Supplementary Memorandum
from the Minister of State for Department of Health to Support
Joint Memorandum from Minister of State (Health) at the Department
of Health, Minister of State for Local and Regional Government
and Minister of State for School Standards, (CVP 024a)
'The Case for User Choice
in Public Services'
1. This paper provides supplementary
evidence to the joint Government memorandum, 'The case for user
choice in public services' submitted to the Public Administration
Select Committee to inform its inquiry into choice, voice and
the reform of public services. It sets out the Department of Health's
policies and approach to delivering the Government's commitment
to extend choice for users of public services.
Reforming the Health Service
2. This Government is committed
to providing high quality health services for all patients and
we have introduced unprecedented sustained investment in the NHS
backed up by a ten-year programme of reform as set out in The
NHS Plan and the NHS Improvement Plan.
3. By 2008 the health and social
care system will be providing faster, higher quality services
that deliver better health and tackle health inequalities, for
example:
· no
one will wait longer than 18 weeks for treatment from GP referral
and those with urgent conditions will be treated much more quickly.
· patients
will have access to a wider range of services in GP surgeries,
pharmacies and other parts of primary care, including access to
services nearer their workplace
· people
with complex long-term conditions such as diabetes, heart disease,
asthma and psoriasis, will be supported locally by a new type
of specialist - there will be 3,000 new community matrons
· there
will be further progress in tackling the biggest killer diseases
so that, by 2010, there will be a 40 per cent fall in death rates
from heart disease and stroke, and 20 per cent fall in death rates
from cancer for those under 75 (from 1997 figures)
4. Giving patients more choice is
at the heart of this programme of reform for the NHS. Extending
patient choice will respond to the public's demand for more choice
and control over their healthcare and services. It will also provide
new and powerful incentives for providers to improve performance,
leading to better local services for all across the whole country.
PATIENTS WANT MORE CHOICE
5. Evidence shows that the public
want more choice and control over their public services and, more
specifically, over their health care: in response to a MORI survey
conducted for the Department of Health's national choice consultation
76% people said that the main priority in healthcare is involving
patients in decisions about their condition/illness and treatment.
There is also increasing evidence to suggest that greater patient
involvement in decisions made about their healthcare leads to
improved health outcomes for patients
6. In particular, people want to
be able to choose where to be treated. This was confirmed by findings
from a European survey in 2003 by Coulter and Magee in response
to which 80% of people surveyed in the UK thought they should
have a free choice of hospital.
7. Certainly, where we have already
introduced choice in the NHS and in social care, the evidence
shows that it is already proving popular. In elective surgery,
pilots offering patients, who would otherwise wait six months
for surgery, the choice of an alternative provider for faster
treatment had high take up rates: 67% of patients participating
in the London Patient Choice Project and 50% of those involved
in the Patient Choice Initiative in Coronary Heart Disease. Since
choice at six months has been rolled out across the NHS from April
last year, some 30 000 patients have accepted a choice offer.
The evaluation of the Patient Choice Initiative in Coronary Heart
Disease also found that 86% of patients would recommend it to
a friend. In social care, direct payments have proved highly successful
and very popular with recipients: in 2003-04, 17 300 adults received
direct payments during the year, increasing from 9 600 in 2002-03,
a rise of 80%.
PATIENT CHOICE IN THE NHS
8. The command paper, Building
on the Best, published in December 2003 following our national
choice consultation, set out our proposals to give patients more
choice over when, where and how they are treated and, increasingly,
over what treatment they receive. It identified a number of priority
work areas where we are already extending choice for patients:
· giving
patients a choice of hospital for their treatment- already the
choice of faster treatment in another hospital is being offered
to eligible patients facing long waits for surgery. By December
2005, patients will be offered a choice of 4-5 hospitals when
they are referred by their GP and by 2008, patients will be able
to choose any healthcare provider that meets the NHS standards
and can provide care within the price the NHS is prepared to pay.
· improving
access to primary care- we are giving patients greater choice
in primary care by introducing new services such as NHS Direct
and Walk in Centres (including at many mainline stations) giving
patients faster, more convenient access to treatment. We are also
introducing a wider range of services in primary care, for example
those provided by practitioners with special interests, providing
localised services in familiar surroundings, giving patients easier
access to secondary care.
