Several articles in your Winter 2000/2001 issue (Hospital Quarterly Vol. 4 No. 2) talk about the changing healthcare consumer. According to Hy Eliasoph (e-Health Consumer: A Diminishing Tolerance of Hospitals), "These new consumers are:

• armed and dangerous;
  
• better endowed and informed;
  
• growing in numbers (relatively and absolutely)
  
• emerging as a new market force;
  
• demanding interactive communications;
  
• looking for more personalized and customized healthcare and information;
  
• and, perhaps most important, feeling empowered."

Whether we call them consumers, customers, or clients one thing is certain, they are not as "patient" as they used to be. People today expect high quality and immediate service. Now more than ever, healthcare clients are better informed about their rights and treatment options.

Our society has evolved in the last decade, now placing much more emphasis on rights at the expense of duties, and our clientele is no exception. As providers of healthcare we have to adapt, but to what extent? To answer this question, an appropriate comparison can be made with the private sector where there is no difference between need, demand and expectation - as long as you can pay for what you want.

When shopping for a car for example, a paying customer has the right to raise his expectations beyond the basic need for transportation and will adjust his expectations to the price limit he has set for himself. It is not the vendor's job to ensure that his expectations match his needs, or even that his needs are met. Maybe his car is only three years old with 60,000 kilometers and could easily last for another three years - the car itself doesn't need to be replaced. But is unlikely that the vendor will even try to convince him that he doesn't really need to spend $50,000, and that a four-cylinder Camry at $25,000 is really all he needs. His expectations, and satisfaction with the car he decides to buy, are directly related to the price he pays. The old adage "you get what you pay for" applies to any good or service. The higher the price, the higher the expectation. In a marketplace based on supply and demand, the supplier will adjust both production and product based on what the consumer wants and is willing to pay for.

In a publicly funded and publicly run healthcare system where there is no "price" to regulate demand, the providers - whether they are governments, individual healthcare professionals, or institutions - must adjust the supply of services based on available resources and perceived consumer needs. Supply is used by governments to control costs of care. And as with any state- regulated economy where the price does not regulate the market, there is a gap between supply and demand, and that gap is more difficult to fill than in a private-sector economy.

Real Needs and Reasonable Expectations

In a publicly-funded system, healthcare professionals are responsible for meeting the basic needs of the client: timely access to service, accurate diagnostics and competent care. And although more people today challenge medical wisdom, clients still have a high degree of confidence in health professionals and assume they are competent and will make the right decision regarding their needs.

It is also reasonable for clients to expect:

• to be informed and to understand their condition and treatment options;
  
• to be treated with respect, courtesy, and attention by staff;
  
• that their time will not be wasted due to unreasonable waiting times;
  
• privacy and confidentiality;
  
• well-organized and coordinated discharge;
  
• acceptable food;
  
• a certain level of autonomy and risk taking;
  
• a social life in the case of long-term care clients.

But in today's healthcare system, it is also possible, and in many cases likely, that some of the client's real needs and reasonable expectations cannot be met because of lack of funding, dwindling human resources or difficulty accessing healthcare services. And all too often, healthcare professionals perceive their clients to be too demanding or unreasonable. And yet, "healthcare organizations must recognize and endeavour to understand, anticipate and proactively meet consumer needs." As Eliasoph points out, "organizations that ignore or are oblivious to these needs do so at their own peril."

I would like to suggest several causes that may contribute to that perception:

1. Because workload has increased, staff has been reduced, and resources are very scarce, the level of attention provided by nurses 10 years ago for example, may not be there today.
   The client's expectation may be exactly the same as it was 10 years ago, but in today's context, it is perceived as unreasonable.
2. Today's society as a whole is better educated and has access to more information (e.g. through the internet). Clients expect good service in all of their interactions with public and private sectors. As explained in the Eliasoph and Berger articles, consumers do their homework before seeing the provider and they expect to participate in the discussion regarding their treatment. This may lead to unreasonable expectations where some patients, for example, demand a full range of (perhaps unnecessary) diagnostic tests.
3. Comparing our (public) system to the American-style (private) where there are no waiting lists, MRIs can be obtained in a few days, and nobody dies waiting for heart surgery. The media are largely responsible for this inappropriate comparison, advocating for more private-sector presence in healthcare, and therefore contributing to increased expectations.

As Earl Berger says (..."the Makings of a Potent Brew of Clashing Cultures"), healthcare professionals ... "are required to conduct their professional activities in ways for which they are accountable, which are guided by professional knowledge and judgement, and which are efficacious and cost effective. It is hard to maintain that professional stance in the face of prosperous, and not so prosperous, consumers who want what they want because of what they have read or heard on the Internet and from the media."

Bridging the Gap

I think, however, that there are ways of bridging the gap between the needs of the patients, their expectations and what can be reasonably expected of our healthcare system. The key is to listen to our clients and make changes to the things that are under our control. Consider the following:

• Is it reasonable to serve meals at 11:30 a.m. and 5 p.m? Whose needs does this serve - patients or staff?
  
• Is it reasonable to make people wait for hours for appointments? Their time is as precious to them as to the healthcare professional.
  
• Is it unreasonable to expect that home care, rehabilitation or convalescent care has been well-organized before discharge?
  
• Is it unreasonable for an elderly person to expect to be treated as an adult, who has the right to make his or her own decisions?
  
• Is it reasonable that a patient has to repeat the same story four or five times, or even repeat the same tests, because of poor communication between institutions, or between professionals in the same institution?
  
• Is it reasonable that in most cases, social workers, physiotherapists, or speech therapists are only available from 8 a.m. to 4 p.m., five days a week?

Perhaps this suggests that hospitals should begin looking at ways to change the way they do things, to better organize the patients' time and access to services instead of their own. Perhaps the time has come for healthcare providers to become more client-focused.

This does not mean, however, that we can or must fulfill all expectations nor that we should even try to. Our first obligation is towards clients' needs and healthcare providers should not compromise on these fundamental needs simply to meet client expectations.

What is patient-centred care?

Being consumer-focussed, or patient-centred, is a constant challenge in an environment where the supply of services is not regulated by price. Any demand or expectation by the consumer may be perceived by the provider as unreasonable because it forces the provider to adjust or modify the way services are delivered. But it may be perceived as a right by a patient who has been told by government that he is a consumer, and who thinks that his taxes give him the right to expect unlimited services. But this is the new reality. "The patient-provider relationship is in flux. Consumers desire greater autonomy and participation in their healthcare decisions, but still strongly rely on their physician's knowledge and advice." (McMurchy and Vujicic, "The Changing Dynamics of the Patient-Provider Relationship")

While I don't think that, in our field, it would be true to say that the client is always right, I think that most of us could do much more to get closer to the patient-centred concept by organizing care around the client. It is because of the client, after all, that we are all here.

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