Everywhere these days the mantra of ‘choice’ rings in our ears. No politician can speak about education or health without choice being a key part of the message.

But, what is less often discussed is the question of who is choosing choice. It does seem that we are simply to take for granted that this idea, one that is driving change and reform across the public sector, will lead us to better public services. For in the name of this idea, we are promised enhanced ‘transparency’, openness and democracy. On the face of it, it’s difficult to see why anyone could question that all these things are simply good things.

However, I wonder just what capacities we need in order to exercise choice in the first place. Exercising ‘choice’ is not just a case of being able to access ‘raw’ facts, after all. Facts always have a surrounding context in which we understand their importance and their meaning. Choice means that we take some care in selecting, that we use judgement or skill to distinguish what is to be preferred, which leads to being able to discriminate. Those advocating choice often seem to assume that exercising choice is a straightforward and uncomplicated matter. But if many of us nowadays find choosing a can of beans, or a electricity company a time-consuming and often ultimately inconclusive activity, how much more burdensome and challenging is it to have to constantly choose between doctors and hospitals for this or that treatment?

Just as has already happened with school ‘league tables’, and after a year-long review of the health service in England by the surgeon-minister, Lord Darzi, an announcement came in early July that hospitals would be required to publish "quality accounts" alongside the financial balance sheet. They will reveal information ranging from the death rates of surgeons to the relative satisfaction of patients during and after a course of treatment. NHS hospitals will be eligible for bonuses worth billions of pounds if they can demonstrate top quality clinical performance, the government said. Whereas a ‘poorer’ performer would lose patients to rival establishments with better clinical outcomes.

Patient's notes on board.

Understandably, potential patients want to know in advance about poor survival rate in particular hospitals. Who would not want to go somewhere safe, and with ‘better outcomes’ than elsewhere? Who would choose to ignore that information, if it was available. But that’s the rub, because the language of choice assumes there is a simple and direct relationship between this desire to reduce risk (to avoid unsafe doctors and hospitals and ultimately to avoid harm or death) and the solution, of successfully identifying doctors and hospitals that are less risky. It seems to me that the language of choice relies on an appeal to primitive desires in the population (‘I want to know if I’m less likely to die if I go to X hospital). But the solution it proposes is highly cognitively complex. Context and presentation are key elements and citizen-consumers would need to be educated in the social science of statistical interpretation before being able to fully take part; are these capacities equally available to everyone?

For, for example, mortality is not the only guide to the standard of treatment. A hospital that picked ‘bread and butter’ cases, turning away difficult operations, would score well. Another unit might have a higher mortality rate, by dint of having hugely expert surgeons prepared to take on complicated cases. How is a patient with a serious condition to ‘choose’, for emotionally s/he’d be drawn towards the ‘low mortality’ unit, perhaps against his/her interests. How does one judge which is ‘better’?

Another development in this armoury of consumer choice is that of a new website, iwantgreatcare.org, which will let patients rate and review every medic who has treated them. This follows hot on the heels of sites for customers of hotels, restaurants, books, travel companies to name a few, to record, praise or deride their experiences. Internet democracy is one way in which customer ‘choice’ is manifesting itself. The doctor behind the site claims that letting the public give medics individual reviews and rate their performance will help to bring about higher standards of care and to ‘choose’ which doctor to go and see.

Lord Darzi said: ‘For the first time, patients' own assessments of the success of their treatment and the quality of their experiences will have a direct impact on the way hospitals are funded.’ This may end up with a ‘social Darwinist’ survival of the fittest, which deals in primitive and absolute divisions between the bad and the good: the ‘bad’ (hospitals) go to the wall, and the ‘good’ are rewarded. Presumably then, the poorer performers, already punished with less income, will still have to treat patients, who will get worse treatment. Similar things have happened in education: parents are told they may ‘choose’ a school; in reality what are deemed ‘good’ schools are oversubscribed (and indeed become 'good' schools because wealthier parents are able to move into expensive catchment areas) and so not all parents may in fact be able to ‘choose’ those good schools. I have visions of ‘popular’ doctors on the iwantgreatcare.org website being in so much demand that there are long waiting lists at certain hospitals and no demand at others. How is this practicable, on the scale of a national health system?

