Medical consumerism in the UK, from ‘citizen’s challenge’ to the ‘managed consumer’—A symbol without meaning?

Abstract Background In Britain's National Health Service (NHS), medical consumerism is disliked by many doctors but managed by NHS leaders. Managed consumers have choices about treatment options, but are expected to help contain costs, improve quality of care, take part in clinical research and advocacy, and increase productivity. There are so many meanings for medical consumerism that it can be categorized, in post‐structuralist terms, as a ‘symbol without meaning’, but meanings are plentiful in the NHS. Policy expectations Choices made by discriminating consumers were expected to improve the quality of medical care for all. Extending choice to the many, and not restricting options to the few, would allow gains from choices to accumulate, so that choice would sustain social solidarity. Managed consumerism would in theory, therefore, instil reasonable choices and responsible behaviours in a moralized citizenry, across the nation. The advocates of New Labour's espousal of medical consumerism expected the accumulative effects of customer choices to challenge professional and occupational power, erode the medical model of health and illness, constrain professional judgements, and open the NHS to new ways of working. Almost all their expectations have been thwarted, so far. Conclusions Managed consumerism is far from being a meaningless symbol. This discussion paper explores the territory of managed consumerism and suggests realistic ways to make it more effective in shaping the NHS. Patient & Public Contribution We developed the arguments in this discussion paper with insights provided by a lay expert (see Acknowledgements) with experience of consumerism in both public sector management and a disease‐related charity.


| BACKG ROU N D
Doctors as a whole do not like medical consumerism and many academics are sceptical about it. From its early days in the United States, consumerism was 'an unwelcome thorn in the medical flesh'. 1 Patient-centred and latterly person-centred and personalized care have gained approval from the medical profession, but patients as consumers are not received so positively. 2 Patient challenges to physician authority-an original definition of medical consumerism-may worsen the relationships between patient and doctor, lead to prolonged and conflictual encounters and reduced patient concordance with treatments. 3 In the UK, National Health Service (NHS) patients consume services out of necessity (not want) and the state (not themselves but through taxation) funds their care, 4 as the recent coronavirus pandemic illustrates. According to Downie, NHS patients cannot become real consumers and doctors could not become simple suppliers of goods and services. 5 The services which consumerism focuses on-maternity services being a prominent example-are seen as an imperfect means to a desired end (healthiness of child and mother), which is simply not a tradeable commodity. 6 Consumerist arguments that what consumers want will equate with their best interests are hard for medical professionals to accept. High profile if rare instances of such a clash of ethical frameworks occur, for example, when children are ill with functional (psychologically based) physical symptoms; consumerist parents seeking an organic rather than psychosocial diagnosis may make the child's condition worse not better. 7 In practitioners' eyes, consumers are often complaining and litigious, but in their own eyes, medical consumers can have many possible faces: chooser, rebel, identity seeker, hedonist/artist, victim, activist and explorer. 8 In mental health services, consumers may find it even more empowering to see themselves and others as 'survivors'. 9 Elsewhere we have sketched out the development of medical consumerism across three generations of policy and practice. 10 Whilst understanding and mostly agreeing with the above concerns and reservations, we also see advantages in medical consumerism, when it is defined as patient challenge to physician authority. 11 In our view, medical consumerism is multi-faceted and is evolving through its encounters with different kinds of health services, producing different generations of consumers and changing definitions of medical consumerism.
Consumerism in health care has been retrospectively identified and seen as emerging in the United States in the first half of the 20th century. Lee, 12 for example, suggested that there was a strong vein of consumerism in the United States during the 1930s, with consumers advocating universal health insurance. As this first generation developed in the United States in the 1960s, patients began to challenge aspects of professional authority, and consumerism crossed over to the UK. In the second generation, arising in the 1980s, self-funding consumers sought their health-related desires, mostly through body enhancement. The third generation was co-opted into health-care systems in both the United States and the UK as 'managed consumerism', 13 starting in the 1990s as market mechanisms became the dominant template for health-care organizations. Managed consumers often have choices but they are also 'disciplined', in that they are encouraged to help contain costs, improve quality of care, and take part in clinical research and advocacy, as well as increase health service productivity.
In this paper, we extend our exploration of the third-generation model, managed consumerism, as it has developed in Britain's NHS and suggest some policy options that may strengthen it as a force for improving the quality of medical care.

