Political Exhortation, Patient Expectation and Professional Execution: Perspectives on the Consumerization of Health Care
| Date | 01 June 2002 |
| DOI | http://doi.org/10.1111/1467-8551.00230 |
| Author | Gillian Hogg,Angus Laing |
| Published date | 01 June 2002 |
Introduction
The requirement for fundamental restructuring
and reorientation of public-sector services has
been a constant refrain among policy makers
in post-industrial economies over the past two
decades (Lynn, 1998). Motivated by political and
economic pressures to enhance the efficiency and
effectiveness of public-sector service provision,
such restructuring and reorientation has been
characterized by efforts to replicate private-sector
management practices and culture in public-
sector settings (Farnham and Horton, 1993;
Pollitt, 1993). Collectively these changes have
been encapsulated in the catch-all term ‘new
public management’. Although the concept of
the new public management has been critiqued as
lacking focus and precision (Dunleavy and Hood,
1994; Ferlie et al., 1996), at the core of this evolv-
ing new management ethos in the public sector is
a change in the relationship between service pro-
viders and users. From being a relationship couched
in terms of citizenship with myriad mutual
commitments and obligations on the part of the
citizen, it is increasingly expressed in consumerist
terms, with emphasis placed on the primacy of the
rights of service users, both individually and
collectively (Walsh, 1994; Keaney, 1999).
This central emphasis in the new public
management on the empowering of public-sector
service users reflected a perceived need to ad-
dress the introverted and unresponsive nature
of public-sector service provision. Although the
specific mechanisms to be employed in address-
ing this issue have varied across the political
spectrum, there has been remarkable unanimity
British Journal of Management, Vol. 13, 173–188 (2002)
© 2002 British Academy of Management
Political Exhortation, Patient Expectation
and Professional Execution: Perspectives
on the Consumerization of Health Care
Angus Laing and Gillian Hogg*
Department of Management Studies, Edward Wright Building, University of Aberdeen, Dunbar Street,
Aberdeen AB24, 3QY and *Department of Marketing, Glasgow Caledonian University,
70 Cowcaddens Road, Glasgow G4 0BA, UK
email: a.w.laing@abdn.ac.uk
A central theme underpinning the reform of public-sector services in western economies
since the 1980s has been the emphasis on reorienting service provision around the user.
Public-sector organizations have been forced to reappraise the design of the service
delivery process, in particular the service encounter, to take account of the resultant
changes in service users’ expectations. Such focus on the service user has fundamental
implications for public-sector professionals, specifically challenging the dominance of
service professionals in the design and delivery of services. Based on a survey of patient
attitudes towards service provision in the National Health Service in Scotland (NHSiS)
and in-depth interviews with senior hospital clinicians and managers, the paper
critically examines the reaction of both patients and professionals to politically driven
initiatives to reorientate the delivery of health-care services. Specifically the paper
explores the emerging perspectives of both patients and professionals towards the
consumerization of health care and the changing nature of the relationship between
patients and professionals within a publicly funded health-care system.
in the underlying critique of public-sector service
provision:
‘In different ways both right and left are sus-
picious of providers and the way in which the
public service has developed in the post war period
seeing it as monolithic and unresponsive . . . pro-
fessionalism is an excuse for avoiding the pres-
sures of competition and individual choice and the
need to be responsive.’ (Walsh, 1991, pp. 9–10)
Breaking the unchallenged power of self-
interested producers has been seen as critical to
the effective reorientation of public-sector ser-
vice provision. Central to breaking this producer
dominance has been the idea that service users
should be viewed as consumers, enjoying the
same rights in respect of public-sector services
as individuals enjoy in respect of private-sector
organizations. The application of commercially-
derived marketing concepts has thus been central
to the reorientation of public-sector service pro-
vision. This has been reflected in the panoply of
policy initiatives, the most notable and enduring
being the Citizen’s Charter, which have been
introduced by successive governments in order to
promote both consumerist patterns of behaviour
and consumer-focused service provision.
The underlying assumption behind such
initiatives has been that encouraging consumerist
patterns of behaviour among individual service
users, when coupled to the provision of informa-
tion on performance and service standards, would
effectively force public-sector service providers to
become more responsive in the design and delivery
of services (Power, 1997). The effectiveness of
such initiatives is ultimately, however, dependent
on the willingness of consumers to change their
established patterns of behaviour and renegotiate
their relationship with service professionals. As
Butler and Collins (1995) observe:
‘Much of the change in the public-sector revolves
around the attempts by governments . . . to
educate citizens to act like consumers.’ (p. 89)
This implicit policy emphasis on the individual
service user, though remaining central to the
reorientation of public-sector service provision,
has increasingly been tempered by the need to
take account of communal rights and requirements
in the design and delivery of services (Wistow
et al., 1996). However, such policy initiatives must
be seen within the context of the broader socio-
economic and increasingly technological changes
occurring from the 1980s, with such developments
impacting on the expectations and behaviours of
public-sector service users. Central to these socio-
economic trends has been the decline in the idea
of community and citizenship values, and a corres-
ponding increase in emphasis on the rights of the
individual (Abercrombie, 1994).
These policy initiatives equally have funda-
mental implications for public-sector professionals,
in that the implementation of such policies falls to
front-line professional staff. Specifically, concepts
of client or consumer focus have challenged
the established dominance of service providers
in the design and delivery of services (Gray and
Jenkins, 1995). This realignment has frequently
been encapsulated in initiatives such as process
re-engineering and patient-focused care pro-
grammes (Willcocks, Currie and Jackson, 1997).
Inevitably, such challenging of established prac-
tices and behaviours has engendered significant
resistance from public-sector professionals.
Although in part such resistance to change may
be attributable to narrow professional self-interest,
as in any organization experiencing major change
(Pettigrew, Ferlie and McKee, 1992; Dawson,
1994), it may also be attributable to more funda-
mental questions regarding the appropriateness
of such user-focused reorientation of the public-
sector (Brown, 1992; Graham, 1994). This reflects
a deep-seated unease with the potential conse-
quences of such consumerization of public-sector
services, particularly professional services such
as education and health care, given prevailing
resource constraints and the informational asym-
metries between service users and professionals
(Hugman, 1994; Michael, 1997). Operationally,
this concern has found expression in antipathy
towards the language of consumerism and the
associated management practices, notably market-
ing and service re-engineering, among public-
sector professionals (Laing and Galbraith, 1995;
Clarke and Yarrow, 1997).
This reorientation of public-sector service
provision is ultimately dependent on changes in
the behaviours of both parties, with service users
adopting consumerist patterns of behaviour and
service professionals acknowledging the legitimacy
of user involvement in the design and delivery
of services. Drawing on research undertaken in
respect of the National Health Service in Scotland
174 A. Laing and G. Hogg
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