Patient-centredness and consumerism in healthcare: an ideological mess

Introduction

Two concepts appear to permeate political rhetoric concerning healthcare in the UK and elsewhere: patient-centred care and consumerism. Concerned that these two important ideas should not get conflated in public debates about healthcare, we outline their different philosophical origins and note their differences and similarities. We would argue that both can be used in ways that are muddled or insincere, with important implications for healthcare delivery.

What is patient-centred care all about?

Patient-centred care was first coined as a concept in the 1950s when US psychologist Carl Rogers¹ used the term to describe building a relationship of trust between therapist and patient in order for the latter to be able to fulfil his or her potential in life. The idea was developed in the 1970s by US psychiatrist George Engel, who introduced the concept of the biopsychosocial model of health as an alternative to the traditional, paternalistic, medical model. In the UK, the 2000 NHS Plan enshrined patient-centred care as one of the 10 NHS core principles, stating ‘The NHS will shape its services around the needs and preferences of individual patients, their families and carers’.² Since then, the concept of patient-centred care has played a prominent role in a variety of public policies and inquiries. However, there appears to be no single accepted definition of patient-centred care; the following are just a few examples:

… a way of thinking and doing things that sees the people using health and social services as equal partners in planning, developing and monitoring care to make sure it meets their needs …³

… putting patients, and their families and carers, at the heart of deciding which goals are most valuable for individuals with a range of health conditions, rather than clinicians deciding what is best.⁴

The philosophy underpinning patient-centred care seems to have its roots in virtue ethics, with the ultimate aim being Aristotelian eudaimonia (flourishing).⁵ This is achieved by adopting a holistic approach; examining all parts of the patient’s life and widening the gaze from a purely biomedical viewpoint to allow the practitioner to understand the patient’s values and life narrative, and to adapt therapy accordingly.

We are constantly reminded about ‘patient-centred care’ in health policy and told of its centrality in modern-day healthcare; but in reality, it is not always being practised. A Royal College of General Practitioners report⁶ states that effective implementation of patient-centred care is hindered by a number of barriers, such as underinvestment in primary and community care, the division between primary and secondary care, the payment by results system, the lack of integral IT systems, the pressure on general practice and a lack of guidelines on managing co-morbidities. Could it also be that policy-makers are conflating a palatable concept to aid the installation of a consumerist model? This quote from a scoping report on NHS service delivery suggests this is perhaps the case: ‘In current UK policy debates, the idea of choice is most extensively discussed in the context of competition … with the implicit and usually unquestioned assumption that these are essentially market mechanisms’.⁷ Here, patient choice – a surrogate marker of patient-centred care, as can be seen in the definitions above – is explicitly equated with market mechanisms.

And how should we understand consumerism?

Consumerism itself can be defined in various ways. The Oxford English Dictionary defines consumerism both as ‘Advocacy of the rights and interests of consumers’⁸ and as ‘The preoccupation with the acquisition of material goods’.⁸ Meanwhile, Shaw and Aldridge⁹ state that consumerism ‘… helps the free market to work effectively: it empowers consumers, protects them from negligence, malpractice and fraud, and supplies them with objective information that will help them to make rational choices’. The philosophy underpinning consumerism is largely based on the concept of autonomy, which has its origin in the idea of liberty set out by John Stuart Mill ‘… the liberty of thought and feeling … [and] doing as we like, subject to such consequences as may follow … even though they should think our conduct foolish, perverse, or wrong’.¹⁰

Consumerism began to influence the NHS in the 1960s and 1970s, largely driven by ‘rights talk’ and actively campaigned for by increasing numbers of consumer rights groups such as the Patient’s Association.^11,12 During the 1980s and 1990s, consumerism moved from the fringes to the centre of healthcare decision-making. Managers were installed to gauge patient opinion and control service provision, complaint procedures were introduced and an internal market installed.^11,12 Between 1997 and 2010, the Labour government championed the principle of partnership, bolstering this consumer revolution, offering patients choice and placing them at the centre of decision-making.^2,12,13

Are consumerism and patient-centred care related?

