Abstract
As primary care practitioners are the health professionals closest to patients' everyday lives, they are most likely to experience the impact of policies that support the patient choice agenda. The government's approach to increasing patient choice has been subject to criticism by those sceptical of its politics and by those concerned with its influence on health providers and some patient groups. A perspective missing from the debate is one informed by research on the psychology of choice. Some psychologists have argued that a seemingly inbuilt preference for choice can adversely affect the decision-making process and that presenting healthcare decisions as choices may result in less reasoned decision making. It is important that GPs encourage patients to make reasoned healthcare decisions that are informed by an evaluation of the options rather than by a simple preference for choice. Patients are likely to be less satisfied with, and experience more regret about, choices made without reasoning.
INTRODUCTION
Choice is everywhere in the NHS: the word that is. In the White Paper ‘Our health, our care, our say’1 ‘choice’ is used no less than 95 times. Increasingly, ‘choice’ appears as a mantra in government policy and ministers' speeches: patient choice, it is argued, is what the modern health services' consumer demands and has a right to expect.2,3 As the health professionals who are closest to patients' everyday lives, primary care practitioners are most likely to experience the impact of patient choice policies.4 The launch of the Extended Choice Network for GP referrals will mean that patients will have ‘dozens more hospitals and clinics to choose from’.5 GPs are now expected to help patients choose where they attend for a specialist appointment or further treatment, and this role looks set to expand.6
A number of commentators sceptical of the politics of the choice agenda have voiced their concerns about its impact on the healthcare system.7,8 Those concerned with inequality of access to services have argued that the offer of increased choice will benefit the vocal middle classes at the expense of more vulnerable groups.9 Missing from existing critiques of the ‘choice in health’ agenda has been the perspective of psychologists researching in the area of decision making. From this work comes evidence that increasing people's options has the potential to affect adversely how they make decisions.10 Framing decisions as ‘choices’ may increase the attractiveness of the options on offer and decrease the likelihood that a systematic evaluation of the advantages and disadvantages of each option is carried out.
THE ‘LURE OF CHOICE’
Why is choice so attractive? Animals and humans seem to have an inbuilt preference for a choice-rich environment that may have evolved because choice can provide advantages in the natural environment.11,12 For example, in many species, female animals are more likely to select a mate where competing males congregate with their competitors.13 There are a number of reasons why a preference for choice may be advantageous in evolutionary terms. First, it is a way to defer commitment to one option for as long as possible and to continue gaining information about alternatives. Second, having a choice of mate (or habitat or food source) may increase the likelihood of selecting a higher quality option. Therefore, humans may have evolved a decision-making heuristic, or rule of thumb, that ‘choice is better than no choice’. Heuristics are cognitive shortcuts that reduce thinking effort so that everyday decisions can be made more efficiently.14 By reducing cognitive and emotional involvement, heuristics can also help to reduce the experience of conflict often associated with making difficult decisions.15 However, decisions made using heuristics are based on judgements about subsets of the decision information (for example, who is offering the decision information) rather than a systematic evaluation of the information about each option and its consequences.16
While the ‘choice is better than no choice’ heuristic could be an advantage in the natural world, in an industrial society this strategy may not always work in the decision maker's favour. The phrase ‘lure of choice’ has been used to describe the situation in which the presence of choice can bias the decisions people make.17 In some cases, people may select an option that appears to offer choice, even when doing so results in a worse outcome than the one that would have resulted from selecting the ‘no choice’ option. For example, a person may prefer a large supermarket to a small one because the larger store offers a wider range of products; this is a preference for choice. If by shopping at the large supermarket the person pays more for the same items, travels further, or gets lower quality for the same price, then choice has acted as a ‘lure’ to produce a suboptimal outcome.
Bown and colleagues have demonstrated the lure of choice in a range of research scenarios.17 For example, after being given appropriate background information, participants were asked to opt for an activity such as a nightclub to visit, bank account to open, or casino game to play. Any given option was more likely to be chosen when it was presented as one of a pair from which a choice had to be made than when it was presented unaccompanied. This was despite there being no actual added advantage of the option being a member of the choice set compared with being offered on its own. In other words, simply being associated with choice per se can make an alternative more attractive, without an objective reason for this to be the case.
Related work at the University of Pennsylvania has also shown that framing decisions as choices increases the chance that a particular option will be selected.18 Participants who were offered the chance to enrol in an insurance plan were more likely to say they would join a particular plan if it were offered alongside another plan, than if it were offered on its own. Participants were also willing to pay more for the plan when it was offered as part of a choice set, even though the detail of the plan had not changed. This suggests that framing a decision as a choice can enhance the perceived value of a particular option.
