Previous studies

There have been a number of empirical studies, which evaluate the impact of patient choice. In England, these studies have mainly focused on evaluation of a series of pilots including choice for cardiac patients (le Maistre et al., Reference Le Maistre, Reeves and Coulter2003), choice for patients waiting for elective surgery in London (Dawson et al., Reference Dawson, Jacobs, Martin and Smith2004; Burge et al., Reference Burge, Devlin, Appleby, Rohr and Grant2005; Coulter et al., Reference Coulter, le Maistre and Henderson2005; Ferlie et al., Reference Ferlie, Freeman, McDonnell, Petsoulas and Rundle-Smith2005), and choice at point of referral pilots (Taylor et al., Reference Taylor, Pringle and Coupland2004). These have generally focused on the level of uptake by different groups of patients and the impact on waiting times.

Studies in the Netherlands have focused on the effect of national websites that provide information on hospital performance on choice (Stoop et al., Reference Stoop, Vrangbaek and Berg2005), the role of insurers in furthering choice for hospital admissions (Knippers et al., Reference Knippers, Breedveld, Andela and Lambeck2001) and the extent to which patients are seeking cross-border care (Brouwer et al., Reference Brouwer, van Exel, Hermans and Stoop2003). Similar studies have been published that focus on the impact of choice in Sweden and Denmark. Vrangbaek and Bech focus on the financial incentives that were introduced to facilitate patients choosing providers outside of their county council of residence and the (limited) extent to which these created incentives for providers to attract patients in Denmark (Vrangbaek and Bech, Reference Vrangbaek and Bech2004).

There have also been a number of papers, which have compared the policies and the extent to which patients are exercising choice (Fotaki, Reference Fotaki1999, Reference Fotaki2007; Vrangbaek et al., Reference Vrangbaek, Ostergren, Okkels Birk and Winbald2007).

These empirical papers have mostly focused on the desired objectives of the policies and their impacts. They have focused much less on how the impact has been mediated during implementation.

The Netherlands

In principle, patients have always been free to choose a hospital (and physician within the hospital) after referral in the Netherlands. In practice, however, choice was not on the policy agenda, nor was it actively supported. Comparative knowledge on secondary care providers was scarce and GPs – who act as gatekeepers to hospital care – tended to have close connections to specific hospitals. Choice of hospitals has emerged as a policy issue for two reasons. First, the growth of waiting lists from the early 1990s onwards as a result of the budgets set for hospital care. Stimulating choice of hospital at that time was seen as a way of reducing waiting times.Footnote 3 Second, choice on the basis of quality of care criteria is high on the current policy agenda, to further the regulated competition in hospital care that was introduced in 2006.Footnote 4

Several instruments have been developed to stimulate choice. First, national websites (both public and private) have been set up to provide information about the quality of hospital care. Initially these focussed exclusively on waiting times and their impact on choice was minimal, although they stimulated public discussion (Stoop et al., Reference Stoop, Vrangbaek and Berg2005). More recently developed websites, such as kiesBeter.nl (‘choose better’) and Independer.nl offer more information; including the Dutch healthcare inspectorate’s set of performance indicators for hospital care (a set of 29 indicators including e.g. decubitus ulcer prevalence and infection rates in hospitals). These websites are primarily designed for use by patients and the public outside the GP consultation. Evaluation of these websites is still underway. As research elsewhere has suggested, however, impact on choice of such websites generally remains low and restricted to specific subsets of the population (Henwood et al., Reference Henwood, Wyatt, Hart and Smith2003).

Second, more direct forms of stimulating patient choice are being explored. One example is the ‘waiting time mediation’ service set up by health insurers from the mid 1990s onwards. Patients with a referral to hospital can contact their health insurer who will try to find a shorter waiting time. In 2000, some 6000 patients accessed this service. On average between 70% and 80% of patients were able to find a hospital with a shorter waiting time (Knippers et al., Reference Knippers, Breedveld, Andela and Lambeck2001). As gatekeepers, GPs also engage in these mediating activities. They have direct contact with medical specialists in the case of urgent referrals (i.e. patients who need to be seen in a few days). In the case of ‘semi urgent’ referrals (i.e. need to be seen in a week) GP assistants will contact assistants at the outpatient ward to arrange quick referrals. Even with normal referrals, GPs frequently discuss choice options with patients. However, patients are able to ‘shop around’ between hospitals if they so wish.Footnote 5 In the region examined in this article, shopping around was not uncommon, with patients living in the border region also accessing care in Belgium to prevent excessive waits (Bal and Mastboom, Reference Bal and Mastboom2004).

