On “Patient Choice”


Why “choice” does not work for me. It assumes that “choice is good” and that all patients are capable of making an informed choice. (That’s not to say this will be the case for everyone, but here goes). 

I really don’t want to have to write this post, but feel compelled to. In part because it’s my third post in 24 hours (which is why I’ve delayed it’s publishing time), and in part because it’s about my messed-up mental health – today being a particularly tough day on the anxiety front. My first blogpost on my mental health issues was Going beyond a pill, followed up by a series of further blogposts in my category Mental Health.

I think it was in this episode of Any Questions where Laurie Penny absolutely destroyed Oliver Letwin MP when the latter asked of Penny “Don’t you want to be a customer?” regarding patient choice.

On patient choice

For me there are two things here. The first is politicians having not caught up with further developments in the field of psychology crossed with economics. The mantra from my A-level and university days was that choice was good. One of the few economics staff I respected at my old university was Robert Eastwood, and it was he who pointed out some of the then new developments (in 2001/02) in the field of the psychology of economics. Had I not been this unstable ball of mental health mess at the time I’d have probably been able to have engaged far more with him because he was one of the few people who seemed to be able to look at economics from a critical perspective rather than being the mouthpiece of those that, as I set out here were compromised up to their eyeballs.

Too much choice

Basically the issue is whether choice is an inherently good thing. In some cases yes, in some cases no. The problem with the political establishment is that they have bought the “choice is good” argument in the same way that they bought “light touch regulation for banks is good” mantra. Is choice always good?

Too many choices cause:

  1. Paralysis rather than liberation – people prefer to make no decision rather than make a complicated choice.
  2. Less satisfaction with decisions as people have greater reason to regret the decisions they have made.
  3. Unrealistic expectations.
  4. Self-blame – when experiences are not perfect, people blame themselves.

This was taken from a lecture by Barry Schwartz back in 2007. In part these explain why I  still view my first university with utter contempt, even after graduation some ten years later. You say that’s not normal? I know. Feelings such as this are part of my condition. The number of universities and the number of courses are so bewildering that there can be a feeling of paralysis. With hindsight I never really had all of the information that I needed to make an informed choice of which university to go to. Again, I come back to the lack of an informed and knowledgeable mentor as being a key factor at the time. 2 & 4 above stand out like a sore thumb with having had too much choice and too little essential information on which to base that choice.

Not having the capacity to make that choice

I have an anxiety problem. I’ve spent the past week trying to fight off the side effects of medication withdrawal having come off it for the first time in five years. One of the things that I need (that the NHS does not provide unless it’s urgent & you’ve been on a waiting list for ages) is suitable mental health treatment irrespective of budgetary pressures. Thus I am in a situation (like many) where I have to look for a private therapist who will charge anywhere from £40 per hour upwards.

But I’m ill. I don’t want to have to make any choices – I don’t feel capable of it. I want my doctor to make that choice for me through a referral. But he can’t – he’s got his hands tied.  At least, that’s what it feels like. I’d rather through discussion we came to an agreement as to what sort of treatment would be suitable and leave him to sort it all for me.

I don’t want choice. I want to recover.


6 thoughts on “On “Patient Choice”

  1. Well said. Who wants choice over how quickly or effectively they ‘get better’? Not me – I want an NHS that helps me get better and renders ‘choice’ entirely unnecessary.

  2. There’s a connection, I am sure, between your post on mental health recovery and the one on courage – at least, in my experience, these two are so intimately entwined that there is not much point in trying to disentangle them, even though one is a personal problem (anxiety) and the other a social decision (courage).

    ‘Choice’, of course, strikes at the heart of both. Not for nothing are there reams of articles on ‘the burden of choice’. The push to give patients, consumers, customers and everyone else ‘choice’ is not about giving them power but about making them carry the load and take the responsibility, regardless of whether they are equipped to do so, benefit from doing so or can get information or advice on how to do so. It is about denying them recourse to ameliorative strategies when things go wrong and removing from government the responsibility for ensuring that people have, or have access to, the support they need. Naturally, consumer choice makes companies and governments more efficient and profitable. It does so by transferring responsibility and risk to the consumer. When the consumers’ minds and bodies buckle under the pressure, they should still have a choice: to turn their backs on the neocon ideology and embrace one more fitted to human beings – or to struggle on. But the barriers to making that particular choice are set very, very high, ‘There Is No Alternative,’ they tell us. ‘No Choice Here.’

  3. Your story bothers me because I was an elected service user governor of Cambridgeshire and Peterborough NHS Foundation Trust and I know there was a lot of talk about psychological services for people with anxiety problems.

    You fixed on the question of choice. This is a tricky one. Resources are always limited but, if the state chooses to take intervene there needs to be some way of making sure that these mental health professionals do a good job. I take it you do not want to hand over your care to a charlatan. There is a pretty good evidence base for psychological treatments for anxiety so you are not asking for an impossible cure but your wish for treatment has yet to result in help. Why?

