The essay examines the idea that the patient is the consumer of health care. It assesses the extent to which patients can be seen as ‘consumers’, and also looks at how far this definition of patients succeeds in delivering the patient-centred care that current government guidelines suggest. While the move has, to some extent, given patients more choice over the healthcare paths open to them, the essay argues that the focus is primarily upon economic choices, and that important dimensions of patient care have been overlooked by this consumerist stance.
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The following essay looks at the idea that the patient is the consumer of health care. It critically examines the suggestion that patients can be seen as ‘consumers’, and also looks at the extent to which this definition of patients succeeds in delivering the patient-centred care that has been embraced by current healthcare policy (Department of Health 2005). While the move has, to some extent, given patients more choice over the healthcare paths open to them, the essay will argue that the focus is primarily upon economic choices, and that important dimensions of patient care have been overlooked by this consumerist stance.
The essay will be shaped as follows. It will first examine definitions of the notion of ‘consumer’, seeing how the concept first arose in relation to business and management, and how it has been translated to the healthcare arena. The term arose from the advent during the period of early modernity of a bourgeoisie or middle class, with surplus income to engage in the practice of consuming goods and services (Clarke and Doel 2003). The focus will then turn to the ways in which this model of consumer, produce and marketplace have been adopted by healthcare, bringing out the advantages and disadvantages of the move. The term was introduced, for example, as part of a slowly evolving view of the nature of the state and its duties: the idea that the state should provide for the health of the people is gradually being replaced by a notion that people need to take an active role in their own health (Henderson and Petersen 2002). The mechanisms whereby consumerism are delivered are considered, for example the recent phenomenon of individualising budgets (‘Personal Health Budgets’) in the NHS, designed to give patients flexibility and control (Department of Health [online] 2012). The critical focus of this essay continues with an assessment of the extent to which patients involvement is delivered through consumerist approaches. For example, does it really involve the patient at decision-making levels, or is involvement low-level and superficial only (McIver 2006). The negative implications of consumerist healthcare are bought out.
In order to address the issue of the extent to which the patient is placed at the centre of healthcare by consumerism, the essay also looks at the notion of patient-centred healthcare more widely, looking at the political and theoretical context which led to its introduction in the first decade of the 21st century in the UK. Arnstein, for example, (Arnstein 1969) discusses a ‘ladder of participation’ from lower levels where the ‘participant’ is, in fact, manipulated, up to true participation. To some extent, consumerism delivers a participation at a lower level of this ladder than is desirable. The tensions between the stated outcomes for the patient and the actual outcomes are brought out, for example the consumerist model assumes patients always have the best range of options to chose from, and that they can access the information needed to make the best decisions, which is not always the case (Greenhalgh et al 2011).
2. The Patient as the Centre of Health Care?
This section looks at the notion of the patient as consumer of health care, including definitions of the term ‘patient-centred health care’ and how consumerism is implicit in this, how the notion originated in management / business theory, and why it was thought appropriate for the area of health care. The ways in which the concept has been put to practical use by successive governments is also discussed.
The notion of the patient as consumer of healthcare is one which is assumed to deliver a goal of ‘patient-centred healthcare’, that is, the idea that care provision within the NHS should put “the patient and their experience at the heart of quality improvement” (The King’s Fund 2012 [online].The notion of consumerism in healthcare is associated with a wide-spread reform of health systems assumed to better equip them to deal with the contemporary world, in which (it is assumed) people are more able to access a wider range of information, and are more willing to challenge figures of ‘authority’ (Goode et al 2004). While it might be thought that consumerism in health care is a function of right wing governments, it was actually embraced by both Tories and Labour in the UK (Edwards and Elwyn 2009). After an initial, more Fabian, approach by the Labour government shortly after they came to office in 1997, they embraced a consumerist approach in ‘The NHS Plan’ (Department of Health 2000) and subsequently, making the notion of patient choice central to their policy (Edwards and Elwyn 2009).
