Patients, Power and Responsibility

The First Principles of Consumer-Driven Reform

John Spiers

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315345574
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Care pathways are being developed throughout the health service to improve the quality and effectiveness of care. Are they being developed efficiently and making the most of the latest clinical computing systems? This is the first practical guide on how Information Technology and systems methods can support the development implementation and maintenance of "e-Pathways". Case studies throughout highlight team approaches to facilitation clinical knowledge management process analysis and redesign and computerisation - providing insights into how e-Pathways can be used to support high quality patient care. The information is presented in an easy-to-read style and requires no prior knowledge of IT systems. Doctors nurses and managers throughout primary and secondary care as well as healthcare information technology specialists and suppliers will find this to be essential reading. An accompanying CD-ROM includes supplementary information providing useful website links and additional material on specific topic areas.

Part 1

Patients: some introductions

Chapter 1

Must reform always be like trying to knit with water?

There are two great principles – demand -

‘A cup of tea if you please, dear,’ interrupted Tibbs.

And supply.

(Charles Dickens)

We are considering the scarcest thing in the world – the days of our lives, their quality, and the extent of our control over them. Health is one of the keys to a good life, as is self-responsibility, self-restraint and self-discipline. The fundamental concept and concern of this book is to explore how to place consumers in charge, in order to guarantee good patient care for all.

To find good answers to the perennial problems of UK healthcare, it is vital to ask the right questions. The answers that this book offers revolve around the radical notion of putting consumers in charge of their own healthcare. This model proposes that individuals should have control – voluntarily grouped in purchasing co-operatives. And that competitive forces be released to spur innovation, integrate services, improve productivity and drive change in our producer-dominated, tradition-bound healthcare system. Believable answers must carry both philosophical and emotional weight if we are to achieve democratic rationality.

The fundamental concept and concern of this book is to explore how to place consumers in charge, in order to guarantee good patient care for all on the basis of first principles of justice and equity. The word guarantee figures largely, and deliberately. I propose a legally-enforceable guarantee of a ‘core’ package of care. For this constitutes a vital re-assurance. Here, ‘guarantee’ is a prismatic word which makes an emotional appeal – and one of moral, philosophical, practical and political significance. It is a crucial evaluative reference for any policy change. It offers the fundamental and explicit promise to provide what people want from the health system. It is, too, the necessary re-assurance of justice and social unity at a time of change. It is, fundamentally, a demonstration that it is within our capacity to realise justice in healthcare. This means a clear guarantee of good services for all. For we must ensure that the poorer and weaker are not left behind in any financial re-structuring. This ambition is intended to appeal to the commonality – to a nobility of sentiment that takes liberty as its ideal and humanity as its spirit. And it seeks to inspire a new confidence in the availability of appropriate services, and to transmit a promise that will be believed.

So the guarantee of patient care – and of how to achieve it in reality – is at the heart of my proposals. We need to discover terms and language which will encourage the discussion. For language, style, and practice – or content together with the descriptive words and the force of their relation one with the other – are inextricably linked. Disraeli once said, ‘We govern men with words.’ But we do so, too, with moral concepts, reason, and common sense which that language must encapsulate. And, too, by referring actions to fixed and fundamental first principles which reflect a profound national moral sense. We should be aware, too, in addressing the necessities of good presentation of ideas and policies, of the benefits of being alert to the rhythm of sentences, to the tone of voice, to the ways in which ideas are heard (and mis-heard), and to the expression of will and imagination which can deliver democratic objectives. To achieve real change we should remember that one of Winston Churchill’s greatest achievements was to have ‘mobilised the English language and sent it into battle’.¹

Today, the presumption in healthcare is all in favour of change. But to find good answers to the perennial problems of UK healthcare – and answers which secure emotional and political legitimacy – it is vital to ask the right questions, so as to reveal the cardinal realities beneath. The answers you get depend on the questions you ask, and how you ask them. And, too, some questions may be more easily asked than answered. But unless we realise that there are insistent questions which need answers – and unless we reconsider answers which have been marginalised for half a century – we have little chance of making progress, or of understanding the problems which prompt the questions. This requires us, also, to be conscious of the genuine concerns people have about change, and to address these concerns.