England

In England patients have traditionally had little choice over where their GP refers them for hospital treatment. GPs have usually made this decision on behalf of their patients. During the 2000s policies have been introduced that give patients more choice over where they get referred for treatment.

The National Health Service (NHS) Plan (Department of Health, 2000) committed the government to giving patients a choice over the time and date of their hospital appointment. Choice over where patients were referred for treatment was only announced later (Department of Health, 2002). Coronary heart disease (CHD) patients nationally and all elective surgery patients in London who had been waiting over six months (CHD) or eight months (London) for treatment were offered quicker care from an alternative provider. Patient choice was intended to make efficient use of capacity in the NHS and reduce waiting times.

The NHS improvement plan (Department of Health and HM Government, 2004) announced plans to give all patients a choice of hospital at the time they were referred for treatment. The aims of the patient choice policy were broadened from an initiative to get patients seen more quickly to a tool for improving the responsiveness of health services to patients’ needs, promoting quality improvement and cost effectiveness. In order to promote competition a new reimbursement system that paid health care providers a fixed tariff price per case was also introduced and hence was intended to promote competition on quality and timeliness of care.

Since January 2006 patients should have been offered a choice of four or five local providers for their hospital treatment. Since April 2008 patients should have been able to choose any provider nationally that meets standards set by the independent regulator of quality, the Care Quality Commission, and will provide care at the national tariff rate (Department of Health, 2007a). The NHS constitution made this a legal ‘right’ to choice in 2009 (Department of Health, 2009a).

Information to support choice has been slow to develop. To help patients choose a hospital they are supposed to be offered a ‘choosing hospital’ booklet but only 7% of those who recall being offered choice say they were offered the booklet (Department of Health, 2009b). The NHS choices website (http://www.nhs.uk), launched in June 2007, has been developed to provide information on providers and allow patients to compare different options. The site was used by 6% of patients only who were offered a choice (Department of Health, 2009b). The information currently available on the site comes mainly from the Care Quality Commission Annual Health Check ratings, along with some patient comments posted on the site. There is a small but increasing amount of information available about the quality of care provided by particular clinics/specialties within hospitals; and, for cardiac patients only, consultant level risk adjusted survival rates are published, although there is a little variation between these (see http://www.heartsurgery.healthcarecommission.org.uk). The recent Next Stage Review suggests that there will be much more quality information, including clinical measures and patient reported outcomes, collected and published in future (Department of Health, 2008a). When asked, GPs say they use a combination of soft knowledge about providers and published data in order to advise patients. They are sometimes sceptical about official information sources and therefore less tangible reputation factors are likely to impact on choice (Rosen et al., Reference Rosen, Florin and Hutt2007).

In summary, there is a stronger tradition of patient choice of hospital in the Netherlands than in England yet both health systems, faced with long waiting times, sought to strengthen patient choice at point of referral to enable patients to secure appointments with providers whose waits are shorter. Encouraging patient choice has been supported as a means of driving competition between providers of health care with the expectation that providers will be more efficient, improve their quality and be more responsive to patients. Increasingly comparative information is available to patients on quality in both countries although this mainly reports on the performance of organisations rather than particular specialties, clinics or clinicians.

The Netherlands

The ZorgDomein project (in literal translation: care domain) in the Dutch Eindhoven region was initiated by the Regional consultation body on curative care, in which the four regional hospitals, the District GP Association and the two main health insurers in the region participated.Footnote 6 In the first instance, only three of the hospitals participated in the project (with a total of four sites); the fourth hospital joined when the project was in its second year. The insurers were not directly involved in the project. Financially, the implementation of ZorgDomein was supported by the hospitals. The basic idea and design of the project was to implement an electronic referral system (ZorgDomein) to enable a smoother communication process between GPs and hospitals, improve the quality of referrals and improve efficiency in the hospitals. Patient choice was implemented as part of this wider agenda.

