Informed patient choice – chimera or reality? : Understanding how patients engage in information-seeking when choosing a provider in Swedish primary care

The steering of health care through patient choice has become an integral part of several health systems. In Sweden, the government introduced a legal right for patients to choose their own primary care provider in 2010. The reform was built on the principles of a quasi-market, meaning that public reimbursement follows patients’ choices to stimulate both public and private providers to compete for patients. Through this the government hoped to achieve higher quality and efficiency of services as large groups of patients were assumed to seek care from the best performing providers. An important precondition of a functioning quasi-market such as the patient choice is that patients make informed choices. By this is implied that they consider the service quality of different providers by actively seeking and using relevant and reliable information. Otherwise, the mechanism behind patient choice might be lost as providers will not be exposed of the risk of being outcompeted due to inferior quality. The specific aim of this thesis was to investigate how patients engage with the assumptions of the informed choice of a primary care provider and the conditions that influence them in this regard. This aim was achieved by conducting four empirical studies. The main findings of the studies demonstrated that not even patients in active choice situations, as they had switched or considered switching primary care provider, searched for information which could underpin a judgment of the quality of different providers. Findings indicated that patients’ overall lack of engagement in making informed choices was the result of how they experienced the conditions of choice, such as a lack of promoted differences in the range and quality of services and a general trust in that they would receive health care of equal quality regardless of choice. Patients also actively resisted the very premises of an informed choice by arguing that the convenience of being geographically close to services was more important than opting for the clinically best provider, or that access to primary care services of high quality should not be dependent on making an informed choice. The results implicate that patients’ choices have poor prospects of function as drivers of quality, and that public authorities must continue to safeguard quality to ensure that all patients receive an acceptable standard of primary care services.