Book Reviews
Responsive healthcare: Marketing for a public service
Rod Sheaff
ISBN: 0-3351996-6-6 2002 248 pages Buckingham: Open University Press
Mary Harris
Adjunct Senior Lecturer, University of Sydney; Senior Policy Analyst, Australian Medical Workforce Advisory Committee, NSW
This book is one in a series published to inform health service managers employed within the National Health Service (NHS). Its objective is to assist managers to make their services more responsive to the needs of patients and the public.
In Australia in recent years there has been a growing interest in consumer participation in health care decision-making in line with government policies with a view to improving the quality and responsiveness of health care services. However, while the rhetoric has been noisy, the availability of information on how to achieve useful consumer participation has been limited. I therefore approached the review of this book with some eagerness to see what Australian health care managers might learn from Rod Sheaff's application of marketing theory to the management of publicly funded health services in the United Kingdom.
The book begins by outlining some of the bad press experienced by the NHS during the late 1990's because of patient waiting lists and the consequences for sick individuals of hospital bed shortages. Sheaff also notes the publication of The NHS Plan, 2000, which states that 'the NHS in the future will shape its services around the needs and preferences of individual patients, their families and carers'.
Sheaff's aim is to describe classic approaches to marketing employed by private sector organisations, to deconstruct these approaches with a view to learning from them and adapting them to publicly funded health care organisations. He argues that while many politicians and others have been critical of the management of publicly funded health service organisations and have called for their privatization, this is not the solution because those who most need health care tend to be in a poor position to participate in a privatized system (that is, the price of entry into the market is too high for many). He also argues against the wholesale adoption of commercial marketing practices to public sector health care organisations on the basis that these organisation have important and essential characteristics that are unique.
The book consists of 9 chapters with each following a similar structure. Useful figures and tables support the text. The first chapter defines the primary objectives and incentives of private sector organisations operating within a market economy and outlines in some detail a commercial marketing model. The chapter emphasizes that the primary objective of commercial marketing is usually about selling to maximize the profits available for distribution to the organisation's owners, or shareholders or managers (that is, marketing is done primarily in the interests of the organisation doing the marketing, not in the interests of the general public). Achievement of this objective in the long-term requires the organisation to accumulate sufficient capital to reinvest. However, achievement of this secondary objective is subject to external environmental factors, such as the status of the economy, over which the organisation and its managers exert very little, if any, control. Hence, effective marketing requires activities, such as environmental scanning, consumer research, planning, and communications.
Chapter 2 explores in more detail the 'commercial marketing model' and analyses differences between 'acceptable' and 'objectionable' marketing strategies. In brief, acceptable strategies are those which provide consumers with accurate information about a given product and its price and which enable them to make satisfying purchase decisions, while the latter involve strategies designed to mislead or misinform consumers in the interests of maximizing sales. In other words, deliberate attempts may be made to increase the level of asymmetry of information that exists between the provider and consumer about a given product or service. This chapter also examines critical differences in the objectives and incentives underpinning marketing strategies used by private sector organisations and those of public sector service organisations such as the NHS (defined as 'modified markets or quasi-markets'). Structurally, quasi markets such as the NHS are described as being like a single, 'huge private firm (that is, as a monopolistic, hierarchical bureaucracy) and providing healthcare practically free at the point of use.' The main strengths of this approach are described: 1) it solves the market entry problem; and 2) by substituting an expert proxy purchaser, such as a GP, as the consumer's source of information, it solves the information asymmetry problem. A major limitation of the quasi-market is that it tends to become non-responsive to consumers' reasonable demands and to develop a tendency towards undersupply of health care compared with needs. Sheaff argues that the development of an appropriate marketing model for public sector organisations requires a realistic and radical redefinition of the commercial model; that is, it requires a model that takes into account critical differences between the two environments.
Chapters 3-6 systematically develop marketing strategies for use by different types of health services within the NHS. Types of health services include: health care purchasers (referred to as 'marketing for healthcare commissioners'); health promotion; primary healthcare providers; and secondary health care providers.
Chapter 7 examines concepts and strategies for managing quality of healthcare and clinical governance with reference to the particular requirements for managing quality in a quasi-market. Sheaf maintains that the 'main difficulties with quality management in the NHS are the semi-detached nature of medical management (clinical governance), its separation from other aspects of quality management, and the underdevelopment of evidence based medicine'.
Chapter 8 is titled 'Consumer research in healthcare' and it outlines issues to be addressed and quantitative and qualitative methods appropriate to obtaining evidence required for effective marketing by public sector healthcare organisations. Unlike clinical or scientific research, Sheaff proposes that consumer research, like much management research, frequently relies on secondary sources of data, such as, existing administrative data (for example, sources of referral, patient waiting times) and methods appropriate to gaining information about community expectations, and patient experiences, behaviours and opinions.
The final chapter, 'Marketing in a post-market system' seeks to gather the main findings arising from preceding chapters and to develop conclusions about the usefulness of commercial marketing theory and practice to assisting publicly funded healthcare organisations to improve their responsiveness to consumers. He concludes that to be of any use in quasi-markets, such as the NHS, conventional marketing models require radical modification. He proposes that the modified model developed and applied to different types of healthcare services in the book represents a new theory and he identifies some steps that could be taken to test the robustness of the theory. He also describes some of the challenges that confront NHS managers who seek to make their services more consumer-responsive.
This book is not for first year undergraduates. It could be listed among the useful references for final year undergraduates and post-graduate sociologists and healthcare managers. However, the book is not an easy read. Furthermore, it is written for managers working within the NHS and there is heavy use of acronyms, which would only be familiar to readers with an understanding of the NHS. A useful addition to this book would have been a table of abbreviations and definitions. For these reasons, I believe the book is not likely to be popular among Australian students.
The potential value of this book to Australian sociologists and sociologists in general include its preoccupation with how to make social systems, in particular the NHS, more responsive to consumers' rational demands. Secondly, it provides a detailed description and deconstruction of approaches to effective marketing in the private sector and then develops in a systematic manner a theoretical framework, supported by strategies, for application to publicly funded healthcare service organisations. The organisations described in the book are similar in many respects to publicly funded health care services within Australia.
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