By: Gemma Hughes (University of Oxford)
The social nature of healthcare
We all need healthcare at some point in our lives, whether due to illness, injury, or as part of the shared human experience of entering and exiting the world when we are born and when we die. The provision of healthcare therefore affects each of us, and in very personal ways. Although there are many expectations that people take care of their own health, optimising their wellbeing through good diet and sufficient exercise, we cannot heal ourselves when sick, provide our own medicine, surgery or nursing care. Therefore, our needs for healthcare can only be met by interactions with other people. This is especially the case when we are very young, very old, or seriously ill, when we rely on others to help us. The use and provision of healthcare is a social experience made up of encounters between people. These encounters often reflect an asymmetric relationship, with the person seeking healthcare, the patient, in a position with fewer resources or less knowledge than the healthcare practitioner. Organisations providing healthcare institutionalise this superior power over help-seeking patients in different ways, including controlling access to services.
The metric culture of healthcare
In England, every healthcare encounter routinely generates data. Each visit to a general practitioner (GP) will involve an electronic record being viewed, created or amended, usually during the consultation between doctor and patient. The ‘metric culture,’ described as the integration of data processes into everyday life at the Metric Culture Conference in 2017, is interwoven with the social encounters of healthcare, part of the everyday practice of healthcare provision. The data generated by clinical encounters facilitates financial transactions; for example, each hospital procedure is coded, and these codes used to quantify financial flows to hospitals. Metric culture pervades healthcare encounters, and allows patients to be readily quantified.
Social organisation of healthcare
How best to organise healthcare, and in a market economy how best to pay for services, are questions that are simultaneously deeply political questions that affect choices of government, and deeply personal questions that affect people’s daily lives. Studying how groups of people respond to these questions can provide a greater understanding of their culture, values and beliefs. Social and cultural theories can deepen our understanding about how and why certain responses are made rather than others, and, stimulate new ways of thinking about these questions as well as exploring assumptions that are sometimes unspoken. My research is concerned with how health and social care services are organised in England, where universal provision of healthcare by the National Health Service, mainly free at the point of access, is in contrast with the means-tested provision of social care which is mostly organised by local councils. The NHS is based on the principle of providing healthcare based on need, not ability to pay, and funded through general taxation. The whole population is therefore engaged in a kind of mutual aid, and a form of social insurance. I have been examining relationships between individuals’ experiences of health and care services and the wider social, political and technological context. Current experiences of healthcare take place against a background of austerity policies. A combination of decisions to restrict public expenditure and the ready availability of information about health service utilisation has some concerning consequences.
Austerity and metric culture
Concerns with rising costs of healthcare are found around the world, leading to efforts to reduce the need for healthcare through preventative programmes. A focus on removing the need for future healthcare, by encouraging healthier lives, or providing more timely and coordinated care, is much more socially acceptable than removing the need for current healthcare. In the NHS, concerns to manage and reduce expenditure has led to a focus on those people that are predicted to need admission to hospital, due, in part, to the high cost of providing hospital care. Analysis of data generated by encounters between patients and healthcare services shows patterns of past health service use. These patterns are used to create algorithms which predict future health service use. People with multiple long-term conditions, particularly respiratory conditions, who have previously been admitted to hospital, are found more likely to be admitted to hospital in future than people without these ‘flags’. The people identified though this predictive risk modelling are then targeted for interventions such as case management which are intended to prevent hospitalisation.
The ready quantification of patients, and ongoing concerns to reduce costs means that health services are being organised to try and identify people before they need hospital care, and provide them with an alternative. The consequence of this way of organising services, in terms of how we categorise and define patients, is to change relationships between individuals and health services, and challenges the principles and values that underpin the NHS. Organising services to be proactive, rather than reactive, changes relationships between health services and people. People become eligible for medical attention not when they ask for help but before they start to use services; they become ‘patients’ before they see their doctor. The social encounters that make up healthcare become ones that are sought by healthcare professionals, not requested by patients.
Identifying people at high risk of hospital admission, and targeting them for interventions to avoid admissions, creates a group of people who are distinguished from the rest of the population by their predicted future high consumption of healthcare. People flagged as being high risk will not be aware of the way in which they have been singled out from their neighbours by an algorithm and have become members of a group defined by their risk of hospital admission. Constructing a group of people at high risk of hospital admission ignores their other characteristics, such as their age or stage of life. They are no longer members of the whole population, all of whom will be costly in terms of the healthcare we use at certain points in our lives, but a separate group, created by concerns to reduce planned expenditure on healthcare, and by the technology integral to the metric culture in healthcare.
The consequences of quantifying patients in this way are problematic in a healthcare system of social insurance and mutual aid, and in terms of perpetuating asymmetric power relations between patients and healthcare providers. Separating out specific groups for interventions aimed to reduce their costs risks undermining the solidarity principle upon which mutual aid is based; rather than thinking about the costs of healthcare as being shared by the whole population, high costs are associated with a small group of people. The principles of social insurance whereby a person contributes towards the healthcare costs of old age or illness during periods when they are young and healthy, are also eroded by the segmentation of the population into different risk groups at specific points in time, regardless of their previous (or indeed future) contributions. The knowledge that healthcare providers create about the risks of hospital admission, and the proactive provision of healthcare can exacerbate asymmetrical power relationships whereby the patient is neither able to access the knowledge about their relative risk, nor able to assert their own eligibility for healthcare, instead relying on an algorithm-driven relationship.
Why this is important
Thinking about how patients are quantified by the metric culture in times of austerity is instrumental in understanding more about the values and choices we are, sometimes unwittingly, demonstrating as a society. This kind of research is also intrinsically important to ensure people can access the health and care that they need. Within a health system trying to reduce costs, a proactive, targeted approach is intended to replace a reactive approach for all, as there are insufficient resources to offer both a reactive and a proactive response. Over-stretched services seeking to identify people who are likely to be admitted to hospital to reduce next year’s healthcare budget, are unable to simultaneously respond effectively to people currently seeking help, leading to increasing waiting times, and reduced access to services. The opportunity cost of targeting future high users of healthcare can mean that people currently attempting to use healthcare lose out.
This short article describes one aspect of a case study of the practice and experience of integrated health and social care for adults with complex needs considered to be at high risk of hospital admission. This case study is part of a wider programme of research investigating organisational support for assisted living, SCALS: Studies of Co-Creating Assisted Living Solutions