TY - JOUR T1 - Is an NHS designed around the patient bad for your health? JF - British Journal of General Practice JO - Br J Gen Pract SP - 810 LP - 811 VL - 55 IS - 519 AU - David Kernick Y1 - 2005/10/01 UR - http://bjgp.org/content/55/519/810.abstract N2 - Concern has been expressed that the current patient choice agenda that equates health-seeking behaviour with any other form of consumerism may not be in the best interests of the NHS.1,2 An alternative viewpoint sees the role of doctor in a partnership with the patient, based not on power or patient choice but one of mutual respect. In this paper I examine the role of patient and healthcare professional from the perspective of the three basic organisational frameworks of hierarchies, markets and networks. It is concluded that the objective of any service reconfiguration should not be to correct the asymmetries between patient and doctor through market or bureaucratic means, but to build upon their differences in networks of trusting relationships and cultural norms that facilitate coordinated action. This approach will provide the most effective and responsive framework to the challenges that lie ahead.Decision making in health care is characterised by two problems. Firstly the transfer process between healthcare inputs and health is often poorly understood, and physicians are required to make implicit decisions. Secondly, there is a knowledge asymmetry among stakeholders due to the specialised nature of medicine.These problems have been interpreted within a ‘principal–agent’ framework. Here, the principal (the patient or healthcare organisation) delegates activities to an agent (the doctor), who is expected to accomplish these activities at the principal's behest. The focus of analysis is on how asymmetries of information and potential incongruent objectives between principal and agent can be minimised.3 Hierarchies and markets have formed the two main approaches.Hierarchies form the traditional model of organisational structure, where upper levels place constraints on lower levels. Each individual has a predetermined function operating in a bureaucratic system of rules and regulations. The contention is that the cost and consequences of alternative resource allocation … ER -