POLITICAL ATTRACTIVENESS OF CHOICE
The response of retailers and manufacturers to this preference for choice has led to the proliferation of consumer options in the market. The current ‘patient choice’ agenda is also historically rooted in a marketplace response to the waiting-list problem.3 Offering a choice of hospital for elective surgery may be a strategy for reducing waiting times, but is also a way to make government health policy popular with voters. David Cameron, the leader of the Conservative Party, commented that the government may have been wrong not to make single mumps, measles, and rubella (MMR) vaccines available through the NHS;19 this demonstrates that politicians are well aware of the attractiveness of choice and the potential unpopularity that comes with being seen to deny it. It is also interesting to speculate whether a decision to license and offer single vaccines as an alternative option (thereby increasing the choice set) may actually have made an argument for the MMR more persuasive.20
How this fits in
There is currently a shift towards increasing patient involvement in decision making. At the same time, the government is promoting an agenda of choice in health care. Research in psychology suggests that increasing choices can lead to poorer decisions and less systematic decision making. This paper uses research evidence to provide strategies to help primary care practitioners support informed patient decision making.
People's preferences are influenced by the way options are framed and how people evaluate the various options on offer.21,22 There are also strategies that can be employed to reduce decision-making biases. Indeed, a great deal of research has focused on the evaluation phase of decision making by exploring how choices are made, and by helping people choose between two or more treatment options using decision aids.23–25 However, health services research has not yet investigated how the presentation of healthcare decisions as choices may in itself introduce potential bias. Because the use of an heuristic reduces cognitive and emotional involvement with the decision-making process, use of the ‘choice heuristic’ may not always be advantageous in important healthcare situations where a more reasoned approach is generally preferable.23,26
CHOICE AND DECISION MAKING IN HEALTH CARE
In situations where people are asked to choose between healthcare options using information that they find complex and unfamiliar, the attractiveness of choice and the ‘choice is better than no choice’ heuristic could come into operation. As the patient choice agenda is relatively new, examples of where the lure of choice may operate within the primary care setting are only now emerging. The choice agenda has been most clearly implemented in the systems associated with choice of hospitals for elective surgery, specialist consultations, and diagnostic tests. The primary decision presented is often which hospital to go to. If this decision is presented as the local hospital default versus choice from several hospitals elsewhere, those hospitals within the choice set may seem more attractive. It can be speculated that the lure of choice effect may influence people to go outside their area when they may receive equal or better care at the local hospital. Given that if all else is equal most people's preference would be to visit a local hospital, care should be taken to present the local hospital as one of the choice set, not the default no-choice option.
It may be true that currently many patients do not perceive a significant differential between healthcare providers and so heuristics of ‘local is best’ or ‘doctor knows best’ may override competing heuristics about the attractiveness of choice. But this situation is likely to change. Within the education system, for example, use of league tables has led to parents perceiving real and important differences in school performance. This has led to an increased focus on the potential choice set and desire to exercise choice. As real and important differences in healthcare providers become more apparent, choice may well increase in salience for patients and the influence of the familiarity heuristic or ‘doctor knows best’ may diminish.
Choices or decisions
Decisions are often framed in the language of choice and the two words are used interchangeably, but are they really the same? A promise to increase patient decisions somehow seems less attractive than a promise to increase patient choice, yet the one should follow the other. ‘Decide and book’ sounds less appealing than ‘choose and book’. Policy preference for the word ‘choice’ (which suggests options) over ‘decision’ (which suggests process and effort) may seem a more palatable way of phrasing what are often difficult cognitive and emotional tasks with potentially life-changing outcomes. The manipulation of language is apparent elsewhere too. In the White Paper cited earlier,1 the word ‘decision’ appears 43 times; fewer than half the number of times that ‘choice’ appears. Only nine of these instances relate directly to patient, carer, or shared decisions. Instead, ‘decisions’ are associated with commissioners, policy makers, and the allocation of budgets and services.1 The implication is that the difficult decisions about which options should be available, are made in advance so that al the patient has to do is select from a range of options in the way they would choose something from a restaurant menu.
THE ROLE OF THE PRIMARY CARE PRACTITIONER
Theories about the lure and value of choice remain to be tested further in real-world primary care settings. Nevertheless, the evidence suggests that creating a choice-rich healthcare environment may have consequences for decision making. What can be done to help counter decision-making bias and encourage patients to think more systematically?
Three practical strategies can be employed in any situation where patients are involved in making decisions about their health care.
Change the language with which decisions are presented
GPs, along with those who develop information materials, should use language of decisions and consequences rather than choices and options; for example, ‘Think about what you want’, ‘You need to decide’, ‘What are the pros and cons for you?’, rather than ‘Choose’, ‘Pick’, or ‘It's your choice’.
