The initial unit of medical production is the consultation, a meeting between a health professional on the one hand, and a person with problems on the other. All other main variable costs in the economy of all care systems originate from such consultations. In the NHS, with a simpler and more structured referral system than any other country, each series of clinical decisions leading ultimately to economically significant acts, for example cholecystectomy, hip replacements, kidney dialysis or coronary bypass grafts (four favourites for health economists), begins from a consultation between a patient and a health worker, usually a doctor.
The quality of decisions in these consultations is therefore critical for efficiency of the entire NHS. They determine how health problems are defined, and the nature of solutions sought. If things go wrong at this point, irrational costs ensue even if a specialist corrects them later. Just as the shape of a large crystal depends on the exact configuration of its infinitesimally small component molecules, the nature of entire health care systems depends on the social relations of production in these consultations, how their objectives are defined, and how their limits are understood.
The conventional view of a consultation is that it is a transaction between a doctor- provider and a patient-consumer. In this view, transactions in doctors’ shops are not fundamentally different from transactions in other shops. Health economists generally concede that consumers of medical care are even less able to behave as omniscient buyers in perfect markets, than other consumers of complex commodities. As few economists any longer believe that perfect markets, ideal buyers, or ideal sellers have ever existed outside economic textbooks, the distinction seems unimportant. However modified, this transactional view still provides the underlying model for all conventional thought.
This transactional view still holds in a State-funded or insurance-funded service. Who pays, and whether payment is by salary, flat rate capitation for continuing care, or by episodic fees for items of service, has powerful effects on the nature of consultation, by changing motivation in providers and expectations in consumers, but none of these fundamentally change the underlying relationship between provider and consumer, as long as these roles are maintained. Transaction implies caveat emptor, let the buyer beware. There is a fundamental conflict of interest between buyer and seller, just as there must also be some fundamental convergence of interest for the transaction to begin in the first place. If patients are consumers, their rights and power can increase only if the rights and power of providers are diminished. Though each clearly needs the other, if understood as providers and consumers, doctors and patients have a fundamentally adversarial relationship.
As soon as we think seriously about this idea, it starts falling apart. If patients are consumers, what do they consume? It’s true that patients, not doctors, consume the pills, but it is doctors who choose whether and what to prescribe, and doctors are the target of pharmaceutical advertising for prescribed drugs, not patients. Patients have operations, not their doctors, but doctors decide if an operation is necessary, and what it will be. If consultations simply initiate consumption by patients of something provided by doctors, what and where is the product of medical care? It seems that all transactions as normally understood either precede consultation (pills purchased from pharmaceutical companies for prescription by doctors) or follow it (technical interventions purchased from hospitals through a doctor’s referral). What about a consultation in which nothing is prescribed, and no referral is made? Does this have no product? As most health economists now acknowledge, for pharmaceutical companies and Hospital Trusts which are the main market players, GPs are the consumers, not their patients.
PATIENTS AS CO-PRODUCERS OF HEALTH
An alternative and more useful assumption is that both doctors and patients jointly create a product through consultation, which did not previously exist. The primary consultation process may or may not initiate consumption of other products of critical interest to other market players, notably prescribed drugs in about 70% of consultations, and referrals for complex diagnostic tests or technical interventions in about 7%, but these are secondary to the main product of all consultations. This product is understanding of patients’ problems, and steps toward their solution, ultimately leading to net health gain.
Though all productive consultations depend, and always have depended, on work by both doctors and patients, doctors established a dominant role, with the patients’ contribution so subordinated, that doctors could appear wholly responsible for the final product. The terms of private medical trade required that this be so, for otherwise patients could have negotiated a reduced fee, in proportion to their own work – or even, in some circumstances, a fee from the doctor. The full potential of patients as producers cannot be revealed until fees are long forgotten.
In the 95% of problems apparently solved at primary care level, without referral, the patient’s contribution to production is high, because this need not conform to any academically respectable form, and can follow intuitive patterns that include much larger inputs from patients. So far as I know, we have no quantified evidence about this. But for the 7% who are referred for a specialist out-patient opinion, patients’ contributions to definition of their problems is much larger in fact (though not in appearance) than the contribution of doctors. Studies of medical out-patient consultations show that 86% of diagnosis depends entirely on what patients say, their own story. What doctors find on examination adds a further 6%; and technical investigations (X-rays, blood tests, etc) add another 8% . To most lay people and even some doctors, these figures are astonishing, the reverse of the proportions expected. Yet in fact even these understate the degree to which the diagnosis depends on intelligent participation by patients, because both physical examination and technical diagnostic tests are not fixed routines, but chosen according to hypotheses generated by listening to patients’ own account of their problems.
As for treatment, it is self-evident that once out of a hospital, patients can and do take their own decisions. Research shows that these are more likely to follow a rational and effective plan if patients know their doctors and nurses, believe in them, and feel they have shared in decisions.
