SUPPORT FOR CHOICE: BUILDING ON
SUCCESS
Patient Care Advisers
216. It is clear that some public service users need
help both in accessing information and in making choices. In the
patient choice pilot schemes, the Government recognised this need
and set up a system of Patient Care Advisers. As the Health Minister,
Mr Hutton, told the Committee:
"We recognise that some people might need
more help than others in making sense of that information and
using it efficiently and effectively… Right at the core of
that proposal around choice in CHD was patient care advisers,
people who have the time, experience and knowledge to take patients
through the various options which are open to them, to explain
things about the different providers which are available to them
so they can make informed and proper choices".[163]
217. An evaluation commissioned by the Department
of Health of the experience of patients involved in the CHD choice
scheme found that: "The Patient Care Advisors played a key
role in ensuring that patients had a positive experience of the
scheme. They were an important point of contact and support and
their role in smoothing patients' path through surgery was greatly
appreciated".[164]
Those carrying out the evaluation went on to recommend that "Every
patient offered Choice should be supported through the process
by a PCA [Patient Care Adviser]".[165]
218. Yet it seems that the Government has failed
to learn the instructive lessons of the pilot schemes which have
used patient care advisers. When asked what support would be provided
for patients to help guide them through the new national patient
choice scheme, Ministers have seen the issue as one for local
decision. Mr Hutton, the Health Minister, said in February 2005
that "It is the responsibility of PCTs to provide or arrange
targeted support for patients to help them make their choice of
hospital".[166]
It appears that no earmarked extra funding will be provided from
the Department of Health for any patient support. We are disappointed
at this apparent failure to build support for patient choice into
the new system. In particular, this lack of central guidance and
action puts even more pressure on the GPs and others who, as we
have seen, are not well-prepared to guide their patients through
the choices they face.
219. Patient care advisers have been crucial to
the success of the pilot schemes for patient choice. It is clear
to us that something similar, and indeed something rather more
ambitious, would be of considerable benefit to those patients
who are now offered the wider choice of hospital for elective
surgery, and in particular those patients who are especially vulnerable
and find the NHS system difficult to navigate. We are disappointed
that the Government has not yet acted to ensure that adequate
support and advice will be available. The Department of Health,
working closely and consulting fully with local NHS bodies, should
give urgent consideration to encouraging the provision of adequate
support, through patient care advisers or other means, to make
sure that some patients will not be disadvantaged by the introduction
of NHS patient choice.
The need for more Expert Patients
220. We saw above (paragraphs 31-32) that the Expert
Patients Programme gave those with long-term illnesses a chance
to play a fuller role in their care and to share their experiences
with others. As we noted, this offers an opportunity for patients
to equip themselves with the information needed to work with clinicians
in the management of their conditions.
221. The BMA responded with some enthusiasm to the
introduction of EPP, saying that:
"This is a positive example of patients
learning to manage their condition better, increasing confidence
and enhancing their expression of preferences, and has the potential
to combine the ethos of both active citizenship and customer oriented
focus. The BMA supports the aim of this initiative and will follow
its evaluation with great interest".[167]
222. An evaluation has concluded that EPP "was
an effective and innovative means of managing chronic illness",
having the potential to "manage chronic conditions more effectively
and engage hard to reach groups".[168]
223. Yet the evaluation also says that "in most
PCTs it was proving a challenge to introduce and establish EPP
in the local health community and gain acceptance of it as a policy
priority". PCTs "felt EPP was a low priority and of
marginal relevance to their core business". Recruitment of
patients has been slow and enthusiasm and recognition among professionals
and GPs are limited. Damningly, the evaluation says that "professionals
were viewed as non-receptive to the idea of user-led initiatives
and EPP was considered a 'priority' which could easily be ignored".
The few thousand patients involved represent only a tiny fraction
of the many millions who suffer from long-term conditions.
224. The story of EPP neatly encapsulates the unbalanced
nature of the current debate on choice in public services. The
EPP scheme is aimed at some of the most frequent and least healthy
users of the NHS, and it is intended to improve their quality
of life by equipping them with the skills they need to make informed
choices about how their conditions are managed. Yet professionals
do not feel that this 'user-led' programme is a priority. The
resources of clinicians and managers are, it appears, focussed
more on other issues, including the introduction of provider choice
in elective surgery. Our perception is that much more could be
done, by Ministers, professionals and managers, to make a success
of EPP.