· improving
access to medicines by increasing patients' choice of where, when
and how they get medicines- for example, by easing the bureaucracy
around repeat prescribing, freeing up restrictions on the location
of new pharmacies, expanding the range of medicines pharmacies
can provide without a prescription, and increasing the range of
healthcare professionals who can prescribe.
· introducing
more choice of treatment and care in maternity services and in
palliative care:
- in maternity services by giving
pregnant woman more choice and control about the care provided
during pregnancy, child-birth and the post-natal period
- in palliative care by ensuring
that all patients, irrespective of their diagnosis, have
access to high quality palliative care and more choice in where
they wish to live and die.
· giving
people a bigger say in how they are treated - everyone will have
their own Healthspace linked to their electronic patient record
enabling people to make their preferences known to the clinical
team and giving them access to their own NHS Care Record over
the internet.
· Finally,
we recognise that providing easy access to quality information
about health and healthcare services is essential to enable people
to make informed choices and decisions. Again, this was confirmed
by the MORI survey for our national choice consultation which
found that 88% of people wanted more information to help them
make informed choices about their treatment and care. That is
why we recently published a national strategy, 'Better information,
better choices, better health', setting out a range
of national and local actions to help give people equitable access
to the quality information then need to make informed choices.
USER CHOICE IN SOCIAL CARE
9. Since 1997, users of social care
services have been able to exercise more choice and control over
the way the services they receive are delivered by taking up the
offer of a direct payment, promoting independent living. Since
April 2003, councils have been under a duty to make direct payments
available to individuals who can consent to have them and to provide
individuals with as much assistance as is available to support
them to manage their direct payment.
PERSONALISATION AND RESPONSIVENESS
10. Giving patients more choice
over their healthcare and services improves the individual patient
experience by enabling patients to make their own choices about
those services which best meet their personal needs and preferences.
11. Research conducted by Dr Foster
and the University of Nottingham in March 2004 demonstrated that
patients value being able to exercise choice over where they are
treated. They become more involved in decision making when this
is offered and want to use this opportunity to access better quality
care.
12. The Dr Foster research also
found that patients would be motivated by different factors when
choosing a hospital for treatment: 68% would consider ease of
access, 58%- the reputation of the hospital, 54%- the quality
of care and 47%- waiting times. Detailed work by MORI found similar
results.
13. Patient choice will also mean
that providers are incentivised to develop services which are
responsive to the needs of patients, resulting in more patient-centred
services.
Choice as an incentive for providers
to improve performance
14. Choice, with Payment by Results-
the new financial framework for the NHS, provides both the incentive
and the mechanism for driving up performance and standards across
the NHS, delivering better local services for all patients.
15. Hospitals will be paid on the
basis of the number of patients they treat. The number of patients
attending a particular hospital will be determined by patient
choice meaning that providers which prove popular will attract
more referrals and hence greater resources. Poor performing hospitals
will have to improve standards and responsiveness if they are
to maintain the number of referrals they receive. This means that
patient choice will have real implications for providers, giving
them a powerful incentive to improve performance for the benefit
of all patients.
16. Evidence from the choice pilots
already demonstrates that choice is having a positive effect on
a number of areas improving the ways services are delivered to
patients, for example by driving down waiting times. Following
the introduction of patient choice in London, average waiting
times fell by a substantial 19.4% compared to a fall of 7.6% In
the rest of England.
17. Patients also believe that choice
will improve standards across the NHS: a BBC MORI poll in June
2004 supported this with 74% of respondents expecting that choice
of hospital will drive up standards for all within the NHS.
18. Our use of the independent sector
to supplement the expansion of the NHS will also increase choice
for patients by introducing new providers for patients to choose
from, for example to date 16 000 patients have already been treated
by independent sector treatment centres. The innovation introduced
by the independent sector will also provide further incentives
to increase productivity and improve performance across the NHS.
