Kevin Lewis: when is a patient not a patient?

When is a patient not a patient? And how much does it matter? Kevin Lewis revisits the myths and controversies of a recurring healthcare debate.

Medical paternalism – conveniently summarised as ‘doctor knows best’ – was rooted in an age where the workings of the human body were something of a mystery for most members of society. Attitudes changed progressively, fuelled by the empowering arrival first of consumerism and after that, the internet.

And just as the world of healthcare decided that doctors may not know best after all, UK dentists decided that they preferred to be called doctors anyway and the GDC eventually agreed. We can learn a lot from taking a second look at what was happening in the intervening years.

The dinner which traditionally forms part of the Annual Conference of Local Dental Committees has had some very special moments over the years, especially when politicians accepted an invitation to be the after-dinner speaker. Anyone who was present at the time will remember the occasion in the late 1980s when Edwina Currie, then a junior health minister, mounted a full-frontal assault on what she saw as the dental profession’s elitist and paternalistic mindset and its unwillingness to embrace consumerism.

To drive her point home, she continually used the word ‘customer’ rather than ‘patient’ throughout her speech and let’s just say she failed to read the room when things were getting out of hand. The speech didn’t go down well at all while the message sank like a stone. An invite to speak at the LDC Conference Dinner has since been the stuff of legend in civil service and DHSC circles.

Different occupations describe their ‘customers’ in a variety of ways; ‘guests’ for some, ‘clients’ for others and ‘punters’ for a few. In the world of selling, potential customers are simply – if cynically – reduced to ‘prospects’. They are all consumers, of course, but (call me old-fashioned) I like to think that there is a particular kind of ‘specialness’ implied into the use of the term ‘patient’ in healthcare. It implies all of those professional and ethical characteristics and values like putting the patient’s interests before our own, respect, care and concern for a patient’s wellbeing, and so on.

Healthcare professionals have ethical obligations to a ‘patient’ which go far beyond the requirements of the average ‘consumer’ transaction in the high street – and that is what Edwina missed when delivering her diatribe.

The extra mile

One needs to look no further than the GDC’s ‘Standards’ guidance to appreciate how much further a dentist must go in their dealings with members of the public, compared to a typical high street customer-business interaction. This guidance confusingly refers to a ‘member of the public’ one moment, and a ‘patient’ the next moment, and one could be forgiven for thinking that members of the public perhaps don’t metamorphose into ‘patients’ until the moment they seek or receive dental care and treatment.

But on closer inspection, the guidance doesn’t support an interpretation that continues that logical distinction and consequently, one must interpret these terms flexibly and inclusively. At least the GDC has resisted any pressure to and favour the term ‘customer’ over the term ‘patient’ so let’s be thankful for that.

A recent chance interaction with a longstanding colleague in New Zealand has reminded me that almost 10 years ago I wrote an article which touched on this same theme, in which I commented that it is interesting that you won’t hear patients saying: ‘There were four other consumers in the doctor’s waiting room when I arrived for my appointment.’ Is it too much to hope, then, that patients themselves place a value on the special relationship that exists when you entrust your bodily wellbeing to a third party simply because they are a healthcare professional? Put simply, if undergoing a surgical procedure, would you prefer to feel like a customer/consumer as the general anaesthetic starts to take effect, or like a patient?

I do accept that some patients, at least, do behave increasingly like consumers when it suits them to. Not least because the Consumer Protection Act and all the regulations made under it, apply to dentistry just as much as to any other transaction. On a daily basis, even the most supine of consumers are being urged to find out about their rights, and to stand up for them. For the past 35 years up to and including this very week I have been privileged enough to have witnessed the shifting currents of the things that dental patients/consumers tend to complain about.

The COVID-19 pandemic spawned some examples which were unique to that time, but there are many enduring themes too. The ‘you promised me I would look like a film star’ variety covers a range of restorative dentistry and prosthodontics, tooth whitening, and increasingly these days, aligner orthodontics – and arguing that Goofy and Bugs Bunny were both film stars won’t help your defence any more than it did in the old days when Walt Disney himself was a lad. Then there is the ‘you refused to offer me NHS treatment solely because [insert protected characteristic here]’ type of complaint.

A particular kind of self-inflicted wound is seen when an irate patient approaches the reception desk clutching a dog-eared ‘Six Month Smiles’ leaflet in one hand, and brandishing a calendar in the other hand marked up to show the passage of 183 days or more since the start of treatment.

There are some misconceptions surrounding the increasingly prevalent view that patients are simply consumers of healthcare, behaving just as they do when acting as consumers outside the healthcare environment.

I see an irony in the fact that many of the same clinicians who actively resent the exchanging of the time-honoured term ‘patient’ for the apparently fashionable terms ‘client’, ‘customer’ or ‘consumer’, still go about promoting their own services and/or their practice in a very ‘transactional’ way, often reducing specific types of treatment to mere commodities.

Lessons from business

It was Harry Gordon Selfridge, the legendary retailer and creator of the iconic Selfridges store in London’s Oxford Street, who coined the phrase, ‘The customer is aways right’. But I was always more attracted to the observation of Gordon Bethune, the saviour of Continental Airlines (which later became part of today’s United Airlines), when he disagreed and pointed out that the customer is very often wrong, and as a result Selfridge’s strapline was wrong too.

Indeed, Bethune went on to explain his thinking in that a blind deference to every customer’s demands and behaviour – however excessive – is dangerous, and not fair to a company’s employees because they will sometimes encounter unreasonable and excessively demanding and rude people and they need to be able to trust their boss or manager to support them appropriately. Some customers will disrupt and damage your business, and destroy staff morale, and continually seeking to humour and placate them is not fair to all the other, reasonable customers. Ultimately, happy and well-motivated staff will help to deliver outstanding customer service if they feel valued and supported.

We all know there is an NHS treatment backlog and after a recent experience I am starting to understand why it exists. I should probably apologise in advance for having made it worse. Filling out a hospital registration form these days has become a long, complex and time-consuming task requiring a lot of thought. I had sailed through the name, address and phone number section and paused only to note with some puzzlement the ‘I would rather not say’ option alongside the ‘date of birth’ box.

The range of options in the ‘gender’ and ‘sexual orientation’ section was something of an education leaving me feeling that I may have been missing out all these years. But what really caused all the problems was my answer to the question about how I identify myself, and how I wanted to be addressed. Naturally, I answered ‘patient’, on the rationale explained above.

Q87 asked me whether I would like the services of an interpreter when completing the registration form and/or receiving treatment. I thought fleetingly that Q87 was a little late in the day to be asking that question, but after trying out a few of the impressive array of options I eventually settled on Serbo-Croat because she was the most helpful in explaining the gender and sexual orientation questions and anyway, she drew some very helpful pictures for me, which threw some light on things I had clearly misunderstood first time around.

Whether or not a skilled interpreter could help us all to make sense of modern healthcare terminology remains to be seen. But it does occur to me that NHS managers are missing a trick; those queuing in ambulances on the approach roads to A&E could surely be called ‘passengers’, those parked on trolleys in A&E could be reclassified as ‘passengers in transit’ and only when a bed is found for them in a ward would they formally become recognised as ‘patients’ and therefore included in the performance data and waiting list targets.

Problem sorted. Next problem please, Wes.

Read more articles from Kevin Lewis here:

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