However, it was Margaret Thatcher’s 1979-1990 Conservative government was instrumental in introducing market forces to the NHS, forming the internal market and separating out purchasers and suppliers. This Conservative governmentintroduced the White Papers ‘Working with Patients’ (Department of Health 1989a) and ‘Caring for People’ (Department of Health 1989b), hoping to deliver a healthcare system which was closer to the consumerist ethos (Edwards and Elwyn 2009). Broadly speaking, consumerism overall developed with the advent of the leisure classes, that is, when a sizeable proportion of the populations of developed countries had surplus wealth and hence money to spend on goods as a way of enhancing social status and making their relative wealth apparent to others (Malkmes 2011). Consumerism nowadays can be seen as both “an economic institution protecting individuals in a free market society” and “the free choice of consumers and their opportunity to dictate the economic structure of a society” (Malkmes 2011, p. 11). That is, it assumes both a free market economy and that the choices of the individual are paramount.
The introduction of consumerism by the Conservatives in the late 1980’s can be seen as influenced by a wider movement towards consumerism in healthcare.The disadvantages of welfare state style provisions were increasingly discussed from the 50’s. It was noted that many patients felt they had little say in the care they received from health bodies, and no recourse when treatments were unsuitable or dangerous. The 60’s saw direct action by public groups on a number of political issues, some of whom embraced the idea of the consumer of healthcare having a ‘voice’ to be heard (Morrow et al 2011). This background in public protest and ethical ideals adds another flavour to the roots of consumerism in management and business discussed above.
Extensively developed in the USA, the idea of consumerist healthcare centres around a number of ideas, for example that of the competent consumer, that is, the idea that the patient is sufficiently knowledgeable to make decisions about his or her health care (Bierbower 2007). Other ideas key to consumerist healthcare are the deregulation of services, a new emphasis on the cost-effectiveness of services, the redefinition of health as a commodity and individuals as consumers, and a new understanding of the relationship between individual and state (Henderson and Petersen 2002). The deregulation of services in healthcare involves opening up the market so that services normally funded publically (in the UK through the NHS) are offered to a wider range of providers (Nash 1998) with an aim to provide a better, lower cost service to users.This deregulation goes hand-in-hand with an interest in services being more cost-effective. As consumers make choices and suppliers aim to offer better choices, public money needs to be spent to purchase services, equipment etc, leading to a greater emphasis upon the cost of goods, supported by what some describe as an increased bureaucratisation of the NHS in order to support this increased emphasis upon value for money (Pilgrim et al 2011). As mentioned, the notion of consumerism also relies upon a new theoretical understanding as health as a commodity and individuals as consumers. Health as a commodity is a widely embraced by somewhat problematic notion. It involves the idea that health is a product which can be purchased like material goods (cars, houses etc). Proponents of this idea might agree that health is a type of good more urgent than, say, jewellery, but insist that the difference is one of degree, not kind. The notion of individuals as consumers assumes that people are primarily rational, that they are able to make free choices, and that these choices are those that best serve their ends. This also involves the idea that outcomes are less important than ensuring free choice can take place (Bole and Bondeson 1991). Finally, the idea of consumerist healthcare also involves a new understanding of the way individual and state are related. Before the advent of consumerist healthcare there was a widespread notion that the state was responsible for many aspects of the lives of its citizens, including their health (Henderson and Peterson 2002). This relationship was complex, for example “state provision also entails state intervention in the private life of the citizen” (Holm and Jonas 2004). Under consumerism, the state’s role is downplayed and individuals are assumed to be more competent and assertive in their actions (Burns et al 2011).
A number of practical initiatives have been associated with this new model of healthcare, including the Patient’s Charter, NHS Direct and ‘individual budgets’ in the UK. The Patient’s Charter in 1992 was an early attempt to introduce consumerism to the NHS, aiming to change the way the health service is managed and making the standards which customers can expect clearer. These were defined in terms of quantitative targets for performance management (Bury and Gabe 2004). As the 21st century opened, NHS Direct and other initiatives were introduced, aimed at increasing the ways in which people can access health services. the NHS improvement plan’ (Department of Health 2004) sets out an idea of “high-quality personalised care” in which patients can select how they are treated, where, and when (Greener et al 2009, p. 110). Individual budgets have been introduced not only in the NHS but for social care generally, with an idea that giving individuals control over the money to be spent on their healthcare offers more choice and feelings of empowerment, and leads to positive health outcomes. It has been reported that over half people with a personal budget had better health (Rogers 2010).