New questions are being asked, and old ones revived. For example, is it really true that public spending is the only way to improve services? Why not a smaller State, and competitive choice instead? Is it really essential that the State provides services, rather than provides for services? Why not the State acting as an enabler which makes sure it happens? Why not recover a system of genuine individual empowerment and self-responsibility? Why not think more radically on how to encourage both doctor-led and patient-led reform in healthcare delivery systems and a re-engineering of care processes? Why not look again at motivation, and at structures which were swept aside by a focus on long-term, inanimate personal social forces and ‘the logic of history’ – and which has proved elusively illogical and frustrating, notably to the poor whose gains from the NHS have been disappointing and to medical professionals, whose morale is disturbingly low.

Cultures and context exert a massive grip. Yet, vibrant leadership matters in determining the course of events – notably in refusing to elevate ‘the system’ above the patient. Here, too, I explore the idea that there are enduring truths and first principles which transcend race, gender, class, and temporary and unenduring events – and which can be set out clearly.

Significantly, the problems are cultural. They are about self-belief, by patients and by staff. I argue that unless patients have to take charge of their lives there will be too little self-responsibility. And that unless doctors are better motivated, better rewarded, and have higher morale there will not be better outcomes. There must be job satisfaction, with people who know they are doing a good job and are being appreciated. This is not just about pay. It is about the broad cluster of feelings summed up in the phrase ‘job satisfaction’. And of how each individual can add value by their own actions. Staff and patients have got to believe in the possibilities of doing better, and not have their hopes and ambitions so easily squashed. It is no good constantly reforming healthcare if large numbers of staff continue to go home in a state of nervous exhaustion.

Individuals (patients and staff) owning change can only come about by a cultural transformation – one which shifts the entire axis of the system. This will turn on how things and people are managed, so that all involved are made to feel that they can do more, achieve more, work harder, and produce better results. A necessity is constant feedback and regular appraisal (including personal contracts for all), which is checked. A different ethos is possible, as continental experience shows (and as UK experience in some other areas of public services which are changing, such as the results achieved with ‘average’ intakes by City Technology Colleges, where levels of achievement are significantly greater). The issue is for every individual consciously and willingly to batten down for quality and outcomes. Then we can achieve the objectives which are supposed to be on the social agenda, but which are not achievable by centralisation and control from above. We can show what can be achieved by vision, clear management, and clear responsibility. But the trigger must be individual responsibility – starting with the patient.

The message here is a simple one, but one which is often overlooked by management. It is this: we need to catch people doing things right, as well as catch people doing things wrong. Good doctors must be properly rewarded, whereas they are poorly rewarded in the NHS. Good doctors must be enabled to do medicine, and not be social cogs in everyone else’s Ferris wheel. Good doctors create something in their own right, which is good care and faith in care itself. Yet if this goes unrecognised then good people will remain poorly motivated and patients feel stranded. This does not mean there must be little or no accountability. Such an idea is absurd, and now hardly canvassed. But it must be accountability for outcomes.

One imperative is to stop the forces trying to stop change and drag us back – and some doctors are among them – in a deft rallentando. One example concerns the role of so-called ‘public sector unions’. Historically, it was important for trade unions to help create better conditions for workers. But we cannot remain locked into problems by changes made for previous generations, and now entrenched by sea-dog opposition and special interest. No doubt change will involve some hardship and agony, but it needs to be explained in terms of first principles, and with sunshine and hope and the promise of conquest and victory – even in Churchillian terms – if the vital energy of the community is to be successfully concentrated.

