• patient choice
• decision making
• surgery

When Henry Ford offered customers of his Model T car a choice of “any colour so long as it is black” there was no need for sophisticated techniques to check out their preferences. Until very recently options for patients in the British NHS were just as restricted as Ford’s colour range. Hobson’s choice was what was on offer—that is, no choice at all, you get what you’re given. The situation is about to change dramatically following the government’s recent launch of the Patient Choice scheme.¹ Patients who have been on the waiting list for elective surgery for a specified period (initially 6 months) will be offered a choice of staying on the list until an operation slot becomes available at their “home” hospital or being treated faster elsewhere—in another NHS hospital, a private hospital, or even abroad. Those people considering such a choice will need to trade off the certainty of an earlier operation date, possibly far away from family and friends, against the perceived advantages of continuity of care in a familiar environment.

In this issue of QSHC Ross and colleagues report on a study in which they asked participants to make a trade off between prompt access and complication risk.² In this “stated preference” game participants were not offered the chance to travel elsewhere to find what many might have preferred—namely, fast access to safe treatment. Instead, the scenario assumed they would stay at their local hospital and be given a strictly limited choice between a long wait for cataract surgery performed by a consultant or a shorter wait for treatment by a trainee with a higher complication rate.

The notion that the way to speed up access is to offer less safe care would be profoundly disturbing to most patients if they knew this was being mooted. The fact that a high proportion of those invited to participate in this study were willing to play the game and make the trade offs, albeit in a hypothetical situation, is indicative of the level of public concern in the UK about long waiting times for elective surgery. Forced to contemplate spending 16 months with poor vision, some people viewed a 10% risk of harm from cataract surgery as a lesser evil.

The doctor’s grade and experience did not have an important independent effect in this study, presumably because participants were unaware of the association between grade and complication rates. Indeed, the authors tell us that it is standard practice to withhold information on surgeon grade, so patients are deliberately kept in the dark.

For ethical and practical reasons this situation should not be allowed to continue. Patients have a right to know about the training and past performance of those to whom they are about to entrust themselves. Those responsible for supervising trainee surgeons should be required to do everything in their power to ensure that patients are not harmed by the trainees’ relative lack of skill. Perhaps publication of performance measures, including comparisons by surgeon grade, would provide a powerful incentive to raise quality standards.³

Most British patients currently have no information about the success rates of their surgeons, and no way of finding out because the data are not yet published. Even finding accurate information about waiting times is a difficult task for most people. Many people on surgical waiting lists have little idea of when they are likely to receive their operation. If the Patient Choice initiative is to succeed in its aim of reducing waiting times by empowering patients, these information problems will have to be solved. But will patients want to use the information to make informed choices?

Information on process and outcome indicators in different hospitals has been a feature of the American scene for some years, but as yet there is little evidence that it is having an impact on patient behaviour. Despite the fact that the indicators reveal considerable variations in performance between hospitals, few patients are aware of the data and even fewer seem to use them to choose providers.⁴ A number of explanations have been proffered for this lack of impact. Patients may be unaware of variations in quality so they don’t seek information about the “best” providers.⁵ Some don’t believe choice is possible or don’t want to exercise it.⁶ And often the information is not available at the time it is needed, or is not provided in a sufficiently user friendly form.⁷ It remains to be seen whether the British public will respond with the same degree of indifference to the publication of performance information. A key issue will be whether greater transparency enhances or undermines public confidence in the NHS. For example, will better information and increased choice make it harder to persuade people to be treated by trainees?

The British government hopes that patient choice will be the grit in the oyster that leads to improvements in waiting times and quality. The roll-out of this experiment will tell us whether it is realistic to hope for such pearls or whether Hobson’s choice is our inevitable fate.