Sunday, 12 October 2014

Healthcare: choice is what you really want. Or so the politicians assure you

For years now, British governments – sadly, Labour as well as Conservative – have attempted to convince us that what we really need in healthcare is free choice.

The argument goes like this. Everyone wants to be sure that the care they’re receiving is the best available. And they can only tell if they’re given the information they need; and once they know which the best choice is, they need the right to exercise it.

What this leaves out of account is that at the moment you need care, there’s every chance that you’re sick, which is hardly the best position to be in if you’re trying to make an informed choice. Why, you might even be unconscious. I’ve known people whose qualities of judgement wouldn’t be harmed by being unconscious – they vote UKIP, for instance – but usually, being out of it doesn’t make us more judicious.

Their relatives might be in a better position to take a decision, but if they’re worried, borderline panicky, they may not be the best judges either.

What about a GP? There’s someone who might be able to help. But one doesn’t always have the luxury of waiting to call between 8:30 and 9:00 the following day, only to be told that the first available appointment is on Thursday week.

The reality is that, faced with a medical emergency, we don’t waste a lot of time making a choice. Or rather, we make the choice on purely pragmatic grounds, without taking medical performance into account.

For instance, I’ve taken people into Accident and Emergency on several occasions. How did I choose the A&E department? Simple. It was the closest.

The L&D: unprepossessing entrance but a centre of excellence
And also my closest A&E department
As it happens, I’m proud of our local hospital, the Luton and Dunstable. It scores highly on most comparative reviews of quality. It’s launched some exciting and innovative initiatives, such as “silent wards”: instead of cutting back on expenditure on administrative staff, it’s taken on large numbers of ward clerks, so that nurses can be freed to concentrate on nursing. Phones and faxes, as well as printers, are looked after by the clerks, behind closed doors. Each nurse has an assigned nursing assistant and looks after ten patients, who don’t even have bells – since nurses are constantly moving round their ten beds, they get to patients more quickly than if bell pushes were in use.

The result? The elimination of bells, phones and faxes, means that wards have a quieter, more restful atmosphere. Restfulness is a major contributor to healing. That enhances the effect of more frequent contact with a nurse.

So I’m perfect happy with the L&D. But what if I’d been told that Milton Keynes (40 minutes away) was even better? Or the great university hospital at Addenbrooke’s in Cambridge (an hour and a quarter)? Would I really have taken a friend or relative in pain to one of those hospitals instead of getting them to hospital in under a quarter of an hour?

To ask the question is to answer it.

Many others answer it the same way. 95% of all hospital treatment for Luton residents is provided by the L&D. What really is the choice? Or more to the point, offered the choice, Luton residents choose to be treated at their local hospital. After all, where else is it as convenient for their friends and relatives to visit them?

It was fascinating to be given a striking illustration of these ideas at a seminar I attended last week, on Clinical Audit. Dr Kevin Stewart, Clinical Director of the Clinical Effectiveness and Evaluation Unit at the Royal College of Physicians, told the story of Bill Clinton’s heart attack.

The ex-President began to suffer severe mid-chest pain while walking in New York with Hillary Clinton who had to make a swift choice. Did she log on to the internet and check the published information on comparative performance of New York cardiologists? She did no such thing. She phoned one cardiologist – one who happened to be languishing in 137th place in the league tables.

On what basis did she pick that particular physician?

She knew him. Personally. His number was in her phone.

As we all know, he saved Bill Clinton, so he can’t have been that bad.

The essential point is that when we make choices of medical care, they’re as often as not arbitrary. So all that fuss about choice is just that: a lot froth, designed to whip up some support among certain voters who are currently in good health and lack the imagination to realise that, in an emergency, they wouldn’t exercise their right to choose anyway.

Choice is a lot cheaper than the real question. Which is care quality. If we could guarantee excellent care, in all hospitals, at all times, choice would be entirely irrelevant.

It’s a lot easier to pledge choice. Even if it would never be exercised.

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