‘Having a heart attack’ is not the same as ‘having a Mercedes’. Which is of course a statement of the bleeding obvious once you put it like that.
Fantasising about whether you would prefer a Mercedes or an Audi is standard consumerist fare. Fantasising about whether you would rather have cancer or a stroke is pretty odd.
A category error
But if it’s all so obvious, how come we spend so much time in the NHS talking about choice and the patient as consumer? After all patients are supposed to act as consumers of health aren’t they?
They are meant to approximate, somewhere deep in their bowels, to that rational economic actor who sums up the pros and cons of every decision and then acts accordingly.
But if, in fact, ‘having a heart attack’ is completely different to ‘having a Mercedes’ then taking consumerism’s easy virtues into the heart of healthcare could be a big mistake.
No matter that we may want patients to act as consumers because it suits our economic and political models. No matter that it really might give parts of the NHS a much needed boot up the backside if people were a bit more picky.
If the truth is that, when faced with the prospect of a massive heart attack or a life with dementia, most of us begin screaming and sweating and praying, then we are not dealing with consumer behaviour but with existential terror. Less emporium of pleasure, more crematorium of terror.
But I can hear you protesting that people do want choice, they do want to be involved in their care and to have a say. And you’re quite right, but to call this behaviour ‘consumerist’ is to mistake its inner reality.
My experience as a GP was that when we hit the “Have I got cancer Doc?” moment people want many things – time, information, a sense that they matter to the person answering the question – but choice of provider is not high on their list.
When faced with death or one of his lesser cousins our warm, human bodies take charge. We do not long for more choice but rather for the sweet smell of mother and escape from our paralysing fears.
Speaking up and getting out
Once we have had the treatment, however, it is a different matter. Released from acute anxiety and buoyed by relief, or anger at the indignities that we have survived, then post-treatment, we begin to be ourselves again.
We share what happened with our friends and re-tell our battle with cancer or the ward sister as part of our moral rehabilitation.
Along the way, we happily take part in a survey or fill out a Net Promoter Score because we want to “give something back.”
For those who believe that markets in health care are important, this magically reconfirms that patients really are ‘consumers’ after all – even if consumers in real life are far more concerned with getting than with giving back.
In policy terms, this means we may have been putting the consumerist cart before the treatment horse.
If people behave more like consumers after treatment, but only sporadically before, then ‘voice’ is more important to them than ‘exit’.
In other words, being able to influence a service, with a view to helping it to improve, is more important than being able to quit it in favour of a different provider.
Interestingly, this also confirms our collective experience over the last ten years of trying to offer choice of provider to patients – the little beggars are just not that interested in it.
Speech is silver (choice costs gold)
All this matters because exit is the theoretical basis for trying to create a market in health care. The idea is that if enough people leave a service it will buck up its ideas or fail; in which case something better may take its place.
Since the economic and political costs of markets in the NHS are rising (just ask former health secretary Andrew Lansley) whilst those of voice are falling (just look at Twitter) a revolution is afoot.
In the future, users of health services are likely to exert pressure primarily via social media rather than market choice.
About the author: Paul Hodgkin is chief executive of Patient Opinion, a website on which patients, service users, carers and staff can share their stories of care across the UK. Patient Opinion is a not-for-profit social enterprise based in Sheffield.
Until 2011 Paul also worked as a GP and has published widely including in the BMJ, British Journal of General Practice and the Guardian and the Independent. He tweets at @paulhodgkin.
Choose & BookMary E Hoult 53 weeks ago
This is the explanation I received when raised concerns about Choice or Choose & Book by the person who introduced it.
The issue of slot availability is a national problem that has become more transparent since the usage of the Choose & Book system has increased across the country.This is primarily due to the fact that the providers now have to make appointment slots available in advance,for slot polling.Prior to Choose and Book ,hospitals were able to react to demand by flexing their capacity in response to that demand,we have a significant role in highlighting the seriousness of this issue,ultimately it is down to the individual commissioners to work with providers through robust commissioning and contract management arrangements to ensure sufficient capacity is made available.I don't think with all the changes any of this will improve,and choice is being used to transfer block patients when difficulty's arise.
It's access not choice the public wants!PhilC273 54 weeks ago
Really good article. This brings me to a soapbox topic I%u219ve bored folk with for years. Patients want access not choice. They want to be able to go to the nearest or most convenient (usually travel-wise) acute hospital and for the standard of service and care to be as good as any other. Surely the NHS should be looking to bring each hospital up to a basic minimum acceptable standard so that choice (other than for Tertiary care say) is not a big issue?
How can any member of the general public really make an informed choice about one hospital over another, unless one is performing very poorly? If so this should be addressed directly, not as a result of patients over time deciding with their GP not to go there.
Choice V VoiceMary E Hoult 54 weeks ago
Great article, I agree with every word.We promote choice whilst having large backlogs of follow up patients waiting to be seen !! These patients have made their choice yet their voice often goes unheard while new services and patients are being promoted.