Happiness

indeed popular among those waiting for elective treatment, less than a third of patients eligible for the scheme were offered a choice of hospital. Two thirds of those offered the opportunity to go to an alternative hospital chose to do so. And 89% of respondents surveyed by the consumer magazine Which? agreed that access to a good local hospital was more important than having more hospitals to choose between. Research on NHS treatment centres indicates that recent reductions in waiting times may have limited the number of patients motivated to choose faster treatment. Indeed, staying with the local hospital might well be a patient’s way of dealing with choice overload. Such a scenario is probably highly specific to the condition, however. In the choice scheme for coronary heart disease, half of the patients who had been waiting six months or more for heart surgery chose to go to a different hospital to avoid a longer wait. Even when patients are willing to seek treatment from another hospital, exercising choice may not be practical for all of them. Will greater choice of providers by primary care services be worth having if it undermines the foundations of a system that works reasonably well at present? Might increased choice be harmful or dysfunctional for certain people or groups? Certainly, unmediated choice will increase inequity because it will favour patients with access to information and transport. This inequity will be magnified if patients in lower socioeconomic groups have lower expectations and less ability—real or perceived—to deal with the choices on offer. How are patients to judge whether hospital or consultant A is better than consultant or hospital B, and by how much, if they do not have the necessary information? And too much information can be as debilitating as too little. Increasingly, patients have “to cope both with the blessing and burden of receiving a superabundance of information, often several treatment options, and the right to choose among them.” Furthermore, choice does not depend only on having information. It also relies on the skill of understanding and choosing between options whose probable consequences cannot be measured or even known. The knowledge that they might be making the wrong decision exposes patients to additional stress. Patients do not have a choice about choice. Current political dogma assumes that choice is inherently good, but patients may soon begin to disagree vociferously if this ideology forces their local hospital to close or disrupts established NHS services. It is time to open up both sides of the choice equation to wider debate and action, recognising that both the upsides and downsides need to be managed. The NHS should shift the focus to assisted or facilitated choice, providing experts and tools to help narrow down the possibilities to a manageable number and to offer support to those least able to negotiate their way around the service. In the early pilot projects on choice in the NHS, patient care advisers— independent of any particular provider—provided a single point of contact and helped patients through the process of choosing where to get care. Patients found this very helpful. The paradox of choice needs to be managed carefully.