Above all, this is true for continuing care of chronic or recurrent problems such as diabetes, high blood pressure, asthma and chronic bronchitis, back pain, arthritis, epilepsy, schizophrenia, severe depression, and virtually every other treatable but essentially incurable problem. As every clinician and health economist knows, these are the conditions where current provision fails, where the greatest scope for improvement exists, and where the greatest savings through prevention can be found, both in health conserved and in NHS costs contained. There is good evidence that for all these chronic or recurrent causes of ill-health, roughly half of all cases are undetected, roughly half those detected are not treated, and in roughly half of those treated, underlying disease processes are not controlled (the Rule of Halves ). There is also good evidence that for such patients at high risk of serious acute problems, continuing anticipatory care of is much more cost-effective than either indiscriminate health promotion clinics of the sort originally promoted by the 1989 GP contract, or attempts at salvage by crisis interventions . Continuing anticipatory care requires mutual respect between health workers and patients.
Recognition of patients as co-producers rather than consumers would begin to solve several problems which are otherwise likely to get worse. As co-producers, patients must share much more actively both in defining their problems and in devising feasible solutions, than they have in the past. At present, diagnosis in exclusively medical terms, excluding related social problems often more relevant to patients’ real concerns, promotes somatization of unhappiness (translation of emotional problems into physical symptoms), often leading to inappropriate, wasteful treatment, incurring unnecessary risks as well as monetary cost. If patients were encouraged to play a more active part in defining the nature of their problems, we could approach these very complex and often intractable problems more honestly, with less labelling as “heartsink patients”, less fruitless referral of patients to exclude diseases they don’t have (rather than search for the real problems they do have) and less inappropriate surgery. With about one-third of all medical referrals having no evidence of organic disease, the scope for savings is immense.
If patients were recognised as essential partners for health production, we could also begin to undo some of the harm done by the adversarial assumptions of litigation for professional negligence. Defensive medicine, clinical decisions prompted by fear of possible future complaint, is not only extremely costly, but also tends to reduce the real quality of care, mainly by occupying time and other resources for what may be useful for subsequent legal defence. Both health professionals and patients need to understand the uncertainties necessarily surrounding all decisions in human biology, and must learn to work within confidence limits broadly understood by both partners. Ultimate legal sanctions against negligence are certainly necessary, but they would be needed less often if doctors were expected to encourage a more active and responsible role to patients, and consultations were no longer regarded as standardised provider-consumer transactions implying guaranteed outcomes.
For a more cost-effective NHS, patients must change from their traditional role as consumers, to a new role as co-producers. This is a different, socialist way to look at health production in the NHS, as neither a State funded autonomous medical hierarchy nor a market of competing corporations dominated by business-trained executives, but a participative democracy developing creative power at the periphery. All proposed changes in the NHS should be judged as aids or obstacles to this necessary development.
CONDITIONS FOR CHANGING PATIENTS FROM CONSUMER TO PRODUCER ROLES
Several factors influence progress of this shift of patients from consumer to producer roles. Patients generally believe the main obstacles arise from professional attitudes, and there is plenty of evidence to support them.
Though one would imagine that patients who think slowly or are poorly informed would need longer explanations than patients who think quickly or are well informed, doctors tend to give most time to patients who appear most knowledgeable and articulate , and to give more time to fellow-professionals than to less educated patients . Despite longer average consultation times than in any other country, a study of physicians in the USA showed they allowed patients to tell their story for an average 18 seconds before interrupting and diverting them to doctor-based topics . Another major study of NHS GPs showed that none, even with psychoanalytical (Balint) training, showed any real interest in patients’ ideas about why they were ill, or made any effort to take these ideas into account when working out plans for treatment .
However, this is by no means the whole story. A passive consumer role may be a lot more comfortable for many patients in many circumstances, and they may not in practice always be pleased if doctors admit their own limitations, or the present limits of medical science. Doctors who actively try to get off the pedestal often find patients who want to put them back. Doctors determined to abdicate from infallibility rarely fail to carry most of their patients with them, but there are many exceptions, particularly in the first five years or so.
Instead of judging these attitudes, we need to consider reasons why both doctors and patients so often cling to traditional transactional roles, despite mounting and generally accepted evidence that these impair output in consultation. The most important of these is probably simply the time available for consultation. Consultations can be done more quickly, and more certainly steered to conclusions with apparently clear clinical meaning, if patients are subordinated to a passive role. Instead of giving their own full account of their problems as they see them, they are encouraged only to answer key questions, as in legal cross-examination. The case can be wound up more quickly and tidily if the often inconclusive mess corresponding better to reality is ignored. Just as cross-examination serves the convenience of judges rather than truth or justice, early imposition of medical priorities encourages unjustified somatization, misuse of technical resources and negative net output; but for the doctor it has the overwhelming merit of getting one patient out in time for the next, and for the patient, comforting illusions of simplicity.
