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When Tony Blair visited the offices of the King's Fund, Labour's favourite health policy think tank, to give a speech commemorating a decade of NHS reforms, he received a generally positive response from the assembled ranks of health experts and professionals.1 King's Fund chief executive, Niall Dickson, set the tone in his congratulations to the prime minister on the eve of his departure for providing ‘unprecedented levels of funding’ and ‘significant improvements in key areas’.
Speaking to the King's Fund conference immediately before the prime minister, David Pink, chief executive of the Long Term Medical Conditions Alliance, a consortium of more than 100 patient organisations, welcomed the commitment of the government to a ‘patient-centred’ NHS. As Pink acknowledged, the presence on such a platform of somebody speaking from the perspective of patients was a potent symbol of the transformation of health policy under Tony Blair. He enthusiastically endorsed a number of initiatives that, while purporting to advance patient interests, reveal the destructive consequences of the government's attempts to reform health care according to the rhetoric of choice and empowerment.
Pink welcomed the Quality and Outcomes Framework (QOF) as ‘a major national programme that has turned the NHS's attention to helping people monitor and maintain their own health’. In practice, QOF operates as a financial lever to shift the direction of medical practice away from the diagnosis and treatment of disease towards intrusive and moralising interventions in patients' personal lives, justified by the dogma that this improves health and prevents disease. Far from benefiting those with chronic conditions, this shift is depriving them of continuity of care, while doctors' energies are consumed with medicalising the worried well. The provision of an incentive bonus to GPs for recording patients' preferences about where they would like to die — a choice over which neither patient nor doctor is, in practice, able to exert much influence — aptly symbolises QOF's contribution to patient empowerment.2
Another government health initiative approved by David Pink is the Expert Patient Programme (EPP), a series of formal training sessions through which people learn to manage their own chronic illnesses. Though the EPP has a commonsensical appeal, it is imbued with bad faith. It offers an illusory empowerment to patients with chronic illness and an illusory relief from the burden of caring for patients with chronic illness to doctors. If the EPP were widely taken up, it would affirm an identity as sufferer from chronic illness for a growing proportion of the population (17 million according to the Long Term Conditions Aliance) while imposing an increasing burden of responsibility for their own care on those with chronic disease. While patronising patients, EPP implicitly degrades doctors, devaluing medical science and professional expertise.
David Pink is also a staunch advocate of ‘patient and public involvement’ in the NHS, another of the favoured slogans of the Labour government. This has led to the cultivation of the professional patient who purports to express the interests of patients in general. Of course, members of the public who are able and willing to assume these roles are inevitably unrepresentative of patients in general, and — unlike local councillors and MPs — are not subject to the episodic recall of the ballot.
In his enthusiasm for ‘patient and public involvement’ David Pink personifies the problems of these initiatives. While he speaks on behalf of people with chronic illnesses, he was not elected by people with chronic illnesses and he is in no way answerable or accountable to them. As the chief executive of a meta-quango, which strictly represents a number of organisations rather than individuals with chronic illnesses, he is as remote from such individuals as any politician (and vastly more remote than the average GP). In fact, what emerges is that his status is conferred by government endorsement of his position rather than by any democratic mandate. It is thus perhaps not surprising to find that Pink provides the perfect warm-up man for Tony Blair on his tenth anniversary celebrations.