The ‘choice’ agenda is part of a wider Labour government move away from a ‘one size fits all’ idea of public services towards a personalised system based around the ‘user’. But how many people really want a government to put so much energy into pursuing an ideology that, even if sounds ideal, has so many unintended consequences and assumes so much about the capacities of citizens?

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Jessica Evans is Senior Lecturer in Sociology, in the Faculty of Social Sciences, and a member of the Centre for Citizenship, Identities and Governance at the Open University.

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On Saturday 5 July the UK will celebrate the establishment of the NHS, arguably one of the greatest British achievements of the post-war years. Politicians, the media, and of course, the health services are celebrating this landmark achievement, reflecting on the history of the NHS and also looking forward to the challenges facing this very British institution.

The NHS was the brain child of Aneurin Bevan and drew upon his experience of the medical aid scheme offered in Tredegar in South Wales by the major employer in the town, the Tredegar Iron and Coal Company. Bevan became minister for healthcare and housing under Clement Attlee’s post-war government and used this opportunity to radically restructure medical care, ensuring that it was free at the point of delivery for all citizens, irrespective of their ability to pay. It has become one of the hallmarks of British identity, summoning up what the then Chancellor of the Exchequer Gordon Brown referred to on January 14, 2006 in his speech to the Fabian Society as 'one of the great British institutions – what 90 per cent of British people think portrays a positive symbol of the real Britain – founded on the core value of fairness that all should have access to health care founded on need not ability to pay.’

Aneurin Bevan.
[image © copyright BBC]

Since the inception of the National Health Service, migrant doctors have been seen as an integral but devalued part of the health workforce. These doctors were necessary for its operation, providing a mobile army of labour in the lower rungs of a pyramidal medical hierarchy, ensuring that UK doctors at the apex did not have to compete too much for pickings from the much diminished private sector. Overseas qualified doctors were provided training in the health service in return for meeting the health service requirements of the population. They were, however, systematically disadvantaged in terms of access to jobs, career mobility, the places where they found employment and the specialties they could occupy. They have come to be called ‘sepoys’ and ‘indentured labour’ pinpointing the situations of trained migrant doctors and the organization employing them. Disproportionately represented in training posts and in non-career grade posts they have, however, been a backbone for the development of this very British institution. Thus, in 2003, only 17 per cent of South-Asian doctors were consultants compared with 42 per cent of white doctors, which provides some evidence that migrant doctors from South-Asia continued into the present century to find their careers limited by the hierarchical nature of the NHS.

But one of the specialties where they have found a home and established a niche is geriatric medicine, a specialty that too was born in 1948. Marjory Warren, often considered the “mother of geriatrics” established the first geriatric unit in the UK, where older patients were admitted, rehabilitated and sent home. This was an innovation in elderly care at that time. Before the establishment of the NHS doctors had provided free medical service to support the charity hospitals but had earned substantial incomes, on the whole, through private practice. After the establishment of the NHS and the amalgamation of most existing hospitals, including the workhouses, into the national provision, doctors’ salaries were paid for out of the national taxation system and there was some resistance to taking over the regular care of elderly frail people. Geriatrics became associated with the wider disdain given to its clientele, older people. As such it became a ‘Cinderella specialty’, a disregarded area of healthcare serving the needs of one of the least regarded groups of patients. However, the work of a few pioneers such as Marjory Warren, slowly changed the nature of healthcare for old people with the development of acute care for older people and its own subspecialisms. It began to offer a career trajectory and eventually became what it is today, the second largest specialty with just under 900 consultants in hospitals. As we enter an ageing society, this development of geriatrics within the NHS is set to continue.

