Tuesday, February 06, 2007

Is choice really an illusion?

The Guardian has a full report of Tony Blair's appearance before the Commons liaison committee this morning.

I was particularly struck by the following:

Second subject, and Lib Dem Phil Willis, the chair of the science and technology committee, leading the questioning.

What evidence is there that patient choice in health drives up quality? he wants to know.

Mr Blair points to reduced waiting lists. No, you're going off on a tangent, says Mr Willis. What about quality, not waiting times?

The prime minister says that in 1997 the key issue was waiting times; a few months rather than a few years for cataract operations is an improvement in health care.

But how meaningful is choice if the hospital you attend is not chosen by the patient or even the GP, but faceless bureaucrats at the primary care trust?

Choice is an illusion, says the Harrogate MP. I don't agree, says Mr Blair; payment by results will mean that money follows the patient.
Granted, it is the job of members of this committee (who are the chairs of other select committees) to ask awkward questions. Granted, it is the job of members of opposition parties to oppose.

But Phil Willis here seems not just to be pointing out all the practical problems in implementing the government's choice agenda. He seems to be questioning the very concept of choice itself. And that seems to me an odd thing for a Liberal to be doing.

I stand by what I wrote on the Guardian politics pages in April last year:
If liberalism is to amount to something more than socialism without the identity cards, respect for individual difference must be central to it.
Perhaps there are ways of respecting individual differences that do not involve giving people more choice. But opponents of choice do not talk about them. Too often - in the Liberal Democrats and beyond - they sound like the voice of public sector professionals and almost contemptuous of the views and interests of the wider public.


Andy said...

Trouble is, if you had to choose everything, you'd be so busy making choices you wouldn't have time to live.

I want to make choices in areas where it matters - like where I live, what work I do, what lifestyle I lead. I don't want to waste my time having to choose a hospital or a school.

In theory, every hospital should achieve the same outcome in that it should make me well. There shouldn't be any need to choose as it shouldn't make any difference which one I went to (except for specialist centres of extreme expertise eg Addenbrokes for head injuries, Moorfields for eyes).

By contrast, it makes a huge difference whether I choose to eat organic food or Big Macs. Whether I choose entrepreneurial self-employment or a staff job or to be a house-husband. Whether I live in the city or the country.

Choice isn't an illusion. It's just, some things should be there as a given, as support for while you're making choices about everything else. I think healthcare is one of them.

Andy Mayer said...

"I want to make choices in areas where it matters"

Surely where your child goes to school or which doctor gets to treat you is about as as close to 'mattering' as it gets? Unless you believe...

"In theory, every hospital should achieve the same outcome in that it should make me well."

Unfortunately in reality they do not, never will, and it wouldn't be desirable if they did. Equal provision means ensuring no hospital or school progresses faster in treatment or educational standards than the weakest provider... or levelling down.

We are surely more interested in facilitating a system that enables excellence and encourages weaker providers to learn from the best?

Further encouraging innovation and excellence in every other field of life requires diversity of provision, why would we believe it doesn't apply to hospitals and schools?

Tristan said...

As Andy Mayer says, in reality the level of service is not constantly high.
I'd go further and say that without choice we cannot has anything close to a consistently high service.
Choice is necessary (although I doubt its sufficient) for good public services.

Too often I do hear LibDems being deeply conservative when it comes to public services. There is too much echoing of the public sector professionals' views, without taking into account that they have their own agenda of protecting their jobs and increasing pay and conditions and resisting change.

Anonymous said...

Tricky one - choice sounds good but access is just as important

I live in Northern Ireland were (for now) we still have a grammar school system and lots of choice – catholic grammar, state grammar, catholic secondary, state secondary, integrated schools, schools were education is in the Irish language and even small independent christian schools and one or two private fee paying schools. So lots of choice but how do I as a parent exercise that choice, I can only access a grammar school is my child completes a test and does well in it, in fact to guarantee the grammar school of my choice s/he must achieve an A grade. Now roughly 25% of the school places are in grammar schools so the top 25% of kids who sit the test are given an A grade. So access to the grammar system does not depend on any child’s ability (and it is far from clear that the test measures ability anyway) but rather on being in the top 25% the actual score achieved. The actual score of the top 25% can and does fluctuate quite markedly. So a child who scores 70 out of a hundred may get an A in one year but this same score may only be awarded a B1 in another year if more than 25% of the children score more that 70. Selection on ability may be defensible (again the caveat around how one measures the ability applies) but selection on the ability of others is not.

So to move this to hospitals if there is choice then there are good hospitals, very good hospitals, poor hospitals, maybe even awful hospitals (how do we decide if a hospital is good or not). How do we ensure that everyone has access to the good hospitals – they are in particular locations so the cost and time of travelling will disadvantage some, they have a limited capacity so not everyone who wants to go there can – how do we decide who gets the good hospitals and who doesn’t is the questions for the choice promoters to answer.

I choose to live in a city and in a particular part of that city partly because that maximises my ability to access (what I regard as) good schools, a good GP and good acute hospitals. To live were I do requires a certain level of wealth so that seems to be the decider on who gets good services – those that can afford to place themselves in the most advantageous positions.

