Patients not Profits. How Markets dehumanize health. | A Better NHS | Last edited 04.06.2009
This is a long, thoughtful essay about the commercialization of healthcare, exactly what we are struggling with in the US. Financial interest and healthcare do not align, their goals and successes are almost directly opposed.
I’ve written this because I believe that the corporatisation of healthcare is dehumanising.
By this I mean that real, whole people living with their hopes and worries, ideas and expectations, are broken down by the process of corporatisation into biological parts not for diagnosis and treatment but so that they can be measured and converted into profits.
We are far more than the sum of our biological parts; we also have relationships with our past and future, our family and friends, our work and environment, our country and our home.
We are irrational and passionate as well as calculating and objective; we need kindness, affection and understanding as well as diagnoses and treatments. And healthcare is far more effective when this is taken into account.
Whilst the NHS can and will always need to be improved, the government’s proposal to introduce competition and markets into the NHS risks seriously damaging it, not only because it has been shown to make it more expensive and less efficient but because it dehumanises us all
A patient-centred NHS understands and respects the complexity of human health and puts human relationships at the heart of healthcare.
Corporate healthcare converts human health into commodities and commercialises human relationships, putting profits at the heart of healthcare.
People, (institutions/ states etc) are unequally autonomous; they vary hugely in how much they can articulate their concerns and act in their own best interests. With autonomy comes freedom and responsibility; freedom to flourish and succeed and the responsibility to care for those who are less fortunate.
Markets offer the possibility of individual and corporate freedom without the necessity of responsibility. Illness robs each and every one of us of the autonomy necessary to flourish in a competitive environment, compromising choice when it is most important. Instead of a culture of competition, the NHS needs a culture of care and cooperation
NHS general practice does not operate within market economies, though the UK government is trying, through the purchaser provider split and the provision of APMS contracts, to create primary healthcare markets.
Markets depend on identifiable commodities that can be bought and sold, so markets in healthcare depend on breaking down complex health into simple commodities.
Profits are made by the provision of services and trading of commodities
Trading includes marketing risk in the form of derivatives, e.g. trading future risks of cancer or diabetes.
Market commodities have no intrinsic value, only the value that the market will pay. This can vary widely according to economic conditions.
The markets for preventative services (screening, statins) are greater than those for curative services because far greater proportions of the population are ‘at risk’. This results in a shift of emphasis from cure to prevention, i.e. from treating the ill, towards treating the well.
Profits are increased by the invention of new services (screening and other investigations) and commodities (new diseases or risk factors).
Markets depend on units that can be bought and sold, so markets in health depend on breaking down healthcare services (investigations, procedures and prescriptions), health (e.g. biological values such as blood pressure and cholesterol) and illness (diabetes or cancer) into unit parts that are measurable and saleable.
The challenge, according to market advocates, is technical. All they have to do is define and value those parts in order that that they become commodities. Critics of the market are accused of failing to have the wit or imagination to come up with a solution to fit the market model, the idea that a market itself is flawed isn’t even entertained by those who support them.
Specialists and generalists.
The further up the chain of specialisation away from primary care the more the undifferentiated patient is broken down into constituent commodities of discrete pathologies, investigation outcomes and treatment responses.
Not surprisingly, it is specialist doctors, like Professor Sir Ara Darzi, a tertiary care cardiac surgeon who drew up plans for redeveloping primary healthcare in London, who are amongst the most influential market advocates
Continuity of care, responsibility and risk management
GPs and specialists practice different types of medicine. The GP is the first point of contact for a patient who is feeling worried or unwell and unsurprisingly a large part of our work involves reassuring anxious patients. What most specialists do not understand well is just how much of our workload is spent doing this or how important this is.
GPs have to make use of the relationships we have with our patients; a detailed knowledge of their life and circumstances and our ability to listen and interpret our patients’ stories in order to provide support and reassurance that they understand and respect. GPs spend a lot of time reassuring anxious patients and we are particularly good at it, because unlike hospital doctors, we know our patient
Consequently, GPs are specialists at risk management. One of the reasons that General Practice is so cost effective is because we can reassure our patients without resorting to the kind of expensive investigations that are increasingly common in hospital.
