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The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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In 2011 there is still a debate over whether the public have the right to a better choice of GP.

Filed Under (GPs, Patient Choice) by Paul on 25-05-2011

One of the most interesting outcomes of blogging regularly is that I am often surprised about what is contentious, and what is not. Last week I discussed some evidence about the outcomes of patients being able to choose their GPs and received a range of different comments, most of which argued against giving the public the right to choose their GP.

One of the later comments – from someone on the side of the argument believing in public choice – was that many of the contributions seemed to come from 1911 rather than 2011.

That mention of history inspired me to dig into this a bit further.

In July 1948 – at the birth of the NHS – a leaflet went out to every household introducing them to the new service. On page 2 the first activity that all members of the British public were advised to do was to “First choose your GP…”

I was 3 months old at the time so I can’t say this had a big impact on me, but my parents felt they now had the right to choose their point of entry to the NHS, that they and their politics had created.

The alternative to people choosing their own GP would have been for the state to allocate a GP to every member of the public. It is interesting to remember that in 1948 the state was still interfering in people’s lives following the war. Rationing told people what they could buy to eat. These were not wild libertarian times.

But even in these more regimented times the first injunction of our new NHS was to choose your GP.

Choosing your own GP is not some wild new Labour idea. It originated with the birth of the NHS.

In 2009/2010 Parliament passed an NHS Constitution that was agreed by all political parties. This had a section on choice which said,

  • .You have the right to choose your GP practice, and to be accepted by that practice unless there are reasonable grounds to refuse, in which case you will be informed of those reasons.
  • You have the right to express a preference for using a particular doctor within your GP practice and for the practice to comply

These seem pretty clear rights to me and I don’t remember at the time any outcry from doctors saying that this was all wrong.

So I think the historical and contemporary development of the right to choose your GP is clearly a part of the NHS and something the public have the right to expect from it.

Much of the argument against choice seems to stem from the belief that choice will create greater inequality because poor people are not as good at making it as the “better off”. Disadvantaged people that I have known and worked with however, have lived their lives making choices that are much harder than most of those made by the “better off”.

Buying enough food for your family when you are on the minimum wage seems to me to contain a harder set of choices than those confronted while browsing the cheese counter at Waitrose.

Making sure that you have enough cash to heat your home in the winter means making more difficult choices than whether to spend Christmas in the Maldives or the Seychelles.

I remember a similar debate about choice in front of an audience in which many in which many were refugees (of course choice is way beyond them.) One Somali woman got up and itemised the choices she had made in order to get from the oppression of war in Somalia to the port of Dover. Several times a day she had made choices more difficult than any I have had to make in the whole of my life.

This argument that poorer people cannot make choices is patronising rubbish.

On the other hand I am sure that if we present choices in a particular form, disadvantaged people will not think it is for them. But that is our fault, not theirs.

The point of policy for the NHS in 2011 is not whether we should have real and open choice of GPs for the public but how to bring these rights into reality. There are areas of the country where this right is observed much more in the breach than in the observance and we need to change that.

In some areas we simply need more GPs.

In other areas we need GPs making a different offer from their colleagues.

Almost everywhere we need more and a better choice of GPs.


11 Responses to “In 2011 there is still a debate over whether the public have the right to a better choice of GP.”

  1. Paul, do you really believe that it is ‘patronising rubbish’ to say that everyone is equally able to exercise choice and that eduction and power have absolutely nothing to do with it? Do you really believe that no matter how disabled you are, traveling is no object? Do you believe that no matter how depressed, anxious or inarticulate you are, expressing yourself is not a problem? Seriously, are you suggesting that an illiterate, blind man with diabetes and schizophrenia is as effective and empowered a consumer of general practice as you or I? Are you saying that my housebound patients with dementia, and my drug-addicted single mothers who I have to visit because they cannot or will not come to see me, will be helped by more choice of GP? My experience of taking over failing practices is that these are the patients who are left behind. That is the inverse care law. I make choices in every consultation I have with my patients, that is patient-centered medicine, and is at the heart of humane, holistic medicine. The choices patients want are about where to die, whether to continue chemotherapy, what type of insulin to use, how to manage the symptoms of their arthritis better, how to avoid surgery for their gallstones, how to cope with their bereavement. The only choice I ever here from policy people is consumer choice to facilitate markets, never the clinical choices that really matter to patients, market centered medicine or patient-centered medicine?

  2. jonathan, sneering at ‘policy people’ and assuming their motives to be to ‘facilitate markets’ doesn’t help your argument. The fact that someone is not able properly to exercise their choice does not mean that they – and everyone else – should not be given it. A better response, as Paul suggested, is to make sure that they can. It’s good that you are a GP who practices patient-centered medicine. Shouldn’t everyone be given the chance to choose you, or others like you, instead of taking what they are given?

