There's been a fairly vigorous reaction to health minister Ben Bradshaw's proposal to allow patients to rate and review their general practitioner on the web.

Reading the blogs and the newspapers, I'd say the vote is probably running 4 to 1 against, with many familiar - and valid - arguments on both sides. Yes, we want more openness, more accountability for apparently aloof professionals. No, we don't want medical decisionmaking to pander to all demands, a site that encourages manipulative behaviour, spurious statistics.

One of the strong themes running through the critical comments - from both doctors and patients - has been a strong resistance to the idea of patients being asked to act as customers. 'We don't want to read or write reviews, nor score our doctors,' say the patients. 'We just want our doctors to be good, and trust them.'

But is asking patients to behave as customers what Ben Bradshaw had in mind when he announced the policy? Well, yes, it seems to be. For example, the Guardian reported:

'I would never think of going on holiday without cross-referencing at least two guide books and using Trip Adviser,' said Bradshaw. 'We need to do something similar for the modern generation in healthcare.'

Fair enough - but, in 2009, isn't this starting to feel a little Web 1.0? Is the 'Choosing what to buy' metaphor the best we can do?

Web 2.0 (this isn't exactly news) offers much more - the chance to move from customer to community, from me to us, from buying something to building something, together. As Ivo Gormley's recent film Us Now makes clear.

Our resolution for 2009 is to find ways to use the web to move from feedback on the web to change in the real world.

In 2009 we expect to be working hard on bringing the magic of Patient Opinion to the world of mental health services. (Indeed, we're already getting a fair bit of feedback from mental health service users.)

So this seems like a good time to jot down my "five-a-day": five things which help keep me stay sane and grounded in my daily life (as promoted by the excellent Mindapples site).

In no particular order:

1. texting my children (and getting a reply!)
2. sitting on the sofa with my wife rewinding each of our days
3. a run with my friend Mark (but not everyday, sadly)
4. a little bit of gardening - instant calm
5. and yes, writing a bit of C# code: very relaxing!

What about you?

 Some really great video clips put together by Ivo Gormley and shown under the ‘Us Now’ rubric at the RSA last week. A kind of pot pourri of all your favourite web gurus and harbingers talking about how the social web is changing the world

Lee Bryant from Headshift talking about the effect on the social life of the office.

William Heath on how Government is – or is not –getting in on the act

Clay Shirky with his usual pin sharp analysis of where and how and why hierarchies are groaning under networks. Plus George Osborne, Charles Ledbetter and many more.

Got me thinking about how to get into the real world and make some of this stuff happen. If you start with a thoughtful posting that we published a few days ago – some good care at   Leeds General mixed with some really bad, thoughtless stuff that no one should tolerate, least of all when you’re feeling ill. This feels like a classic hierarchal organisation in which people, all individually good and well motivated, some how conspire to give care that they know is substandard.

How could we use the new tools of the web to nudge them into doing better?

Let’s assume that

a. its patients not staff that are most highly motivated to changing these micro aspects of care and

b. that we have a set of ‘Us Now’ tools to help them. What might happen? What behaviours might change the world? Relatively easy to think of social networking mediated things that would have an effect. A clip from a mobile phone of the woman reportedly crashing around at night on the wardin this recent posting  would surely get the hospital’s attention if it were posted on YouTube or (in time!)  Patient Opinion. But after the 15^th clip was posted about the 15th incident would the hospital still be so bothered? And what of the woman who was videoed – would she thank us for putting her vulnerability on the web for all to see even if it is for the ‘greater good’?  

Seems to me that the harder trick and the real challenge is to build platforms that really are about ‘Us Now’, that work with staff and not against them, that enable them to post their side of the story.

I was wondering whether perhaps we'd been a bit over the top with Wordle on this blog.

We previously had a few posts showing the "big picture" of recent postings and responses on Patient Opinion. The we added one about the promises people made after our event in Rotherham.