If we consider the definitions of patient-centred care quoted earlier and compare them to the definitions of consumerism, we can see that there is conceptual overlap, particularly in relation to patient empowerment and decision-making. Arguably, the lack of a single, coherent definition of patient-centred care permits various interpretations and understandings and allows the term to be appropriated in ways that are politically insincere. One of the justifications of patient-centred care in the 2000 NHS plan states ‘Today, successful services thrive on their ability to respond to the individual needs of their customer. We live in a consumer age.’² Consumerism is explicitly used as the vehicle for the emancipation of patients in the name of patient-centred care. Yet, in its purest form, patient-centred care never saw health as a commodity that could be bought and sold, dependent on the response to consumer choice for survival. It saw health as a means of betterment and flourishing.

The move towards including patient choice and empowerment in recent definitions of patient-centred care (as above) is perhaps a sign that its meaning in public documents (such as those relating to the British NHS) has changed over time. Patient-centredness now reflects a philosophy of libertarianism much more than a philosophy of patient flourishing. It therefore has much more in common with definitions of consumerism. The question that remains is, is this change in definition purposeful or just a case of mistaken meaning?

What are the implications?

Although the two terms were originally philosophically distinct, it seems like the more politically palatable ‘patient-centred care’ may have been used cynically by political and commercial institutions to persuade patients and consumers to want what is good for the institution. It is easy to see why successive governments would want to create a virtue of consumerism as it promises patients empowerment and increased autonomy while simultaneously disempowering the wider medical establishment. This disempowerment also limits clinicians' commitments to patient benefit.

A consumerist model gives the patient what they want out of obligation. In a resource-strict setting such as the NHS, this is not always achievable and so limits to patient choice are unavoidable. This is in direct conflict with the very notion of consumerism and its underlying philosophy and highlights the unsustainability of it as a model of healthcare in a rationing environment. Hence, the expectations of healthcare consumers are unattainable within current budgetary constraints. Logically, the only way in which to meet expectations would be to increase resources to meet existing demand, or to deflate demand. We welcome verifiable examples of politicians doing this in correspondence.

If this system is then viewed as inadequate by these ‘empowered’ patients, the argument might go, if a tax-funded, centrally run, healthcare service fails to meet my needs, why should I support it? Every citizen (or consumer) making his or her own personal arrangements (at his or her own expense) for healthcare then begins to seem a more desirable option. We feel that if the UK were to dismantle its NHS, the main losers would be the patients whose choices would become more restricted by cost than by plurality of service. This is already the case in America where high health costs leave many without adequate access to healthcare, particularly the most vulnerable in society.^14,15 However, even for those who could afford this commodity, there would be implications. Although initially local provision for those who could afford it would probably be improved, market forces and competition survive only as long as there are mechanisms to prevent monopolies forming (after all – in a competitive market weaker competitors will fail). This presents two threats: first, that a monopoly will favour more profitable activities at the expense of patient choice and need; and second, that those who have chosen a failing provider will be left without care. While a ‘marketised' service might well continue to meet the major needs of a paying public it might resemble an industrial market rather than one aimed at consumers.¹⁶ At this point, even a promise of consumerism becomes insincere as consumer choice is no longer meaningful.

Conclusions

There is greater potential for sincere patient-centred care than sincere consumerism in a resource-restricted setting such as the NHS. A patient-centred practitioner is motivated to do the best for the patient within the available resources. By acknowledging and discussing the patient’s values, thoughts and concerns, treatment can be prioritised and the most appropriate intervention given. By contrast, if practitioners are sincerely consumerist, then they should be motivated by offering meaningful choices, with the balance of power in favour of the patient. Many productivity targets in healthcare are not consumerist – those that are (e.g. choice of healthcare provider) may be compromised by lack of resources or ‘competing’ efficiency targets. We reflect that there are multiple barriers to effective patient-centred care⁶ and consumerism but suggest that consumerist approaches in a resource-limited healthcare system that prizes efficiency are insincere.

Declarations

Competing Interests

None declared.

Funding

None declared.

Ethics approval

Not applicable

Guarantor

AP

Contributorship

All the authors contributed equally to this article.

Acknowledgements

We would like to thank the Society of Apothecaries’ Philosophy Fellows’ group for comments on and discussion of drafts of this paper.

Provenance

Not commissioned; peer-reviewed by Azeem Majid.