Essay: New Labour Consumerism ideology and its impact on the User participation model

User participation
This assignment looks at New Labour Consumerism ideology and its impact on the User participation model. It will present a wide definition of Democratic and Consumerism theoretical ideologies which have influenced the area. It will be narrowed down looking specifically at New Labour consumerism, explaining and analysing ways this ideology has shaped the conceptual model. We will discuss the conceptual impact and how it has worked or fits back into the ideology using academic literature but also showing awareness of arguments in the area by engaging with critics, contesting and criticing policies and practices. This will end with a conclusion drawing up implications, arguments and making some recommendations on how the conceptual model could be better approached.
Definition
There is a long history of attempts to reform the notion of the patient in the provision of the National Health Service in Britain. NHS Plan of 2000, stated that the health and social care system should circulate around patient needs and not the reverse.(Department of Health, 2000 cited in Mold 2010). Since 2000, several government documents and initiatives accented the importance of patient ‘choice’ and ‘voice’ in developing and improving NHS services (Department of Health, 2000, 2004, 2006 to 2009). New Labour politicians declared that these policies were formulated consequent to broad society displacement. Alan Milburn in 2001 the then Secretary of State for Health, acknowledged that people are now growing in a consumer society and services whether private or state-supported, succeed or fail in accordance with their power to react to modern anticipations. Milburn together with other important New Labour officials in justifying the necessity for health service reform by declaring that the NHS had failure in contending with the social change pace resulting in inadequate attention been paid to the needs of patients (Mold, 2010)
A history of initiatives and campaigns exists from policy-makers, professionals, patients and carers aspiring to involve ordinary people giving them more control over their health and care. Patient involvement dates back to the roots of the NHS. The first considerations of involvement was individual choice of a general practitioners, later choice in services related to their need, including accessing private treatment. The involvement of active choices by patients formed a core constituent of policy in Margaret Thatcher’s government, outlined in the White Paper Working for Patients (Department of Health 1989).
The Patient’s Charter, 1991 advanced this by setting out several rights for patients, including maximum waiting times and the right to investigating complaints. For those already in receipt of treatment these new rights to involvement included the provision of enhanced rights to treatment and care. Studies of unwarranted variation in clinical practice and abuses of power created interest, ensuring that values and orientation of patients’s were taken into consideration (Wennberg 2010; Coulter 2011). The General Medical Council’s 1995 guide included an obligation respect patient rights to full involvement in decisions regarding their care (General Medical Council 1995), and the Mental Health Act 1983 provided a specific legal framework restricting circumstances where patients could be treated without consent. The Labour government in 1997 brought additional interest in personalisation, permitting patients’ individual needs and preferences in shaping provision (Department of Health 1997). In 2000, The NHS Plan declared a redesigning of the NHS while offering a personalised service by 2010 (Department of Health 2000).(Foot et al (2014).
The Public health and health improvement;1999 White Paper intended to achieve a new relationship with patients in assisting them to have healthier lifestyles (Department of Health 1999).
Patients role as independent agents for their own health, was further extended by the Wanless Report in 2002, arguing that only when people become ‘fully engaged’ in their own health and health care can we anticipate limiting the escalating costs of health and social care provision associated with the increasing encumbrance of disease (Wanless 2002). Mostly recently the involvement of individuals has accumulated at all levels of provision, from preventing, health promoting, through decisionmaking by individuals to self-management for individuals with long-term conditions. The initiation of a legal duty for NHS systems involving people in planning, considerating proposals for modification, and decisions concerning services came in the National Health Service Act 2006. The Health and Social Care Act 2008 defined the Care Quality Commission’s duty to consider ways of advancing and engaging service users and carers in its work, and Regulation 17 (Health and Social Care Act (Regulations 2010) requested providers to support people in participating in decision-making and self-management.
In 2009, NHS Constitution returned with an interest in patients’ rights including a set of responsibilities for patients to managing their health and interacting with health services (Department of Health 2009). For the first time, the Health and Social Care Act 2012 separated patient and public involvement and included separate duties for each, and NHS England issued guidance on meeting these statutory duties (NHS England 2013).(Foot et al (2014)
Examples of definition
The Consumer and New Labour: The consumer as king?
