Patient choice in psychiatry

The government has embarked on an ambitious plan to make patientchoice central to the way healthcare and treatment are delivered.Mental healthcare is incorporated into this agenda. This editorialconsiders the implications of patient choice for psychiatryand some of the main challenges associated with this policy.

INTRODUCTION

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INTRODUCTION

Choice of care is viewed as important to the modernisation ofhealth and social care services, and has formed part of thegovernment's new delivery plan outlined in Creating a PatientLed NHS (Department of Health, 2005). Increasing choice isexpected to create better alignment between what patients wantand what services subsequently provide. It aims to promote greater patient autonomy, involvement and empowerment in the treatmentand care received, to expand the range of available services,to help reduce waiting lists and to improve the quality ofcare through competition.

IMPLICATIONS OF CHOICE

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IMPLICATIONS OF CHOICE

The implications of patient choice are potentially huge forboth patients and health and social care managers and staff.Choice places treatment or care decisions squarely with thepatient. This is different to shared decision-making whichinvolves at least two people (a clinician and a patient) agreeingwhich treatment option to implement (Charles et al, 1997). Informed choice is difficult to define and keep distinct fromshared decision-making, participation or collaborative approaches.One definition includes `obtaining useful information fromthe practitioner or professional and then deciding individuallyor collaboratively on the best course of action that promotesindependence, recovery and an improved quality of life' (New York State Office of Mental Health, 2004).The provision of information alone, however, is not sufficient.It must be understood and presented in a balanced way so asnot to suggest a right or wrong choice (Hope, 2002).

Critics of choice highlight concerns about the practical implementationand the potentially negative consequences to the patient. Atan organisational level, creating the type of infrastructurerequired to support patient choice is complex. An effectivehealth service based on choice requires fundamental changesto managerial and information systems, more time for consultationsand a highly coordinated system to guide patients to appropriatecare settings once choices have been made (Goodwin, 2006).At an individual level, Schwartz (2004) contends that too much choice can be debilitating, requiring more time to make decisions,with an increased risk of mistakes in decision-making and morenegative psychological consequences to the patient.

CHOICE AND PSYCHIATRY

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CHOICE AND PSYCHIATRY

A framework has been developed which sets out the government'svision for choice in mental health. This includes four `choicepoints': promoting and supporting life choices (e.g. work,education, leisure, housing, self-help, direct payments); accessand engagement (choice of how to contact mental health services,including in an emergency, and the role of advance directives);assessment (choice of when and where assessments take place);and informed choice of service or treatment and care pathway(including patients being supported to make their own decisions) (Care Services Improvement Partnership, 2006).

It might be particularly challenging for psychiatry to takeon board this agenda for patient choice. To date acute physicalhealthcare and elective surgery are the main areas for patientchoice. Initiatives such as `choose and book' enable patientsto select up to five different service providers and book appointmentsat preferred times. However, these initiatives might not be the best models for modern mental health services, whose ethosincludes breaking down stigma and creating social inclusionby providing opportunities for employment and social activities (Valsraj & Gardener, 2007). The recovery model for mentalhealth underpins the choice agenda, in which a meaningful lifecan be lived despite a diagnosis of serious mental illness(Lester and Gask, 2006). Recovery seeks to work outside themedical model, and move away from a paternalistic approachto decision-making, to allow patients to regain independenceand to access services that they feel best meet their needs.

A fundamental issue concerning patient choice within psychiatryis the dilemma posed by caring for patients and at the sametime protecting them and society from harm. Of importance topsychiatrists is the patient's capacity and competency to makevalid treatment decisions. Using the example of anorexia nervosa,Henderson (2005) highlights how the capacity for choice andself regulation of behaviour becomes a core part of treatment.He goes on to suggest that individuals are helped to regaintheir own volitional control, perhaps through cognitive psychotherapy.The danger, however, is that psychiatrists too readily assumethat patients are not able to deal with information and choice.Hope (2002) suggests two methods to facilitate patient choiceduring a consultation: including patients' values in the decisionanalysis and giving patients the necessary high-quality informationto allow them to make informed decisions.

However, choices for those with mental illness can quickly becomelimited for those at high risk of harming themselves or others.For example, the application of the government's proposed newpowers of compulsory treatment, as set out in its Mental HealthBill 2006, will not take into account a patient's capacityto make decisions about their medical treatment. It is unclearhow compulsory community treatment in particular would coexist alongside patient choice, whether choice would act to reducethese powers or vice versa.

INTERNATIONAL LESSONS

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INTERNATIONAL LESSONS

What can we learn from how the choice agenda has been tackledelsewhere? Health departments from other high-income countriessuch as Australia, New Zealand, the USA and Canada broadlyagree that patients should have more and better informed choice(Warner et al, 2006). In the USA it is accepted that consumerneeds and choice should drive mental health services, but truechoice is limited by the range of available services, and thecomplexity and lack of coordination between different agencies(statutory, voluntary and private). In a list of ten `rulesfor quality mental health services in New York State', rulenumber one states `There must be informed choice' (New York Office of Mental Health, 2004).Underpinning this document is a recovery-based principle in which informed choice includes obtaining useful informationfrom the practitioner and an educational approach to medicationsand side-effects. However, a key problem identified is thelimited willingness of many psychiatrists to collaborate aboutdecisions concerning medication, citing their professionaltraining or lack of capacity of the individual to make theirown decisions as reasons.

In Australia, New Zealand and Canada a range of mental healthplans, strategies and guidance refers to the importance ofchoice, sometimes using the language of consumer participation (Warner et al, 2006). Key elements include adequate informationfor people to make informed choices, a range of alternativeservice providers and a recovery-based focus. However in practicechoice is commonly not available. This might arise from health professionals' reluctance to offer choices or through limitationson available services, primarily as a result of financial constraintsboth on services and on patients.

FUTURE DIRECTION

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FUTURE DIRECTION

It is yet to be demonstrated whether patient choice will befully embraced by psychiatry. The shift towards psychiatristseffectively handing over the reins to patients is likely tobe gradual given the need to take account of issues such ascapacity and risk. In addition, a better alignment between what patients want and what services they receive is dependent onfactors, such as funding and service availability, which maybe beyond psychiatrists' control.

The profession would, however, leave itself open to fair criticismif it fails to engage with the government's choice agenda.That agenda underpins much of the current reform in the NationalHealth Service, and mental health patients should not be deniedthe possibility of the benefits that come from increased choice.

REFERENCES

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