Choice is yours: A psychodynamic exploration of health policymaking and its consequences for the English National Health Service

Abstract

Patient choice is at the forefront of the debate about the future of healthcare provision in many industrialized countries. It is argued that understanding the complexities and the multiple consequences involved in implementing individual patient choice in public health systems calls for an analytic framework extending beyond economic determinism and positivist social science paradigms. This study applies psychoanalytic concepts to illuminate policy dynamics and limitations, using the example of patient choice in the English NHS. It separates declared from unexpressed policy goals theorizing on the role of imaginary institutions and their defensive and less obvious functions in society, and reflects on the implications of policies that are formulated at a distance from operational reality on healthcare organizations. By focusing on the deeper primitive anxieties that are evoked and enacted in patient-doctor interactions, this article examines opportunities and limitations involved in developing individual patient choice. K E Y WO R D S imaginary institutions patient choice psychoanalysis social defences 1 7 1 1 Human Relations

Delivering patient choice in clinical practice: a conversation analytic study of communication practices used in neurology clinics to involve patients in decision-making

“…Yet the concept of patient choice is a contested one, used in diverse ways across different academic, political and policy literatures. 1 Even within the context of the NHS, patient choice is taken to mean very different things. As a key part of the (Labour) government-driven public service reforms, for example, the patient choice initiative had a limited, measurable definition: it referred to a set of deadlines by which patients were to be offered choices that were previously unavailable within the NHS (such as which hospital to attend for elective surgery).…”

A culture of mania: a psychoanalytic view of the incubation of the 2008 credit crisis

“…While writings on social and organizational themes have long been part of the psychoanalytic literature, a substantial number of studies in these areas emerged in the latter part of the 20th Century, with authors such as de Board (1978), French and Vince (1999) and Gabriel (1999) applying these concepts to organizations, and Lasch (1979) and Badcock (1980) using them to examine wider cultural and social issues. Drawing on a variety of psychoanalytic concepts, authors in this field have depicted certain organizational and social dynamics as perverse (Long, 2008), psychotic (Sievers, 1999) and narcissistic (Lasch, 1979;Schwartz, 1990;Stein, 2003), or as characterized by defences against anxiety (Menzies, 1960;Fotaki, 2006) or envy (Stein, 2000). While it would be interesting to discuss the relative merits of these approaches, an examination of these matters-involving long-standing debates within psychoanalysis-lies beyond the scope of this article.…”

Do patients want choice? An observational study of neurology consultations

“…Yet the very concept of patient choice is contested and used in different ways across academic, political and policy literatures [1]. Even within the NHS, patient choice may mean very different things.…”