Value for Money and Willingness to Pay
Participants who had accessed acupuncture on the private sector described being willing to pay for it because they valued their health. For some, acupuncture represented value for money; for others it was expensive but this was money well spent - provided, that is, the acupuncture worked. The converse was also true; if acupuncture was not working then it was not worth paying for. These participants were acting like the "consumer as chooser" [14
] in that they were making an active decision to seek acupuncture. They particularly emphasised their willingness to pay for an effective treatment and judged their experiences on that basis. This suggests an additional face of consumerism in private sector healthcare: the consumer as pragmatist, who emphasises the likely health effects of their choices. Indeed, if acupuncture worked for them, then many of our private sector participants were not only willing to pay but were also willing to overcome additional practical barriers. For example, when NHS funding was withdrawn for John's acupuncture he paid to see the same practitioner privately despite his being located a considerable distance away. He did this because this practitioner's treatment was effective:
"Doesn't matter about the cost, you know. I used to have it on the [NHS] they paid for it for 2 years then they stopped paying, but I'd sooner pay the sixty five pounds and go all the way over to [acupuncturist] and have three quarters of an hour of excitement and come out tingling. I feel brilliant and I'm alright for at least three and a half weeks then." (John, both)
Private medical insurance was one means by which people could access acupuncture on the private sector without having to pay at point of use. Those participants who had private medical insurance did not talk about the cost of the insurance premiums. Instead, they talked about how their insurance made it possible for them to have acupuncture. Some participants who had accessed acupuncture in the private sector stopped treatment because they could not afford to continue, despite wanting more and feeling it could help. Lisa's choices in the private sector were limited by her financial situation: she did not have the resources to act on her preferred choice, to continue with an effective course of acupuncture.
"If it wasn't so prohibitively expensive I would use it a lot more but at thirty pounds plus a session every week [...] to do a really good course of acupuncture to get really good results I believe you should really give it a proper course, but I can't afford do use it like that... I stop as soon as I can simply because of the price." (Lisa, both)
While some participants were willing to pay for their health (to varying degrees), for others the private sector was simply unaffordable. They were unable to consume private sector healthcare even if they might have benefited from it. This disparity was acknowledged by private sector patients like Richard:
"I paid for it, fortunately I was in a position to be able to pay for it [...] I would feel sorry for people who couldn't." (Richard, private).
Free and Fair Access
Not having to pay for acupuncture was an attractive feature of the NHS, for those who had accessed acupuncture on the NHS, in the private sector, and in both sectors. Unlike the private sector, the NHS was seen as supposedly offering equal, fair access to treatment for all. Here participants touched on more political themes, drawing on moral discourses to argue for NHS provision of acupuncture to facilitate access for people in pain who otherwise could not afford it and/or would not be aware of it. This concern with fairness suggests a "consumer as citizen" [14
], with an interest in the social dimensions of the provision of healthcare: from this perspective, given that acupuncture is an effective pain management tool it should be offered freely to all who need it.
"I think it should be given as part of the NHS for it is a pain management tool [...] I know it's a very good pain management tool, it's unfair you have to go outside of the NHS and pay for it yourself [...] well maybe it was all in my head but it worked, and pain management is all about working isn't it? I mean you know, what works for one person's pain management doesn't matter, if you're living with chronic pain you've got to use what gets you by, don't you?" (Sue, private)
A lack of awareness of available services constituted a barrier to our participants accessing NHS acupuncture. Some participants who had only accessed acupuncture in the private sector were attracted to the idea of free acupuncture but did not know whether it was available on the NHS. Typically, participants in the private sector actively sought out acupuncture (although some received acupuncture after consulting a complementary therapist or physiotherapist practicing multiple modalities). They had researched acupuncture and made an active choice to use acupuncture rather than another therapy, but had not researched its availability in the NHS. Participants who chose acupuncture in the private sector were thus not making a fully informed choice (one of the characteristics of the "consumer as chooser"[14
]), and might not be considered "smart consumers" [26
"I wouldn't necessarily particularly want to pay out of pocket if I didn't have to, um, but I'm not aware how many there are in NHS" (Jane, private).
