Choice and “Gaming the System”

Choice – how to ensure that you as a patient can choose your own Consultant or Hospital. True choice for all needs “overcapacity” before it can be meaningful.

In an insightful diagram Richard Smith in the BMJ 2007 tried to look into “The future of Health Care Systems” where patients were allowed to use information to make choices. His diagram is on the “post” “Choice in the the Information Age.” The article and prediction may seem ironic to doctors and patients in Wales, who cannot get choice, and who do not have access to specialist cancer treatment centres.

Have we really got Lip Service to patient Centred Care? There is an NHS site about patient choice – does not apply to Wales.

In England there is “Choose and Book” and a right to exert choice. This is not the case in Wales. This page will be updated with advice and options for Welsh citizens to obtain choice. Almost all Docotrs would like choice for themselves or their family, so why should this not apply to patients? Those who do claim to approve of “no choice” often change their minds when their nearest and dearest is suddenly affected. The problem with health complications is that its only when it affects you personally that you will realise how bad things have become.

The importance of choice cannot be understated. There are vast differences in complications and Standard Mortality Ratios (SMRs) in different Trusts and PCTs. Hospitals with all cold orthopaedic surgery have much better outcomes than those which accept everything, including infections and gut surgery, especially if operated on in the same theatres. The incidence of C. Difficile and MRSA would infections varies greatly, and some hospitals are quick to adopt changes and some are slow. E.g When a large meta-analysis of wound infections in the BMJ showed that clips were inferior to sutures, some changed practice and some have still not changed.

There is an Individual Patient Funding Request (IPFR) form in Wales.

IPFR Application form 20.10.11 Finalversion for Wales.

This causes a great deal of heartache. It takes a long time to complete in a busy day, and is resented by most physicians. Once the form has been submitted it goes through a bureacratic process, which varies dependign on whether or not it requests a new, hitherto unconsidered technology. It takes time..

It is never a good idea for a unit to know there is no competition. Knowledge that patients have no choice ensures a captive population, and without cross region comparitors consultants wont and dont know how they are performing. Combining them into “super specialist” units is helpful and the Langley report confirms a rise in standards across the board if this occurs.

One other comment before I list the methods to get choice: Your GP in Wales has been told that choice does not exist (and does not matter) for some time now, and this means that he does not explore choices for patients as often as he used to, or he would in England. He is getting less and less aware of the choices, and also, because Wales does not allow/publish statistics that compare with England or other areas, he does not know how his own Trust and local consultants are performing. If statistics are published they are like apples and pears, as since FundHolding ended there seems to be deliberate disagreement on what statistics matter.

So the methods to obtain choice are listed below, some of which are unpalatable to many:

1. Go Private – Expensive.

2. Use Insurance (It is very hard to get private cover once you are older or have had a serious illness)

3. Ask your GP to complete an IPFR and wait, but be prepared for rejection. Simply wanting to go elsewhere is NOT enough.

4. Register elsewhere (outside Wales) in the UK where choice is still available. If you have a relative in “Metropolis City” then you must register fully for over three months (Not temporarily) with their GP and arrange for all correspondence to be forwarded from that address. Once you are in “Choose and Book” you can elect to be referred anywhere, including to those Welsh Heath Trusts that you do not have access from in your own.

5. Attend a Casualty department in the Hospital of your choice and claim your symptoms are worse (They usually are with time) and hope that you will be accepted as an “emergency” by a liberal consultant on call.

Update 7th October 2014: Don’t go West – go East!. An example for us all: Welsh patients in the dark about EU treatment options