Even in this highly technical age, by far and away the most powerful diagnostic tool a doctor has is their ability to listen. We elicit, understand and interpret our patients’ stories, gain their trust, and in so doing allow them to reveal their ideas, fears and expectations and then we try to understand and interpret their stories. In most cases, the physical examination and investigations play a minor role in confirming or refuting the diagnosis conferred by the history.
Investigations themselves can be harmful; some can even kill you.
One of the best ways of improving the reliability of an investigation is to select people who are already at risk of having the condition you are testing for. Though protocols and questionnaires can help with selection, they lack the discriminatory power of a doctor who has borne witness to their patients’ suffering for years or even generations.
In contrast, commercial organisations that offer medical investigations, not only do not know (and cannot know) patients, because they don’t have patients, only customers, they deliberately downplay the risks in order to encourage more people to pay for their products
Historically GPs have known our patients intimately because we have had sole responsibility to provide comprehensive care for a list of patients and because we have had a long-term commitment to them. The introduction of markets into healthcare will undermine this responsibility by allowing a PCT to commission care from different providers, so that for example, you go to one place for diabetes, another for depression and another for arthritis. It will remove the possibility of long term commitment by forcing corporations to renegotiate contracts to provide care every few years, and by measuring short-term productivity rather than valuing relationships developed over years. Corporate doctors are employed on short-term renewable contracts so that patient and doctor don’t know how long they’ll be together.
Science is a part of medicine though not the major part of it. Evidence-based medicine refers to the application of the scientific method to disease management.
It depends overwhelmingly on quantitative studies of diseases (or quantifiable markers of disease) in carefully selected populations. The patients are selected so that the disease under investigation is uncomplicated by coexistent disease, they are motivated to take the treatment exactly as prescribed and attend for monitoring and follow up. They are also less likely to include ethnic minorities, the very elderly, mentally ill, pregnant or institutionalised.
And yet most patients encountered in primary care, the point of the majority of doctor-patient contacts, are not suitable for medical research. Barely half take their medication as prescribed, many, especially those most likely to suffer disease, are mentally unwell and/or elderly and in inner-city areas are from ethnic minorities. And yet the results of evidence-based medicine are applied to them.
Markets are unstable and corporate healthcare is a risky business.
The creation of these health commodities allows them to be bought and sold on global markets like other commodities such as pork-belly or barrels of oil. Future risks, for example, of diabetes, cancer, heart disease or mental illness can then be traded as derivatives, with the disease risk traded against the possibility of a new or cheaper treatment in the future.
Essentially, health is converted into chips which are gambled on markets with all the inherent risks which the global economic crisis is making us painfully aware of
We are all sick!
In the past, for most people, health was to be enjoyed until it was interrupted by illness, at which point a visit to the doctor was appropriate. Now people are worried into illness by an obsession with risk factors for illness rather illness itself. Healthcare corporations depend on sickness not health because sick people are their consumers
Pharmaceutical companies spend more money on advertising drugs to compete for their share of the market wealthy countries, than on research and drugs for treatable infectious diseases in the majority of poor countries in the world.
They advocate for new treatment thresholds so that medications are prescribed for risk factors as well as disease, for example for milder forms of depression and anxiety, increasingly lower blood pressure and cholesterol levels, and so on.
If a doctor then gives legitimacy to the new diagnosis and prescribes a drug, especially one you are expected to take for the rest of your life; it means that you have an illness; welcome to the rank and file of the sick
Satisfaction; the new goal of healthcare.
According to Zack Cooper and Julian Le Grand, writing in support of patient choice and provider competition in the BMA News in May 2009, “the true test of how a health service is performing is whether patients are satisfied with their care”. It seems extraordinary that this should be the ‘true test’ of healthcare.
of the 26 key performance indicators for ISTCs only 8 are clinical indicators of any kind and only one can be considered a ‘pure clinical outcome indicator’. Whilst I would never deny that I want my patients to be satisfied, I know that quite frequently what they want (another scan for their back pain) is not the same as what they need (to re-engage with physiotherapy and negotiate regular breaks from their sedentary job)
the anxiety, frustration and despair that people feel about themselves and their lives is more often than not a product of society, but they are encouraged by healthcare corporations to seek the answer in their products instead of confronting the causes of their malaise
Health transformed and commodified.
Health has been transformed in other ways by pressure from different sources, including government, media and industry.