It was not just those participants who had used acupuncture in the private sector who were unaware of acupuncture services on the NHS. Often, those who had accessed acupuncture on the NHS had been pleasantly surprised to be offered it. Unlike those consuming acupuncture in the private sector, there was little evidence that participants using acupuncture on the NHS had made an active decision to seek out and try acupuncture. Instead, they typically accepted an offer of acupuncture made by a health care professional during the course of multi-modal treatment. Of the 8 participants who had experienced acupuncture in both sectors, only 1 had actively sought it in the NHS, while 7 had initiated their private sector acupuncture. Of the 5 participants who had only experienced acupuncture on the NHS, none had requested, suggested, or otherwise initiated acupuncture treatment. This passive acceptance of an offer of acupuncture is not characteristic of any of the faces of consumerism identified by Gabriel and Lang [14
]. Instead, it resonates much more strongly with a paternalistic model of clinical interactions, where the expert benevolent practitioner determines the appropriate course of treatment (with the patient's consent).
"I just thought they were going to sort of give me exercises, medication, and that was about it really. I didn't think it was going to be alternatives. [...] So I thought it was quite good actually." (Tina, NHS).
Those participants who had used NHS acupuncture services did not necessarily continue to be passive recipients of acupuncture. Instead, they treated the offer of acupuncture as an opportunity to become an "explorer" [14
], to try an unfamiliar treatment. This was positive for participants who had tried acupuncture in the NHS, discovered it worked for them, and were able subsequently to seek it out in the private sector. These participants reconfigured their experience of NHS acupuncture as a chance to "try before you buy", to experience and evaluate a therapy and so be in a position to make an informed decision about whether the financial cost of private sector acupuncture was going to be worth paying. From this perspective, the opportunistic and comparatively passive use of acupuncture in the NHS can be seen as a stepping stone towards a more informed, active, choice to consume acupuncture in the private sector.
"I am glad I am having it on the NHS really. I don't know if I'd have tried it if someone had said 'you've got to pay for it first'." (Michelle, both)
However, there was also a downside to the NHS providing a means of trying acupuncture. Those who believed themselves unable to afford the private sector were very concerned that they might discover an effective treatment that they would then be unable to access in the future.
Individualised Holistic Care: Feeling Cared For
Participants valued the individualised, holistic care that they reported receiving in the private sector. They felt cared for, and linked this to the length and depth of consultations and to continuity of care. Practitioners were perceived as caring when they: allowed patients to communicate new health problems or concerns during treatment; took into account the patient's context, views, and desires; and provided treatments that were tailored to the individual patient. This is reminiscent of the mutuality model of doctor-patient relationships, in which an egalitarian partnership entails negotiation, respect, and joint decision-making.
"[private sector healthcare] is friendly, it's informal, it's not inhibitive, it's not institutional like a hospital. It enables you to consult with your medical practitioner on a range of topics that concern you, in other words when I'm on the couch as I said for acupuncture I can talk to him about the radiation colitis if I want to." (Paul, private)
Patients receiving acupuncture on the private sector typically contrasted positive descriptions of individualised care in the private sector with negative expectations of NHS treatments. They attributed individualisation not to acupuncture per se, but to acupuncture as delivered in the private sector. Len valued having more time to open up to his practitioner in the private sector than in the NHS; Jill felt that in the NHS she would be "shunted around from person to person" rather than seeing one acupuncturist; Gemma referred to the NHS as a "factory farm" and chose a private acupuncturist to get more individual attention.