The (commercial) ZorgDomein application supports structured choice options on the basis of regional care provision and waiting times, medical and logistic information for patients, and communication between the GP and medical specialist. It consists of referral protocols (based on existing national guidelines as well as local working practices), up-to-date and/or guaranteed waiting times for specialist consultations, and patient information. ZorgDomein also adds new referral types to the pre-existing ‘normal’, ‘urgent’ and ‘semi-urgent’ referral: the ‘combination referral’ in which patients are referred for diagnostic tests and specialist consultation at the same time, and the ‘shortened access time referral’ for which there is no need for a telephone consultation between GP and specialist. GP’s can send an electronic referral letter to the hospital of their choice (being limited to the participating hospitals).Footnote 7 The format for the referral letter is standardised for specified patient groups, for example, heart failure patients, agreed on in GP-medical specialist consensus meetings and based on existing national and regional standards. Ideally, the letter automatically extracts all relevant information from the GP’s information system (but see Bal et al. (Reference Bal, Mastboom, Spiers and Rutten2007)). The ‘return letters’ from medical specialists to GPs also have standardised formats. A separate but parallel development has been the introduction of standardised care trajectories within hospitals, especially for the combination referrals.

How does a ZorgDomein referral come about? When, during a GP consultation, a decision is made about a referral, the GP can open the ZorgDomein application from his GP Information System. ZorgDomein will then show a list of medical specialties for which referrals can be made in the region. Scrolling down the list, the referral options for each of the specialties are shown. Choosing one will then show a second screen in which the referral options in the region are shown. This screen lists the kinds of referrals that can be made to each of the participating hospitals, the trajectory that will be followed in the hospital, the waiting time for this specific referral, and the diagnostic criteria that have to be met in order to make the referral (which may mean that there is additional diagnostic work to be done by the GP in order to make the referral). Waiting time information in ZorgDomein is added by the system administrators on a weekly basis. A standard definition of waiting time – the third available time slot for the clinic – has been agreed upon between project members. Hospitals at first tried to set up automated systems to generate waiting times using this definition, but these sometimes generated inaccurate waiting times as, for example, clinics could have appointment slots that appeared available when in fact consultants had agreed not to add new patients to that clinic list. Because of this, waiting times in the system are mostly generated by administrators phoning participating wards individually to ask them to report waiting times.

After choosing one of the referrals, a third screen is opened with a data sheet that needs to be completed in order to make a referral. At this time, the ZorgDomein application will extract name and address as well as medical data from the GP information system. If the GP wants the patient to be seen by a specific specialist at the ward, this can be made explicit in the screen in an open text field. Once the screen is filled, the letter can be generated by clicking on the relevant button and can be sent electronically to the hospital (where it will be automatically transferred to the ward for this specific referral). The GP can also print a copy of the referral letter for the patient as well as a separate sheet with the contact details of the ward. Both letter and sheet contain a unique patient number. The patient is then expected to call the ward to make an appointment, stating the unique number that can be used for identification of the referral letter.

Choice of hospital in ZorgDomein is a GP-assisted process and is limited to: participating hospitals, which in this case were all public hospitals in the Eindhoven region; and the specific referral types that are defined in the GP-medical specialist consensus meetings. ZorgDomein, like other GP information systems (van der Ploeg et al., Reference van der Ploeg, Winthereik and Bal2006), structures the conversation between the patient and the GP regarding the issue of choice for, respectively, medical specialty, referral type and hospital. Patients can, however, always opt-out of the choice made during the consultation, and in fact this happens regularly (Bal and Mastboom, Reference Bal and Mastboom2004), creating a new category of patients for the wards: that is, those that were referred but never made an appointment. It was not initially clear who was responsible for following up these patients and it took some time (and legal advice) to resolve the issue.

In the hospitals, referrals are received at the wards as attachments to Emails. When patients call for appointments they are in principle treated as any other patient and assigned a time slot for consultation; in the case of combination referrals, this time slot includes both diagnostics and specialist consultation. At the time of our study (2004–2005), there was no electronic connection between ZorgDomein and the hospital information systems and referral letters were just printed and added to the patient paper file. Due to the fact that the ZorgDomein referral letters are sent by e-mail they are present in the hospital before the patient is seen allowing the specialist to prepare for the consultation (which is not the case for patients referred without systems like ZorgDomein).

