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In these troubled times, it can be useful to see whether there are any sociological or political theories that could help us analyse issues from a fresh perspective. Several theories might be relevant but Alford's political theory of interests seems to me especially illuminating. Published in 1975, it is based on Robert R Alford's study of the failure of reforms to improve health care in New York city.1 Its detailed categorisation of interest holders and examination of the political relationships among them, and its general applicability to western healthcare systems, promise to make sense of conflicts of objective and of view in debates about proposed policies and changes in UK health care. Here I outline Alford's theory and look at the convergences and conflicts of interests among the major categories of interest holders he identifies: clinicians, corporate rationalisers, and patients. (Corporate rationalisers is a useful term for bureaucrats, managers, and many academics, see below.) Patients' interests are excluded from discussions about proposed policies more often than other interest holders always realise or intend. Using Alford's framework, I suggest that a more thorough consideration of the interests of all three categories of interest holder could sometimes lead to policies that met the interests of them all.
Alford's theory is expressed through the political concepts of interests and power. Interests are difficult to define but roughly mean a stake in something that is important to the interest holder because of the benefit or harm it can do to him or her or to the social group to which he or she belongs.2 Power is ability to bring about significant effects, specifically by furthering the agent's own interests or by affecting the interests of others, whether positively or negatively.2 Values, the worth of something to a person or group, are closely linked to people's view of their own interests; if someone values something, he or she has, or holds, an interest in it.
Alford put interests in health care into three categories.
Although many policy- and decision-making bodies, committees, or working parties have one or two lay or patient members, confusion about who exactly can speak for whose interests is common. Lay people, members of the public, ‘ordinary’ patients (those not politically engaged with the health service through trying to improve patient care), and patient advocates overlap but have different types and levels of experiential and specialist knowledge.5,6 Failure to appreciate this can lead to the appointment of people unsuited for the scope and level of the group's work.
When individuals who have enough expertise to speak for other patients' interests are appointed or are in place to be consulted, health professionals and managers are not obliged to seek their views. Although trusts in London consulted patient groups about some aspects of the mental health services, their views were not sought on crucial issues like the restraint of patients.7 The views of ‘ordinary’ patients about their own experiences can fare no better. A handbook for staff in York about how to elicit patients' views advised staff not to invite comments on ‘sensitive’ topics or ones that staff themselves could not act on.8
When the public's views are sought through large-scale consultations, the findings can be disregarded.
Some policies and practices are concealed from patients and the public who, therefore, cannot judge whether or not they are in their interests, as they would define them. Not telling patients who might need a blood transfusion after elective surgery that their own blood, collected in advance, could be used instead of donor blood, is an example.9
Alford knew that his three major groups of interest holders included subgroups with slightly different interests.1 He also saw that members of one major interest group could support some of the interests of another major group. In 1975, the support of patients and the public for clinicians' interests and values was taken for granted and sustained doctors' dominance. It still does; and even some patient advocates support dominant or challenging interests and values when they conflict with those of patients as well as when they converge. Similarly, some medically-qualified persons and many lay policy analysts, advisors, and commentators are corporate rationalisers.1 These deviations from what might be expected are little recognised, by themselves or by others.
Health care and health services have become more complex since Alford's day. The pharmaceutical industry, private healthcare and insurance companies have become more prominent, and new paraprofessional groups take part in clinical practice. Dominant interest holders are now subject to strong and sometimes successful challenges from corporate rationalisers.10,11 They are also now subject to weak and often unsuccessful challenges from patient advocates.3 But even when dominant interest holders accept other groups' proposed policies, they often modify or subvert them to their own ends.3,12 The basic dynamics of conflicts and convergences of interests have not changed. In the following sections, I look at how Alford's concepts are still relevant today.