Originating in notions of patient-centred care and heavily indebted to the notion of consumerism in economics and business, consumerist healthcare strives to deliver patient-centred outcomes. Certainly, it has been embraced by both Labour and Conservative governments, but, as the next section will show, the extent to which it really delivers the desired outputs is debatable.
3. To what Extent has this Idea Succeeded in Placing the Patient at the Centre of Health Care?
This section takes a critical overview of the ideas behind the notion of the patient as consumer. It will be argued that there are both flaws and advantages in the idea that patients are consumers, particularly that it fails to address participation at all levels (as suggested by Arnheim’s model of participation as a ladder), and also that there are practical issues with the instantiation of this idea.
There are clear advantages and disadvantages to consumerism in health care. On the positive side, consumerism seems to go some way towards delivering a patient-centred healthcare, by ensuring that his or her choice is taken into account. In the years which preceded the interest in consumerist healthcare, we have seen above that patients often felt ignored by decisions made by professionals positioned above them. Forces such as the woman’s health movement during the 1960’s and 70’s helped point out the need for patients to be more involved (Kuhlmann 2006), and to some extent this has been delivered and embraced by government guidelines. Patients are increasingly involved in their care, thinking of themselves as having an input and becoming better educated about possible health options (Lighter and Fair 2000). These advantages have been underlined by research into patient satisfaction: A 2005 audit by the King’s Fund looked at perceptions of changes to the NHS, finding that patient satisfaction had improved. This was reiterated by a 2008 study by the Picker Institute, which found that patient satisfaction with most aspects of care have been increasing year on year (Cockerham 2009).
There are a number of disadvantages to consumerism in healthcare, which are worth mentioning in brief, before looking at Arnheim’s model of participation. For example, it has been suggested that an over-emphasis upon choice for the patient delivers a view of his or her self and body as something that needs increasingly to be perfected, for example delivering a growing acceptance of changing the body through plastic surgery (Frank 2002). This was also pointed out by Pickstone (2000): the consumerist movement seems to embrace the notion of the body as a site of individual investment, and thus contribute to a level and type of demand which cannot be met by existing healthcare provision. Others also suggest that consumerism increases pressure on health care providers by fuelling demand and leading to struggles between funding sources, users and staff involved in health care (Harrison and Moran 1999).In addition, Through an increasing focus upon the individual, it also means that awareness of the wider implications of health – the social and political – are lost. As Frank puts it “consumerism individualises the bases and morality of action. The self is the sole referent…. the consumer defines money as his or her exclusive resource to extend as she or he chooses” (Frank 2002, p. 19).
One particularly important criticism is that the equation of patient with customer is flawed. As the patient does not pay directly for the services they ‘consume’, as they might resist treatment or feel they gain little from it, and because there is often very little competition in a real sense for the service, the translation of consumerism from the context of business to healthcare is inappropriate (Edwards and Elwyn 2009) It has also been suggested that evidence for new initiatives is incomplete, for example Rogers (2010) claims that the introduction of personal budgets in health care took place before the trials had been fully evaluated. There are also a number of unintended consequences, for example the increase in choice given to the patient has meant a growth in administrative burden, as patients need to be increasingly informed about the range of choices open to them, and managing this flow of information to patients might lead to increasing fragmentation of management as well as an increasing burden in terms of tasks (Robinson and LeGrand 1994).Another critique is prompted by Baudrillard’s discussion of consumerism in his ‘The Consumer Society’ (Baudrillard 1998). He points out that consumerism has become not a matter of choice for individuals, but something more akin to a duty, and also that for contemporary consumers everything is a possible object of consumption. This all-pervasiveness of consumerism has pervaded even the human body and the social mechanisms whereby it is treated. As such, notions of consumer choice are “constrained by the prevailing symbolic and value systems, which attach meaning and significance to certain behaviours and patterns of consumption” (Henderson and Petersen 2002). That is, not only does the consumerist model offer a flawed way of approaching health as it is not value neutral, it is also problematic due to the lack of choice the individual now has about being a consumer in contemporary society.
