Ill people make poor shoppers

All health care systems are bedeviled by the problem that sick ill people make poor shoppers. Patients are consistently disadvantaged by having less knowledge, less power and more vulnerability than other players in the health care system. In economic terms this is an example of an actor-agent problem: doctors and 3^rd party payers have to act as agents for the principal actor (the patient) but inevitably and always the interests of patient, professional and insurer/government diverge. This is why markets are such a poor way to deliver health care. As Robert Evans a great Canadian economist said: ‘The search for the informed, rational consumer of health care is of the same order as the search for powdered unicorn horn’.

The system is stuck because the costs of reversing the fundamental asymmetries of information, power and vulnerability have been too high to change. The direct result on patients is that their views are consistently under-valued and, combined with the dependence inherent in illness, they are systematically (if unintentionally) disempowered.

The direct result on healthcare as a system is that these agent-actor problem gives rise to multiple conflicting accountabilities - to patient, tax payer, professional values, local budget, local partners, the scientific evidence-base, local and national political processes, staff, and somewhere out along the tail, the patient. These accountabilities have multiplied in recent years and the NHS now frequently appears as a Gulliver - magnificent, well-meaning, and gigantic but completely constrained by a thousand Lilliputian ropes.

The web has changed some of the fundamental reasons for these asymmetries. This is most clearly seen with information where the free-for-all released by Web 1.0 greatly reduced informational asymmetries. For the first time patients could access the knowledge base of professionals. As esoteric knowledge disappeared out of one door, patients clutching web printouts entered by the other. Some information gradient remains but professional knowledge is no longer seen as either esoteric or zero-sum and everyone now recognises that the more patients know the better.

Web 2.0 creates other opportunities. Blogs, YouTube, and MySpace have dropped the cost of having a public voice to zero. Alone, this simply creates an over supply of voice which in turn leads to people shouting and becoming less civil in order to increase the chance of being heard. Thus to date, democratized voice has under-performed as a driver of quality in service industries.

But the web has also created RSS feeds that enable your comment about an aspect of service to be directed to ‘just the right manager’. This dramatically increases the signal to noise ratio for busy managers. Cheap voice plus highly selective listening should substantially lower the costs of responding to citizen comments.

Patient Opinion is about building system-wide information streams around these new, and as yet un-noticed, cost opportunities. The generic aim of these streams is to reduce the asymmetries to which patients are subject.

The final piece of the jigsaw is to create a web currency that rewards public and staff for using feedback to change the service. Instead of clicks and hits such a currency would place a value on responsiveness and improvements made.

Public voice gives explicit power to patients. And becoming a real co-creator of change in the system empowers people in their struggle with illness. This is especially true when the change that patients suggest is directed to the benefit of others rather than to bettering their owwn immediate care.

None of this will make markets more suited to health care but it should mean that where ever patients are struggling with the helplessness, lack of control and fear associated with illness, they can find tools that help them to feel more informed, included and valued.