Standardisation of treatment was seen as constraining individualisation and was raised as a disadvantage of NHS treatment by participants who both had and had not experienced it. NHS acupuncture was described as having a fixed number of treatments (too few) and a fixed duration of each treatment (too short). The standardisation of treatment in this way reduces opportunities for negotiation because many key decisions about treatment have already been made, probably encouraging paternalism rather than consumerism or mutuality. Participants understood standardisation as a consequence of the high volume of patients and the limited resources in the NHS - it was seen as a feature of the organisational structure, within which well-meaning individual practitioners had to work.
"I mean I loved going over there for it and they didn't want to stop it but they were trying to like carry it on, you know. But they just said there's no funding for it. They just done it out of a favour, really, I think, to try and help me get out of this pain." (Rebecca, NHS).
Consequences of Choice: Empowerment and Vulnerability
Greater perceived choice and control were empowering features of private sector acupuncture. In particular, participants accessing acupuncture in the private sector valued: being able to start and stop a course treatment when they wanted to, rather than having to seek referral from a GP gatekeeper and/or join a waiting list before starting; being able to select their own practitioner whom they often described in glowing terms (and being confident that they would be treated by that practitioner); and participating in clinical decisions about, for example, the use of additional modalities and treatment frequency. In an extreme case, Peggy described her consumerist relationship with a practitioner to the extent that when she did not receive the treatment she requested, she switched practitioner. This is one of three examples in our data of a participant rejecting a practitioner through the mechanism of "exit", a key mechanism available to consumers dissatisfied with a service which cannot be returned in the same way as material goods [31
"I went asking for acupuncture and he was sort of saying 'I don't think you should have acupuncture, I want you to try diet and I want to try other tests, perhaps you've got a sensitivity that's causing all this.' Well, ok, but it's going back to what I said about being in control of what I want to do." (Peggy, private)
In the NHS, the lack of choice available to individual patients had disempowering consequences. In particular, patients were disempowered by the paternalistic situation in which they neither knew what would happen after a first course of treatments, nor contributed to the decision to stop treatment.
"So I had six weeks of acupuncture which I felt did help a hell of a lot and it was a shame that I was only offered six weeks because, that's, I think when something is working, you know, where the patient should be able to say well look, that's working, why can't I go on with that?" (Len, both).
While the lack of voice was a problem in the NHS, too much choice in the private sector was associated with vulnerability and could thus be problematic. Some participants perceived a risk of being taken advantage of by unscrupulous practitioners, and were concerned about finding a suitable - trustworthy, qualified - acupuncturist in the private sector. Karen reported being "dubious" about the qualifications of acupuncturists based in shops, while Debra thought that being in pain exacerbated one's vulnerability when seeking treatment. This reflects the "consumer as victim" face of consumerism [14
], reminds us of the embodied vulnerability and emotional dimensions of ill-health [17
], and suggests that these participants did not feel sufficiently empowered or informed to judge the quality of a practitioner without some institutional protection or legitimisation.
"Just Added Extras": Physical Environment
This final theme illustrates the disparity between participants' experiences and (somewhat stereotypical) expectations of private sector acupuncture. Participants who had only experienced NHS acupuncture typically expected only the physical environment to be different in the private sector. They believed that the essential features of acupuncture would be identical in each sector, as did some participants who had used acupuncture in both sectors.
"I don't know what else I would have if I was going private, I have no idea. Whether I would have the - you know, your own room, and your own...your bit of music and everything. But I mean the treatment would still be the same I guess. So all those are just added extras" (Michelle, NHS)
This suggests that consumers of private sector healthcare might be vulnerable to being seen by others as "hedonistic consumers" [14
], using private sector acupuncture to benefit emotionally from a more pleasant physical environment. However, this face of consumption was not present in private sector participants' accounts. Indeed, patients who had only used acupuncture in the private sector rarely talked about the physical environment, and focused instead on the value for money and effectiveness of their treatment and their experiences of care, control, and choice as described above. Interestingly, the private sector did not always live up to its reputation for better hotel services: Ann's NHS acupuncture was in a "nicer room" than her private acupuncture.