225. The Government should urgently examine the
scope for an expansion of the Expert Patients Programme. EPP is
an important and innovative way in which patients can equip themselves
with the information and expertise needed to strengthen their
hand in the era of choice. It needs to be promoted by the Government
with much greater vigour and commitment.
Improving school choice through lotteries
226. We noted above (paragraph 87) that the location
of a child's home often effectively restricted his or her choice
of school. Philip Collins saw one way to correct this imbalance:
"The only way you can sort that out is for the whole area
to be the catchment area and, if one school is over-subscribed,
the only fair mechanism for sorting people out is a lottery".[169]
227. Lotteries are in use by a small number of schools
in England. Stephen Twigg MP, Schools Minister, told us of one
example, the Lewisham Academy in London which he described as
a "struggling school", where 50% of its places on over-subscription
are allocated by lottery within a wide catchment area.[170]
The Chief Schools Adjudicator, Dr Hunter, told us that he had
recently approved a lottery for places at a school in Brighton,
and that there was "nothing to stop a school using a lottery
if that is what it wants to do".[171]
However, whilst good schools can exercise selection through catchment
area, no real incentive exists for schools to hold lotteries.
It is currently a matter for schools admissions authorities themselves
to set admissions procedures which are in line with government
guidelines on objectivity and fairness. The experience of school
lotteries in the USA suggest that there should be further exploration
by the Government of the use of that method of allocating places
in this country.
Progressive school vouchers
228. Professor Brighouse, who told us that choice
based systems can be designed to combat cream-skimming and promote
equity, favoured the option of progressive school vouchers. For
schools admissions he proposed "a progressive voucher-like
mechanism, providing much higher per-pupil funding for high-need
children, regardless of the school they attend would help to level
the playing field". He went on to support a system where
"low-income children should receive 300% of the regular per-pupil
funding, at least in metropolitan areas".[172]
This system would be similar to that used in Milwaukee in the
United States. It would make the more difficult service users
more attractive to providers, changing the basis of school selection.
The Government has indicated that all schools should be prepared
to accept a proportion of challenging children.[173]
It has not, however, yet fully resolved the issue of how to make
that happen in practice. Despite proposing the extension of choice
schemes, the Government memorandum explains that "the policy
challenge is to identify which of these options is likely to be
most effective and consistent with other government policies".[174]
We believe that progressive vouchers should be given serious
consideration as one way of combining choice with equity.
ENTITLED TO CHOICE, ENTITLED TO
HIGH STANDARDS
229. While there is merit in using such methods to
mitigate the ill effects which might follow from an extension
of provider choice, there are also other, more radical ways to
use choice to increase equity and to support a range of other
goals of public service.
230. An important underpinning to the notion of choice
in public services is the principle that service users not only
have a right to choose the sort of service they want, but also
a right to expect at least a guaranteed minimum standard of service
when they make that choice. A choice between several poor schools
or hospitals would, of course, be no real choice at all. Choice
and rights need to go together.
231. The idea that citizens should be entitled to
certain minimum standards in the provision of public services
and to have the means to hold service providers or public bodies
to account for this has been long in development. The Parliamentary
Commissioner Act 1967 first introduced the concept of maladministration
and redress with regard to public bodies. The Citizen's Charter
represented a further refinement of the idea that users of public
services should not be mere recipients but should enjoy legitimate
expectations about the quality and efficiency of those services.
232. The introduction of Public Service Agreements
in Whitehall with their targets and associated investment were
themselves accompanied by the unheralded service delivery agreements
(SDAs) of lower level, more output specific targets. However,
developing ideas about entitlements to quality services give rise
to two issues: how to measure that performance and what to do
if there is a failure to meet it?
Building on the Citizen's Charter?
233. The Citizen's Charter lost public respect because
it was seen as being too confused in its objectives. However the
basic idea, that public services should operate at a minimum standard
of performance, whatever the provider, is one that has survived
and, to an extent, prospered. Its current incarnation, the Charter
Mark, is "the government's national standard for customer
service for organisations delivering public services, independently
and rigorously evaluated and assessed".[175]
The Charter Mark is both a standard setting mechanism and also
an assessment tool with external, independent certification. It
is widely applied with over 2,000 organisations and public bodies
operating to it. To obtain a Charter Mark organisations are expected
to meet six criteria:
