A sizable proportion of patients in this study referred through Choose and Book do not consider that any choice was available to them. That over a quarter (29%) of Choose and Book patients felt they had not been offered choice is in itself striking, but that even higher proportions did not perceive that they had been given a choice of hospital (32%), appointment date (66%) or appointment time (66%) means that, even when patients are offered choice, it does not match Government intentions. While the confidence intervals for these results are wide, even their lower limits are surprisingly high. The clearest demonstration of this misalignment is that, of the complete study sample, only one patient stated that they had been offered a choice of four hospitals with a choice of appointment dates and times, that which Choose and Book supposedly offers to everyone.
As far as we know, this is the first study of patients experiencing the live implementation of Choose and Book. This is a small study; non-significant statistical test results in comparisons between the Choose and Book and Partial Booking patients should not be over-interpreted given the limited power. It must be recognised that, at the time of the study, not all outpatient clinics at Hillingdon Hospital were Choose and Book enabled and a limited number of GPs were using Choose and Book locally, so the Choose and Book patients surveyed are not necessarily representative of the population coming through the system over the next few years. Restricted interviewer resource prevented achieving a complete consecutive series of Choose and Book patients. Matching between Choose and Book patients and Partial Booking patients was also limited. However, the sample group was representative of the total first outpatient population of Hillingdon Hospital NHS Trust in terms of gender, age and ethnicity.
The methodology was retrospective in nature and relies on patients' recall. For a true account of how choice is being enacted by healthcare providers and received by patients, observational studies are required of patient/GP consultations.
It might be anticipated that people with current health issues would have greater awareness of NHS policy than the general public. We found 63% (95% CI 53 to 71%) of patients had no prior knowledge of patient choice compared with a poll showing 80% of British residents aged over 40 knew little or nothing about choice reforms .
Our results suggest the Choose and Book booking process may be one factor contributing to the discrepancy in patients' experience of choice. The booking method influences the degree of choice patients perceived. Those booking appointments at the GP surgery are less likely to consider that they have been given a choice over the date or time of their appointment than patients booking their own appointments through the call centre or over the Internet. This may be due to the manner in which the options are either expressed by staff or understood by the patient. For example, where options are framed by the GP as a package of a hospital, a date and a time, any focus, by the patient or the GP, on one individual component may overshadow that further choice has been offered. The reality of there being low awareness of choice among the general public could also mean that patients tend to accept the first date/time offered and primary care staff, therefore, do not present further choices. In contrast, Internet booking involves discrete stages for each of the three choice elements.
Comments made by participants during data collection suggest, however, that booking online is not always successful. A number of respondents spoke of initially trying to book their appointment over the Internet, but technical problems forced them to call the booking line or go back to their GP to book their appointment. This could partly explain why the proportion of patients booking online is small and suggests that, for Choose and Book to deliver the intended scope of choice, online booking needs to be improved.
Patients' perception of the scope of choice offered may also be influenced by their own priorities. Comments made by a number of participants suggest that being offered an alternative hospital with, for example, an unsatisfactory waiting time did not consitute a real choice for them. The same was suggested of hospitals with long travel times. For other patients, the fact that their preferred hospital was not on the menu of providers compromised their perception of being offered choice. Ancedotal reports suggest that the timing of clinics is such that the choice of appointment time and day that patients want cannot be delivered, leading to disappointment.
Neither patients' nor GPs' behaviour necessarily conforms to models of rational choice economics. For example, they tend to show loyalty to their familiar healthcare providers even when they may not offer the best quality care . Our results here may be an expression of that cultural barrier to choice. Given the asymmetric doctor/patient relationship, patients may also choose not to choose: even competent adults may prefer to delegate their choice of treatment to someone, typically a health professional, whom they regard as better informed to take the decision on their behalf [14, 18, 35]. The role of the GP is anticipated to remain fundamental to patient choice, which places potential constraints on how Choice at referral is implemented as the GP can decide how to frame options available to the extent that not all the options are perceived by the patient as being available.