Silhouette of elderly man in wheelchair.
[image © copyright BBC]

In part responding to the dire medical neglect of older people within the NHS hospital system and in part to government and management pressure to improve bed occupancy figures, geriatric medicine grew rapidly, to large extent depending on recruits from overseas for its expansion. But this 'Cinderella specialty' status also gave room for overseas trained doctors who found their own opportunities for career growth to find a home. They too became pioneers in this discipline, shaping the nature of geriatric care today. It came to be a field where South Asians could find jobs so that 22 per cent of all geriatric consultants appointed between 1964 and 2001 were non-white and had trained outside the UK, compared to 14.1 per cent of all consultants in the NHS.

These doctors felt drawn to the UK, rather than the USA, because in South Asia they were already part of a socio-cognitive community for whom markers of participation in the UK labour market were central to notions of career progression. Migration to the UK for the purpose of training, gaining membership of prestigious UK Royal Colleges (MRCP etc) has long been embedded in South Asian doctors’ professional cultures.

For many doctors, their lecturers in medical school had undergone some form of training in the UK and that upgrading and validating skills through training at one of the UK royal colleges was seen as crucial to being recognized as a good doctor. Thus, the doctors’ mobility was already embedded in a network of professional development which valued temporary movement to the UK. Moreover, at least in medicine, the power of empire continued to be forceful as medical practice and qualifications were very much influenced by regulating bodies and by professional organizations, located in the metropolis. Doctors were thus already in some ways part of a professional community where migration to the UK was seen as part of career progression.

As the country is poised to celebrate, and rightly, the establishment of one of the most remarkable institutions of twentieth century UK, it is also worth remembering and commemorating the twists of history that led to the development of geriatrics and the role of overseas qualified doctors therein.

For details of a project exploring the experiences of South Asian geriatricians, visit Overeseas-trained doctors and the development of geriatric medicine.

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Parvati Raghuram is Lecturer in Geography at the Open University. Her research interests focus on the ways in which the mobility, of individuals, goods and of ideas is reshaping the world.

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Joan died last week in a Midlands hospital. She was 83. Joan was one of those old fashioned ladies who model their lives on the better natures of the late Queen Mother. However, unlike the Queen Mother towards the end of her life, the care and health authorities failed her. She had a most painful and undignified conclusion.

According to the final report from the UK Inquiry into Mental Health and WellBeing in Later Life, a mental health pandemic and an inadequate Government response mean that over 3.5 million older people who experience mental health problems do not have satisfactory services and support. Joan was one of more recent victims.

She had been suffering from vascular dementia. For the past 3 years, since the death of her husband of 61 years, the family had been able to look after her with the care of an agency. Joan benefitted from pleasant stays at the county respite centre where she became known as ‘the Scrabble Queen’ because of her intelligence and prowess at word games. But, as her behaviour deteriorated, she was forced to leave the safe environs of the respite centre, and under the threat of being sectioned, was admitted to a special geriatric mental health unit in the middle of February.

I visited her there daily for the last 50 days of her life. This was an appalling facility. It was a living testimony to the complacent and systematic disregard by a succession of governments towards those elderly vulnerable people in England who suffer from mental ill health. Stigmatised and starved of resource, the care for such people is in crisis. There is a huge chasm in care, and systematic failures, many of them avoidable, count against the elderly (I have not even mentioned the cruel vagaries of the postcode lottery of provision).

The elderly geriatric mental health facility where Joan spent 42 days of her life resembled a prison. The main door had two double locks. All the doors in the facility were constantly being locked and unlocked. All the games and stimuli to stimulate the patients were kept under lock and key. It resembled a prison. The 8 patients displayed a range of mental ill health symptoms. Some had been there for months. One spent every 20 seconds screaming blasphemies with the other patients sitting around in low chairs, too low most patients struggled to climb out of them. The patients were only there because no where else would have them, or, they had been abandoned by their families, or all the care and nursing homes were full. One kept trying to break out using her Zimmer frame as a battering ram.

Joan was profoundly deaf and suffered from arthritis. She walked with a stick. On many occasions she was left isolated and alone, her hearing aids locked away in the office, or the shared bedroom area, together with her stick. Gradually, she deteriorated. She developed skin tissue sores on her posterior and back. She became less co-operative, and refused some of the dreadful meals, and more critically, her medication.