| WHAT IS ME ANT BY MED IC AL CONSUMERIS M?
McDonald et al 14 argue that the term consumer has limited value in understanding changes in health services; it conceals as much as it illuminates. It seems antithetical to citizenship, its critical approach undermines the pervasive, hegemonic trust between consumers (patients) and providers (professionals) and in the highly emotionally charged environments of health, illness and death it can generate anxiety in the patient rather than reduce it. Ill people may simply not want to be consumers. Reliance on consumerism as a mechanism for improving the quality of health care could be detrimental to the health of non-consumers, especially in an ageing population with multiple and complex needs. 15 Powell and colleagues assert that the term consumer is in danger of collapsing into meaninglessness, with multiple and contrasting perspectives on what consumerism is. 16 A binary model of 'choice/ exit' versus 'voice' oversimplifies medical consumerism, which appears to have many dimensions, including desire for positive, long-term, respectful clinical relationships which allow free communication of expectations. 17 O'Hara describes so many meanings for medical consumerism that it can be categorized, in post-structuralist terms, as a 'symbol without meaning'. 18 Raymond Williams, on the other hand, found powerful if sloganistic meanings; consumer behaviour is American, capitalist and bourgeois, a wasteful illusion promoted by producers. 19 Others have argued that moral criticism of market reforms in health services should call consumerism into question, because consumerism is fundamentally objectionable. 20 The many forms that medical consumerism may take are summed up in Table 1.
This typology expresses the heterogeneity of terms, ideas and constructs used in studies of medical consumerism, but in our view, it also reflects a compressed history of consumerism in Britain.
It is easy to forget the history of consumerism, or imagine that it did not exist before the NHS was formed, although the opposite is true. The forms of public involvement in medical services before the NHS reflected the forms of the labour movement, with elected worker-governors on hospital Boards, oversight of general practitioners by friendly societies (mutuals) and elected local government influence over municipal services. 21 Almost all these forms of public engagement with the fragmented health services of the pre-Second World War period were swept away by the centrally controlled NHS in 1948, 20 as part of the foundation of the British Welfare State The institutions that represented the interests and concerns of health service users (patients) had to be re-invented.

| REBU ILD ING E XPRE SS I ON S OF MED I C AL CON SUMERIS M (1961-1979)
In 1961, an editorial commentary in The Lancet commented on the findings of a survey of what the UK public thought about health and welfare services. 22 The commentary was entitled 'Patients as consumers: wants and needs' and was favourable towards consumerism, in that it acknowledged that the public had currently no means of judging medical services and no means of redress against them.
Consumer groups in the UK proliferated in the nineteen sixties and seventies, some being lobby groups or advocates for specific conditions and others claiming to represent the interests of medical consumers as a whole. Examples of the latter were the Patients Association (founded in 1963), Community Health Councils (established in 1974) and the National Association for the Welfare of Children in Hospital (NAWCH) (founded in 1965). 23 The organizations with a wider remit promoted participatory democracy, encouraging patients to press for more public involvement in the planning and delivery of services. 20 The managed consumerism built into the 21st century NHS has its roots in the participatory experiments of the sixties and seventies.

| MED I C AL CON SUMERIS M AND THE TURN TO THE MARK E T (1979-1997 )
The

| NE W L ABOUR ' S LIMITED G AIN S
In the New Labour period, the NHS did engage with its public in a wider variety of ways, and public and patient representatives did appear in policy meetings, in management of patient-facing services, and in research projects and programmes. Nonetheless, the changes expected by political advocates of consumerism did not, in the main, appear. The NHS seemed able to minimize consumerist challenges to professional power, and even smooth over tensions between them.
Consumerism was reframed around a professionally endorsed aim to involve individual patients in treatment decisions. Consumer choice was welcomed where it extended or amplified a professional ethic.
The meaning of 'choice' was subtly detached from the political narrative of change and moved towards professionals' concerns with better models of care.
Newman and Vidler 27 cautioned against assuming that medical consumerism was a coherent entity to be welcomed or resisted.
Instead, they saw it as multi-faceted, being at least part of the ideology of capitalism, possibly a transformative way of life, conceivably a component of identity or even a social movement (see Table 1). The task, they argued, was to unpack medical consumerism and reveal its actual character and function.

| TAK ING A LONG (ER ) VIE W
So what should be done about managed consumerism, in the circumstances that we find ourselves in, not the circumstances that we would like? Elsewhere we have argued that consumerism centred on challenges to medical authority will express itself in conflicts over specific decisions in particular people, whilst the excesses of niche market consumerism (typified by 'cosmetic surgery') will call for market regulation. 10 Managed consumerism, on the other hand, may encourage increasing numbers of people to voice opinions that are synoptic as well as individual.
Here realistic expectations need to be fostered. Converting people from being citizens into being consumers-even if it is possiblewill not bring about the transformation of the NHS. 30

| CON CLUS IONS
Professional hostility to medical consumerism is an understandable but unhelpful response to managed consumerism, which can assist professionals in service development and system reconfiguration.
Berwick urges professionals and managers to 'really listen' to their publics 42

| AUTHOR S' DISCL AIMER S
The views expressed in this paper are the authors' alone and should not be interpreted as those of the National Institute for Health Research, the NHS, or the Department of Health and Social Care and its Arm's Length Bodies.

ACK N OWLED G EM ENTS
We thank Dick Coldwell for his comments on this manuscript.

CO N FLI C T O F I NTE R E S T
None declared.