Biotech corporations market the myth of genetic determinism, by over emphasising the degree to which your future health can be predicted by genetic profiling
It shifts the balance of control over the prediction and treatment of disease from people to biotech corporations despite a lack of evidence
The separation of health and illness from the person
When a patient presents with an illness, the doctor names the disease and then it becomes transformed into something other, named so that doctor and patient can work together to ‘struggle against it’. The patient experience of ‘having cancer’ or ‘being depressed’ is transformed into ownership of ‘my cancer’ and even ‘my depression’ and this disease rather than the patient is treated
One of the reasons that ‘medically unexplained symptoms’, that category of illnesses that cannot be named, present doctors with such difficulties, is that without a name it cannot be separated from the patient and yet most of the symptoms patents present with in general practice do not fit the diagnostic criteria for a disease entity
Health as leisure
After work, leisure time that might have been spent relaxing with the family has become replaced with healthy work to compensate for the ‘unhealthiness’ of work and the self improvement industry of personal trainers, nutritionists, relaxation therapists, psychoanalysts and self-help gurus are cashing in. For those that can’t afford the personal touch there are gyms and training aids, diets and supplements, books, classes, courses and on-line resources
The body project.
Like illness, the body has been objectified and commodified. It is a project of constant improvement to be modified, manipulated and enhanced. It is worked on in the gym, modified by drugs, supplemented with vitamins, and surgically enhanced. It is scanned, scraped and sampled
Not because of any illness, but in the vain pursuit of an idealised, homogenised, very heavily marketed ideal. The global corporations marketing the images are often the very same corporations selling the means, pharmaceutical, surgical, cosmetic, fashion and so on which are claimed to make your project a success.
Your health, your choice.
The Kantian imperative, “you can because you must”, has been inverted; “you must because you can”.
In other words you must be healthy, (and slim and beautiful), because you can. Fat or thin, sedentary or active, smoker or non-smoker, whole foods or junk-foods, in short, whether you are in control of your life or not, according to ‘Your health, your choice’, it all comes down to a matter of personal preference
Health differentials based on social class and circumstances out of your control are blamed on lifestyle choices
In developed countries such as ours, there is a social gradient in health, which means that the lower your socioeconomic group the greater risk you have of suffering from almost all types of illness, especially cardiovascular disease and most types of cancer.
As the level of inequality increases, as it has done over the last 40 years, the social gradient widens even if the level of absolute poverty stays the same. As the rich get richer, the poor get relatively poorer and consequently become more socially excluded as the costs of participating in society increase. The health gradient “cannot be attributed, in the main, to diet, smoking or other determinants of ‘lifestyle’”.
The result of the government’s failure to protect health by increasing social inclusion through education, employment, and housing, is to shift the burden of responsibility onto patients who are expected to improve their lifestyles, and doctors who have to spend more and more time promoting healthy choices. Corporations are encouraged by the Government to offer a market driven culture of dependency; your choice, you choose yourself the products you need to be healthy
The naive consumerist position is based on the imaginary construct of an ideal consumer based on rational choice theory which assumes that people are fully informed and fully able to understand the information, are rational and not subject to bias, are self interested rather than altruistic, in other words, fully autonomous.
This position assumes that society consists of equally autonomous individuals making rational choices in their own best interests. Autonomy is not equally distributed; it’s strongly associated with educational and financial empowerment so the least educated, poorest and unhealthiest are also the least autonomous. Illness undermines autonomy
When chronic illness such as diabetes or heart failure is compounded by depression as they frequently are, your reasoning skills are seriously impaired. Physically disabling illness causing pain, breathlessness or visual impairment restricts your ability to choose where to go for your treatment because travel is so difficult.
Chronic illness is financially disabling, resulting in unemployment or high costs for care or adaptations, so that choices that incur additional costs are closed off. People with learning difficulties and many elderly people find choices difficult and anxiety provoking and they value quality and continuity rather than choice
When people are ill and hence most vulnerable, they need doctors who know them well enough to understand how illness robs them of autonomy, doctors who are skilled enough to step in and take care of their patients by sharing the burden of responsibility at a time when it weighs most heavily. In contrast the commercial health industry exploits illness and anxiety with advertising and fear-mongering to encourage people to choose and consume their products.
Offering choice without addressing the conditions within which people live their lives, the experiences that affect their decisions, and aspirations which shape their vision of the future, widens inequality by empowering those ready to make those choices and alienates those people who have very different priorities.