The alternative to choice is making all services good (not identical to each other but good enough) this way there still is a variety of service provided but it starts at good and goes to better and then excellent. Deciding on what is the minimum standard is in each service and then ensuring that at least that standard is provided everywhere is the goal I think. I don’t believe this requires centralized control or uniformity. For example I believe that a school should help (note only help, the kids and parents have a role too) children develop their skills and maximise their potential - how a school does this should be its own business – no need for a National curriculum at all in my view. Similarly GPs are there to provide primary care and help (again only help, the patient is responsible as well) maintain good health – if they want to do this by providing lots of preventative services that fine, if they would rather react to illnesses as they develop that is fine too. So is only working 9-5 and depending on a good quality out of hours service. So is having evening and weekend clinics.

The minimum standards might even vary across the UK – lots of heart disease in Scotland may require different levels of cardiac services. Lots of older people in Bognor Regis? More Elderly Care services. And so on. Of course this produces the postcode lottery argument but it shouldn’t be a lottery it should be a logical choice, under local democratic control. I want my local health services attuned to the needs of the people who will use them (i.e. those close by) not attuned to a UK average. So there ought to be different things happening in different places. As long as these are clinically (or educationally and so on for other services) sound and under democratic control, with a high regard for professional advice I don’t see a problem.

What I am saying is the structures don’t matter much and often the content may not matter a lot either but what always really mater is the outcome – am I well educated? Am I healthy? Do I recover from an acute illness? I see no necessary connection between lots of choice and good outcomes.

Andy Mayer said...

"if there is choice then there are good hospitals, very good hospitals, poor hospitals, maybe even awful hospitals"

Not necessarily, to use your own analogy of minimum standards there might be good, better and best. The ambition you've proposed around minimum standards is entirely compatible with allowing patients some say in how they are treated and where.

"The alternative to choice is making all services good"

I know this is a mantra that gets trotted out a lot, but it doesn't frankly mean very much. Who doesn't want all services to be good?

This is what we have today, a worthy ambition to have all schools and hospitals good and a very different reality. The choice argument is about whether the provision of choice mechanisms helps or hinders encouraging services to improve.

Aaron Trevena said...

Choice of hospital is something exclusively of value to those well off and therefore living near at least 2 decent hospitals, and able to reach them both.

If I'm in a car crash I don't care which hospital has acheived a 3 or 4 star grade on breast cancer care, I want it to be the nearest and able to see me before I die or get more ill.

If I have cancer I don't really have a choice but go to the nearest hospital with an oncology department that has room for me and a consultant who knows whichever of the thousands of different kinds of cancer I have.

If you're having a baby, you don't want to (as somebody in my wife's maternity ward has) be ambulanced in labour from Torbay to Truro, and then be charged for an ambulance back to a hospital close enough for friends and family to access you.

All in choice of hospitals isn't a worthy target - most of the country geographically and economically will never have a choice of hospital for any serious ailment. You go to the nearest and hope you don't come out sicker than you went in.

An example of how 'choice' is doing more harm than good is my local hospital - they've just recruited a 90k salary director of marketing, who will naturally have his/her own office, secretary and other staff.. while elsewhere in the same hospital the 'friends of RCH' are trying to raise 70k for a CT Scanner. Fantastic! Isn't competition great!

I'm very liberal, but just as I don't expect to have to choose where I can get petrol when I'm running out, or where best to buy milk at 3am, I don't expect to have to think about which hospital - particularly when the next nearest is over 90 minutes away, in a different county and over a toll bridge. Especially as it's just as ugly, poorly funded, and over-stretched as the one in Truro.

Andy Mayer said...

"I don't expect to have to think"

I know, that's the problem with choiceophobia...

Liberalism, to my mind, is about empowering people, where possible, to take greater control and responsibility for their own lives and caring for others. It encourages the notion that thinking is a good thing to be encouraged, rather than unfair on people who don't want to.

Allowing people to think about health statistics and then disagree with their GP's decision to send them to the local hospital and request an alternative strikes me as compatible with that. Suggesting that they should take the GPs advice and lump it does not.

It's not, for example, much compensation to someone maimed by their local hospital that the reason they were forced to be treated there, despite both they and the Health Authority knowing it had one of the worst success rates in the country, was a sincere and well-intended hope it might improve, given time.

Aaron Trevena said...

nice quote out of context, congratulations on totally missing the point.

I don't have a problem with choice - but it isn't always necessary, and can cause more harm than good.

The problem with libertarianism such as you've suggested is that it's alright for those who have the time, money and access to make a considered choice, but providing that choice means that somebody else somewhere doesn't get it - there is nothing wrong with being assertive and having a healthy interest in your local healthcare facilities but to demand that you have the choice between 2 good hospitals within a reasonable distance when others are lucky to have a single adequate one within a few hours travel is selfish and short sighted.

I'd much sooner stop wasting money on false competition, where much like your water and train company there isn't ever going to be real competition, only a veneer of branding, hyperbole and marketing, combined with the occasional headhunting.

Run down hospitals aren't going to improve because those who can afford avoid them, particularly when more well supported hospitals will headhunt any remaining decent staff they have away, while reduced budget will force cuts, and lower quality ancillary services like cleaning, food etc.

Your thing for choice instead ends up with polarisation between the best and the worst hospitals, and those with only poorer hospitals within reach will be stuck with them.

This all sounds more like tory libertarianism than liberalism.