  3. Paul
    I read this and the above post with immense interest. There seems to be a polarity being described and its not ‘either/or’ but rather ‘and/both’. What the system needs is ‘market segmentation’ for patients (dare I use these words for fear of invoking the wrath of millions!). As a taxpayer I want to be free to choose – to choose which practice (or even practices because at this stage of my life, my interaction is transactional rather than relationship), where and when I access and then within the practice which doctor I choose to see. I do not have this nor can see this happening in the foreseeable future. The people described above may need a different approach, more tailored, more intensive even and choice may not be entirely appropriate all the time. However, the one size fits all approach is inefficient all round.
    The NHS is too afraid to take a tailored approach to access and General Practice. It could and would be so much better if it did


  4. on this subject it is worth noting that the Kings fund did a report on patient choice that found “75 per cent said choice was either ‘very important’ or ‘important’ to them; older respondents, those with no qualifications, and those from a mixed and non-white background were more likely to value choice.” it went on to say “the results show that GPs’ perceptions that it is younger, more educated patients who want choice are misguided.” They also found that older patients were more likely than younger patients to choose to attend a non-local provider. The report suggests the so called inverse care law exists, not in the real world, but in the minds of GPs who believe they know what patients want better than the patient knows themselves. As the kings fund concluded, “it may be worth communicating to GPs the diversity of patients who think choice is important”

  5. Paul,

    I am getting increasingly concerned about your lack of understanding and feel for the realities of General Practice. Whilst we need more and better GPs in deprived areas, the analysis is cerebral and impractical, as one of the earlier commenters noted.

    Of course people need good access to general practice. But your solutions (as suggested in your blog) betray an alarming lack of a feel for reality.

    Get out of the home counties bunker and see some real general practice.

  6. Paul,
    I don’t think many doctors oppose the idea of patient choice. In fact, as you state, patients have always had choice in the NHS. The key point, as you should well know as a New Labour pro-marketeer, is that the patient choice agenda is really about promoting a market in healthcare. The “free to choose” ideology is Friedmanite and has resulted in a failing $2.3 trillion US healthcare system.
    The patient choice agenda is clever political rhetoric, which on the surface promotes the idea of patient empowerment, but in reality it is really about opening up the public sector to a competitive market, where the private sector will gain access to billions of pounds of taxpayer funds.
    This has happened right across the public sector as described by John Denham:
    “All public services have to be based on a diversity of independent providers who compete for business in a market governed by Consumer choice. All across Whitehall, any policy option now has to be dressed up as “choice”, “diversity”, and “contestablity”. These are the hallmarks of the “new model public service”
    John Denham MP, former Health Minister quoted in 2006

    I also refer you to Barr et al:
    Barr et al concur with this:
    “This patient choice agenda has been developed in terms of a prerequisite for competition and marketisation. While adopting this policy program, new Labour has appended the claim that choice—and the market mechanisms this will facilitate—will make the NHS fairer. This claim has not developed prospectively from an analysis of the causes of healthcare inequity, or even with a consistent normative definition of equity. The limited justification that is framed in causal explanations of inequity has suffered from an apparent disregard for the available evidence”
    Barr et al. J Med Ethics 2008;34:271–274.

    n.b Larry,
    The King’s Fund report on patient choice was not published in a peer reviewed journal. It is a simply another report published by yet another a pro-market Think Tank. Asking patients whether they like choice is like asking children whether they like sweets. It is the context that is crucial.

  7. I am genuinely puzzled as to what the anti- GP choicers are saying. Is that that if I have a unsympathetic GP with poor access and limited services I must stick with that practice come what may?

  8. Or is it all code for- no new entrants to the local GP landscape, especially if the new entrants are not existing contract hoolders.

    Because if it the latter it seems to me all you are doing is defending a cartel.

  9. Clive-
    “asking patients whether they like choice is like asking children whether they like sweets”
    comparing patients to children says everything about the patronising dismissive attitude of the doctors unions

  10. I’m sure Clive Peedell can speak for himself, but the response of Larry at 11.02 is rather silly. He is not comparing patients to children. Maybe the level of discourse can be raised.

    Mark – we are not defending a cartel. People have plenty of choice in my patch, with the opportunity to register will more than a dozen practices. Is a dozen enough choice for you? Or would you describe that as a cartel too?

  11. Dear Jobbing Doc,
    12 is fine so long as they are operating at a reasonable standard of quality and access. It’s a cartel when local primary care is poor and the local contractors resist improvement efforts and bringing in new services.

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