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Comment: Clear choice

Comment: Clear choice
17 March 2014

Until patients know what their options are, how are they supposed to make informed decisions about their care? Are you ready for the world’s most transparent health service?

Until patients know what their options are, how are they supposed to make informed decisions about their care? Are you ready for the world’s most transparent health service?
That’s the ambition of Tim Kelsey, NHS England’s National Director for Patients and Information, who firmly believes that not only will transparency save lives, but it is a basic human right. How can you give your informed consent to anything without knowing the likely outcomes? Kelsey cites his Medical Director Sir Bruce Keogh as ‘a hero of our time’, as he leads the charge for publication of comparative data on NHS outcomes. 
His track record is impressive, having persuaded heart surgeons to do just that, coinciding with survival rates that increased by a third. Kelsey believes this transparency saves 1,000 lives a year, although proving cause and effect is notoriously difficult. Improvements in technique and technology are equally, if not more, important. But what transparency does do is leave nowhere for poor practice to hide, and the full glare is now shining on general practice. 
Comparative data released suggests some GP practices are much better than others at referring cancer patients early. And the first wave of GP inspections have found problems with essential standards in a third of practices inspected so far, and headline grabbers such as live maggots in the treatment room, warm vaccines and no doors on consulting rooms. The nine worst have been named and shamed. Soon, all GP practices and clinical commissioning groups (CCGs) will be ranked by the Care Quality Commission (CQC) and chief inspector of general practice, and websites like I want great care will encourage patients to rate GPs and practices according to experience, and to swap GPs if that experience is poor. Remove practice boundaries, as Jeremy Hunt is proposing, and general practice could turn into a consumer market for patients willing to shop around. 
This is where transparency becomes more contentious. Very few patients at present shop around for heart surgery, and improvements in care have not been driven by consumerism but rather by the professionalism of the units benchmarking themselves against each other, cooperating and sharing best practice. This government is very keen on consumer choice but as we know, some patients are more able to choose than others and switching to a better GP, at least according to the ratings, could mean that more popular practices can cherry pick more profitable patients and others will be left with a larger percentage of those with multiple chronic diseases and mental illnesses. 
NHS general practice is efficient because GPs get paid a fixed amount for having a patient registered with them. Money isn’t taken away if the patient never visits, and so healthy, low-attending patients subsidise elderly, chronically sick and mentally ill. This risk-pooling is fundamental to the ethos of the NHS, and if you’re fit now it’s your insurance policy for later illnesses which happen to us all. 
But an inevitable consequence of transparency will be more choice, so we’d better get used to it. And when the data is out there, some patients will want to use and control it to manage their conditions better. Personalised healthcare records may become the norm, and assertive patients will decide who they see, which treatments they want and who to share their data with. Kelsey believes we must ‘liberate data and give customers the ability to do more for themselves so that services are delivered better, faster and at lower cost.’ I hope he’s right, but a £30 billion funding gap seems a lot to fill with better data. My own belief is that healthcare begins with self care, and until patients take more responsibility for their health, the NHS is doomed. Feeding back personal data to patients through text-alert systems like Florence so they have better disease control is key, but we’ll always need human beings to support us when we’re sick and anxious. Good luck. 

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