‘Having a heart attack’ is not the same as ‘having a Mercedes’. Which is of course a statement of the bleeding obvious once you put it like that.

Fantasising about whether you would prefer a Mercedes or an Audi is standard consumerist fare. Fantasising about whether you would rather have cancer or a stroke is pretty odd.

A category error

But if it’s all so obvious, how come we spend so much time in the NHS talking about choice and the patient as consumer? After all patients are supposed to act as consumers of health aren’t they?

They are meant to approximate, somewhere deep in their bowels, to that rational economic actor who sums up the pros and cons of every decision and then acts accordingly.

But if, in fact, ‘having a heart attack’ is completely different to ‘having a Mercedes’ then taking consumerism’s easy virtues into the heart of healthcare could be a big mistake.

No matter that we may want patients to act as consumers because it suits our economic and political models. No matter that it really might give parts of the NHS a much needed boot up the backside if people were a bit more picky.

If the truth is that, when faced with the prospect of a massive heart attack or a life with dementia, most of us begin screaming and sweating and praying, then we are not dealing with consumer behaviour but with existential terror. Less emporium of pleasure, more crematorium of terror.

But I can hear you protesting that people do want choice, they do want to be involved in their care and to have a say. And you’re quite right, but to call this behaviour ‘consumerist’ is to mistake its inner reality.

My experience as a GP was that when we hit the “Have I got cancer Doc?” moment people want many things – time, information, a sense that they matter to the person answering the question – but choice of provider is not high on their list.

When faced with death or one of his lesser cousins our warm, human bodies take charge. We do not long for more choice but rather for the sweet smell of mother and escape from our paralysing fears.

Speaking up and getting out

Once we have had the treatment, however, it is a different matter. Released from acute anxiety and buoyed by relief, or anger at the indignities that we have survived, then post-treatment, we begin to be ourselves again.

We share what happened with our friends and re-tell our battle with cancer or the ward sister as part of our moral rehabilitation.

Along the way, we happily take part in a survey or fill out a Net Promoter Score because we want to “give something back.”

For those who believe that markets in health care are important, this magically reconfirms that patients really are ‘consumers’ after all – even if consumers in real life are far more concerned with getting than with giving back.

In policy terms, this means we may have been putting the consumerist cart before the treatment horse.

If people behave more like consumers after treatment, but only sporadically before, then ‘voice’ is more important to them than ‘exit’.

In other words, being able to influence a service, with a view to helping it to improve, is more important than being able to quit it in favour of a different provider.

Interestingly, this also confirms our collective experience over the last ten years of trying to offer choice of provider to patients – the little beggars are just not that interested in it.

Speech is silver (choice costs gold)

All this matters because exit is the theoretical basis for trying to create a market in health care. The idea is that if enough people leave a service it will buck up its ideas or fail; in which case something better may take its place.

Since the economic and political costs of markets in the NHS are rising (just ask former health secretary Andrew Lansley) whilst those of voice are falling (just look at Twitter) a revolution is afoot.

In the future, users of health services are likely to exert pressure primarily via social media rather than market choice.

About the author: Paul Hodgkin is chief executive of Patient Opinion, a website on which patients, service users, carers and staff can share their stories of care across the UK. Patient Opinion is a not-for-profit social enterprise based in Sheffield.

Until 2011 Paul also worked as a GP and has published widely including in the BMJ, British Journal of General Practice and the Guardian and the Independent. He tweets at @paulhodgkin.