Empowering patients: New Labour’s unhealthiest idea?

After Tony Blair’s lip-trembling resignation speech, commentators were inclined to give him credit for his public sector reforms while questioning his judgement over Iraq. But New Labour’s widely approved ‘patient-centred’ reforms are a real threat to the quality of healthcare in Britain.

When, a week earlier, Blair visited the offices of the King’s Fund, New Labour’s favourite health policy think tank, to give a speech commemorating a decade of National Health Service reforms, he received a generally positive response from the assembled ranks of health experts and professionals (1). King’s Fund chief executive Niall Dickson set the tone in his congratulations to the prime minister on the eve of his departure for providing ‘unprecedented levels of funding’ and ‘significant improvements in key areas’. Though there were some reservations about disruptive reorganisations, there was general agreement that New Labour reforms have succeeded in their key objective of making the NHS more responsive to patients. While the soundbites about ‘patient-centred’ healthcare may appear merely banal, they reflect the corrosive cynicism of New Labour that is Tony Blair’s true legacy to the NHS.

Speaking to the King’s Fund conference immediately before the prime minister, David Pink, chief executive of the Long Term Medical Conditions Alliance, a consortium of more than 100 patient organisations, welcomed the government’s commitment to a ‘patient-centred’ NHS. As Pink acknowledged, the very presence on such a distinguished platform of somebody speaking from the perspective of patients was a potent symbol of the transformation of health policy under Blair. He enthusiastically endorsed a number of initiatives that, while purporting to advance patient interests, reveal the destructive consequences of the government’s attempts to reform healthcare according to the rhetoric of choice and empowerment.

While many commentators have criticised the Quality and Outcomes Framework (QOF) as a crude target-driven payment-by-results system imposed on general practice, Pink welcomed ‘a major national programme that has turned the NHS’s attention to helping people monitor and maintain their own health’. In practice, QOF operates as a financial lever to shift medical practice away from the diagnosis and treatment of disease towards intrusive and moralising interventions in patients’ personal lives, justified by the dogma that this improves health and prevents disease. Far from benefiting those with chronic conditions, this shift is depriving them of continuity of care while doctors’ energies are consumed with medicalising the worried well. The provision of an incentive bonus to GPs for recording patients’ preferences about where they would like to die – a choice over which neither patient nor doctor is in practice able to exert much influence – aptly symbolises QOF’s contribution to patient empowerment (2).

Another New Labour health initiative approved by David Pink is the Expert Patient Programme, a series of formal training sessions through which people learn to manage their own chronic illnesses. (As, according to the Long Term Medical Conditions Alliance, there are some 17million people with such conditions in Britain, at least one in four of the population is deemed eligible for this programme – though only 23,000 have so far participated.) For Pink, ‘the great significance of this programme is that it is an acknowledgement of the vital role that patients and their families have in improving their own health’ – and he welcomed the support of the British Medical Association for the programme.

Though the Expert Patient Programme (EPP) has a commonsensical appeal, it is imbued with bad faith: it offers an illusory empowerment to patients with chronic illness and an illusory relief from the burden of caring for patients with chronic illness to doctors (3). If the EPP was widely taken up, it would affirm an identity as sufferer from chronic illness for a growing proportion of the population while imposing an increasing burden of responsibility for their own care on those with chronic disease. While patronising patients, EPP implicitly degrades doctors, devaluing medical science and professional expertise. Who benefits? Not patients, not doctors, not society; perhaps a few politicians and health policy bureaucrats.

David Pink is also a staunch advocate of ‘patient and public involvement’ in the NHS, another of the favoured slogans of New Labour. Given the ‘democratic deficit’ resulting from the decline in popular participation in political parties, local councils and elections, the government has sought to increase public involvement in many areas of public life, from the arts to schools to hospitals. Such initiatives inevitably have an artificial and bureaucratic character, particularly in the sphere of healthcare, which people – at least in the past – sought to avoid when they were well and to keep to a minimum when they were sick.

New Labour’s promotion of ‘patient and public involvement’ has led to the cultivation of the professional patient (together with the professional carer) who purports to express the interests of patients (and carers) in general. Of course, members of the public who are able and willing to assume these roles are inevitably unrepresentative of patients and carers in general – and, unlike local councillors and MPs, are not subject even to the episodic recall of the ballot box and hence are under no obligation or even pressure to reflect the interests of those they purport to represent.

In his enthusiasm for ‘patient and public involvement’ David Pink personifies the defects of these initiatives. While he speaks on behalf of people with chronic illnesses to top politicians and policymakers, he was not elected by people with chronic illnesses and he is in no way answerable or accountable to them. Indeed, as the chief executive of a meta-quango, which strictly represents a number of organisations (also unrepresentative and unaccountable) rather than individuals with chronic illnesses, he is as remote from such individuals as any politician (and vastly more remote than the average GP). In fact, what emerges is that his status at the King’s Fund assembly of health policymakers is conferred by government endorsement of his position rather than by any democratic mandate.

It is thus perhaps not surprising to find that, of all the assembled dignitaries, he provides the perfect warm-up man for Tony Blair on his tenth anniversary celebrations.

Dr Michael Fitzpatrick is a GP in London and author of The Tyranny of Health: Doctors and the Regulation of Lifestyle published by Routledge. An edited version of this article will appear in the British Journal of General Practice in June.

(1) Tony Blair, Speech to the King’s Fund on the National Health Service, 30 April 2007

(2) Daniel Munday, Jeremy Dale, Scott Murray, ‘Choice and place of death: individual preferences, uncertainty and the availability of care’, Journal of the Royal Society of Medicine, JRSocMed 2007; 100: 211-215, May 2007

(3) See Who wants to be an expert patient?, by Stephen Bowler