As a result of the macro factors described in outline here, more fully here and even more fully here, health care in the UK and many other countries is changing in nature. It is becoming seen as a set of auditable transactions, often in a market (or quasi-market) economy.
While effective, efficient transactions are essential in health care, and will sometimes be all that is needed, often they are not enough. Sometimes elements of a gift economy are needed, by both care receiver and care giver.
The differences between a market and a gift economy:
| In a market economy | In a gift economy |
| Status is gained according to what we acquire. (This can be material goods or things like power). | Status is gained according to what we give away. |
| We talk of value. Value can usually be expressed I monetary terms and allows us to compare and trade things that are completely unlike each other. | We talk of worth. The worth of an object has nothing to do with its monetary value. The worth of a painting is to do with the labour (see below) of the artist and the reaction of the viewer. |
| We describe our efforts as work: we can measure the skills we deploy and energy we put in for a given time period. | We describe our efforts as labour: we give something of ourselves, what we do includes some essence of ourself, it cannot be measured in the same way as work, only described or felt. |
See The Gift- How the creative spirit transforms the world. Lewis Hyde. 2007
When these elements of a gift economy are present, care becomes a covenant between the two people. A covenant that includes the transactions of care but also aspects of a relationship.
In the table below I show in the left hand column the features of transactional care, and in the right hand column those of care as a covenant.
Some of the terms may need further explanation that can be found in the fuller descriptions listed above.
| Transactional careHealth care as a set of auditable transactions in a market economy – patient as consumer, professional as provider | Covenantal careHealth care with elements of the gift economy – patient and professional are in covenantal relationship |
| Patient is cared for ; ‘you have condition X for which the best, evidence based, most cost effective treatment is Y. I will make sure you get Y’ | Patient is cared about as well as for: ‘I care about what happens to you and about how the quality of our interaction can help you and I will make sure you get the best treatment for you, within the resources available’ |
| Professionals are seen as givers (or suppliers) of a service | Professionals recognise that in their encounters with patients they give and receive, that care is a practice and not merely a service |
| Focus on calculation and counting – this can be seen as objective | Focus on thoughtful, purposeful judgement – this is necessarily subjective but incorporates objective measures and evidence |
| Predetermined protocols | Emergent creativity which can include the use of protocols |
| Discourse and (hyper)activity | Wisdom and silence in addition to discourse and action |
| Explicit knowledge | Tacit knowledge as well as explicit knowledge |
| Reflection on facts and figures | Reflection on feelings and ethics as well |
| Focus on efficiency and effectiveness | Focus on the quality of the moment as well |
| Dealing with the presenting problem | Keeping in mind the meaning of the encounter – for both parties – while addressing the presenting problem |
| Competence is what is called for on the part of the professional | The humanity of the professional is also called upon |
| Individuals have a relationship with the state and with the market | Individuals have a relationship with the community and with wider society |
| Good policy ideas MUST degenerate as they are translated at every level of the system into a series of measurable, performance manageable actions and objectives. The focus here is on being able to demonstrate the policy has been implemented. | Policy ideas can stay rich and be added to creatively, so that solutions are responsive, humane, practical, flexible, and adaptable. Here the focus is on implementing the spirit and intent of the policy. |
It is very important to remember that the left hand and right hand columns are not opposites. Neither is good nor bad.
And that the right hand column always includes the left. We cannot shirk effective efficient transactions of care in the name of ‘relating’.
Neither can we ignore the relating aspects of the covenant in the right hand column when these are needed. So we need to find ways of engaging these that do not prevent effective and efficient transactions.
Perhaps the right hand column is about the ‘how’ while the left is the ‘what’.
Certainly, for clinicians to pay enough attention to the left hand column managers need to pay enough to the right (and vice versa).