The problems with choice

Mike Fitzpatrick is correct. The perverse truth is that inequity is a necessary precondition for choice to be meaningful. The choice evangelists try to repel their critics by quietly conflating consumer choice with moral choice and rights talk. It is important, therefore, to distinguish between consumerism (the preoccupation with, and increase in, consumption), and moral choice (the patient’s inalienable authority to give and withhold consent). If patient choice drives quality and empowerment, to where is it driving it? A state of equity, and satisfaction for all, by way of the necessary evil of market forces. Who said Marxism was dead? operations from GPs book patients in to clinics before placing them on a waiting list. As part of an initiative programme to reduce waiting times at King’s College Hospital in London, GPs were given an opportunity to book patients with eyelid pathology directly onto the minor operations list over a 6-week period. We audited this data retrospectively. There were 85 subjects (50 males and 35 females) with a mean age of 41.6 years (range 16–75 years). The referring diagnoses were divided into three categories: chalazion/cyst (80% of referrals); skin tag/papilloma (16%); and unknown aetiology (4%). When compared with the diagnoses made by the senior attending ophthalmologists, there was a 34% diagnostic discrepancy. The main discrepancy (65% of cases) occurred in the skin tag/papilloma group (referred initially as cysts). The unknown group contained skin tags/papillomas (66%), and cysts (34%). Analysis of the final outcome revealed that 26% of patients did not require (or want) surgery; these patients were discharged. The proportion of those discharged was directly related to the length of time between referral and the appointment, which averaged about 3 months. The clinical diagnosis of benign eyelid lesions at ophthalmic departments has been shown to be fairly accurate when compared to histological samples, in particular for chalazia (up to 94%). However, where discrepancy occurs the lesions often have a premalignant or malignant aetiology. The accurate diagnosis of ophthalmic conditions is clearly in the best interests of all parties involved, and would optimise the use of resources in the treatment of conditions considered suitable for management as ‘minor ops’. Improvement in this arena has been demonstrated by organising workshops in some units. Furthermore, it appears that including ophthalmology as part of vocational training is the best way of achieving this aim. The direct-access pilot scheme was not shown to be an efficient way of conducting the minor operations service. JOHN MAGUIRE General Practitioner Wibsey Medical Centre, Wibsey, Bradford BD6 1TD. E-mail: [email protected]