Politicians of all colours are now very keen to offer us increased choice in healthcare. There is an assumption that if you can choose to ‘buy’ your healthcare from anywhere you like then this will lead to the best becoming better and if a provider is not good enough then they will see that they need to improve or else suffer the consequences.
Choice, or perceptions of the ability to choose have been evident in education for some years. The schools that have been perceived to be ‘good’ are over subscribed, they are staffed by excellent teachers and people move house to be able to send their children to them. In some areas, where people are particularly mobile and affluent this may be the case. In healthcare choice in relation to maternity has been a particularly popular phenomenon with some people. Choice of the place you have your baby, whether this is home, a midwife led unit or obstetrics unit, or whether it is about choosing one hospital provider over another is very important to some people. Exercising choice can be a tricky thing. For one thing you have to know what choices are available, and in maternity you have to understand something of your own level of risk in exercising that choice. Perhaps your pregnancy is medically or socially risky when it comes to making some of those choices, perhaps you don’t have the means to travel 30 miles to a chosen different hospital. Perhaps also the services in your area struggle to attract the right mix of skilled staff, not because they are providing a poor service but because they are geographically situated close to an area where staff can attract higher pay.
If you are pregnant, then one thing is sure you will need some kind of maternity service, and it will be the duty of your local healthcare commissioners to make sure you can access it safely. Those commissioner will be required to make sure that the maternity services offered are safe, adequately staffed and that those staff are appropriately qualified to fulfill their role. Maternity Matters gave us a role in promoting choice and in making sure that those choices were available and that people were assisted in making those choices. When though does choice become a want or a demand? When does choice and the way it is exercised by the few mean that those who are more able to move, more affluent, more able to make choices have a detrimental impact on the many?
As a nurse working in a PCT I am obliged to take part in one of the much maligned prior approval schemes that are popping up all over the place to manage the demand for healthcare. ‘Low priority’ treatments such as removal of non cancerous skin lesions and varicose vein surgery are judged against a set of criteria set by a panel of doctors and approval is given or not for surgery to take place. What strikes me most about the way in which cases are presented is the extent to which GPs and surgeons struggle to tell patients that their problems don’t quite meet the criteria. Often they will write that the patients ‘wants this surgery performed’, and I am left wondering; yes, but do you think it needs to be performed.
I had the pleasure of setting up a new nurse led service a few years ago for people with rheumatoid arthritis. My job was to manage the day-to-day issues that arose for patients coping with a long-term illness, while taking potentially lethal drugs and still needing to deal with normal life. We set up a great service with a help line, monitoring clinics, home visits etc. What it taught me though was that where you create choice and opportunity you will also create demand and to a certain extent want. The people who shout loudest will often if you are not careful get the biggest share of what is on offer and that may be to the detriment of those who cannot shout and indeed may not even know what to say.
Whoever is in charge, whoever does the work of commissioning or buying healthcare, whoever provides it, there will never be enough of it to go around if someone doesn’t take the responsibility for making sure that decisions aren’t only made because of what is wanted, where it is wanted and whom it is wanted from. That of course is what makes my job interesting if not tricky!