Obviously, very short consultations can rarely do more than meet minimal patient expectations, so more time is necessary to develop anything new. Forced to curtail consultations, doctors do so at the expense of newer options such as listening, advising, explaining, preventing, and searching out opportunities for anticipatory care . This hard-headed view of priorities corresponds with the wishes and beliefs of patients, who welcome a search for needs after their elementary wants are satisfied, but not as an alternative to traditional demand-led care . However planners and administrators may imagine otherwise, all primary health workers on the ground must either give first priority to known wants, before searching for imagined needs, or lose the confidence of their patients.
When Britain’s first mass primary care system began in 1912, the rich doctors of rich people warned that if doctors were paid by salary or capitation to provide mass medical care for the poor, it would be “perfunctory care, by perfunctory men”. So it was, and in large part still is, in most areas of heavy industry, highest unemployment, highest morbidity, and heaviest medical workload. To get beyond this requires not only new attitudes, but also new resources (above all, of time) to make those attitudes possible. Health theoreticians without practical experience of trying to apply medical science within the constraints of ordinary practice are incapable of seeing this as a primarily material rather than moral problem. Bad conditions make bad health workers, not the other way round.
POTENTIAL EFFICIENCIES OF CONTINUITY
Compelled to fit gallons of necessary care into pint-pots of time, NHS GPs took advantage of their one supreme asset, continuity of care. If all you have is about 5 minutes, you learn to remember, or better, to record, a cumulative store of information, so that you don’t have to start again from the beginning at every consultation.
In the NHS, virtually everyone is registered with their own GP, who keeps a continuing record of both GP and specialist care. This record follows patients to their new doctor if they move. Though we take this for granted, few other countries have any such arrangement. Where, as in most other West European countries, patients can shop around for their care between competing doctors in a free market, or where patients have direct access to specialists, there is no organised transmission of records between family doctors, no properly organised referral system, and no systematic exchange of information between primary care teams and hospital specialists. Virtually all relevant information may have to be assembled all over again in each episode of illness, and it is simply not possible to build up any continuing story of people’s lifetime experience of health care.
Continuity of care – seeing not strangers, but people you already know, and not isolated clinical events, but successive episodes in life stories – is enormously important for real clinical efficiency , for patients to make sense of what happens to them, and thus help them to become active producers , and so for health gain. This need not mean always seeing the same doctor, since doctors no longer work 24 hours a day, and continuity should not mean that patients “belong” to their doctors. It means patients need to be registered with one small team of people who all use, record and share the same information efficiently. This is extremely difficult to achieve with traditional record systems, not only because the rhetoric of teamwork is far in advance of reality, but because of practical difficulties of duplicating written information and retrieving it from thick files. Computerised information systems, so often seen as dehumanising, are in fact a precondition for the personalised, democratised continuing anticipatory care we need, including medical records held by and accessible to patients themselves.
Continuity is not in practice valued in a competitive market, in which consultations are seen as isolated provider-consumer transactions, scattered between competing providers. Free markets depend on shopping around, encouraging short-term consumer choices, impulse buying, salesmanship and promotion of packaged technical interventions to patients as passive consumers of health care, not critical co-producers of health.
Nor can the competitive market, at least as presently constituted, expand consultation time. The greatest cost in the NHS is the cost of labour, so the greatest scope for savings and improved efficiency appears to be replacement of labour by machinery, or saving of labour by speed-up. More people processed in less time may represent greater output efficiency if we are talking about technical interventions, but this is untrue of consultation at any level. Unless consultations are understood as the points of production of critically important decisions which determine all other consumptions, the cost-effectiveness of the entire NHS will fall in terms of net health gain, even if it improves in terms of reduced waiting times or raised output of technical procedures. The quality of consultations must in large part depend on freedom from time pressures, without perverse incentives to save time by ill-considered somatization, prescription or referral, and with protected time in which to develop patients’ capacities as producers rather than consumers.
The overwhelming experience of all NHS staff over many years, is that unless they simply stop trying, they can never stop running. Diagnosis and initiation of treatment on the run is both wasteful and dangerous. If professional staff are rushed off their feet, they cannot listen, inform, explain, or sympathise. All they can do is give orders, and there is no hope at all either of encouraging patients to develop new, more active and responsible roles, or of persuading professionals to help them do so.
Yet this is precisely where current notions of productive efficiency lead us; more output from less labour by fewer people. If doctors are seen as active providers of health care in commodity-units to passive consumers, efficiency will be measured as output of process, not output of health gain. If the consultation is recognised as the birthplace of both good and bad care, requiring time to develop the critical imaginations of both patients and professionals as co-producers, we can begin to make the entire system more rational and therefore more cost-effective. Without this, the NHS will just keep on growing, bigger but not better.