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Patients in the NHS have always had some choice over how and where they receive treatment, but it is only recently that patient choices have been seen as a mechanism for improving the quality of NHS services. Since April 2008 NHS patients in England, referred by their GP for specialist care, have been able to choose to have elective treatment from any approved provider on a national list. This chapter provides the background on this policy and its impact to date, including: how patient choice and the broader programme of system reform was designed to work in theory; a brief policy history; how offering patients a choice has been implemented; the impact of patient choice on patients, GPs, and providers; and other ways in which the government is seeking to empower patients and give them more control over their care.

This concluding chapter sums up the key findings of this study on patient choice in end of life care. The philosophy of medicine and of end of life care in particular which emerged in the second half of the 20th century stressed the importance of patient choice in the light of information provided by the doctor. Consumerism is taking over health care, and the best interests of patients are being seen as patients getting whatever it is they choose, in terms of treatments, care and place of death. This chapter suggests that an end of life service should have the following characteristics: realism, fairness, humanity, and adoptability.

This chapter examines patient choice and consent and its current status in clinical decision-making in end of life care. The findings indicate that the idea of patient choice can exist comfortably in the consensus view of health care and a stress on choice is simply a stress on the patient's right to choose between treatment options offered in the process of joint decision-making. This chapter also suggests the possibility of providing an end of life care service run on consumerist lines.

This chapter aims to explore the use of a case-study approach to a specific policy. The use of narrative approaches to analysis provides a way of understanding how policy evolves but also a framework for the analysis of policy. It explores how (often ill-defined) policies can be examined within a case-study approach. It draws on our experience of researching patient choice to describe how policy can be defined as a ‘case’ for analytical purposes and the kind of methods that can be used to examine policy cases. The concept of patient choice in England emerged gradually, and over time there was a shift in how patient choice was conceptualised and what it covered. In contrast with the variation between the countries at a policy level, it appeared that choice had been operationalised in a much more uniform way across the countries.

This chapter reviews research on the introduction of patient choice and competition (alongside the introduction of PbR) and the reorganisation of PPI systems within the NHS. It examines the Quality and Outcomes Framework and the conflicts presented between clinical evidence and increased patient choice. The chapter also makes a comparison of the internal market of the 1990s with the mixed economy of care of the 2000s and looks at lessons from public and patient involvement programmes in the 2000s.

This chapter addresses the role of ‘choice’ in UK health policy documents. It studies the changes in who is meant to make choices in the National Health Service and the kinds of choices that they are supposed to be making. It considers ‘choice’ as a key aspect of consumerism in contemporary welfare policy. The chapter also compares patient choice with previous attempts to use choice as a policy instrument, and then considers its future implications.

This chapter presents an example of Advance Care Planning (ACP) from Victoria, Australia, the Living and Dying in Style project. It considers the Respecting Patient Choices Program from Austin Health, Melbourne, Victoria, the Respecting Patient Choices training programme, and the impact of the Living and Dying in Style projects and guidelines for the future. The discussion notes that dying can be hard work; that there are conversations that everybody needs to have, and nobody wants to start; that ACP provides a framework to overcome this difficulty; that the Respecting Patient Choices Program is an efficient method of ACP; and such preparation for end of life care contributes to living and dying in style.

Central to the question of methodology in research on complementary and alternative medicine (CAM) is the practitioner-patient relationship, the most unambiguously rhetorical element of clinical medicine. Increased interaction between practitioners and patients in any medical model may have unintended—and unquantifiable—therapeutic effects. Chapter Four examines how research on CAM configures practitioner-patient interaction, particularly in relation to prevalent models of medical practice, including patient-centered care and evidence-based medicine. It argues that studies of CAM posit practitioner-patient interaction as a potential contaminant in trials of acupuncture and chiropractic, wherein attempts to control for placebo effects are, in many cases, attempts to control for interaction effects. Probing these interaction effects can further contribute to new understandings of how practitioner-patient encounters can influence health outcomes. Finally, the chapter examines patient autonomy, closely linked to interaction and central to discourses about CAM both in the texts under study and I medical discourse more generally. The actual extent of autonomy afforded to patients in medical settings, alternative or not, is often illusory, framed within generic and rhetorical processes that necessarily tilt the course of decision-making in particular, and predictably biomedical, directions.

Variation in clinical practice in seemingly similar populations of patients has been described for more than seventy years. International collaboration to increase understanding of the sources of practice variation and respond constructively have spawned efforts to expand and better manage professional knowledge, and to elicit and accommodate the personal knowledge of patients about what matters most to them when they face medical decisions under conditions of uncertainty. The approach, which has come to be known as shared decision making, can move us toward assurance that patients receive the care they need and no less and the care they want and no more. The use of decision aids to support shared decision making can effectively address the limitations in statistical thinking among clinicians as well as patients and thereby help establish informed patient choice as a standard of practice and improve the quality of medical decision making and the efficiency of health care.

This chapter discusses problems of autonomy and competence, alternative therapy, the place of care, and the quality of care. Patients' choices are respected, even if they are not fully autonomous nor perfectly competent, in order to preserve the principle of respect for autonomy in palliative care. Refusals of treatment are overruled only if there is no doubt that the patient is incompetent to make the decision. There is a moral obligation to strive to improve quality of care. Some essential aspects of palliative care are not quantifiable in numerical terms; they must be assessed in qualitative terms, which entail value judgements. It is not morally acceptable to omit them because they cannot be evaluated numerically.

For many years, the dream of bioethics has been to confide medical decisions to patients and not to doctors. The favoured key to doing so has been the doctrine of informed consent. The success of informed consent depends on two things. First, patients must be able to understand and remember the information doctors give them. Secondly, patients must be able to analyse that information and use it to make a decision. The first of these requirements has been studied extensively. The second requirement for the success of informed consent has, in contrast, been virtually unstudied. This chapter examines a case study involving prostate-specific antigen (PSA) screening to gain further insight into the way patients think about their medical choices.

This chapter examines quasi-markets in publicly funded systems of healthcare, particularly as they have developed in the UK in the last two decades. It begins with a brief review of the theory behind the use of quasi-markets as a mechanism for delivering healthcare. It then considers some of the empirical evidence concerning quasi-markets in practice, concentrating on the impact of patient choice and competition — the principal elements of the new quasi-market — in healthcare systems that have already tried them, including the UK Conservative government's internal market. Finally, it draws on that experience to discuss some of the conditions necessary for the quasi-market to deliver high-quality, efficient and equitable healthcare — that is, for the healthcare system to work.

This chapter first considers the programme theory of the effects of the 1990s internal market reorganisation, before taking the story on to the change in government in 1997 and New Labour’s various attempts to reorganise healthcare in the 2000s. It explores the emergence of new approaches to performance management under more central government control, and institutional changes that saw attempts to get local healthcare organisations to work to central targets. It also examines patient choice and the creation of a mixed economy of care.

This chapter discusses developments in health policy. It makes clear that individual choice has a number of different roles to play in healthcare. It explains that the introduction of patient choice combined with payment by results further extends the use of market mechanisms as the means for achieving quality, responsiveness and efficiency in hospital care. It concerns policy towards health care outside of hospitals, since, with regard to the NHS in England, the government is increasingly turning its attention to care beyond the hospital doors. It focuses wholly on the NHS in England, since devolution in Scotland and Wales has resulted in health policy developments that diverge somewhat from the English model. It describes policies intended to ‘fix’ the hospital sector and offers an explanation for the shift in attention beyond this sector. It also examines demand and supply-side policies.

This chapter examines the contested nature of mental health provision within the context of proposed legislative changes, exploring the key ethical dilemmas that are raised. It discusses the proposed changes to the 1983 Mental Health Act, and the resulting practical and ethical dilemmas they raise for frontline practitioners in health and social services, service users, and indeed for wider society. The chapter then considers the 2004 Draft Mental Health Bill, which raises significant ethical issues with regard to autonomy, beneficence, and individual liberty. It is argued that the proposed changes to the 1983 Mental Health Act are focused on risk and public safety rather than on the health and welfare of those people whose decision making is impaired by reason of their mental disorder. The 2004 Draft Mental Health Bill is also out of step with other current relevant government policy initiatives in this area, particularly the choice agenda, which risks disadvantaging people with mental health problems relative to other patient groups.

This chapter reviews recent developments in user involvement practices across a range of European health care systems in terms of their implications for the medical profession and regulation of its practitioners. It will review the dominant models of user involvement, from Arnstein (1969) ‘ladder of participation’ onwards within Europe. The chapter will be particularly concerned with the growing linkages between user involvement in its various guises and the governance and regulation of European health care and medicine. The analysis will critically examine the variations in user involvement from ‘choice’ to ‘co-production’ and the range of ways they have been implemented in various European countries, with particular attention to England, Italy and Denmark. The discussion will focus on the implications for the medical profession as much as for the patients themselves.

This chapter looks at the fast pace of recent reform in health policy. The continuous process of organisational and structural change has been coupled with the significant additional resources that were given to the NHS since 2000. The discussion is concerned with the developments that aim to improve patient choice and increase public and patient involvement. A description of the recent developments on the supply side of healthcare is included.