Patients are both individuals and members of patient populations: they want good care for themselves and for other patients. How ‘good care’ is defined changes over time. Patient autonomy is a key value in the early 21st century and is supported directly through information, choice and shared decision making and indirectly through respect, access, equity, safety, support, redress, and representation.12,13
But the repression of patients' interests means that it is not always easy to be certain what ‘ordinary’ patients, carers or members of the public would say that their interests were, if they knew how their interests might be affected by policies and practices unknown or misrepresented to them.9 By contrast, how professional monopolists and corporate rationalisers define their own interests and values are, respectively, well understood and fairly well understood. In Table 1, some of the patient positions are provisional, pieced together from evidence and argument from several sources.
The rationale for each patient position are shown in Box 1.
The positions in Table 1 characterise typical corporate rationalisers, professional monopolists and patients. They show that the interests of each group zig-zag between the other two: sometimes converging, sometimes conflicting. Similar tables could be drawn up for other sets of issues.
The positions in Table 1 are typical of each set of interest holders. But real individuals, as distinct from ideal types, can hold varying and mixed positions, depending on their alignments (not necessarily clearly-defined or consciously held), their role in the health service and the specific issues. Some patients choose to leave decisions to their doctors.15 GPs can feel tension between ‘professional’ (professional monopolist) and ‘practice’ (corporate rationalist) values.24 Some clinicians in part-clinical, part-managerial roles promote corporate rationalism; they are ‘corporate rationalisers from within.’11 Others comply with corporate rationalist policies while complaining about them privately. So individuals' alignments can be obscure. This recalls Alford's point that interest holders sometimes support some of the interests of other groups, even when those interests apparently conflict with those of their own group.1 Because clinicians are dominant interest holders, corporate rationalisers and patient advocates must gain their support for changes to policies and practices. Mixed positions and confusion about alignments sometimes hinder, sometimes facilitate, this.
Patients' interests are not so completely repressed, so little articulated or heeded, that corporate rationalisers and professional monopolists are unaware of any conflicts between their interests and those of patients. But a notable feature of almost every discussion of relationships and shifts of power between corporate rationalisers and clinicians, of reorganisations of the health service or of the future of medicine, is the absence of any serious reference to patients' interests and values.
Major policies have been devised and implemented with little, if any, consultation with the public, patients, or patient advocates. Yet consultation could sometimes lead to policies that met patients' interests at the expense of only slight modifications to corporate rationalisers' or clinicians' initial assumptions about how their own interests could be protected. Referral management is an example.
Referral management is a new system in which GPs' and consultants' referrals are scrutinised by a doctor or manager in a referral centre and forwarded, redirected or barred.25 Corporate rationalist reasons for promoting it included sending patients to services that are either cost-effective or underused.25 Other reasons, scarcely spelled out to GPs, patients, or the public, included getting data on each GP's referrals to check against trusts' claims for payments; checking whether GPs were complying with national and local guidelines; edging out GPs' clinical autonomy; gaining more control over them and their patients; and weakening the bond between patient and GP and patient and consultant. This weakening was put in motion through inducing GPs to switch their patients from a personal to a practice list. Although patients can choose which GP to consult, GPs have allowed restrictive policies to be imposed on their patients as well as on themselves.
GPs' reasons for opposing referral management included the threat to their clinical autonomy and to ‘patient choice of hospital’, and the delicacy of persuading some reluctant patients to accept referral.25,26 But patient issues, that is, issues where the interests of patients are likely to diverge markedly from those of clinicians or corporate rationalisers, have received scant attention. First is patient autonomy as realised through the GP's and the patient's shared decision-making, with its tacit or explicit negotiation in which each is free to request or refuse referral, and where the interests of each, as each defines them, manifestly converge or conflict. From patient autonomy follow issues of patients' consent or refusal to their shared decision being reviewed by someone not directly involved in their care, to confirm or overturn that decision; who the reviewer will be and how the patient will be told who he or she is; how a decision to overturn their GP's advice is to be explained truthfully to the patient; what the patient's right of appeal will be; to whom the reviewer is accountable; and whether the reviewer will have access to the patient's electronic health record, and if so, how consent is to be sought. Although scrutiny of referrals could perhaps sometimes be to a patient's advantage, changing the doctor–patient relationship to bring a third person into it should have had extensive public, patient, and patient activist debate first. It had none.