Choice will increase equity
19. We know that the NHS has not
always delivered equitable services. For example, a recent review
of the NHS found substantial inequalities in key areas:
· 'affluent
achievers' had 40% higher CABG and angioplasty rates than the
'have-notes', despite far higher mortality from CHD in the deprived
group
· hip
replacements were 20% lower among SEGs despite roughly 30% higher
need
· a
one point move down a seven point deprivation scale resulted in
GPs spending 3.4% less time with the individual concerned.
20. Patients who are better informed
may also have better access to choices about their healthcare.
We believe these choices should be accessible to all; by explicitly
introducing patient choice and providing the necessary information
and support arrangements, these benefits will be made available
to all patients. Targeted information and support may be provided
by the voluntary and community sector or by Patient Care Advisors,
guiding patients with the greatest need through the system and
enabling them to make informed choices.
21. Again, evidence from the choice
pilots demonstrates that choice is popular across all age and
socio-economic groups, including those patients from black minority
ethnic backgrounds, those on lower incomes and the unemployed.
For example, the Picker Institute evaluation of the London Patient
Choice Project found that 80.2% of patients on below average incomes
would consider moving to another hospital for treatment compared
to 94.3% of those on above average incomes, similarly 78.2% of
unemployed respondents compared to 91.2% of employed and 83.1%
of white respondents compared to 82.7% of non-white respondents.
22. There have also been concerns
raised that transport will severely limit choice, however 92%
of people have access to at least two or more acute NHS trusts
within 60 minutes travel time by car, meaning that most patients
will be able to benefit from some choice. As most NHS trusts offer
services on more than one hospital site, patients will, in most
cases, have even wider choice of location for their treatment.
The independent sector is also introducing innovative solutions,
such as mobile cataract units, to help patients in rural areas
take up choice.
ROLE OF VOICE
23. 'Voice' also plays an important
role in developing responsive and patient-focused services, designed
by individual patients and users to meet their personal needs
and preferences. That is why we have dramatically modernised and
improved the mechanisms to strengthen patient and the public voice.
We have introduced comprehensive changes to ensure greater patient
and public involvement, so that many more voices than ever before
are being heard and taken into account.
VOICE IN THE HEALTH SERVICE
24. The NHS Plan set out a number
of wide spread reforms to give patients and the public greater
support, influence over and involvement in the NHS:
· all
NHS organisations are now under a legal duty to involve and consult
patients and the public- not just when major changes are being
made but in the planning and development of services too.
· there
are now 572 patient forums, one for every NHS trust and Primary
Care Trust, these are independent, statutory, patient-led bodies
with significant powers of inspection and with the ability to
require information from the NHS. Being patient-led, they bring
to the NHS locally the views and experiences of patients and carers.
· Patient
Advice and Liaison Services (PALS) have now been established in
every NHS trust and Primary Care Trust to provide information
and on the spot help and advice for patients, their families and
carers. They are a focal point of user feedback and a powerful
lever for change and improvement in the NHS.
· We
are committed to improving the way complaints are handled to help
improve patients' experience of the health service and have given
the Healthcare Commission responsibility for the independent review
of complaints. We have also set up the Independent Complaints
Advocacy Service to provide support to some of the most vulnerable
members of the community, many of whom without advocacy support
would have been unable to raise a complaint about the NHS.
25. NHS Foundation Trusts have introduced
a new level of accountability into the NHS. They have been set
up in law with a new bespoke form of public ownership as independent
Public Benefit Corporations, meaning far greater local ownership
and involvement of patients, the public and staff. Patients and
the public make up the majority of members on the Board of Governors
who elect patient/carer and public governors from amongst their
membership. The Board of Governors also has a role in appointing
the Board of Directors, working with them to ensure that the NHS
Foundation Trust acts in a way that is consistent with its terms
of authorisation giving patients and the public a direct role
in its day-to-day running.
Conclusion
26. Greater public and patient involvement
will be key to developing the high quality responsive health service
we all want to see. The traditional "voice" mechanisms
continue to have an important role to play in shaping the development
of our health services. This is why we have reformed and strengthened
these systems.
27. Patient choice introduces powerful
new mechanisms for patients to express their preferences and to
drive up standards of care. There are already more choices available
to NHS patients. We will continue to expand these choices as we
move towards a truly patient focused NHS.
January 2005
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