The absurdity of a ‘patient-led’ NHS

Health ministers have angrily rejected suggestions that the much publicised ‘listening exercises’ carried out in advance of the Your Health, Your Care, Your Say white paper were simply a publicity stunt designed to rubber stamp proposals already decided by the government. Early reports open up an even more disturbing scenario: in their desperate desire to appease consumer demand, health ministers are planning to draft ideas thrown up by these focus groups directly into the forthcoming public health policy document.

Three proposals topped a poll of options for reform at the ‘listening exercise’ attended by more than 1,000 people in Birmingham: extending GP opening hours, annual health MOTs and more walk-in centres. This familiar list of the preoccupations of the professional middle classes confirms the way in which this focus group approach places the demands of the worried well over those of the seriously ill (or even of the not very well, but socially marginal). ‘Listening exercises’ tend not to include those who are ill, particularly the elderly, children, people with mental illness or learning disabilities, families with young children, those who are not fluent in English – in fact, the majority of our patients and certainly those patients most in need of healthcare services. These proposals will increase costs out of all proportion to benefits and are likely to disrupt continuity of care for those patients for whom this is the most important aspect of primary care services.

Yet these proposals are now set to be imposed on general practice in Britain, together with a number of similar initiatives, such as ‘choose and book’ (a – largely non-functioning – computerised system for booking hospital appointments) and ‘practice-based commissioning’ (a return to the GP fundholding system introduced by the previous Conservative government, as a device for restraining hospital spending). Many commentators have objected to the fact that the government is extending the role of the private sector within the NHS. But while the scope of privatisation remains uncertain, increased fragmentation and more bureaucracy seem inevitable, as does growing staff confusion and demoralisation.

Whereas past Labour governments were inspired by the vision of the National Health Service, Tony Blair’s government has no vision for the future of healthcare. It is passionately concerned about health, but only as a sphere in which it can do something to overcome its wider loss of authority, by finding points of contact with society and winning back some of the respect it has lost. For New Labour, health offers both opportunities and threats. The government seeks to respond to popular preoccupations about health, expressed in increased awareness of diseases from AIDS to SARS and of the measures required to sustain health, in terms of lifestyles, screening tests and treatments. The success of NHS Direct, the government’s 24-hour health helpline, confirms the value of such initiatives, not to public health – there is little sign that this service alleviates anxieties or reduces attendances at A&E departments or GP surgeries – but to the government’s popularity.

At the same time, the government is deeply ambivalent about the fact – reflected in numerous surveys – that the NHS as an institution and doctors and nurses as professionals retain high levels of prestige in British society. On the one hand, acutely aware of the low esteem it enjoys in the eyes of the public, the New Labour elite is envious of medical authority and keen to cut the medical profession down to size. These sentiments, often expressed in a virulent hostility to ‘medical paternalism’, run high in influential health-policy NGOs and think tanks. This outlook was forcefully articulated in recent controversies over the Bristol children’s heart surgery unit (see After Bristol: the humbling of the medical profession), the retained organs furore at Alder Hey (see No way to respect the dead – or living), and in the scapegoating of paediatrician Roy Meadow (see Society’s unhealthy obsession with abuse).

On the other hand, New Labour politicians are envious of medical authority and aspire to usurp it or to find ways of taking advantage of it for their own ends. Thus there is a continuous pressure to relocate coercive functions formerly carried out by social services – such as child protection – in GP surgeries. One recent recommendation is that every time a new GP surgery is being built, a police station should be included in it (a measure credited with a sharp reduction in the crime rate in the Leicester constituency of health minister Patricia Hewitt) (New Statesman, 21 November). Health ministers are willing to promote and exploit any grievances expressed by patients to achieve their objectives of reshaping the health service according to the arbitrary agenda thrown up by focus groups.

The concept of a ‘patient-led NHS’, which now guides government health policy, reflects New Labour’s desperation to appeal to the demands of middle-class consumers. But, as numerous commentators have pointed out, healthcare cannot be provided in the same way as consumer goods in a supermarket. More importantly, patients should not be reduced to the status of customers.

Patients tend to be ill (it seems strange that it is necessary to point this out), and have always therefore been provided with care and attention and relieved of the burdens of everyday life. They are not expected to play a leading role in their own treatment, never mind in leading the NHS. Patients also tend to lack the knowledge and expertise required to play a leading role in NHS administration, even in their own medical management. When patients cease to be patients they generally have little interest in leading the NHS, instead having jobs to do, families to look after, lives to lead.

Those few patients who express a great interest in running the NHS tend to lack these other interests. Hence they are highly unrepresentative of patients in general and, while giving them a greater say in the direction of the NHS may advance their exclusive concerns, it is unlikely to prove beneficial to the vast majority of patients. In my view, patients expect competent care from a doctor-led NHS, within a policy and funding framework decided by a democratically accountable government. I can think of numerous innovations in healthcare over the past 50 years – from special care baby units to hospices for the terminally ill – that were introduced on the initiative of medical and nursing staff. The dramatic improvements in standards of primary care over recent decades owe little to patients and less to politicians. Though it is difficult to think of any useful innovation that has resulted from either political or consumer intervention, numerous useless and wasteful initiatives – from NHS Direct to ‘choose and book’ – come readily to mind.

But according to NHS chief executive Nigel Crisp, we must abandon the hopelessly old-fashioned concept of a ‘patient-centred NHS’ (1). The Department of Health has struggled to explain its revolutionary concept. Back in March it indicated that ‘a patient-led NHS means that patients are supported to make choices about, and take control of, their health and healthcare, and services evolve to provide personalised care by listening and responding to patients’ (2). It is difficult to see any relationship at all between the first and second half of this sentence. It suggests, on the one hand, a government-led NHS in which patients are guided towards officially approved lifestyles and behaviour, and, on the other, an NHS which provides services according to consumer demand.

In October, perhaps in response to bemused patients, perhaps in an attempt to resolve its own confusion, the Department of Health again asked itself the question puzzling the nation: ‘What does patient-led mean?’ Its answer: it means ‘reshaping how the service delivers care, based on what patients need and want’ (3). The same ambivalence persists: the government knows what patients need, but who knows what they want?

The true purpose of a ‘patient-led NHS’ emerges as the subordination of the NHS to the political and electoral requirements of New Labour. This will do nothing to improve the health of the nation, though it is likely to destroy the NHS.

Dr Michael Fitzpatrick is a GP and author of The Tyranny of Health: Doctors and the Regulation of Lifestyle (buy this book from Amazon UK or Amazon USA), and MMR and Autism: What Parents Need to Know (buy this book from Amazon (UK) or Amazon (USA)). This is an edited version of an article that appears in the December 2005 issue of the British Journal of General Practice.

(1) Creating a patient-led NHS – delivering the NHS improvement plan, Crisp, N., Department of Health, 17 March 2005

(2) About a patient-led NHS, Department of Health, 22 March 2005

(3) What does patient-led mean?, Department of Health, 25 October 2005