regulator Ofgem.

Commissioners said they felt the free choice policy was playing a part in where patients were treated, but that commissioning decisions, increases in referrals and data inaccuracies could also be behind the changes.

Policy experts said it is difficult to see whether choice is driving up standards in hospitals.

Picker Institute head of policy and communications Don Redding said patients would need a strong incentive or disincentive to choose a trust other than a local provider and the main incentive - long waiting lists - had been removed by government targets.

“Another disincentive might be the reputation of individual hospitals but there is as yet no strong evidence that even where patients are strongly aware of a poor reputation, that affects the choice of provider in large numbers,” he said.

King’s Fund chief economist John Appleby said the think tank’s own market trend analysis for hospital trusts had revealed that the change in most hospitals’ market share was “virtually flat”.

He said large shifts were often down to supply side changes such as moving a service to a different trust, meaning it was hard for hospitals to see the effect of free choice.

“The net result is it’s impossible to see what individual choices were so the signal a hospital gets is no signal at all unless they do some digging to find out whether patients are making choices.”

The King’s Fund and the Picker Institute are working together on a major research project for the Department of Health to evaluate why patients have or have not made use of their right to free choice, and what impact that has had. Its final report is not expected until next year.

But one of the architects of choice policy, Julian Le Grand, professor of social policy at the London School of Economics and former adviser to Tony Blair, said: “I would not have expected massive changes and it sounds to me that a little bit of that’s going on - that’s what I’d expect and it might be enough to provide the incentive effects we’re looking for.”

Professor Le Grand said work under way on improving quality measures was important to produce the benefits anticipated as a result of the choice policy.

In Brighton, where the percentage going to Brighton and Sussex University Hospitals trust appears to have increased slightly, PCT deputy director of commissioning Geraldine Hoban said total referrals had risen in the area, which was likely to have a disproportionate effect on the local trust.

But she added: “[The hospital trust] has had really significant changes around quality markers. The changes that have happened locally have definitely increased people’s confidence in it and [the pattern] reflects where people want to go.”

Plymouth PCT saw static patterns, with 93 per cent of referrals going to Plymouth University Hospitals trust. But assistant director of commissioning Fiona Phelps said Care UK’s Peninsula treatment centre had made a significant difference, with patients asking to be referred there even before being offered a choice.