As the patient becomes more central to pharmaceutical industry activities, let’s look at how the major healthcare provider in the UK is thinking about the very same thing. Previously we highlighted the NHS Constitution, by which Gordon Brown pledges to give patients “far greater control and choice over their own health and their health care... We need an NHS that gives all of those with long-term or chronic conditions the choice of greater support, information and advice, allowing them to play a far more active role in managing their own condition in partnership with their clinicians.”
Mark Spedding 
19 Aug, 2008
NHS Constitution and Choice
“Choice” is
a fascinating word. It’s the last sacred cow in a world in which nothing
else is sacred. Everything else is open to mockery, but the concept of choice
is left unsullied. Indeed, it defines how we live. In the post-modern era,
we’re told, there are no “big narratives” anymore. In other
words, we are no longer tied down by class, creed, nation or ideology, and
are free to define ourselves as we choose to. In view of this, it’s hardly
surprising that the PM emphasises choice as a cornerstone of the NHS Constitution.
But is it what’s actually needed? Talk to NHS service users, and see their views in the many polls which are conducted on NHS services, and they rarely talk about abstract notions like choice. What they’re concerned about is fairly predictable, and utterly concrete. If they’re going into hospital, they want to feel confident they aren’t going to contract MRSA. They want to feel that they won’t be therapeutically penalised because of their postcode. They want to feel less threatened by the environment, and the other “customers”, in A&E. Like pharma reps and market research recruiters, they really don’t like GP receptionists. For the most part, they like their own GP, and the issue is not choosing to see another one, but getting to see their own GP more easily and more quickly. As the Healthcare Commission recently reported, mums-to-be want easier access to pain control and to have a midwife when they need one. Not a choice of midwives. A midwife. On the “provider” side of the fence, GPs aren’t making as much use of the “choose and book” system for making hospital referrals as the government expected. They don’t object to it. They’ve just found that many patients aren’t interested, as they want to go to wherever’s most convenient. If you’re old and frail, that makes a lot of sense.
Some people, however, are keener on having a choice. They tend to be younger, and healthier, and to have less emotional attachment to the very notion of the NHS. They’re more willing to pay for private treatment, and they don’t use the NHS that much. Yet.
The major users of the NHS, as always, are the old, the very young (and their
parents), and the less affluent. The old, it could be argued, are still tied
to the “big narrative” of social progress, and see the NHS as a
major part of that - an idea which means much less to younger people. What’s
probably more important is why the old – and the parents of young children – are
the main users of NHS services. They suffer from chronic illnesses - and older
patients often have many co-morbidities. The quality of interaction with a
healthcare professional is well-known to have a beneficial effect on care outcomes.
It’s easier and more productive to discuss a long-term and potentially
complex condition with someone who’s been treating it for a while, rather
than someone you’ve never seen before. Given that, it’s no surprise
that patients don’t want a choice of doctors, but to get to see their
own doctor a bit more readily.
But what of the younger folk, less attached to the NHS and more accustomed to a culture where choice is king? Shouldn’t the NHS be planning for their needs? In which case, doesn’t it make sense to embed choice now?
Of course it does. No-one, old or young, should be forced to have to use an inferior GP or hospital. But should choice be quite so high on the agenda? The younger people who aren’t attached to the NHS now may feel very differently when they’re a bit older and have one or more chronic conditions that they can’t afford to have treated privately, or which their private health insurance won’t cover. At which point, the NHS, and particularly the continuity of care with the same clinician over a long time, may suddenly seem much more important than choice.
After all, “big narratives” are still out there – they’re
just less visible in the affluent West. Notions of nation, race, creed and
ideology are still with us: the Balkans, Darfur, the Maoists in Nepal and the
Middle East situation all serve to remind us that the 1990s announcement of “the
end of history” was, at the very least, somewhat exaggerated. Attachment
to the NHS isn’t as big a narrative as those ideas, but it too could
make a comeback, once those who don’t feel the ties at the moment find
they start to need it. At which point, choice, though an important part of
what the NHS needs to provide, may find it’s much further down the priority
list than Gordon Brown is suggesting.
Another thought – is choice all it’s cracked up to be? At a superficial level, many of us have had that feeling in a supermarket when there are so many product choices, where once there was almost none, that we go into a mild panic. That’s a trivial example, but it’s indicative of what may be a bigger problem. The American academic Barry Schwartz has made a substantial case for the notion that “increased choice may actually contribute to the recent epidemic of clinical depression affecting much of the Western world”. Depression is now the most frequent cause of GP consultations in the NHS. It could be that, in promoting more choice, the NHS might end up placing even more stress on itself.
So if not choice, what are the choices? What else could the NHS be offering?
Well, they still haven’t sorted out postcode prescribing, ages after
NICE was supposed to have addressed this. Better access to services seems to
be fundamental. “Free at the point of delivery” is a wonderful
idea, but it’s somewhat less useful if the time of delivery is ten days
after you first phone your surgery. If that’s too ambitious, how about
improving the quality of patient interaction from initial points of contact – the
much, and often rightly, criticised GP receptionists and A&E triage staff?
Also, how about something that could be a whole new “big narrative” of its own – a culture change that sees pharma – and other suppliers – as key contributors to what the NHS offers, and not, as too many NHS managers still feel, “the enemy”. Case in point – the refusal of the MHRA (not part of the NHS, but obviously linked through government) to grant licences to drugs which don’t show improved survival rates, but do show substantial improvements in quality of life, for terminal conditions such as motor neurone disease. It’s really hard to see who benefits from such decisions, especially as they discourage companies from conducting research into drugs which might show improved survival rates – if given the chance to. This would require a big change in the mindset of our industry too, but, difficult as it would be to implement, it’s probably a choice worth making.
A final thought. One great benefit with strong brands and branding is that
they take away “choice anxiety” – the idea space is clearly
claimed, so customers can get what they need without the panic and blankness
that can accompany choosing. Or, in plain English, brands are great because
you don’t have to think about anything. Well, there are brands in the
NHS already, though they tend to be negative – brands to be avoided. “I’m
not going into Saint Staphyloccus’ Hospital for my operation, our Mavis
got a horrible bug in there”. “Bad” hospitals acquire idea
space very quickly. If NHS users – and remember, they’re often
the old, the poor, the disadvantaged, the ones that some “brand-driven
marketing” strategies write off as unreceptive to branding - are defining
brands, isn’t that a great opportunity for our industry to create brands
that offer benefits to patients, the healthcare provider and the companies
themselves?
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