06 January 2006
A senior health analyst has cast doubt on the centrepiece of government reforms to inject competition into the NHS.
Under new principles announced by the Department of Health on January 2, all NHS patients should now have a choice of at least four hospitals for non-emergency treatment – including private sector providers where available.
The commitment to widen options was underlined on January 5 when Prime Minister Tony Blair's newly appointed health adviser Paul Corrigan published a report arguing for a replication and even expansion of the choice reforms to primary care.
But Professor John Appleby, chief economist at the King's Fund, criticised the lack of clarity in the proposals. 'It is worrying that the department is unclear about what sort of choice it is offering,' he told Public Finance.
Under the new rules, patients will have to be offered an inpatient bed within three months of their initial booking, although they can opt to receive treatment at a hospital with longer waiting lists if they believe the benefits of choosing that provider outweigh the costs of a longer wait.
At present, such bookings will be largely manual, as the national Choose-and-Book electronic system is not expected to be complete before the end of this year.
Health Secretary Patricia Hewitt argued recently that the vast majority of NHS patients wanted to be offered a choice of inpatient treatment, basing her claim on the experience of the 2002/04 London Choice Project.
In that scheme patients who had been waiting for treatment for more than six months were offered quicker treatment elsewhere. More than 60% of patients took the offer up.
But Appleby, who worked with the DoH in analysing the results, told PF that the type of choice offered in the project and the choices now being offered to all patients were 'not comparable'.
He said: 'In the London Project, patients who had already been diagnosed were offered the choice of faster treatment. This was nothing to do with the outpatient choice now on offer.
'A lot of people who go to outpatient departments don't know what's wrong with them, that's why they're going.'
While patients will initially be able to choose which hospital they are sent to for diagnosis, those who are unhappy with the result would have to go back to their GP and choose again, DoH primary care director Dr David Colin-Thome confirmed to PF. In terms of the stipulated three-month maximum wait, the clock would then restart.
Colin-Thome cited the example of Jehovah's Witnesses, whose beliefs against blood transfusions might mean they are turned down for a risky operation at one hospital, but if they choose again, they might find a hospital willing to treat them.
Overweight patients rejected for treatments by some hospitals might equally use the choice mechanism to ask for an alternative diagnosis.
A further lack of clarity emerged last month around the degree to which the DoH will force primary care trusts to include at least one private provider in their menu of choices.
In December 2004, then health secretary John Reid and DoH director of service delivery John Bacon told the Commons health select committee that they would 'require' PCTs to include at least one private option.
Yet at a recent briefing, health minister Lord Warner confirmed that a number of PCTs would not be offering a private option this year and that'private providers will be included on the menu only if the PCT has a relationship with one'.
Appleby said the DoH's apparent stepping back from its original intention reflected more the 'reality of the situation' that in some areas private providers simply did not exist, rather than an indication of any loss of nerve over the government's commitment to extend private sector involvement.
Paul Corrigan's report, Registering choice, published by the Social Market Foundation, argues that PCTs with closed lists for GP services should be automatically forced to open their primary care market to new providers.
Patients should also be able to 'undermine' failing PCTs and demand that new providers – from either the public, private or voluntary sector – be commissioned.
'We must not leave the whole process in the hands of the PCTs,' argues Corrigan, 'since the very nature of the existing gaps in provision means that they do not have the capacity to tackle them with the challenge of alternatives.'
PFjan2006