England

The introduction of choice at point of referral in England has been supported by the development and implementation of an electronic booking system called ‘Choose and Book’. This system provides a computer interface that links GP IT systems with hospital patient administration systems (PAS) and allows appointments to be booked online in the GP surgery or by patients over the internet or telephone using a secure password. The system was developed by Atos Origin who won a contract for its development in October 2003 following a Europe wide tendering process. The contract was worth £64.5million over five years (National Audit Office, 2006).

In addition to the improvements in efficiency and quality expected from giving patients a choice of provider, the electronic booking system hoped to create greater convenience and reduce the stress and uncertainty of the referral process for patients, reduce the number of enquiries GPs have to deal with about appointments, and lessen the bureaucracy associated with the referral process. It was also expected to reduce the number of patients who do not attend (DNAs) their hospital appointments and reduce cancellations as well as provide more consistency in the format and standard of referrals (Department of Health, 2004).

The implementation of ‘Choose and Book’ has been led by the National Implementation Director for ‘Choose and Book’ at the Department of Health. Primary Care Trusts (PCTs) are responsible for ensuring patients can choose to be treated at any clinically appropriate hospital (Department of Health, 2009c) and that the ‘Choose and Book’ system is implemented at a local level (Department of Health, 2004).

GPs across England have various different IT systems for monitoring patient activity in their practices. When GPs make a decision to refer a patient for treatment, their own IT system, in most cases, links to ‘Choose and Book’. The ‘Choose and Book’ system then picks up the patient’s identity from their NHS number and the GP chooses the priority of the referral to outpatients (urgent, routine or two week wait). They then select the specialty and clinic type the patient needs from preset menus. Although the system is designed to allow choice of named consultants, so that GPs can refer directly to a particular specialist, this is not available in most cases. Once these clinical options have been selected, the GP can search for possible providers either by using a patient’s postcode to search by distance, by inputting a key word (such as the name of a provider) or a search by waiting time (an indicative waiting time is given for each provider based on the last 20 appointments in the system). Information is then displayed showing name of provider, clinic and the distance from the postcode used in the search, as well as indicative waiting time. From this list GPs can click on any of the providers and get information about them from a directory of services, which lists the services available at the hospital and the type of patients that should be referred to each clinic. This information is supplied by the providers.

There are a number of ways in which patients can make their choice and book an appointment. The GP can confirm the booking during the consultation, other practice staff can process the booking (e.g. receptionist), or alternatively patients may wish to make the booking themselves, in which case an appointment request is generated by the system and given to the patient. They can then either call a telephone appointments line or access ‘Choose and Book’ on the internet through their own personal ‘health space’ page where they can also access the NHS choices website, which provides information on providers and allows comparisons to be made on performance against published indicators, patient views and distance from home.

Once a provider has been chosen, if they have ‘directly bookable’ appointments (i.e. the hospital booking system is electronically linked with ‘Choose and Book’), a time and date can be selected on the system and a booking form printed. If the provider’s booking system is not yet integrated with ‘Choose and Book’ then the patient is given the hospital’s telephone number along with a generic booking form with a reference number for the referral but no time or date on it. They must then phone the hospital to book their appointment. The booking request is received by the hospital who decides whether it is appropriate and either confirms, or rejects the referral. In some cases they may also contact the patient to change the appointment time.

Within three days of the booking, GPs are required to attach a referral letter to the ‘Choose and Book’ system to pass on clinical information to the hospital at which an appointment has been made.

Similarities and differences in systems design

There are some similarities and differences in the design of the systems.

Although ZorgDomein creates an electronic referral including clinical information, in England the primary purpose of the system is to generate an electronic booking to which referral information can be attached. However, the choice of clinic within ‘Choose and Book’ does require clinical judgement to determine the appropriate clinic type and therefore this decision must be made with the GP before a booking request is generated. In the Netherlands, it is up to the patient to contact the hospital to make an appointment. In England it is possible for the booking to be made directly by the GP, though this may also be delegated to other practice staff, or to the patients themselves. Where the chosen hospital does not have appointment slots available on the system, the patient has to ring up to make the booking in much the same way as a patient in the Netherlands would.