‘Traditionally the left turned its back on choice as the preserve of the right. In a consumer society where the consumer is king, vacating this political terrain is not a feasible strategy for progressive politics’ (Alan Milburn, 2004 quoted in Joint Ministerial Memorandum, 2005: 1)
Recently there has been a general acceptance that the public should have a more participatory role in the state, and those who use various services possess a particular interest in decision making and planning including the nature of service they receive (McKeown, Malihi-Shoja and Downe, 2010)
There is immense literature about defining User Participation, with no apparent agreement in its meaning although two dominate. Bracht and Tsouros 1990 viewed it as a social participating independent role in conventional or non-conventional activities, programs and/or discourse resulting in planned community life, services or resource modification or transformation. The World Health Organisation (WHO) stated a fundamental indicant for community participation in health service planning as an existing mechanism, including ordinary community members in national health implementation strategies within health service delivery, in national and regional standards including assigning and/or usage of funds (Haworth, R and Melling, B 2009).
At minimum there are three types of users : ‘policy makers’, those mainly superior politicians, officials and professionals who possess political, organisational or professional power to ascertain the determinant philosophy or important inclination of the policy procedure. Second are activists wih diminutive power, but are still actively involved in the policy process to a degree where they can commission or provide services. Thirdly there are everyday makers who, although are passively involved in shaping or changing the process, are directly affected by it. Users of each type could be governmental or non-governmental and ordinary makers could comprise of inferior council staff as well as common citizens; and activists could include committed GPs and community leaders. This is understandably more of an ‘inclusive’ approach in understanding user participation than purely in terms of ‘service users’, typically conceived as clients or consumers of state welfare services, like patients, students, tenants and benefit claimants) (Bochel, Bochel, Somerville and Worley, 200
A number of frameworks for measuring participation have been developed including, Hirgcham 1970, Hoggett 1992, Harrison 2000 and Arnstein’s 1969, whose classic ladder of participation is probably a favourite. Arstein prefered using the term participation instead of involement because of its meticulous accent on interaction. Arnstein’s ladder of participation involves a range of eight levels of participation portrayed as a ladder. The first two rungs; therapies and manipulation represent zero participation in decision-making. The next three rungs; consultation, placation and informing indicate varied degrees of tokenism and the last three partnership, citizen control and delegated power indicate degrees of citizenship participation (Haworth and Melling 2009).
Two main conventional approaches to user involvement are the ‘democratic’ and the ‘consumerist’ models.Ian Greener introduced the twin concepts of ‘choice’ and ‘voice’ based his analysis on a 1970 article by Hirschman suggesting that individuals who desire an improvement in a service they receive, have two principal strategies: exit or voice. Exit allude to a change of a provider, and voice, means voicing complaints or demanding improvement from a current service provider. The voice (democratic model) objective enhances influence and control over the services used. Introducing democracy to a therapeutic community is not new. Existing discussions are sometimes linked to the democratic model dating back to the late 1960s with Arnstein’s ladder of citizen participation (Greenhalgh, Humphrey, and Woodard 2011)
This assignment shall focus on the New Labour consumerist model which became conspicuous in the past 40 years since Hirshman proposed his original exit model. The development of welfare consumerism was connected to growth in common levels of income and a general ascension in people’s anticipation of a prolonged, healthy, symptom-free and riskless life. People generally demand public services to be as responsive and dynamical as the private services and the foundation of this model views every person as a rational decision maker, willing and able to choose respective services and executing their choices. Regarding medical care ,the assumption is that individuals, know what is best for them or have access to information required in sourcing it, and service users are inclined to vote accessing a full scope of choice representing best quality care (Greenhalgh, Humphrey, Woodard.2011)
Arguably, such situations are rare cases in health care and if many people were asked before getting ill if they could choose from various providers if ever diagnosed with a serious illness, only a small minority would prefer a choice. In these situations, most people rely on medical professionals and making choice becomes less of a priority than trust, continuity of care and the therapeutic relationship. The consumerist model language has been blatantly challenged and naming service users as consumers insinuates a payment is made for services but in reality majority of consumers are in receipt of free public sector services. However, it is equaly true that accumulating choices available to NHS patients and launching of individual carebudgets means that money, to a degree precedes the patient’s choice of services.(Greenhalgh, Humphrey, and Woodard, 2011)
Consumerism in the United Kingdom has been influential in Health and Social Care Policy, specifically in care delivery institutions. Frequently coming from various ideological positions, the similar ending chased by a growing social motion of service users and community groups. Recently personalisation and personalised care concepts are foremost in examining service failure and rectification for improvement evident in the Darzi review of UK National Health Service (NHS) and increasing acceptance of social care individual budgets (HM Government, 2007; DH, 2008, 2009a cited in McKeown, Malihi-Shoja and Downe, 2010)