    I think it is a good idea to identify the real customer in this situation. People with ample funds can buy mental health care but they are not necessarily knowledgeable customers. However most people cannot afford it. The NHS tries to deliver. If your problems are severe you may have no choice. In certain circumstances NHS staff may choose detain you and the detained patient is most definitely not the customer. Some people feel damaged by the experience of detention but even people with a greater power of choice – people with so-called light-to-moderate illnesses – find they know what they want but they cannot find a doctor who will help them. Mental health in political terms is a weak lobby because most people are embarrassed to say in public that they are ill. Politicians do not see votes in mental health.

    I say all that but sometimes good quality interventions can be liberating. Some doctors do know best but, in my view, they acquired their expertise by learning from service users and other experts in the field.

    You say you want recovery. Well that is a contested term. What does this word mean to you? What does it mean to people around you? I do not have easy answers here and besides I do not think it is my place to impose my views on you but I can I finish by shaing one of my little sayings? Shit happens. Most folk survive. Not enough for a PhD thesis but maybe more succinct.

  4. It really isn’t difficult. To begin with, Puffles, you are not a customer. To be correct, you, along with the rest of us are the employers of the NHS and everyone else who are employed by the State. Using State services does not make you a customer, it means you are using the services for which you have employed people to provide.

    Tha language used by the current Establishment are carefully selected by the politicans to ensure you feel like you have lots of choice, but never forget the business model. In the UK if you want bespoke clothes you well be told by shop assistants ‘No we don’t do that here. Sorry’ You are not the employer of that shop assistant. There is nothing you can do, except keep on searching for a business who will meet your needs.

    Now imagine you own a company of builders. Would the builders respond to your request in the same way? Of course they wouldn’t! If you have incompetent builders, when you tell them you want a block of flats built on the river bank, they’ll do it and follow your plans, your details. If you have professional builders they’ll took one look at your plans, bring themselves to your office and tell you they will NOT follow your plans because they are professionals. They know what they what they are doing. That river bank is shingles and is not only useless land in terms of being solid, it is simply dangerous to build a block of flats there. A barn might be acceptable, but definitely not flats where there is a need for really solid foundations, and that can not be created in that area.

    A good boss will listen to his builders. He has hired them for a reason; they know what they are doing, and they have the knowledge he lacks. And a boss will listen to them, because he knows those builders are helping him stay out of bankruptcy court or worse further down the line. In effect, if the relationship is as it should be. He has been told what is good for him, what he needs to do, or not do.

    Which one are you? A customer, or an employer?

    I know I am an employer and my doctor does the job I pay him to do, I pay him, via taxes to do the job I can’t. And yes, once or twice he has told me in no uncertain terms exactly what is going to happen to me. My choice was to live or die, and he told me, told me I was going to do as I was told. I had no idea at the time just how much trouble I was in. Why would I know the condition I had would progress within a week if it wasn’t treated? Why would I? Im not a doctor!

    I’ve even known of a woman with a headache and pain in her eye who was ORDERED to get in the rural doctor’s car becasue they going straight to the hospital. He saved her eyesight that day. We pay them to do their jobs. Their jobs is not to be salesmen in shop offering array after array of choice of paint colours to decorate those flats.

  5. An overall comment from very recent personal experience. Patients have very little choice at the basic level like choice of GP. We have moved 4miles and now reside in a different county (boundary is about 50 yards from our house). As the result we HAD to change our GP of 30 years since NHS funding precludes out of hours visits and district nurses being sent out of county limits. Thus i Have Had to move to a new GP surgery (choice if only 2 locally) which belongs to a new grouping with a totally different demographics. Their HQ is located at least 10 miles away. I do not see this changing at all.

    Further lack of choice comes from local NHS Commissioning Boards deciding where local patients can go to see specialists. I have a set of interlinked conditions but have been able to find a clinic where both can be treated by a specialist who covers both endocrinology and menopausal gynaecology. In the new GP surgery the proscribed rule from above us that I would need to see two separate specialists who obviously will not speak to each other. This is madness.

    Please do not object to real choice. What we should object to is irrelevant choices of the kind one finds in supermarkets where everything is nearly the same only the label differs. At least in the supermarket I can read the ingredients. In being referred to a doctor or when prescribed a drug I can’t find data that allows me to compare like with like.

    My concern is that with all these changes we still do not have transparency. And my patient data though personal to me is not owned by me. Why not?

  6. It is difficult to respond to specifics of your case except by comparison. There is too much fiddling with the system and much of unnecessary and obscure rules set out by various local bureaucratic offshoots of what we know as NHS. When you go to your GP, as I have just found out on having had to move to another practice (long story but instructive and better left for now), if and where they can send you is determined by the bunch of commissioning people in the grouping which that doctor’s practice chose. Talk about patient choice – who ever asked the patients about this? I know I had no say. Moreover, the GP practice probably had a very limited choice themselves. It is also possible that underneath it all it was no choice as they appear all to be much of a muchness.

    There is a great book by Jane Jacobs called Systems of Survival. It is wonderfully written and offers very important insights. It shows simply why the way NHS has been pushed from the time of Thatcher reforms and installation of Managers with growing powers has created an impossible situation in the organisation which is now neither a public service nor a private company.

    Of course tackling the real fundamentals is beyond our politicians.

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