London project raises questions for Choose and Book

Patients offered a choice of hospital are more interested in hospital reputation than length of waiting time, according to a report published last week.

The final evaluation of the London Patient Choice Project (LPCP) carried out by the King’s Fund, City University and RAND Europe raises a series of issues for Choose and Book policymakers.

The researchers looked at what factors patients consider when deciding whether to accept an alternative hospital, what weight was placed on each factor and the trade-offs patients were willing to make.

Peter Burge, lead researcher on the evaluation, said the study had thrown uo some surprising results. He told EHI Primary Care: “When the study was set up everyone was saying that patients will go where the waiting times are the shortest but we found that really isn’t the case and reputation is incredibly important to patients. They were prepared to trade off significant increases in waiting times and to travel much further way to get what they perceived as being better treatment.”

The study also found that the choice project created inequalities so that patients who were on low incomes were less likely to choose faster treatment at an alternative hospital but more likely to accept being treated at hospitals with a poor reputation.

The London Patient Choice Project was a Department of Health funded scheme which ran from October 2002 to April 2004 and aimed to offer patients who had been waiting for treatment at an NHS London hospital for a specified length of time (six months to start with and then less) the chance to choose from a range of alternative providers who could provide earlier treatment.

A total of 22,500 patients were offered choice in five specialties covering 35 operations. Of these, 15,000 patients accepted treatment at another hospital rather than their local one. Their care was paid for by the LPCP.

The report says: “Reputation emerges as a very important factor in patients’ decisions about whether or not to take up an offer of quicker treatment at an alternative hospital. Our analysis suggests that where the reputation of the alternative (shorter wait) hospital is either worse than the existing (longer wait) hospital or simply unknown, patients place a relatively high negative valuation on the choice.”

The researchers sent questionnaires to patients who were eligible for choice to find out what their stated preferences were and then looked at almost 20,000 records of patients who had made a choice of hospital under the project.

The report says that although current Choose and Book guidance indicates that patients will need information on clinical quality its plans to encourage PCTs, GPs, primary care advisers and patient representatives to provide support and guidance would not fully fill the need for ‘reputational’ information.

It adds: “Although there is information from national patient experience surveys on which to draw there is a dearth of information on clinical quality and in particular information on health outcomes.”

The researchers found that better off patients (those with a household income over £10,000) were much less likely to choose a hospital with a worse reputation even though it had a shorter waiting time that those with incomes less than £10,000.

Overall patients who were older, female, with low education levels or who were parents of children under 18 were less likely to select faster treatment at an alternative hospital.

The study also calls into question the government’s goal to widen choice beyond the current four or five choices offered by Choose and Book to any hospital in the country.

The report states: “Our results suggest that while some patients are probably willing to spend a significant time travelling to go to the hospital of their choice, on average, waiting times at the more distant alternative hospital would have to be considerably shorter than the local provider to persuade patients to travel.”

The report found that patients place a positive value on the NHS organising transport even if transport costs have to be met by patients but points out that current guidance states that the NHS will not arrange or pay for transport except for patients currently eligible for free transport.

The study adds: “If a goal is to maximize the take-up of choice then our results suggest for example that the NHS should not only arrange transport to alternative hospitals but for parents in particular the NHS should also pay for transport.”

The government has now commissioned the same research team to go on and look at the Choose and Book scheme and identify the factors important to patients at the time of referral rather than when already on the waiting list as covered by the London scheme.

Burge said the Choose and Book research has already begun and will involve questioning about 1,000 patients from all over England about their priorities at referral.

“We want to gain some insight into how patients might trade off information such as health outcomes or hospital facilities and we are particularly interested in looking at the role of the GP and how patients rate the advice that their GP may give them about where to go.”

The Choose and Book report is due out at the end of September.

Links

Final evaluation of the London Patient Choice Project