Fotaki original article Ethical implications of introducing patient choice in the National Health Service in England Marianna Fotaki Patient and user choice is at The limitations of the market-type Warwick Business School the forefront of the debate patient choice in health care about the future direction of the provision of health and other public services First, the necessary theoretical pre-conditions in many industrialised countries (Beusekom rarely apply in health care since health is not a Tonshoff, de Vries, Spreng, & Keeler, 2004; commodity that can be easily sold and Williams & Rossiter, 2004). Specifically, in exchanged. Health care markets are rarely publicly funded and provided health care competitive, and patients often lack information systems, where choice has been, or is perceived needed to make choices although patients with to have been historically lacking, increasing it long term conditions may be more able to make has become a key policy objective (Ashton, informed choices (Singh & Ham, 2006). The Mays, & Devlin, 2005; Vrangbæk, Robertson, narrative of knowledgeable users of public Winblad, van de Bovenkamp, & Dixon, 2012). services exercising their preferences via acts of Promoting market-based individual patient consumption overlooks something that is choice, first introduced in the 1990s, has now actually central to health care choice in real life: become a standard health policy objective in the the patient’s need for trust-based relationships National Health Service (the NHS) in England. with care providers (Taylor-Gooby, 1999). The passing of the Health and Social Care Act Precisely because patients lack the information 2012 (Department of Health, 2012), means that needed to make informed choices about their this trend is set to continue. care, they need medical professionals they can The idea of patient choice in health services trust; this overrides their desire to ‘shop around’ is founded on two general assumptions: one is (Fotaki, in press). Even in material markets that it will aid competitive markets in their people are seldom rational choosers and least of tasks to improve the efficiency of providers as all in relation to health services (Ferraro, Shiv, & well as improve quality; the other is that the Bettman, 2005). Individuals do not always exercise of choice is an important good in itself choose what is in their best interest even if they for patients. But the assumptions on which the are able to identify it (Hoggett, 2001) – allowing policy rests have been found wanting (Fotaki et them to make decisions which are acceptable to al., 2006; Greener, 2008). Their applicability is them but which may not be entirely rational - a either severely limited or invalid when applied reality that economists have now come to to health care, for both theoretical and empirical acknowledge (Thaler & Sunstein, 2008). For reasons. The paper discusses these limitations patients, the severity of their medical condition and then explores the ethical implications of amplifies the bias in processing information that introducing market-based patient choice in the human mind is prone to even further health care. (Kahneman & Tversky, 1979). Second, choice means different things to 95 ehp volume 1 6 issue 3 ehps.net/ehp ethical implications of introducing patient choice different or the same people at various points in resources are likely to be needed to meet time because users of services share multiple individualized patients’ wants at the expense of identities as citizens, family and community equal availability of services to all (Oliver & members, members of religions, and much more. Evans, 2005). This can happen either because Patients’ ability, and even their willingness to some patients receive preferential access and make choices, is influenced by their beliefs, treatment under certain schemes (as was the cultural values and expectations as well as their case under the internal market in the UK with life circumstances, personal characteristics and the patients of GP fund-holders obtaining a their experiences of health care services (Fotaki, preferential access to hospitals with shorter et al., 2008). Put differently, the individual waiting times) (Mannion, 2005) or because choices we make are socially constructed physicians are likely to modify their behaviour (Pescosolido, 1992). in order to fit the market, which could benefit Third, patients do not seem strongly some patients more than others. Such outcomes attracted to the idea of consumerist market are incompatible with the goals of universal choice in health care. Thus a recent review of health care systems. choice in public services in the UK found that Last but not least, introducing market only 35 percent of patients exercised choice of incentives of competition and choice is likely to hospitals (Boyle, 2013). What mattered more to have important implications for not only patients was obtaining information about their changing the ethos of public services but also treatment (Picker Institute Europe, 2007). for ethics of care underpinning patient and Although generally positive about having doctor/nurse interaction. The latter might be choices, the most important aspects from the effect of moderating health professional patients’ points of view concerned their behaviours after introducing markets incentives involvement in treatments rather than hospitals when they are expected to respond and report or providers (Coulter, 2010). In reality, patients on financial and other targets rather than were able to choose between hospitals and devote time and energy to provide care services appointment times rather than primary doctors, to the patients. The widely discussed Francis hospital consultants and treatments. The ability Report (2013, p. 4) caused alarm amongst of a patient-consumer to assess the quality of regulators and central government alike, medical services received is for many types of identifying "the need to change a culture treatment is thus limited to such relatively focused on doing the system's business - not peripheral issues as waiting time, comfort of that of patients". A key lesson and ethical waiting rooms and wards, and friendliness of implications from Staffordshire hospital’s tragic staff, which they can use as a proxy for neglect of patients care are discussed next. information to exercise choice. Fourth, introducing consumer choice might alter the meaning of trust in different situations in health The ethical implications of care and damage the legitimacy of the service introducing markets in health care: through eroding public’s trust in the system The case of the Mid Staffordshire such as the NHS (Taylor-Gooby & Wallace, 2009). NHS Trust Overall, personalised choices are in conflict with the collective goals of public health The Mid Staffordshire NHS Trust failures in systems (equity and efficiency) as more june | 201 4 ehp 96 Fotaki rudimentary aspects of care and the widespread incentives (and/or disincentives), people will and systemic patient abuse taking place in this strive to meet them often at the expense of a instance (involving leaving dying patients common sense (Schwartz, 1987). This could hungry, soiled and in pain for hours see sometimes even lead to them violating socially –Donnelly, 2013) is extreme but not unusual. accepted norms (Fotaki & Hyde, 2014) as they While the hospital’s management embarked on are working towards meeting impersonal cutting costs in this specific case, the staffing organizational targets (Ferlie, McGivern, & requirements needed to provide adequate FitzGerald, 2012). Indeed, the findings from the patient care, and arguably the patients Francis Report confirm the absence of ‘a themselves, were ultimately seen as ‘getting in sufficient sense of collective responsibility or the way’ of achieving the hospital’s strategic engagement for ensuring that quality care was goal. This has also been shown to be a direct delivered at every level’ (Francis Report, 2013, result of giving priority to demonstrating p.44). Managers and organisations are critical to ‘financial health’ which was a necessary the creation of an ethical environment but the precondition for achieving foundation trust overall policy framework in which they operate status by the hospital. The Francis Report is even more important. Therefore, providing provides a damning indictment of such an adequate training proposed by the UK approach: ‘While the system as a whole appeared government on its own is unlikely to be an to pay lip service to the need not to compromise effective way of ensuring that nurses and services and their quality, it is remarkable how doctors treat their patients with compassion little attention was paid to the potential impact given that they will be introduced at a time of proposed savings on quality and safety’ when new competitive pressures are being (Francis Report, 2013, p. 45). introduced to the health service. The evidence But how could managers or even the frontline from the USA suggests that combining staff distance themselves from the obvious task marketisation with cost-saving mechanisms has of providing care to the point of criminal reduced trust in the health system and negligence? Though moral responsibility for any physicians (Rhodes and Strain, 2000; Mechanic, action rests ultimately with the individual, the 1996), who report that they are less able to widespread failing in care standards cannot be either avoid conflicts of interest or put the best simply attributed to callous and uncaring