For weeks, the family tried hard to find a nursing home. All were full. Eventually the family did find a wonderful nursing home which would take Joan and she passed the assessment in the Ward on, irony of ironies, the day before the fall which precipitated her premature death. She died 13 days after the fall in the orthopaedic ward of the local General Hospital.

Her neck was broken in two places in that fall, on the 25^th March. Later that day she was sent in a taxi to the nearby General Hospital but returned to the geriatric ward and given aspirin. No X ray was taken. No scan. Over a week elapsed during which the family implored the staff to have Joan thoroughly examined. Two other doctors visited the ward and checked Joan but neither thought there was anything ‘sinister’ wrong.

On the 1^st April she was finally taken in agony, and in another taxi, back to the General Hospital. Her pain was now unbearable. There, a doctor immediately diagnosed a critical cervical spinal injury. Joan was admitted but she slipped away, under morphine, on the 7^th April.

One of the causes of death was the injury to her spine, sustained under the care of the NHS. Later on the 7^th we visited the geriatric ward where Joan sustained the fall. On being told the news staff said nothing, and stood in shock. My partner told them they should take better care of the remaining patients than they did her mother. Some of the patients applauded as she left the ward, which was locked swiftly behind her as she flew the cuckoo’s nest.

The Age Concern report revealed that older people with mental health services are often ignored and receive little support services. It found a poor level of service for people growing older with longstanding mental health problems. Women over 75 are more likely to take their own lives compared to any other age groups, and men over 75 have the second highest suicide rates of all men in the UK.

Dr June Crown, Chairman of the Inquiry, said: ‘Mental health problems in later life are not an inevitable part of ageing. They are often preventable and treatable, and action to improve the lives of older people who experience mental health difficulties is long overdue. Current services for older people with mental health problems are inadequate in range, in quantity and in quality.

‘We have no excuse for inaction, and no time to waste. We need a radical shift to improve services and support for older people with mental health problems. At a time when the Government is aiming to make the most of older people’s contributions, the neglect of older people’s mental health needs represents a waste of human potential that we simply cannot afford.’

With the rising numbers of older people, the situation is set to deteriorate. Without a major change in policy and practice, there will be nearly 1 million with dementia by 2021, and 5 million with depression and 1.7 million with dementia by 2051 – around twice the current numbers.

The report found that older peoples’ mental health issues remain poorly understood, highly stigmatised and are not given the priority necessary in policy, practice and research – despite official reports since at least 2000 highlighting discrimination and calling for action. Two thirds of older people with depression never even discuss it with their GPs, and of the third that do discuss it, only half are diagnosed and treated. This means of those with depression only 15 per cent or one in seven are diagnosed and receiving any kind of treatment.

Even when they are diagnosed, older people are less likely to be offered treatment and the Inquiry heard of GPs who have called depression a symptom of growing older. Joan had such a GP. You will know of others. In 2006, a review of progress against the Government’s National Service Framework for Older people said that since 2001 explicit age discrimination in mental health had not declined.

To date, the Department of Health framework for mental health services has focused only on people up to 65. People over 65 receive different, lower cost and inferior services to younger people – even if they have same condition. Many find they are moved into ‘older people’s services’, regardless of the suitability of these services, just because of their birth date.

The Inquiry’s findings are unequivocal: years of ignorance, discrimination and underfunding must be overturned. There are thousands of vulnerable people like Joan in the system, and tens of thousands of more Joans yet to enter it.

Joan’s family are to pursue a negligent claim against the healthcare trust. Leaving this world with dignity is a right any civilised society should bestow on all its inhabitants. We failed Joan. I hope she might be the last, but I doubt it.

The UK Inquiry into Mental Health and WellBeing in Later Life began in late 2003 out of concern about the neglect of older people’s mental health in policy, practice and research. It is an independent inquiry supported by Age Concern.

About the author

Richard Skellington edits Society Matters for the Faculty of Social Sciences at the Open University. He’s an administrator who manages the Environment, Development and International Studies programme.

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