The proposal to put the consumer in charge – with services for all still to be mainly funded by central taxation (which of course I recognise is coercive) – offers the potential for much better and essential partnerships between consumers and providers, for better, more responsive, better-funded care and higher morale and reward for those delivering good care. And for outcomes relevant to, and significantly defined by, individual consumers themselves. If the structure offers incentives for better services to be offered, the State should empower individuals to use them and contribute towards their cost, in whole or in part. I offer the concept of patient fundholding, with the individual owning a specific healthcare fund, empowering choice. This can have many benefits, not least in educating consumers about the cost of health services, prompting individuals to seek information about those services they consume, and – perhaps – evolve more cost-effective patterns of use. Informed purchasing decisions will not necessarily be inexpensive decisions, but the provision of cost and quality information will educate and perhaps amend some behaviours.

As Professor Regina Herzlinger of Harvard University recently said of the US system, which is in no less difficulty than our own:

When consumers apply pressure on an industry, whether it’s retailing or banking, cars or computers, it invariably produces a surge of innovation that increases productivity, reduces prices, improves quality and expands choices. The essential problem with the health care industry is that it has been shielded from consumer control – by employers, insurers and the government. As a results, costs have exploded as choices have narrowed.²

This book examines some very difficult problems of policy and conscience, and different theories of ‘community’ in the functioning of the State. These dilemmas are not easily simplified by rough-hewn labels and abstractions like ‘collectivist’ or ‘individualist’ as we seek to distinguish what we think should be ‘class actions’ to be taken by the State and what should be specific actions to be taken by the individual. This discussion will, however, inevitably lead us from the present State monopoly of funding, purchasing and providing, into a more subtle if more complex approach which combines the remedial action of the State, the actions of the self-responsible individual, and voluntary or ‘community’ effort. Reform will need the State to occupy a supervisory role rather than an incessantly directive role, and this itself will evolve in self-adjustment.

This is an approach which co-ordinates all three elements – the State, the individual, and voluntary effort. It offers great operational as well as moral value, with self-responsibility in the foreground. The individual seeking the best, including from themselves in self-responsibility. The mutual-aid organisation offering leadership and incentive to persuade people to do some things or stop doing others. The State as rule-maker, with the power to enforce patient guaranteed care by law but encouraging the spontaneous discipline of the individual and the family. In this description, the ‘individual’ never constitutes a uniform pattern, the more so in an increasingly diverse society. And so we should seek an approach which employs organisations that stand separately both from the State and the individual. This can enable time and money to be marshalled by which to investigate individually (and empower financially) the hidden and deeply personal reasons for individual action. These should be assessed by the patient and the adviser in a necessarily delicate balance of risk and opportunity, and with an approach which ensures that everyone gets their chance. The adaptive patchwork this constitutes can reflect many of the characteristics of mutual-aid: stable but adaptive, ingenious and innovative, transparent and often inexpensive.

The trend of modern healthcare is towards more complex and more highly individualised care, which improves outcomes and the quality of life as determined by the patient.

Here, choice and control are the essential elements for successful change. In the UK we have made virtually no progress towards either. This, despite Mr Alan Milburn’s drive to focus the system on the individual. And so we have to start from basics, and imagine the possibilities all over again. Raymond Williams tells us that ‘It is the ability to raise a structure in imagination before erecting it in reality that marks out human activity from other kinds.’³ So we should have more confidence in imagining, in describing and in testing out what might be possible and what we could achieve. We should not necessarily rely on the ‘obvious’, or on a master-plan. But any proposals should be predicated on an architecture of consumer control.

Is the consumer necessarily inadequate, a priori, in making personal judgements? I argue that this is not necessarily so. Granted, there is an information asymmetry – one which has been reinforced by NHS rationing and by Government deliberately restricting the flow of information in order to suppress demand. This denial of information to patients has proved inefficient, shown the structure to be vulnerable and unable to defend itself against its own weaknesses. However, we should recognise that much healthcare concerns lifestyle choice, in which the individual has the intimate and special information and self-knowledge about their own life. And if i...

Table of contents

• Cover
• Title Page
• Copyright Page
• Dedication Page
• Contents
• Foreword
• Preface and Acknowledgements
• About the Author
• Part 1 Patients: Some Introductions
• Part 2 Power and Responsibility: Some Policy in Practice
• Postscript
• Index