"I liked the love, care and attention of every member of staff, it was terrific .What needs improvement are the toilet seats – those on the wheel chairs and those fitted to the home toilet are useless.
“They are only made for women. Men cannot sit and urinate and open their bowels, as men’s genitals will not sit inside the opening. This means one has to open the bowels, then stand and turn to urinate. With a knee/hip replacement operation it becomes like mission impossible.” [Patient Opinion story 676]
Patients so often know how things could be better. Give them the chance to comment on their services anonymously and they are incredibly positive, thoughtful, specific and generous.
Far from being angry – even when things have been less than perfect – most people want to help the NHS.
Of the tens of thousands of stories on Patient Opinion, more than half are like the one that opens this column – positive but with a suggestion about how things could be better.
Serious or very serious stories account for around 20%. And fewer than one in four thousand contains an obscenity or swear-word.
Stumbling on the gift economy
So how is it that our experience at Patient Opinion is a million miles from the narcissism of Facebook or the rancour of the blogosphere?
People obviously use Patient Opinion for all sorts of reasons, from gratitude to rage. But the most interesting and useful stories are those that quietly assert their own insight, humanity and ability to help others.
Although it took us a while to see it, we eventually understood that we were running something more akin to the blood transfusion service than to the blogosphere.
People were donating stories because they knew it would be useful to other people and because it made them feel good about themselves.
Since information, unlike blood, can be used over and over again insights about post-operative commodes are as useful in Swansea as Southampton.
Quite by accident we had stumbled on one of the emerging phenomena of the 21st century – a digital gift economy. There are bigger and better examples – Wikipedia, Linux and Ushahidi – but all are exploring a new terrain quite unlike anything else.
Back to the future
Accustomed to the self-serving rhetoric of the market, we find the idea that significant parts of the human world are governed by giving not getting absurd. Yet, in reality, gift economies lie at the heart of families, teams, friendship – in fact much of what we value most.
Gift economies are systems of exchange driven by the rewards of giving not getting. They are destroyed by money (try paying your mother-in-law for the meal she has just cooked you). This means they are largely invisible to markets, businesses and economists.
Giving, and the web of mutual obligation and pleasure that it creates, has been the glue within kinship groups and tribes throughout pre-history.
Our predilection for giving is probably rooted in the cooperative childrearing practices that were needed to enable hunter-foragers to find the 13m calories required to raise a human infant to the age of 18 in pre-agricultural societies.
All of which fits with evidence that the act of giving, even when invisible to others, increases well being.
Of course, people aren’t stupid and they give stuff for good reasons – to enhance their reputations or create a sense of obligation. So, gift economies are run by ordinary people not angels.
On the other hand, they are very different from markets because the value of the gift is determined by relationship not scarcity. A birthday card made by a grandchild is more valuable than any card that has been bought.
Digital overcomes freeloading
The problem is that gift economies don’t scale well- precisely because they have to be rooted in a relationship. Giving stuff to strangers is a mug’s game.
More importantly, economies based on giving physical things tend to run out of either stuff (the empty cooking pot problem) or meaning (the too-many-socks-at-Christmas problem).
These constraints limit traditional gift economies to groups that can exchange physical stuff over existing webs of face-to-face relationships.
The digital world changes this. Gift economies based on the exchange of digital goods can access an infinite supply of free gifts to exchange to drive the giving.
The cost of distributing stuff – and tracking who is more generous than who – is also really easy on the web. This dramatically reduces the overheads required to run a digital gift economy.
However, the most important effect of the web is to solve the free-loader threat. Having 250 people turn up to eat your free lunch when you were only expecting the 25 who came with food is a supply problem and a social disaster.
By contrast, having 25,000 people download your (digital) software rather than the 25 you wrote it for is the pinnacle of success. In a digital world, freeloaders become audience and moral hazard becomes reputational pay-back.
Digital gift economies are exciting because they manage, as if by magic, to conjure massive commitment to common ends from a small minority who willingly contribute to the good of all for no financial reward whatsoever.
Digital gift economies have appeared because the web has lowered their transaction costs by several orders of magnitude. What was once expensive (Britannica) is now free and better (Wikipedia). All this has profound implications for solving human problems.
Looking for the modern campfire
Understanding digital gift economies matters a lot. Partly, this is because they can be subverted – for the jihadist suicide is the ultimate gift, dead bodies the currency, and video statements the means to gain reputation.
More importantly, digital gift economies are a way to release large amounts of free resources in ways that draw us together.
At some deep level, digital gift economies are the answer to what happens after market capitalism and its pursuit of ‘stuff’ has run its course.
Gift economies mediate the transactions of the heart and hearth that we still crave. The digital world liberates these economies to massively scalable platforms.
Where money accelerates transactions in the marketplace of desires, digital goods and the on-line accounting of reputations accelerate transactions in these new economies of the heart. The hidden hand of the market is becoming matched by the hidden heart of the digital gift economy.
And along the way, when we strike the magic Wikipedia moment, massive social wealth is created as if for free.
No matter that constructing working digital gift economies is a hit and miss affair just at the moment. The point is that we are on the way home, that we have found the other half of the market, the half that existed around the campfire before the market was dreamt up.
Digital gift economies release creativity, action and meaning from their tribal roots and allow them to embrace the global.
Fixing the toilet seat
And what of the toilet seat? Well, when the matron saw the posting, she rounded up as many different kinds of commode as she could and asked the next cohort of men to decide which they liked best – and that is what they use now.
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. Follow him on Twitter @paulhodgkin.