Introduction

In the past 10 years, there has been a significant increase in interest in the way that policy has positioned the users of public services in relation to professionals and managers (Deacon and Mann, 1999; Le Grand, 1999; Greener, 2002b). From being overlooked in much analysis in the 1970s, which often focused on the relationships between the state, managers and doctors, an interest in the experience of the user of health services has come along with a new emphasis on both consumerism and citizenship in healthcare. The central question this chapter examines is how the NHS, and how NHS policy, has positioned the users of health services. Have they been thought of largely passively, receiving services from professionals, or having their interests looked after by managers? Or are they instead assumed to be active co-producers of their own healthcare, or even healthcare consumers, taking responsibility for making medical decisions for themselves and demanding improved care from doctors?

Position of the public in the early years of the NHS

At the creation of the NHS in 1948, lists of GPs were published to allow the public to choose the GP with whom they wished, in the terminology of the time, to form an ‘association’ (Ministry of Health, 1944). This means that the public were establishing a long-term relationship with their GPs, and were not expected to change their doctor frequently, or even at all (Greener and Powell, 2009: forthcoming). Doctors initially appeared to be concerned that, as patients were now receiving care free of charge, they would march into practices declare that as doctors were now public employees they had better start improving their service (Webster, 1998b). These fears appeared largely unfounded, however, with patients usually relieved just to be receiving free care for themselves and their families, and so largely happy to accept doctors in their professional roles. General practitioners were regarded as family doctors, trusted local people often held in high regard, in whose presence patients were largely deferential and grateful. Considering that around half of GP practices comprised doctors acting alone, there was the potential for a close and long-term relationship between the GP, who might know families across several generations, and the patient.