Priorities for Health: Patient choice and public involvement
November 2006
Introduction
In August 2006, BMA Scotland conducted a survey of members to identify their priorities for health. Around 600 doctors from all branches of the profession responded to the survey and their priorities for improved public engagement are reflected in this policy briefing.
Background
Developing a user focus is by no means a concept new to the NHS in Scotland. In 2000, Our National Health: a plan for action, a plan for change defined a patient-focused NHS as “a service that exists for the patient and which is designed to meet the needs and wishes of the individual receiving care and treatment” [reference 1]. This was followed in 2001, with the publication of Patient Focus and Public Involvement , which sought to build on existing work and provide a framework for change, and in 2003, by Partnership for Care which required NHS Scotland to adopt an approach which allowed it to “recognise and respond sensitively to the individual needs, background and circumstances of people’s lives’ [reference 2 and 3]. Patient focus has been integral to significant developments over the past few years such as the establishment of the new Scottish Health Council and the introduction of a new NHS complaints process.
Give patients meaningful choice
Patient choice is central to any discussion on developing a user-focused NHS. In England, the choice agenda has largely been limited to choice of treatment location, attempting to use choice–generated competition between hospitals as a driver for improving public services. However, having the same treatment at a choice of hospitals can be seen as being essentially an NHS-defined choice rather than a genuine one, and one which does not necessarily accord with patients’ priorities [reference 4]. A survey recently conducted in England for the BMA found that on specific choice issues, people rate the timing of their treatment and choice of family doctor substantially higher than choosing between hospitals or where the treatment takes place [reference 5].
The 2006 BMA Scotland survey of doctors’ priorities for health found that more than seven out of ten doctors (72%) thought that offering choice of where patients receive treatment, including private facilities, was not important. Almost 90%, however, believed that patients should be involved and informed to help them make choices about the treatment options available to them.
For Scotland, the BMA would welcome an approach that provides, where possible, meaningful choice tailored to patients’ needs and which makes a genuine difference to the care they receive.
Arm patients with the information they need
People need to be able to make informed choices on the various treatment options that are available to them. However, choice must be available to all, and for many people, particularly those less confident in handling information and negotiating the healthcare system, the information they require is not always available in an easily understandable way. More support is required for patient decision-making but this is not simply a question of producing glossy leaflets and flashy websites – face to face communication is key [reference 6]. Most patients look to their GP as a trusted source of advice, and general practice has an important role in co-ordinating and managing care. The development of individual choice should be a natural result of the patient-clinician consultation and should apply to all types of care. Clinicians aim to deliver this but a lack of capacity and increased clinical workload levels can make it difficult to achieve.
A change in organisational culture is required to support the development of the patient-professional relationship, at the most basic level this will require more time for doctor/patient consultations [reference 7].
For many people with chronic conditions, models of self management can empower individuals to make choices, navigate their way through the system and encourage the development of services responsive to their needs. For some patient groups, advocacy programmes can also perform a similar role. For those with greatest need, there is potential for the development of a patient care advisor role, providing information and support to assist patients making choices about their treatment [reference 8]. This could include practical arrangements for travel, as well as helping patients navigate their way through the care pathway.
Implications of choice
However, the resources available to the NHS are not limitless and given the ongoing need to build capacity, there is a need for clarity and honesty on the limits of choice and the options available. Increasing choice for some may impact on the resources available for others, and it is important that patients’ expectations of what the NHS will provide are consistent with what the NHS is realistically able to deliver. For example introducing a policy to provide patients with access to GP appointments out of hours would mean resources being taken away from elsewhere. Even where extra funding is identified for a new service, the decision to provide that service could mean that another potential service does not become available.
Public involvement
A patient-focused NHS is not just about individual choice, it is also important to ensure that there is a constructive role for the patient/public voice in setting priorities and developing services locally.
97% of doctors responding to the BMA survey believed that all decisions on local service reconfiguration should be transparent, effectively managed and involve the public as well doctors in consultation.
Boards have a duty to undertake public consultation where major service redesign is considered, and BMA Scotland believes they should be involving all stakeholders, including those who work in the NHS and those who use the NHS, at an early stage to help the public understand why change is needed and to engage them in drawing up the options.
Accountability
It has been suggested elsewhere that meaningful involvement could be best achieved by elections to NHS Boards. Although this approach is superficially attractive, we believe that the cost involved in conducting such elections would be an inappropriate use of NHS funding that would be better spent on clinical services and equipment. More significantly, such a move would not improve local public consultation on service change.
Politics inevitably has a role in the NHS given that Ministers are ultimately responsible for the allocation of funding and for setting broad strategy. However elections to NHS Boards would lead to greater political involvement and decision making at a local level, with the risk of decisions being made to secure future votes rather than to evolve, innovate and develop services. Local health care provision could be determined by short term targets, regional planning overruled, difficult decisions avoided and long term planning distorted, as resources are diverted into areas of political priority rather than areas of clinical need.
The BMA believes that local structures within Community Health Partnerships already exist that can be more effective in engaging and involving the public in local decision making and that efforts should be made to improve their functionality and support them to maintain an effective dialogue with local communities.
Improve and develop existing mechanisms for public engagement
BMA Scotland believes that meaningful forums for ongoing public engagement in health services exist within the newly established Scottish Heath Council and also through the development of Community Health Partnerships (CHPs). The Scottish Health Council is a national body with a specific remit to ensure that NHS Boards are delivering a patient-focused NHS that involves the public in decisions about health services. Meanwhile CHPs have the potential to support effective service development and are required to maintain an effective and formal dialogue with their local communities through the development of local public partnership forums (PPFs).
The Scottish Health Council was established in 2005 and CHPs (and therefore PPFs) are also still in early stages of their development. However BMA Scotland believes that given time and the appropriate level of support, commitment and resources, these mechanisms together could provide a robust and effective means of ensuring public involvement and increased local accountability.
There has been much debate on whether new structures or organisations are required to facilitate this process. BMA Scotland believes that mechanisms already exist and that they should be the focus of the politicians in their attempts to engage local communities.
Recommendations
In order to deliver true public involvement and meaningful choice, the BMA calls on political parties to:
- Give patients meaningful choice.
- Arm patients with the information they need.
- Involve and engage with people at an early stage in the consultation process.
- Improve and develop existing mechanisms for public engagement.
1. Our National Health: A plan for action, a plan for change, Scottish Executive, 2000 p50
2. Patient Focus and Public Involvement, Scottish Executive, 2001
3. Partnership for Care, Scotland’s Health White Paper, Scottish Executive 2003, p20
4. Smith T and Blunden F, What does choice mean? How can it be made more meaningful to patients?, Health Policy Review, Autumn 2005, BMA Health Policy and Economic Research Unit, p.22
5. Patient choice and the NHS, research conducted for the BMA Health Policy and Economic Research Unit by Andrew Irving Associates. May 2006
6. Smith T and Blunden F, op.cit. p29
7. Ibid, p31
8. Ibid, p30
For more information:
BMA Scotland Public Affairs Office
Tel: 0131 247 3050/3052
Email: press.scotland@bma.org.uk