All health care systems are bedeviled by the problem that sick ill people make poor shoppers. Patients are consistently disadvantaged by having less knowledge, less power and more vulnerability than other players in the health care system. In economic terms this is an example of an actor-agent problem: doctors and 3^rd party payers have to act as agents for the principal actor (the patient) but inevitably and always the interests of patient, professional and insurer/government diverge. This is why markets are such a poor way to deliver health care. As Robert Evans a great Canadian economist said: ‘The search for the informed, rational consumer of health care is of the same order as the search for powdered unicorn horn’.

The system is stuck because the costs of reversing the fundamental asymmetries of information, power and vulnerability have been too high to change. The direct result on patients is that their views are consistently under-valued and, combined with the dependence inherent in illness, they are systematically (if unintentionally) disempowered.

The direct result on healthcare as a system is that these agent-actor problem gives rise to multiple conflicting accountabilities - to patient, tax payer, professional values, local budget, local partners, the scientific evidence-base, local and national political processes, staff, and somewhere out along the tail, the patient. These accountabilities have multiplied in recent years and the NHS now frequently appears as a Gulliver - magnificent, well-meaning, and gigantic but completely constrained by a thousand Lilliputian ropes.

The web has changed some of the fundamental reasons for these asymmetries. This is most clearly seen with information where the free-for-all released by Web 1.0 greatly reduced informational asymmetries. For the first time patients could access the knowledge base of professionals. As esoteric knowledge disappeared out of one door, patients clutching web printouts entered by the other. Some information gradient remains but professional knowledge is no longer seen as either esoteric or zero-sum and everyone now recognises that the more patients know the better.

Web 2.0 creates other opportunities. Blogs, YouTube, and MySpace have dropped the cost of having a public voice to zero. Alone, this simply creates an over supply of voice which in turn leads to people shouting and becoming less civil in order to increase the chance of being heard. Thus to date, democratized voice has under-performed as a driver of quality in service industries.

But the web has also created RSS feeds that enable your comment about an aspect of service to be directed to ‘just the right manager’. This dramatically increases the signal to noise ratio for busy managers. Cheap voice plus highly selective listening should substantially lower the costs of responding to citizen comments.

Patient Opinion is about building system-wide information streams around these new, and as yet un-noticed, cost opportunities. The generic aim of these streams is to reduce the asymmetries to which patients are subject.

The final piece of the jigsaw is to create a web currency that rewards public and staff for using feedback to change the service. Instead of clicks and hits such a currency would place a value on responsiveness and improvements made.

Public voice gives explicit power to patients. And becoming a real co-creator of change in the system empowers people in their struggle with illness. This is especially true when the change that patients suggest is directed to the benefit of others rather than to bettering their owwn immediate care.

None of this will make markets more suited to health care but it should mean that where ever patients are struggling with the helplessness, lack of control and fear associated with illness, they can find tools that help them to feel more informed, included and valued.

Last week that staid and august body EURIM published its report on "transformational government".

The bit that caught the attention of some bloggers was the idea of "sous-veillance". The report said:

"New web applications such as YouTube or Patient Opinion enable people to monitor the state and to be heard. People can easily post videos of dirty hospital wards, of uncollected rubbish or of pot holes in the road, to a world-wide audience...Sous-veillance might transform political engagement due to its ease of use, by engaging even the time-poor majority and extending citizenship beyond the usual special interest groups.

What is extraordinary is how rapidly the notion of "sousveillance" has moved into the mainstream of political discourse - and that people can point to practical examples such as Tidy Oldham, and even Patient Opinion (which I think I would prefer to see as co-creation rather than any kind of -veillance).

But EURIM also says something else which, from where I sit, feels important. It says:

"The key lies not in treating users as passive recipients but in engaging them as active partners in the creation and development of their own services. This will require new community governance models from design to delivery in a ‘virtuous circle’ of participation, collaboration, commitment, accountability and feedback, both online and offline."

I think that's right. This isn't about "building a website" - ultimately, it's about building a different way of doing things. 

There's a lot of talk around about using technology to improve healthcare - making more information available, giving patients a voice, helping them manage their care by making patient records accessible online, and it's thowing up some real key issues.  Empowering patients to have more knowledge about their conditions, more information about the services they receive, to have more choice, appears to a step in the right direction, but what about the implications?  A lot of the issues are around power and who is in control - the public has access to more information than ever before, and this all works against the paternalistic model of care.

We are starting to see a real power struggle, between those who have traditionally controlled healthcare (clinicians, GPs) and those receiving it.  For a number of years there's been a recognition that expert patients, those with a good understanding of their condition, visit their GP less often - in 2005 the Department of Health launched the Expert Patient Initiative.  At the time only 21% of doctors were in favour of this approach to supporting those with long term conditions like diabetes, arthritis and Parkinson's, there's still a considerable number out there who think patients "do not have wisdom but follow prejudice, hearsay, and urban mythology" (Ray Jones).

Patients are being encouraged by the government to take control of their care, the internet has supported a new phenomenon, patient opinion leaders, and expert patients are becoming more and more common, as this post in HSJ indicates "People with chronic conditions are sharing their stories with each other, not just for emotional support, but for the clinical knowledge they gain in an online community." (Jane Sarasohn-Kahn of the think tank THINK-Health and author of a report on health 2.0).

This power struggle is becoming a major issue in the US.  According to Dr. Robert Lamberts, an internal medicine physician and medical blogger in America “Doctors used to be the only source for information on medical problems and what to do, but now our knowledge is demystified.”  “When patients come in with preconceived ideas about what we should do, they do get perturbed at us for not listening. I do my best to explain why I do what I do, but some people are not satisfied until we do what they want.”

Sharing information is driving the shift in power.  Patients have a voice and have access to others stories about their care, but is anyone really listening to them?  Here's the real issue - technology is just an enabler, it supports change and improvement and innovation, but it can't make it happen.  Without the ability for people to make it happen, it won't.  Throwing money at technology is not the answer.  Technology can only go so far, it needs a real, adult conversation between patient and doctor and the ability of staff to make changes without being stuck in a bureaucratic loop.  Patients are changing and starting to take control, those working in the NHS need, in my humble opinion, to release some.