Choice has become a mantra within the public sector, a sine qua non, an indisputably good thing. Politicians are so entranced by its allure that they are blind to both the inherent paradoxes and blatant inequities that are frequently the close companions of choice. The result is that we are often left feeling let down and oddly disempowered.
There are three main types of choice within healthcare: Those that are promised to all but only available to some; those we don’t like to talk about, because the reality is that they aren’t available at all; and those we could all have, but that the powers that be prefer not to tell us about – because they don’t trust us to make the right choice.
The first type of choice we might call the big slice of cake choice. When my teenage son and I cut two slices of cake, inevitably one is larger than the other. With equal predictability, since we are rather partial to cake, we both choose the larger piece – but the reality is that only one of us can have it. Similarly in healthcare – the best surgeon cannot operate on everyone, but who would ever choose the second best? Or I might like to choose the beautiful new hospital on the other side of town, but I have no car and the bus only goes to the tired old DGH down the road.
The result of these big slice of cake choices is that only those with the wherewithal to navigate their way through the confusion of options, and are both savvy and mobile enough to take advantage of the range if choices on offer, will actually benefit – which usually equates to the better off and the less unwell, yet another example of the inverse care law in action.
The second type of choice is the one we like to brush under the carpet – the unpalatable lack of choice that we have to face due to the reality of rationing. The NHS can no longer afford to say ‘yes’ to every health choice we would like to make. The latest, most expensive drug may not be available to us, and our varicose veins may not be deemed worthy of treatment. We are getting used to this in the NHS, and should not be embarrassed by a degree of rationing – although the decisions about what we can and cannot choose need to be made ethically and carefully, and not just by a board of panicked managers frantically trying to balance the books.
The third type of choice is the one that really interests me. It could and should be given to us all, and yet it is rarely talked about – because it has little political value, and involves actually trusting patients. If you are going to trust patients, you have to accept that they can be irrational, unpredictable, and sometimes make foolish choices – and here I speak not as a doctor frustrated by his patents, but as a member of the human race celebrating our glorious diversity.
The choices I am talking about here are these: Should I take a tablet for my mildly raised blood pressure? Should I have a mammogram? How do I feel about statins? These are the sort of health choices many of us are faced with when we visit the doctor, or receive a letter in the post inviting us to engage in a health screening programme. And yet it is rarely presented to us as a choice. We are told to take this tablet, made to feel irresponsible if we ignore the invitation letter, and risk being branded as non-compliant if we disagree – as though it is our duty to bend to the will of the medical profession.
This lack of choice is enshrined in the fabric of the GP contract, as GPs are given an ever-increasing number of targets to aim for – including achieving tight blood pressure control, prescribing anti-coagulants or performing cervical smears. Pressure to deny patient choice comes in the form of prescriptive guidelines, which are frequently dictatorial in the manner in which they tell doctors what they should be done in a particular situation. While evidence-based guidance has been an invaluable tool in helping to achieve excellent standards of care, the words ‘depending on patient individual preference’ appear all too rarely in published guidelines, and doctors are in danger of projecting the pressure that they feel to conform onto their patients.
Many treatment decisions are a complex blend of objective medical evidence concerning risk, and need to take account of highly individual, subjective preferences, priorities and health beliefs. Respecting autonomy is one of the principal pillars of ethical practice, but all too often this is reduced to waiting for the patient to raise objections to the proposed treatment plan, or asking them to become an ‘expert’ in their own health, which can equate to expecting the patient to become the doctor.
True respect for autonomy is a highly active process. It involves creating an environment in which autonomy can flourish, and empowering the patient to make the right choices for their individual situation. It requires that the doctor knows and understands their patient, has a thorough grasp of what matters to them, and is able to distil the available medical evidence into an understandable, personalised format. It may involve supporting the patient when they choose to have treatments or investigations which the doctor would not choose for themselves, or giving licence to opt out of guidelines if they wish to, and turn down treatment without being made to feel like a naughty school child,
This respect cannot be confined to the consulting room, but needs to be enshrined in all aspects of health care – and health promotion in particular. Invitation leaflets for health screening should seek to enable informed choice rather than tell us what to do, and health awareness campaigns should avoid emotional manipulation and never, ever, look like this:
9 thoughts on “Choices, Choices , Choices”
All I can say as an awkward non-compliant patient, finally a Dr speaking some sense!
Been fairly ill this week with an infection. Needed to be seen in hospital and GP was kindly arranging it. I’m sat there, swollen face, slumped over here desk because I’m feeling like collapsing and then she starts parroting about the fact she’s noticed that a certain 5yrly screening test is overdue and we have a quick discussion and she’s kind of expecting me to arrange the appointment there and then. I’m kinda going – what? (There are some very valid reasons why I don’t want the test). I managed to get the discussion pushed back to another day but I left the consultation room thinking are they that desperate to meet their QOF targets?
And really shows what the priorities are deep down at heart …
Thanks for sharing this, Mandy – so important that we hear all perspectives on the effect of the GP contract on the doctor-patient relationship. If it wasn’t painfully true, your experience would be quite comical!
Excellent post, thank you Martin. And excellent comment, Mandy!
I will never forget when the visiting nurse, ‘Little Miss Side Effects’ came to my house and reeled off all the dire things that could happen to me as a result of chemotherapy. I was terrified. She then asked in a very ‘smiley’ way whether I was ‘happy’ with that. She clearly needed to complete the final box on her tick-list.
Also, the time I was trying to explain to a social worker over the phone exactly how my Mum-in-law was; she was living with dementia – better days and worse days, perhaps depends on hydration etc… But the social worker was clearly getting frustrated. “But can she (i.e. implication it must be Yes or No) do the following….?”
Some of these encounters have truly lost the plot.
Comical in a ‘Computer says NO’ sketch type situation – but sadly real life here 😦
Amen to all that you say, Martin. The voice of the patient as an autonomous human being with free will is being lost as we are engulfed in protocol driven healthcare. It seems that patient choice no longer seems so important when it conflicts with the guidelines, and so much for ‘no decision about me without me’. I think it is our professional responsibility to support our patients in whatever choice they wish to make (assuming they have mental capacity!) and to provide the information and guidance to help them. We probably should be using patient decision aids more than we do, and providing reassurance that it’s OK to say no. It could potentially save a lot of money as well!
Wonderful articulation of what I have always felt but not been able to express. Most of us, most of the time, don’t want choice. We want good quality local care. Is that advert for real?
Thanks Harry, and great to connect with you on Twitter!
Yes, sadly the advert is real and from Kirklees NHS Trust. I don’t think people think these things through.
What a great blog post. Thank you Martin.
The issue of choice is so complex and you have done an excellent job of unpicking the various different kinds of choice.
One thing that strikes me in any discourse or discussion about choice is the lack of any mention of responsibility. Patients have rights, yes, of course. Everyone knows that 🙂 but they also have responsibilities, including the responsibilty to inform themselves about their particular health issues and to share responsibility with the GP for making appropriate choices in the context of the rest of their lives.
Faced with an increasingly ageing population, with more and more complex chronic conditions, it is more important than even to be able meet people where they are, listen to their stories and then work together to find appropriate solutions – which might not be drugs or investigations or invasive treatments.
If the rights of the patient, as well as those of the clinician are combined with responsibilities on both sides then, it seems to me, mutual respect will ensue, with better, more open communication and the most appropriate solutions in the circumstances.