Slow down the decision-making process. Heuristics are more likely to come into play in situations where the time for making a decision is constrained, or the person perceives a pressure to make a quick decision.27 The aim would be to slow down the decision-making process wherever appropriate. One way of doing this would be to state that decisions do not have to be made immediately during a consultation. Another would be to provide information before or after a consultation so that people can take time to read and discuss the options with others before reaching a decision. This approach has implications for the use of the ‘choose and book’ system, which encourages both patient and doctor to focus on the immediate choice or outcome rather than on how the decision is made. This may encourage the ‘speeding up’ of the decision process.
Make explicit the need for patients to ‘think actively’
Work in the area of shared decision making has shown that patients are often unfamiliar with taking responsibility for healthcare decisions, and in some cases they are reluctant to do this. Practitioners often struggle to implement academically-devised models of shared decision making due to competing agendas and real constraints on everyday practice.28 Nevertheless, the movement towards greater patient involvement continues and practical ways need to be found to support patients faced with decisions they are unused to making. It may be helpful to raise the idea that different consequences have different values for different people, and that there may be advantages and disadvantages for each option that vary by individual. Encouraging patients to write down the pros and cons of each option as it relates to them specifically may help them make a decision that suits their particular circumstances most closely.
Higher levels of intervention
In some cases, the outcome of a decision may be so important, or the context so complex, that a higher level of intervention is required. For these situations, two techniques, well tested in the health setting, may be of benefit: decision aids and motivational interviewing.
Decision aids
Decision aids are designed to take people beyond the present and into the potential consequences of each option on offer.25 They have been shown to improve people's knowledge of the options, create realistic expectations of the benefits and harms of each option, and increase involvement in the decision-making process.24 Decision aids usually include good quality information about the risks and benefits of all the treatment options, a technique to help people think about the value of the consequences, and assistance to help patients interpret this information so that it is relevant for them and the decision they are making.
The website of the Ottawa Health Research Institute provides access to a wide range of evaluated decision aids29 and also provides a general template called the ‘Ottawa Personal Decision Guide’ which aims to support any ‘health-related or social decision’.30
Motivational interviewing
Motivational interviewing is a goal-directed counselling approach that aims to help people make changes in their behaviour. It has been used successfully in relation to smoking cessation and drug and alcohol addiction.31 The approach specifically aims to help people face and then resolve ambivalence by taking them through the personal pros and cons of engaging in a particular behaviour. A motivational interviewing approach may be useful to primary care practitioners who are required to support patients faced with a particularly challenging set of options, although this approach has yet to be tested in this specific context. Training in motivational interviewing techniques is available via the International Motivational Interviewing Trainers website (www.motivationalinterview.org).
What decision aids and motivational interviewing have in common is a focus on the process of decision making rather than the outcome. In these situations, it is usual for a third party (for example, a GP, nurse, counsellor, allied health professional, and/or computer programme) to work through the pros and cons of each option with the patient to find out how each of the possible consequences fit with the patient's personal circumstances and values. However, making decisions between healthcare options using these techniques is effortful, in some cases emotionally uncomfortable, and it may not always lead to greater satisfaction with the healthcare encounter.15,25 Further, these particular interventions are complex and have an impact on the patient, practitioner, and consultation. Evidence is needed to ‘unpack the active ingredients’ of these interventions to identify which component parts are necessary for informing patients, facilitating involvement, and encouraging shared decision making (Table 1).32
Guidelines on the component parts of patient information by goal of intervention.
CONCLUSION
The shift towards increasing patient involvement in decision making is growing. At the same time, the government is promoting an agenda of increased choice in health care. This combination may result in patients having more control over how and where their health care is delivered. However, because choice is inherently attractive, increasing the greater range of options on offer may lure people towards healthcare options that are less than optimal for them. Further research into the psychological impact of the choice agenda in health care is warranted. In the meantime, primary care practitioners can play a key role in ensuring that increased choice does not mean poorer outcomes for patients. They should be aware of how the language and context of choice can influence patient decision making and should emphasise decisions and consequences. In situations where the decision could have a potentially serious outcome, practitioners may benefit from adopting some of the established techniques that can support systematic decision making.
Acknowledgments
The authors would like to acknowledge the contribution of Professor Jenny Hewison to the development of this paper.
Notes
Funding body
Not applicable
Competing interests
The authors have stated that there are none
- Received December 14, 2006.
- Revision received February 15, 2007.
- Accepted May 16, 2007.
- © British Journal of General Practice, 2007.
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