Consumerism was publicised in a way of reframing public and professional relationships, through application of values of access, choice, information, redress and representation to public services. It was introduced with a panoramic rousing of the idea of participation with a new intensity on citizen rights and responsibilities. Some researchers discussed top-down ‘consumerist’ methods to involvement contrary to empowerment and within this line of thought argued that \’top-down\’ service users had a political and managerial controlled involvement, including a \’bottom-up\’ lay-man ideology of democratic empowerment (Wallcraft, B. Schrank and M. Amering 2009)
This whole system approach to change is far beyond most local and national service improvement enterprises
undertaking to accomplish a comprehensive modification in multiple sections of the service and different facets of care. Total system alteration depicts the complexity and difficulties of providing quality health care in the new twenty-first century health economies. Neither the democratic nor consumerist models of user involvement are sufficiently complex or nuanced to explain how users might contribute to such a multifaceted approach (Greenhalgh, Humphrey and Woodard, 2011)
The nature and purposes of participation
The consumer was central to New Labour’s approach in public service reformation and modernisation. Consumerism, was a commitment to organising services around a public appreciated consumer of services emerging after 2000 as a central motif in the Blair Government’s narrative, a generic organizing principle for public service reform (Vidler and Clarke, 2005: 19, 20. See also Clarke et al, 2007). New Labour\’s central organising approach principle of the public policy is repudiating ‘ideological thinking’, believing in approaching issues ‘without ideological preconceptions’ and seeking practical solutions ‘through honestly constructed and pragmatic policies\’ (Blair and Schroder 1999 cited in Straw, 1998).
It claimed decisions were based on virtue of the case and practically of all policy choices grounded in a principled investigation of their probable outcomes. It is evident that New Labour were prepared to experiment, looking at issues with fresh eyes, questioning received disposition and concealing ancient beliefs. This may have been, ‘non-ideological’ but is it possible to adopt a entirely applicable individual evidence based approach, presumably not but who knows what works? With dubiety, imperfect information, time constraints, inferential capability including absolute pressure of circumstances – certain dependency exists on the assumption of what works best (Straw, 1998). All politicians require a framework of beliefs templet for many individual decisions to be made every day’ (Straw, 1998).
A conviction that, in absence of choice and competition, public services lack an independent mechanism of transformation was a recurrent and insistent Blair refrain (Barber, 2007) reflected a major shift in thinking. In traditional Labour thinking public service ethos operated as precisely such a mechanism. Indeed, a notion of a deeply-implanted ‘public service ethos’ regulating conduct in public sector organisations (especially in healthcare and education) permeated Labour thinking regarding motivation, character and moral importance of the public sector within the political community (Plant, 2003: 561).
By a ‘consumer society’ New Labour presumably meant a society where numerous frequently high quality consumer goods and services, offering multiple choices were readily available and highly competitive markets ensured that producers exhibited an acute sensitivity to consumer preferences. The experience of being able to choose between a wide range of goods and services proposed by rival suppliers contending for their custom raised popular expectations .If ordinary consumers are get a taste for greater power and control in their lives they expect services tailored to their individual needs and demand choice and expect highest quality (Milburn, 2007).
Traditionally Labour viewed public services not only as a collective way of providing for individual material security, but as affording an institutional framework which bringing people together, and strengthening social bonds. For New Labour, in contrast, the consumer role has increasingly come to define mass aspirations and expectations in all walks of life. A market-oriented programme of public sector reform is thus presented as a response to powerful social forces where the Government has to respond if the welfare state – understood here as public services universally delivered, free at the point of use and financed by progressive taxation – and not forfeit its legitimacy.
Historically the UK has had a anemic record of public and patient participation inclusion in decision making in both primary and secondary care despite numerous approaches and policies assisting greater public participation. Evidence cites prolonged distance before witnessing what Armstein referred to as true degrees of citizen participation delegated power or true partnerships. Critics argue that choice and competition mechanisms would inevitably skew services in favour of the more knowledgeable, educated and confident. Further down the income scale a family comes, the less likely it is to receive anything other than the residue which is left after others have made a choice (Hattersley, 2005). The Government felt that monopoly was a larger cause of inequality than choice and absence of choice was overcome by the ability to deploy ‘voice’ by more confident and persistent middle class decidedly more advantaged. Typically lower income groups were less able to navigate the system, less confident in dealing with professionals, and venting their dissatisfactions and utilising complaints procedures (Joint Ministerial Memorandum, 2005).
