Niall Dickson, Kings Fund

A new dispensation - at the time of the creation of the NHS in 1948 the response from the public was gratitude and a huge welcome, but no real expectations of what it would provide and what universality of provision would really look like. One size fits all was accepted and at the same time doctors knew best. It seems that deference and placebo were key to medical practice.

But the world has now moved on with the creation of the notion of a consumer culture and customer influence, we all have expectations of being listened to but you won’t necessarily find it in care homes or in out-patient departments.

There has been a challenge to professional dominance in the UK especially after a number of scandals, Shipman, Bristol, Neal and there is a general loss of public trust in experts. Together with the arrival of the Information Age this all means that patients and service users question more and accept less. We have to accept that access to information will not be equal though and this is primarily seen as an age-related difference.

We are in the age of choice, we use it as voters and as consumers - and we’re losing the idea that vulnerable people can’t make choices for themselves. Yet we have a system that denies choice. People think they should have more choice than they currently do. Women more pro-choice than men and the assumption that choice is a middle-class privilege is challenged by the evidence.

Information and involvement are still poor. 33%-50% of patients wanted more information and involvement. Around a third received conflicting information from professionals. If you were a private company and you had that sort of customer feedback, you’d be worried.

The social care system in England is a system that fails to meet aspirations - it’s not well defined or resourced, massive budget constraints, help concentrated on those with severe needs, relationship with benefits system extremely complex. However there are lessons to learn for healthcare. CSCI have found that many older people ask questions about vfm and press for more choice and control. We are putting users now in charge with direct payments which have much higher satisfaction rating. Kent CC have given people getting direct payment a VISA card effectively outsourcing much monitoring to the banks. But change is slow - there has been a duty to offer direct payments since 2003 but still only 4.2% of service users get them. For elderly people who just need simple home care then it’s perhaps too complex and some are just one-off payments rather than regular arrangements.

Now adopted another approach of individual budgets as a direct payment or managed by the LA as required which is showing great promise. Focus now on empowering service users, living independently.

Example: Andrew was a mental health user, he was offered day care went in and out and then relapsed and went in and out of hospital, didn’t want day care any more. He was allocated an individual budget and given a chance to evaluate his life - asked what he’d like - he said a holiday and a photographic course. He’s now discharged and employed as a photographer.

What are the lessons for this? Why wasn’t he listened to first time round? As well as handing over financial control we need to look at the whole paradigm for supplying care. This has parallels in Expert Patient studies. So could we do individual budgets in healthcare? There is some evidence of success in US, health & social care users are often the same people, but in UK co-payment could undermine universal health care and we’re not sure how to reconcile with increasingly evidence-based care pathways. Nevertheless there are lessons for the new professionalism. We are moving from the reactive episodic directive model where doctor knows best, to proactive, ongoing, shared decisions where the doctor helps the patient to navigate.