As was demonstrated once again with the ‘NHS People’s March’ in London on Saturday (though remarkably under-reported in mainstream media), concerns over what many see as the “secretive privatisation” of the National Health Service are widespread, and seem to be growing steadily.
But amid all the concern about changes to the formal structure of the NHS imposed from the outside, there seems to be little discussion of changes in the culture that are growing from the inside. This matters because there is a deeply troubling trend emerging: while we look out for privatisation from without, we are missing the Consumerisation from within.
The most significant voice in this shift is that of Healthwatch, the “consumer watchdog for the NHS”. The story they tell goes something like this: for a long time we have been treated as ignorant patients by the NHS, who assumed they knew best. As experts, doctors told us what treatments we could have, and expected us to accept what we were told. As patients, we got what we were given. Now, this has to change. Instead of seeing ourselves as patients, we should become consumers. We should claim our rights; we should demand that what we want is provided; and when it isn’t, we should complain and hold the “experts” to account.
There’s a lot that seems right about this story, not least the apparent empowerment of the individual in the face of the establishment. But can we do better? Need we do better?
Clearly, as Healthwatch have found, many of us have a problem with this idea of being consumers of health and social care, though it’s difficult to pin down why. It can easily be dismissed as “just words”. But in the age when a social psychologist can win the Nobel Prize for Economics for understanding among other things the power of language to affect our decision making, nothing is “just words”. I think there are some very serious problems.
The first problem is that the idea of the consumer, while it reverses the power relationship, actually reinforces the divide between us and our healthcare. As patients, the doctors were in charge and we have to take what we were given. As consumers, we are in charge and they have to give us what we want. But the ‘us and them’ nature of the relationship is if anything reinforced. At worst, it makes doctors the enemy. Not ideal.
Even without going to that negative extreme, this separation is a major problem if you think about where we are going in healthcare in the wider context. The NHS Sustainable Development Unit have a fascinating table of shifts that will be required in order for us to achieve what they call sustainable health, in an era of decreasing budgets and increasing pressures (ageing population, climate change, etc):
Many of these shifts fundamentally depend, not just on a reversal of the power relationship, but on a more equal and participatory relationship between us as the public and the healthcare system. To move from a sickness system to a health system, from institutionally led care to a system where health and social care are part of the community, and from curative to preventative care, we will need to see ourselves not just as consumers of healthcare, but as participants in it.
Participation is not something that sits well with the concept of the consumer, as our own research has shown. We worked with YouGov on a very simple priming study based on omnibus questionnaire with 3000 people, nationally representative. All three groups were asked two questions: to what extent do you think it’s important to participate actively in society, and to what extent do you think it’s important to participate actively in your local community? But the sample was split into three. One group of 1000, the control, were only asked these two questions. A second group was primed to think of themselves as citizens, and a third as consumers. These were the results.
Merely being exposed to light priming had a significant effect on response to the participation questions – with consumers likely to see participation in either society or their local community as far less important. This is an astounding result, and ought to provide serious pause for thought as to whether we really want to push the idea that we are consumers of the NHS. If we need to become more active participants in our own healthcare, we need to recognise that thinking of ourselves as consumers is likely to be in direct conflict with this need.
The idea of the consumer has other impacts too. In another study, a survey of social attitudes , the sample was split in two. For half, the front cover said Consumer Reaction Study; for half it said Citizen Reaction Study. Levels of social and environmental motivation were significantly lower on the Consumer Response Study. Other studies got participants to walk along a commercial or residential street to the research facility, and found a similar impact.
This suggests a second major problem with thinking of ourselves as consumers of the NHS: the knock-on effect this would have in other areas of our lives. If even the NHS starts to use this language, one of the last remaining areas where we are something other than consumers will have gone. And this matters, because the language of the consumer, it seems, is directly opposed to social and environmental motivation – two things which arguably we really need to be supporting, not undermining right now. In short, further accelerating the atomising of society – with highly negative consequences discussed elsewhere on this blog for democracy and climate change among other issues – would seem a likely if unintended consequence of bringing the consumer into healthcare.
So much for the problems, Bradley and co might say. If we’re not consumers of healthcare, what are we? Patients is too subservient, users too inhuman, consumers too atomising… so what do you want to do?
I think the healthcare system should lead not follow. I think we should be championing the idea that we are citizens, capable not just of choosing between options, but of informing ourselves and participating in shaping the options; not just of demanding service from institutions but of looking after each other and ourselves. If the language of the consumer appeals to Healthwatch because it brings a framework of rights, the language of the citizen should appeal more – it brings both rights and responsibilities.
Exactly this approach is being explored through the pioneering NHS Citizen project, set up to explore how the NHS can best take into account all public views in its decision making – asking us not just to expect the NHS to serve us as consumers, but to take ownership of it, making it ‘Our NHS’ not just ‘The NHS’. Their first major assembly takes place on the 18th September, and looks set to be a fascinating event.
This initiative should show us that there is a different way to think about the future of our healthcare system, just as there is a different way to think about the future of our society more broadly. Across the world, there are initiatives springing up all the time that offer us the opportunity to get directly involved in shaping the society we want, rather than seeing it as Someone Else’s responsibility (whether state or market) to dictate what the options are, and as the limit of our responsibility to choose the best thing for ourselves.
At some level, I think the fact that the deep concern about the potential privatisation of the NHS is born out of an awareness of this possibility – this is not just about a battle between state and market, but people wanting to play a greater not a less role in society, willing to step up as citizens, not just demand as consumers. But that concern that manifests in protest marches needs also to focus on the change that is coming from within. And as for Healthwatch, they need to be very careful what they wish for.