The Patient Choice Paradox

This article was originally published for the benefit of doctors in Independent Practitioner.

The term ‘patient choice’ has been so heavily corrupted that the altruism of the two little words is almost entirely lost. In the United Kingdom, the Government has coined ‘Patient Choice’ to represent an unclear, albeit well intentioned strategy. In the United States, the term is used to sell insurance policies. 

It is probably already too late to save the term ‘patient choice’ from the spin merchants. However, despite having lost that battle, people still remember the original meaning of the words and so there is no need, just yet, for an alternative.

For doctors, however, and particularly independent practitioners, patient choice has real implications. Success comes from knowing how to deal with a smarter, less tolerant patient population than ever before.

For patients, it begins with general questions such as:

1. I assume my doctor is right, but what does this diagnosis mean?
2. How do I know that this information is correct and relevant to me?
3. What are the latest technologies and treatment options?
4. Who are the experts?
5. Do I need a second opinion?
6. Where do I go and who should I see?
7. Can I afford it?

For those who become more knowledgeable about the options available, the questions become far more specific.  These might include:

• How do I decide on what type of hip replacement to have?
• What are the latest medically recognised allergy treatments, and what actually works?
• Should I have surgery on my slipped disc and if so, what sort of surgery should I have?
• Should I see an orthopaedic surgeon or a neurosurgeon?

All of that and more is brought into the consultant’s office – and you have to be prepared not only to answer their questions, but to do so in a way that satisfies them on a variety of levels.  That is why patient choice is more than a spun message.  It has implications for everything from patient satisfaction to your income.

So, what are the realities of ‘patient choice’? What is the relevance of the ‘Patient Choice’ government policy to independent practitioners in terms of communicating with their patients – particularly as they become increasingly well informed? And for the independent practitioner operating in an economic downturn, will spend on private medicine be a casualty?

Well informed or better informed?

As we all know, increasing information is available to patients especially via the internet.  As we also know, some of it is more useful than others. But how do patients really choose their consultants?

In any situation, there are at least three ways of making a choice: by referral whether from a trusted friend or practitioner, by ‘gut feel’ on meeting the consultant, or by comparing facts such as performance and outcome data. Ultimately for the patient, when it comes to their healthcare, it’s a combination of at least those three factors.

There is too much information out there and the vast majority of it is partisan or straight advertising. Those patients who have the wherewithal to ‘go private’ are little better off than their NHS patient counterparts dependent upon the “Choose and Book” system.

The fact that we are now in a global village means that things keep getting even more complicated. With medical tourism on the rise, patients have an increased choice of international expertise, clinics and hospitals. But patients find themselves still hamstrung by the lack of independent, authoritative information. 

External scrutiny and transparency

Following the 3 A’s of private medicine (Accessibility, Affability and Affordability), there is increasing pressure from the Healthcare Commission and others to make medicine both accountable and measurable. However, no matter how much patients search for facts and data such as post-operative infection rates, surgical experience, diagnostic accuracy, patient feedback and performance data it is still difficult to find decent comparative information.

Some doctors feel that this is a good thing as no-one particularly likes to have their work scrutinised. Some surgeons report their concern that if we go too far in creating transparency without adequately accounting for case mix and complexity, there is a risk that surgeons will become less enthusiastic about operating on difficult cases as it will potentially damage their statistics.

Yet, at the end of the day, providing the right information to empower patients in making considered choices, although highly complex, is neither impossible nor unnecessary.  As well, considerable care will be required in the construction of such data. But the data will be made available in one form or another. This is a direction of travel that will continue to be pursued and is something that various parties are working on.  As well,, practitioners need to be prepared to audit their own work to this level and provide those data in the not distant future.

Economic implications of patient choice

Initially, the most fundamental choice a patient makes is: Can I go private? Clearly, in an economic downturn there will be more patients opting to be treated on the NHS. In marketing terms, this means that there is inevitably going to be far greater competition between hospitals and clinics for a shrinking slice of the pie. 

Starting now and going forward, the patient population will be divided roughly into three Groups:

Group 1: High net worth individuals unaffected by the downturn and who will probably continue to behave as before.

Group 2: Medium net worth individuals for whom the choice is more important.

Group 3: Patients with health insurance, but worried about the increasing cost of their premiums.

In this context, other than the maintenance of excellent standards of care, there is little that will affect the behaviour of Group 1. However, Groups 2 and 3 will now be less inclined to accept either direction or recommendations at face value. 

This is the outcome of the fundamental market change that has come with both the economic downturn and simultaneous increase in information.  Independent practitioners are well advised, therefore, to make ‘patient choice’ central to any plans.

How, then, can we help patients to ensure that they are making decisions based on reasonably accurate and relevant information?

Often, getting ill and possibly getting time off work gives time for thought and discussion with friends and family. Even if the patient doesn’t access the internet, a friend or relative will on their behalf. This is when the words; independent, impartial and authoritative become important. 

Patients to know that they can trust what they are reading, that the author is a senior, experienced expert and that the ‘recommendations’ are not biased based on the ‘expert’, in fact, secretly flogging a particular pharmaceutical product. Advertising, banners, pop-ups and other on-line marketing devices are counter-productive in this context. 

Of course, the other problem is that the more expert the author, the more they are used to writing for the specialist journals and the more impregnable the language. This is where an editorial process as part of a consultant-led, patient medical education initiative to translate the evidence-based jargon into plain English is important. The open nature of the internet means that it is also open to abuse and often, plain ‘quackery’. There is therefore a real need for those senior, practicing and academic doctors to describe the latest evidence-based technologies and how they may be relevant to different patients in a way that patients can understand.

The totalhealth difference

In response to this need, in January 2009 the patient medical education website totalhealth was launched by a collaboration of leading medical consultants across London’s teaching hospitals to provide patients with the independent medical education they need to decide on the next step in their treatment plans and has now been expanded across the UK. Because the quality of any publication relies on one thing – the quality of its authors – the totalhealth medical panel consists of only those doctors who work in or with the major recognised hospitals and their associated medical schools – such as Hammersmith Hospitals NHS Trust and Imperial College.

This combination ensures that patients get immediate access to authoritative, independent advice on the latest medical philosophies for the different treatment modalities.

Medical Director of totalhealth, Consultant Vascular Surgeon, Mr Daryll Baker says:

My patients are often confused by what they have read on the internet and they naturally then make demands for treatments that quite frankly would not be appropriate. In fact, they could even be harmful. totalhealth has been constructed by medical colleagues from across the disciplines to provide patients with some of the information they really need. Their task is to effectively provide the essential medical educational material on their specialist subjects that will save time and ensure that patients are sufficiently informed to become actively involved as part of the decision making team.

Patients naturally have a right to demand access to the latest information. This is about giving patients trustworthy and authoritative access to the specialist information that they need, quickly, and at a time when they need it.