Choice allows users to become more assertive customers helping ensure that public services responded more promptly and precisely to their needs. There are two key assumptions in this seemingly unremarkable statement, firstly what people want and need are broadly the same. Therefore one influential document calls for services to be refocused on the general public needs whilst encouraging new ways of responding to customer demands. Another assumption was that what people wanted, could broadly be equated with social need, or the common good. Both suggest a growing permeation of New Labour thinking by market discourse accenting on needs as consumer preferences.
The end here was not a small government with an expanded role for the market as supplier of public goods. Instead it was big government invigorated by market mechanisms of competition and choice. Therefore repudiating ‘one-size-fits all’, a public provision system of monopoly where professionals are trusted with ample power to determine need and how best to meet it. New Labour consumer choice and contention were essential means in achieving more efficient and higher quality service. It was considered to be inevitable if the welfare state was to accommodate new social challenges: In this consumer age services must be custom-made not mass-produced, designed to meet users needs not the convenience of producers’ (Faucher-King and Le Galés, 2010)
What the research said
Birmingham University Health Service Management Centre incitated little transformation in the priority for closer collaborative working within NHS Trusts, local authorities and social services. There was little evidence of PCT,s facilitating greater public participation in the decision making.
“Patients and the public do not appear to be particularly high up the agenda.” (Smith,J.et al 2000:13)
Similar conclusions were reported from the Audit Commission 2000 and the Kings Fund 2000:
“Limited time and recourses have inhibited the integration of public involvement into work and decision making of PCG’s / PCT’S.” (Anderson and Florin 2000:17)
Other concerns included lack of professional knowledge on how to include the public. Regan & Smith 1999 :53)
Considerable consensus existed between board members about the purposes of public engagement. Ordinarily, public involvement intention was viewed in three-fold : improving the provision of service quality (clinical governance); legalising decisions and developing local responsibility (local governance), and improving public health through education and empowerment (health improvement). The most ordinarily reported purpose of public involvement for all board members was making services more responsive and appropriate to users’ needs (Rosemary Rowe and Michael Shepherd( 2002).
Excitement expressed by some respondents to the idea of an ‘expert’ patient or the ‘responsible’ health user, can be viewed as an attempt to secure more effective treatment alongside moves towards better demand management. The interviews suggest that many of the professional developments taking place in health; more emphasis on health promotion, more person-centred care, more effort to inform and involve the patient in their treatment, were being excluded with the idea of a more consumerist approach. In the process the consumer was being diminished from the market oriented government discourse of choice and reworked into a more professional narrative of improved treatment outcomes (Rowe and Shepherd 2002)
Staff Perspective/Attitude?
Gagliardi et al identified health professional attitudes as a significant barrier to patient involvement in planning etc.
They identify negative attitudes by clinicians and managers
Physicians and nurses more supportive of involvement of patients in own care but not in health planning issues
Identified the need for a significant cultural shift to enable PPI to occur
This has resource implications re training needs
They cite the evidence that most activities in the PPI arena are consultative rather than interactive partnerships.
Conclusion
Despite accelerating local and national decision makers acceptance in the UK that public views should be considered when developing health services, problems exist in constructing efficacious relationships between the NHS and the public. This can not be a description of a partnership, as the power distribution is weighted massively towards NHS professionals. Regardless if public opinion is required, clinical and managerial professionals will mediate their power over decisions . If this is recognised by national guidance this situation it could reduce slocal decision makers uncertainty and anxiousness, permitting them to concentrate on developing effectual relationships needed for communication and consultation processes. Ensure every level of public involvement can only be effective successful in augmenting local susceptibility for participation together by addressing cultural restraints hindering involvement.
reconstructing attitudes and behaviour has not easy but, like so much in the NHS, requires time and adequate resourcing (Rosemary Rowe and Michael Shepherd, 2002)
In political speeches and policy documents New Labour has repeatedly asserted the need for health services to be more strongly consumerist. The public had to be grateful for what they received, having little say and diminutive choice. Life today is different as we live in a consumer age. People should demand services tailormade to individual needs. This is an informed and inquiring society expecting choice and demanding quality.
The equation of consumer demand with individual needs and the public good might be a little more problematic than is acknowledged. An approach allowing users to shape services through expressing preferences and making a choice has a potential radical implication for public service provision(Faucher-King and Le Galés, 2010).