Both systems rely on GPs for their implementation. In both countries GPs have had to be given financial incentives to use the system. In the Netherlands, ZorgDomein allows for direct referral for diagnostics, which reduces the number of consultant visits. The additional work by GPs reduces the work required of hospitals and so they demanded a shift in financial reimbursement (see below for more detail). In England, where the majority of GPs are paid through a national contract, a special additional payment was introduced in the GMS contract from 1 April 2006 of 96p per registered patient (Department of Health, 2007b) which has now been replaced by locally agreed incentive schemes.

The Netherlands

Choice

Patients generally are also positive about the choices offered to them through the ZorgDomein system. The extent to which patients actually do get a choice, however, also depends on the strategy of the GP. Although some GPs discuss all referral types and waiting times in the system with their patients, some GPs only tell patients the referral options and waiting times for the hospital in the immediate locality. Only when patients ask, mostly because of long waiting times, do the GPs go into other options. Some others argued that they would not tell their patients anything about waiting times as the GPs did not see this as their responsibility. Waiting times in the ZorgDomein system, these GPs argued, were ‘promises’ made by the hospital and if these promises could not be met, the hospital should be the one to be held accountable, not the GP.Footnote 11 These differences are reflected in the finding that some 43% of patients stated in the questionnaire that they had not been informed about waiting times by their GP (with 34% of respondents stating that waiting times in the system were met, and 16% that they were seen earlier than stated in the system; only 4% had to wait longer and 3% did not recall).

Interestingly, waiting times were not the principal criterion for patients choosing between hospitals, only 16% of patients indicated that it was one of the reasons for their choice (respondents could list more than one reason); the reasons most often referred to were that the hospital was ‘in the neighbourhood’ (52%) or that the patient had ‘been there before’ (50%). GP advice was listed by 17.6% of patients as one of the reasons for their choice (see Figure 1).

Figure 1

Reasons for choosing a hospital, data from a patient questionnaire on ZorgDomein, N = 176

Although patients in general reacted somewhat conservatively to the choices offered, hospital management and medical specialists in general saw ZorgDomein as an ‘infrastructure for competition’. Almost all medical specialists in our survey preferred knowing waiting times for their speciality as shown in ZorgDomein (to which they had no access at the time of the survey). Hospital managers argued that the visibility of differences would lead them to focus on waiting times more than they had done in the past. As one Chief Executive expressed it:

We are patient centred. It is not just the GP; it is also the patient who has a right to know and a right to make choices. If that leads to shifts in patient flow, because we have longer waiting times, then we just have to make sure that waiting times are reduced (interview hospital CEO, 11 November 2004).

In general, hospital managers saw this as a positive driving force for change within the hospital, adding to a culture of transparency and competition, which they favoured.

England

There has been little published academic evaluation of the ‘Choose and Book’ system. Most published reports either relate to pilots where choice was offered to patients already on waiting lists rather than at the point of referral (Dawson et al., Reference Dawson, Jacobs, Martin and Smith2004; Taylor et al., Reference Taylor, Pringle and Coupland2004; Burge et al., Reference Burge, Devlin, Appleby, Rohr and Grant2005; Coulter et al., Reference Coulter, le Maistre and Henderson2005; Ferlie et al., Reference Ferlie, Freeman, McDonnell, Petsoulas and Rundle-Smith2005) or early stages of ‘Choose and Book’ implementation when usage by GPs was still very low (National Audit Office 2005; Rosen et al., Reference Rosen, Florin and Hutt2007). Two smaller scale studies have looked in depth at use of the system by GPs and consultants in one PCT (British Medical Association, 2009) and at patients’ experience in one London hospital (Green et al., Reference Green, McDowall and Potts2008).

Take up of the system has been slow. Although ‘Choose and Book’ was installed in nearly every GP practice during 2005, when the system went live in January 2006 only 8% of GPs were making full use of the system (Rosen et al., Reference Rosen, Florin and Hutt2007). The NHS Improvement Plan target that all referrals would be booked electronically by 2005 was not met and the 2006–2007 operating framework set a new target that 90% of referrals should be booked through the system by March 2007 (Department of Health, 2006). The NHS is still well short of this target, with ‘Choose and Book’ used for less than half of GP referrals to first outpatient appointment in 2007–2008 (Healthcare Commission, 2008).