Perhaps the most telling critique concerns the extent to which patient involvement is fully delivered through the consumerist approach.There is a question whether patients are involved at the highest levels, or only in terms of making small decisions. The extent to which patients play a part in decisions made about policy is arguably limited. This is compounded by the possibility that patients may not all want to be fully involved in heathcare decisions. Further, to be involved in decisions is likely to require a level of knowledge about medical issues which is beyond the scope of the average lay person (Rothman et all xxx). To understand the different ways in which patients can be involved, and to see how the involvement which consumerism allows is inadequate, it is useful to look at the ‘ladder of participation’ proposed by Arnstein (1969). Arnstein saw participation in decision making by authorities as a matter of politics and power. She suggested that there are a number of ways in which citizens can participate in process, and that these ways can be seen as a ‘ladder’, that is, with lower and higher rungs. At the lower rungs, participation is somewhat superficial, but can by used as a way of accessing deeper participation. The rungs of the ladder are as follows:
6,7, and 8 can be seen as true power for the citizen, 3,4, and 5 what Arnstein calls ‘Tokenism’, and 1 and 2 as non-participation. At the bottom two rungs, the objective “is not to enable people to participate… but to enable power holders to “educate” or “cure” the participants” (Arnstein 1969, p. 217).There is a need for participation to occur at higher levels for true participation to take place, with citizens able to negotiate with the holders of power and with established roles and relationships.At the lower levels, participation is little more than a public relations exercise in which citizens seem to be taking a role in decisions but in fact are relatively powerless to change things (Arnstein 1969). Some of Arnstein’s ‘rungs’ are not useful for this consideration of healthcare: for example step 2, ‘therapy’, concerns a very specific situation in which health service users are offered therapy as a way of helping them come to terms with situations which might more appropriately be seen as a spur to action against authorities. However, the general distinction between increasingly ‘real’ participation seems very useful. For example, she points out that while informing and education can be seen as a first step to more involved participation, too often education of this type is a one-way process in which there is no mechanism for participant to feed back to the authorities regarding the subject about which they were informed (Arnstein 1969)
In terms of this, it has been suggested that consumerism in healthcare within the NHS has failed to rise to the top of this ladder, being limited to tokenistic attempts at involvement.Critics claim that involvement is limited to unequal partnerships with patients having no real power over providers, and choice being largely illusionary, being based on “what the NHS is prepared to offer, rather than what the patient may want” (Kenyon and Gordon 2009 [online]). This failure of the current system to embrace real participation has been acknowledged by the Houses of Parliament Health Committee (Barron 2007), who suggest that more citizen involvement and less tokenism is needed in healthcare
The notion of consumerism in healthcare has been embraced by UK governments of different political persuasions. It arises from consumerist ideas in business and economics, and was introduced in the hope it would provide better patient-centred care than the previous state-interventionist model. Certainly, there have been some advantages to this approach, for example allowing greater choice for patients and delivering higher satisfaction (Cockerham 2009). However, there are some serious problems with the idea and its practical instantiation.There are many ways in which the concept is problematic, for example the question whether it aims to import an unsuitable model which doesn’t fit the world of healthcare and which fetishises improvement of the body, and whether the notion is unethical.However, perhaps the most pertinent criticism is that the model fails to deliver full participation for patients. Arnstein’s ladder of participation is a useful one here, because although participation takes place at lower levels in terms of education and token involvement, full patient involvement in decision making remains elusive.
CONCLUSION – HAS NOT FULLY SUCCEEDED
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