More evidence on NHS targets and patient choice

With the National Health Service (NHS) featuring heavily in David Cameron’s conference speech this week, here’s an analysis of NHS targets and patient choice in the context of the Conservative policy on health from our occasional correspondent, François Briatte a researcher from the University of Edinburgh. Find out more about his work, from his website.

Intute: Social Sciences features more resources on the topics of the NHS, health policy and health services, plus there are plenty of resources in the Intute: Health and Life Sciences collection.

From 2000 onwards, target-setting in the National Health Service was portrayed as an important departure from previous governmental initiatives when New Labour came into power. In its Health Green Paper, the Conservative opposition has now committed to a symmetrical shift in health policy, claiming to replace Labour’s top-down process driven targets with NHS health outcomes, or the recorded result from the care that a patient, or a group of patients, experiences (page 15). As underlined in an earlier report, the contemporary history of health services policy in England indicates that the commitment to targets has already been replaced in effect with a different orientation for the NHS – patient choice. Moreover, observers have commented on the strategic nature of the Conservatives’ rhetorical emphasis on outcomes in their policy agenda.

In economics and public administration research departments, skepticism towards public sector targets tends to be fuelled by expectations of gaming among accountable senior managers. In that respect, studies which conclude that targets can nevertheless prove successful at accomplishing what they were set up for might deserve some particular attention. With regard to targets in the NHS, several statistical analyses now exist along with anecdotal evidence, whether negative or positive. Tim Doran and colleagues have matched possibilities of gaming within NHS targets with one year of empirical data on GP practices; their paper shows that gaming, if it exists, is a small-scale phenomenon among English general practitioners. Carol Propper and colleagues also recently submitted new data that complement previous studies by Gwyn Bevan and Christopher Hood. In a nutshell, Propper et al. find that the reduction in waiting times within the English NHS has been more significant than the reduction in waiting times within the Scottish NHS, where the targets and terror policy was not implemented, Scotland remaining instead with the collaboration and cooperation approach that characterised Third Way health policy before 2000: broad targets for hospital treatment and no aggressive naming and shaming among NHS Trusts by governmental bodies.

Patient choice, an idea currently in good political currency, has been equally controversial among health policy analysts. The economic evidence that exists in favour of competition does not ward off concerns regarding how choice might affect health equity, nor does it solve the general issue of patient involvement. The situation of patient choice in England is still difficult to assess properly: Because of delays in the patient choice implementation agenda, empirical evidence on that topic is still scarce. A report recently authored by the Audit and Healthcare Commissions, Is the Treatment Working?, points out that public opinion does not unanimously view patient choice as an efficient driver for better quality of care, echoing a common line of criticism towards that policy: People do not want choice; they want a good local service (see Julian Le Grand’s lecture on choice and competition for a critical discussion). Commenting on that same audit report, Gwyn Bevan stresses the fact that patient choice has been only one reform in an ocean of system-level tweaks and experiments in health care. Most analysts seem to agree with his opinion that too much tweaking and successive redisorganisations, as Donald Light presents them in light of the Darzi report, have had damaging effects on the NHS and its governability. What these last comments seem to indicate is that the overall edifice of health care reform is more than the sum of its parts.