Who chooses ‘Choose and Book’ for orthopaedic referrals? An evaluation of GP practice data as a source of information on inequalities in patient choice

Since the introduction of ‘Choose and Book’ in 2006, several authors have contended that it is liable to be used differently by different sectors of the population and so increase health inequalities. However, since most of the data relate to whole populations or to individuals, it is difficult to build a picture of the way choice is exercised in regional and local communities. The objective of this study was to gather and analyse data on patients’ choice of hospital for orthopaedic surgery from one GP practice; and on the basis of this analysis to assess the value of such data in identifying inequalities in the exercise of patient choice at the level of the local community. The choice of hospital for non-urgent orthopaedic referrals was examined across a diverse population registered with a single large GP practice which covered a mixed urban and rural population of significant ethnic and cultural diversity. The frequency with which patients chose a non-local hospital (used as a proxy for patient choice) was analysed against the variables of patient age, gender, ethnicity, first language, level of formal education and whether they lived in a more rural or urban area. There was a significant positive correlation between tendency to use a service other than the local NHS hospital and White British ethnic status. However, the reasons behind this trend remain a matter for debate and no evidence was found for other proposed correlations with sex, location, education or language. The available proxy measures do not seem to give a sufficiently reliable picture of the exercise of patient choice; population studies at the level of a single GP practice do not yield either sufficient numbers or sufficient individual detail to yield valid and reliable results. Although initially promising, data gathered at the level of a single GP practice do not seem likely to yield many new insights. Instead, more attention should be given to regional-level analysis; to more direct data-gathering that is less reliant on proxy measures; and to direct studies of particular sectors of the population (such as young people; minority ethnic communities) whose distinctive behaviour is overlooked in the large-scale studies.