Dr Grumble has a good decorator. He is more expensive than most decorators but he does a better job. He has never advertised. He doesn't need to. People recommend him to their friends and his small business thrives. Dr Grumble likes these artisan types. They are mostly self-employed. They provide something people need. They are honest Johns we trust.
If you run a business you need to make sure there is a demand for whatever goods or services you offer. If you want to sell something people don't need you somehow have to create a demand from nowhere. Regular readers may know that bottled water is the example Dr Grumble likes. When Grumble was a child bottled water was something foreigners had because their water supplies were unsafe. Now it is an essential item for youngsters. Even younger consultants go around the Grumble hospital with an emergency supply of water just in case they get stuck in the lift or the hospital's heating overcomes them. Go to the hospital shop and you will find several brands of water. Each contains, well, water. And it costs more than petrol. It is a collective lunacy on a massive scale. Yet if you challenge this behaviour it is you who will be seen as mad.
What can we conclude from this? It is that people are very vulnerable to the powers of advertising and more subtle efforts to influence their behaviour. Don't think that Grumble considers himself immune. The Grumble children all waste
If you can persuade people to buy water when they could drink it for free you can probably persuade them to do almost anything. In the Great War when people felt vulnerable there were lots of volunteers for the trenches. And in the Second World War Japanese volunteers for suicide missions were so numerous as to be compared with swarms of bees. When people become patients and are worried about their health they are particularly vulnerable to unscrupulous persuasion. The GMC recognised this in Advertising (1995) where it states:
People seeking medical attention can be particularly vulnerable to persuasive influence. (pdf)
Curiously, Advertising (1995) was withdrawn in 1997 about six months after Tony Blair took power. It didn't last long at all. Now why do you think that was?
As it turns out, Dr Grumble has been a patient recently. He broke a premolar. The NHS dentist had obviously been trained that he must give patients choice. Grumble was given four treatment options. One was private and three were NHS. One of the NHS options was immediately dismissed by the dentist because of the location of the nerve - so one wonders why this option was offered. The private option was 'unlikely to last as long'. Dr Grumble did not quite grasp the difference between the other two options. In any case he didn't have enough knowledge to make the choice between two possible treatments about which he knew very little. Dr Grumble gently made the dentist decide what was best. He is more likely to make the right decision than Grumble. Dr Grumble just wants his tooth fixed. And he trusts his dentist.
Most patients are like Dr Grumble. They have a problem and they want to be made better. Quite often there are various options. The occasional patient wants to know about all of them and wishes to weigh up the pros and cons of each treatment. These people tend to make themselves unhappy with their agonising over things they do not know much about. And if they need help in their agonising who will they ask? Dr Grumble of course. So Grumble will dutifully go into it with them and, at the end of the day (and it can take a long time), they will make a choice which would be the very same treatment option that Grumble would have chosen for them. Which is hardly surprising because the patient's information all came from Dr Grumble. The choice they think they exercised was really an illusion.
Our governments seem intent on developing wants. They tell us patients want choice. Patients want GPs open all hours. They want information. It all seems so reasonable that Grumble hesitates to question this mantra. Dare he suggest that the NHS should be giving patients what they need and not what they want?
The argument goes like this. People want bottled water. They don't need it. Patients may want antibiotics. But they may not need them. An insomniac might want sleeping pills but they are often not needed. Giving patients choice and dealing with their wants rather than needs is superficially laudable but it is not what the taxpayer should be paying for. And it is not good medicine either.
Needs are fixed. You need to drink water. You don't need to drink lots of bottled water. Bottled water is a want that has been cleverly created. It is a waste of money and resources generally. If you want to buy bottle water, you can. It is your money. But in providing universal healthcare we must distinguish unnecessary wants from essential needs. Governments should avoid generating wants which, in a system that is free, can never be met. It is the needs that matter.
It was like this with Grumble's broken tooth. It needed mending. The dentist, following the NHS mantra, thought Grumble wanted choice but choice was not needed. Wants are things private businesses create. Needs are what governments should identify and provide to their electorate. In dentistry a set of pristine expensive new teeth is a want. Having a broken gnasher mended is a need.
Dr Grumble's dentist could have made some extra money from the private option if he had been less honest. He needn't have been quite so frank about the drawbacks of the private treatment. But he did what a professional should do. He was scrupulously honest. His talking down the private option made Grumble feel comfortable. Being given choice did not. He would have been even happier if the dentist had just told him what he was going to do. But that is not allowed any more. It is all about the market in healthcare. And that is much more about wants than needs.