Image: Flickr / Drew Stephens
The right to choice of individuals needs to be balanced against the efficiency and effectiveness of the NHS as a whole, and the broader needs of society.
Giving patients more freedom to make choices about their healthcare sounds like a good idea. It is increasingly becoming established wisdom in health policy. Choice is seen as an indisputably good thing, like buying a new car.
So it follows logically that a high-quality therapeutic relationship is one that supports autonomous choice by the patient.
But this is not necessarily the case.
Philosopher Anne-Marie Mol has written a seminal book called ‘The Logic of Care’ based on the study of patient-doctor and patient-nurse encounters in the context of diabetes care. She argues that good care has little to do with patient choice - and creating more opportunities for choice doesn’t improve care.
Mol argues that choice is secondary to the core business of clinical care, rather than its essence - especially in relation to chronic illness.
She talks about the “art of caring”. Good care is not something that comes from making well-argued individual choices, but is something that grows out of collaborative and continuing attempts to “attune knowledge and technologies” to diseased bodies and complex lives.
The American psychologist, Barry Schwartz, wonders if the drawbacks of choice outweigh the benefits. He suggests that too much choice can be a bad thing. It produces paralysis, rather than liberation. With so many options to choose from, people find it very difficult to choose at all.
Even when we manage to overcome paralysis and make a choice, we end up less satisfied than if we’d had fewer options to choose from in the first place. Schwartz’s research found that the more options people are given, the greater the anxiety, the greater the dissatisfaction, and the greater the disappointment they are likely to experience.
As Schwartz says in his entertaining and thought-provoking TED talk on the “Paradox of Choice”:
“The tyranny of life is choice…whether that’s 176 different salad dressings or 40 different brands of toothpaste for sale in the average supermarket.”
Do we really want to be offered choices like this about our healthcare, I wonder?
And are the choices we make meaningful when we lack the specialist knowledge to make an informed decision?
Schwartz tells us,
“It is no longer the case that in the US that you go to a doctor and he tells you what to do. Now, you go to the doctor and the doc tells you,
‘Well, we could do A or we could do B. A has these benefits and risks. B has these benefits and risks. What do you want to do?’
And you say ‘Doc, what should I do?’
And the doctor says ‘A has these benefits and risks, and B has these benefits and risks. What do you want to do?’
And you say ‘If you were me, doc, what would you do?’
And the doctor says ‘But I’m not you’.”
We call this ‘patient autonomy’. Which makes it sound like a good thing. But what it is really, is the shifting of the burden of responsibility for decision making from someone who knows a lot, namely the doctor, to someone who knows little, and is almost certainly sick, and hence not in the best shape to be making decisions, namely the patient.
When my mother-in-law was first diagnosed with cancer of the oesophagus, the young doctor breaking the news had to contend with my mother-in-law, my blind father-in-law, and me - all of us frightened.
He offered her choices. Palliation. Operation. Operation and palliation. Radiotherapy. Radiotherapy and operation…
I became anxious - this was way beyond my level of expertise. How would we choose what to do for the best?
“What would you do if this was your mother, doctor?” my mother-in-law asked.
There was a pause. Then he took her hand in his. He sat forward, closing the space between them. And he told her what he would do. And we did it.
That, for me, is a good doctor.
A doctor who listens, a doctor who cares, and a doctor who knows what to do. That’s what patients want and need.
The Royal College of GPs is concerned that the emphasis on choice will mislead patients. At a time of financial retrenchment the reality is that there is likely to be far greater rationing of services and hence a reduction in choice for many patients.
While we as GPs aim to offer choice to all, there are other imperatives in clinical care. Most of the time in a good consultation is taken with understanding the patients concerns and expectations, making a diagnosis and management plan, and ensuring the patients understand the next steps (including medications use and self-care). The time taken to negotiate referral options may be organised outside the consulting room, but the more complex the options, the more NHS resource will have to go into managing these.
The Royal College argues that the key to choice lies in shared decision-making - greater ability of real time information for GPs and patients, retaining continuity, and adequate consultation times.
To achieve this we must invest in primary care. We must increase the number of GPs, district nurses and other staff. At the moment this is not happening. Whilst spending on hospital care grew 1.2% in England in 2011/12, there was a 1.2% real term reduction in GP services.
That is why we have launched our campaign. Fair funding for GPs means fair care for our patients.
This is an edited version of a speech given by Clare Gerada to a series of fringes at the party conferences organised by Help the Hospices entitled 'Can giving patients choice be cost effective for the NHS'?