LAUSR

Most doctors do not like medical consumerism. From its early days consumerism was ‘an unwelcome thorn in the medical flesh’. According to Downie, NHS patients simply cannot become consumers and doctors cannot become suppliers of goods and services. NHS patients consume services out of necessity (not want) and the state (not themselves) funds their care, so they are not customers. Medical services are, for the patient, an imperfect means to a desired end (like ‘good health’ or relief from pain), which is not a commodity. Patient-centred care has medical approval, but patients as consumers do not – as Gusmano et al. declare: ‘Patient-Centred care, Yes; Patients as Consumers, No’. We understand and partially agree with these concerns and reservations, but we also see potential advantages in medical consumerism when it is defined as patient challenge to physician authority. In our view, medical consumerism has evolved through its encounters with medical services, producing different generations of consumers and changing definitions of consumerism. There is no such thing as medical consumerism in itself, but there are different forms of it which can combine in different ways. We used a selective review approach to identify papers from medical, policy and health services research domains that contributed ideas and insights to the process of hypothesis generation. Synthesising this literature, we conceptualise three generations of medical consumerism. In the first generation, beginning in the USA in the 1960s, but spreading later to the UK, patients challenged professional authority. The response of the NHS to this challenge was to offer a menu of choices, for example, giving birth at home or in a midwife-run unit with or without a water bath. In countries with commercialised medical care, like the USA, these responses were driven by the need to compete for customers. In the NHS, patients do not pay directly or through insurance but increased custom could still be used by the service to negotiate additional resources from the NHS. In the second generation, arising in the 1980s, selffunding consumers purchased their desires, mostly forms of body enhancement, in a burgeoning niche market. Second-generation medical consumers are commodified – their bodies have exchange value, and the customer (not an insurance policy or a public health service) pays. The third generation of medical consumers was coopted into healthcare systems starting in the 1990s, as market mechanisms became the favoured model for healthcare organisations, to help contain costs and increase productivity; its consumers are ‘disciplined’. This third generation has evolved special forms of disciplined consumerist behaviour, three of which we describe in this paper: successful ageing; selfmanagement; and prosumerism (blending production and consumption). The relationships between these generations are summarised in Figure 1. Although they emerged at different times, all three generations are still having effects on health services and patients, to differing extents at different times, in different places. As far as we can see, the consumerist generations do not succeed each other but co-exist.