Jill Palmer - Prescriptions

GIVING patients more choice about how, when and where they receive treatment is a cornerstone of the Government’s health strategy, insists the Department of Health’s website.

From this month, this commitment to free choice in elective care was extended even wider. Instead of choosing between four or five hospitals, all patients who need non-urgent hospital treatment are able to go to anywhere in the country for their care, so long as the provider – National Health Service or private – meets NHS standards and price.

However, that is not the case if you need mental health services or maternity care. Then you have no choice. Yet surely these are two high priority areas in the option of choice, where is it a very personal decision as to the type of care you want and where you want to obtain it?

If a woman is pregnant, why doesn’t she have the choice of where to have her baby? Apparently, according to the Government’s Maternity Matters guidance published in April last year, women will have a choice from the end of 2009.

But could this lead to a sudden, overwhelming demand for giving birth in private hospitals, where new mothers have their own rooms with en suite bathrooms, there is a nursery on site where the newborn babies are cared for overnight so mum can get a good night’s sleep, where there is always a midwife for every woman and time to assist with breastfeeding and support first-time mums in how to care for their baby.

NHS hospitals will never have the finances or facilities to match those offered in private sector maternity units. Perhaps this is the reason pregnant women won’t get a choice until the end of next year. And perhaps the Department of Health has realised that choice in this field of care could be a big nail in the coffin of many NHS maternity wards. Without sufficient NHS maternity wards, there will not be the facilities to train the doctors, nurses and midwives who work in the private sector. A vicious circle will have been created – brought about by choice.

Just as worrying is the potential threat of choice spreading across the Channel. If European Union plans for an open health market go ahead, British patients could soon find it easier to obtain free medical treatment abroad, paid for by the NHS. And, like so many other EU directives, we will be able to do nothing to resist.

The cross-border healthcare directive, due to be published in June, is expected to lift restrictions on treatment within the EU and guarantee that, in most cases, it will be funded by the home country’s health service.

The decision, which will be binding on all EU member states, will open up competition between the NHS and European health services. It will provide a clear and legal framework which will define what medical services patients have a right to across EU borders, what quality of care they can expect and clarify who will pay for it.

British patients can already go abroad for treatment and be reimbursed under specific conditions which include facing “undue delay” in this country, but they must have secured prior funding approval. In England, this is from primary care trusts, practice-based commissioners and GPs; in Wales from local health boards and Health Commission Wales; in Scotland from the NHS board of the patient’s residence; and in Northern Ireland from health and social services boards. This can be a lengthy and complex process.

The directive should make the situation much easier and end the current confusion and uncertainty for patients, healthcare professionals and funding authorities.

Patients would still have to demonstrate they faced an “undue” delay and be referred by a medical professional, but they would no longer have to secure funding in

advance and could claim automatic reimbursement on their return (up to the amount that would have been paid at home).

But it would certainly not increase choice for all, just as the existing system does not increase choice for all, only those who have the knowledge and wherewithal to “work” the system. Instead, it would lead to a two-tier health system where patients who could afford to pay travel costs and living expenses abroad – which are not refundable from the NHS – might receive care more quickly than others who cannot.

And what about the effect on our hospitals, already under financial pressure from the growing involvement of the independent sector in treating patients and taking money out of the health service?

Introducing continental providers into a system which already buys care “in bulk” from the private sector in Britain could result in even more cash flowing out of the NHS and could lead to severe deficits for some NHS hospitals. If treatment packages offered on the continent were lower cost than in this country they might become increasingly attractive to British-based NHS commissioners who would send patients abroad as a cheaper option. This could pose a serious threat to NHS hospitals and potentially even push some to the brink of closure through lack of patients. At the same time, British health service providers (both NHS and private) might seek to offer attractive healthcare packages to encourage patients from elsewhere in the EU to come to England. That could adversely affect accessibility to services for patients in this country.

It would also cause undue pressure and uncertainty on existing health and social security systems in terms of capacity planning, as unexpected numbers of NHS patients went abroad. And it could undermine the economic sustainability of the NHS and cause uncertainty in financial planning due to indiscriminate claims for reimbursement and bills for treatment of which primary care trusts and GPs had no prior knowledge.

The Department of Health says it is committed to ensuring the right legislative framework is developed which ensures that, where patients choose to travel abroad the NHS retains the ability to decide what care it will fund to meet their clinical needs. But there is really only one solution: make the best care available as quickly as possible and close to home.