There are a number of reasons why take up of the system has been so slow. A survey of GPs conducted by the National Audit Office before the system went live found 93% of them felt that there had been inadequate consultation with GPs about the implementation of ‘Choose and Book’, and 78% were either negative or very negative about the idea of ‘Choose and Book’ (National Audit Office, 2005). Technical difficulties have caused frustration. A postal survey of GPs found time constraints and inflexibility of the system as the reasons for disengagement (Pothier et al., Reference Pothier, Awad and Tierney2006). Disengagement has been evident in focus groups carried out with GPs (Rosen et al., Reference Rosen, Florin and Hutt2007) as well as interviews with consultants working in acute trusts (Hendy et al., Reference Hendy, Fulop, Reeves, Hutchings and Collin2007). GPs report that the system is difficult to use as it often ‘crashes’ making it impossible to process an appointment request (Rosen, Reference Rosen2007, personal communication). The British Medical Association found that even some enthusiasts who felt the system had the potential to improve patient experience had become frustrated with its lack of reliability and felt it was not worth using (BMA, 2009).

A major problem has been linking the GP system to hospital PAS. Planned upgrades to PAS systems fell behind schedule with only seven of the planned 22 upgrades in 2004 taking place (National Audit Office, 2006). GP focus groups identified a lack of training as a barrier to ‘Choose and Book’ use (Rosen et al., Reference Rosen, Florin and Hutt2007). The system was regularly updated and GPs reported difficulty finding time to update their training (BMA, 2009). GPs have been frustrated about not being able to refer to a named consultant; they often do not know in which clinic a particular clinician works so find it difficult to refer patients to a recommended consultant (Rosen, Reference Rosen2007, personal communication; Rosen et al., Reference Rosen, Florin and Hutt2007; BMA, 2009). GPs have also been frustrated that some good providers to whom patients would like to be referred are not available on the options list (Rosen et al., Reference Rosen, Florin and Hutt2007), although since free choice was introduced in April 2008 patients’ options are no longer limited to hospitals with which their trust has a contract, and patients should be able to book an appointment at any eligible provider nationally.

A survey in 2005 for the National Audit Office found that over 90% of GPs thought ‘Choose and Book’ would lengthen consultation times and that it would increase workload (National Audit Office, 2005). More recently, the Audit Commission found GPs were concerned about the extra time taken in their consultations to use the ‘Choose and Book’ system (Audit Commission, 2008).

Some of the expected gains from more efficient administrative processes have not been realised: low take up of the system means hospitals have to administer both paper based and electronic referral systems simultaneously and, rather than using the system themselves, some consultants prefer to annotate printed referral letters from which administrators (often in a centralised booking office within the hospital) input information into the system (BMA, 2009).

In contrast to GPs, patients seem fairly enthusiastic about choice. In September 2007, 79% of patients surveyed by the Department of Health were satisfied with the process of being offered a choice (Department of Health, 2008b). Another survey found 75% of respondents said choice was either important or very important to them (Robertson and Dixon, Reference Robertson and Dixon2009). Some patients have complained about problems getting through to the telephone appointments line (Department of Health, 2008b) and in one month, in 2008, 27,000 (8%) of the 338,000 calls to the appointments line were not answered (Hansard, 2008).

Use of ‘Choose and Book’ is not a perfect predictor of whether patients have been offered a choice of provider for their treatment. A GP can book an appointment through the system without offering the patient a choice, or a patient may be offered a choice and booked into hospital via a paper based, rather than electronic, referral. In one hospital in London a study of just over 100 patients found 32% of those whose appointments were booked through ‘Choose and Book’ were not given a choice of hospital and 66% were not given a choice of appointment date (Green et al., Reference Green, McDowall and Potts2008). In general, recall of choice is still fairly low, with 47% of patients surveyed by the Department of Health for their bi-monthly monitoring survey recalled being offered a choice by their GP, and this varied substantially between PCTs, from 27% in Newcastle to 80% in Solihull (Department of Health, 2009b).