Other ways of securing ‘better’ referrals could be designed if patients were seen as partners in their health care. If they were routinely offered the national or local referral guidelines for the condition or disease they or their GP suspected, patients (who wished to) and their GP could go through them together and discuss whether or not the guideline should be followed in the light of the patient's individual predicament and any other information the GP or patient might have. That would protect the patient's safety. It would respect the relationship or bond between GP and patient and would uphold the autonomy of both the GP and the patient. GPs would become accustomed to following referral protocols, even for patients who did not wish to discuss them. That would help secure corporate rationalisers' interests in cost-effective, uniform standards of care that reduced inequities. The repression of patients' interests through referral management and its dubious ethics would be overcome.
Alford's theory and categorisations can help us understand how dominant and challenging interest holders see their interests and so understand the reasons behind their proposals and policies, even when they do not declare them. We now know more about how patients' define their interests than Alford did, but as those interests are still pervasively repressed, they still fit into his framework. People currently considering proposed policies should be able to analyse potential conflicts and convergences of interests among the three categories of interest holders with more thoroughness than marked consideration of policies like referral management. All proposed policies require open, informed, detailed, and honest explanation and debate between all three sets of interest holders. This could go some way towards releasing patients' interests from repression as well as leading to policies that were acceptable to all interest holders.
Questions of how far individual patients' interests converge or conflict with those of other patients or of the patient population need more careful analysis and less arbitrary answers than they have customarily had. They should not be used as an excuse for excluding patients and patient advocates from decisions or from policy making.
Dominant interest holders seem to be tending towards accepting corporate rationalism in western medicine. That is probably inevitable because of the increasing technology of medicine, its rising costs, and the need for team working.19 Moreover, some aspects of corporate rationalism meet some of the interests of patients more closely than professional monopolism can (Table 1).19 Nevertheless, new policies should only be accepted after thorough consideration of their cumulative implications. Corporate rationalisers have found ways of influencing clinicians through financial incentives. But clinicians should bear in mind that patients may fail to see the difference between a new expense, not yet covered in the ordinary way, and a bribe.
Corporate rationalisers at every level need also to think through the implications of the policies they promote. The Chief Medical Officer for England observes that financial and activity targets have higher current priorities than quality and safety.22 That is a criticism of corporate rationalisers (politicians, civil servants, managers, and trust board non-executive directors) as well as a comment on a lack of attention to quality and safety in the NHS.
A distinction may be drawn between corporate rationalism as a set of principled beliefs and the more transient predilections and aspirations of political parties, although they are linked in the UK through civil servants in the Department of Health in England, or its Scottish or Welsh equivalents, and the government of the day. For instance, the government's introduction of commercialism into the NHS is carried out by managers but is not an integral part of corporate rationalism. Most business people appointed to positions in the Department of Health or to trust boards, however, can be assumed to be corporate rationalisers. That is why they are appointed.
How far repressed interest holders, the public and patients, accept which aspects of corporate rationalism is unknown, partly because the full implications and consequences of proposed policies are seldom explained to them. Patient advocates have scarcely begun to consider corporate rationalist interests and values as carefully as they have considered professional monopolist interests. They must.
Corporate rationalism is partly a response to dominant interest holders' past waste of resources and inability or unwillingness to ensure that all patients were offered health care to acceptable standards. Patient advocacy is partly a response to dominant interest holders' inability or unwillingness to ensure reasonable standards for all patients, and to their sometimes coercive approach to patients and lack of respect for their autonomy. It is important that clinicians as dominant interest holders consider how far they can meet the wishes and evidence-based requests of corporate rationalisers and of patients and patient advocates, while retaining and developing or refining those aspects of their professionalism that give clinicians their unique value to society.
I thank Liz Cairncross and Patricia Wilkie for their helpful comments.