And now our Christmas Card features a rather nice Wordle in the shape of a Christmas tree. Perhaps that is too much - but it looks really good.

So imagine our delight when Justin Kerr-Stevens let us know that even Obama has drunk the Wordle juice. Maybe he reads our blog?

OK... back to work.

Hits and clicks are the steroids of the web. Got ‘em and you’ve got growth, revenue and eyeballs. Without ‘em your dead in the water – or at least that’s the conventional wisdom. But whose interest do clicks and hits really serve? Well sometimes it’s useful to know that lots of other people liked an item – it’s a great way to get a sense of a field that you know nothing about. But thereafter hits and clicks mostly serve advertisers and shareholders. They are important because they reflect the ability of the site to raise revenue. But what if your site isn’t interested in selling things? What if you’re site is about changing the world?

Of course if your site is about campaigning or growing a political movement, then getting the message out is important and size still matters. But there is a new game in town, sites that are about generating hyper-local change. Patient Opinion for example is about making ward 15 in Solihull General less noisy at night, or about working with staff at Rotherham to improve how relatives are cared for. Here the motivation comes from the citizen - people are often strongly motivated to stop others going through some particular aspect of  care that has been poorly delivered at some specific site in the NHS.

No point in thinking that this posting will or should garner thousands of hits. What is much more important than size is that just the right 3 or 5 or 15 people who can do something practical about the problem see it and act on it. If we could find a currency and a business model that drove such micro changes, then we would be looking at a way to release the energies of citizens to improve the world in hundreds or thousands of small but significant ways. We might also be looking at the next YouTube. 

Four economic aspects of the web make such a system possible: cheap voice enables everyone to have a public say; RSS feeds increase the signal to noise ratio and enable your message to get to just the right people; the web makes it easy to find ‘people like me’ cheaply and quickly – people who are driven by the same passion or problems as your self; and finally the web makes it easy for people to coordinate action from email to PledgeBank to MeetUp new tools are helping people get organised.  All these tools are currently citizen-centric not organisation centric. For the first time in history it’s easier and cheaper for citizens to put together an effective response than it is for organisations. The problem is that such citizen campaigns can undermine collective solidarity. Such effects can be seen with both Al Quada and the ability of particular patient groups to (understandably) pursue their own with the effect of reducing benefits to others.

So what we need are tools and a web currency that rewards citizens for their efforts and passion about some hyper-local aspect of a service whilst incentivising busy staff so that they no longer see patient comments as blemishes but as the starting point for getting professional and organisational rewards.

Hyper-local tools are what Patient Opinion is now working on. How can we exploit the new economics of the web to enable citizens and front line staff to change thousands of micro-aspects of care?

Last week I talked about Patient Opinion at Alex Stobart's very excellent ScotWeb2 unconference. Lots of very interesting, knowledgeable and motivated people there, so it was a great day.

One or two people wanted the slides, so I've put them on SlideShare and embedded them here:

We're keen to provide a proper Patient Opinion service for patients and carers in Scotland who want to offer feedback about their health care (and we already get stories). One challenging issue, which we are already bumping into elsewhere too, is that there are many, many small hospitals located in very sparsely populated areas.

Why is this a challenge? Because we aim to maintain the confidentiality of those posting on Patient Opinion, and because we don't want to inadvertently defame a member of staff. Suppose we receive a posting about the Royal Isolated Hospital which says: "I was seen at this hospital last week with my genital warts. The nurse I saw was clearly incompetent." So far so good: the patient and staff member are not identified - unless you happen to live locally. In which case you and everyone else round about will know that the only patient seen there in the last month was Iain, and the only nurse at the Royal Isolated Hospital is Margaret.

This doesn't seem desirable - but neither does the option of publishing feedback without saying which service it is about.

We have a few ideas on how we might tackle this - but we're looking for more. Suggestions, please!

When people are ill they want the best care they can get but of course professionals vary in their interests, skills and expertise. So how do you find out who the local expert is?

People imagine that their GP knows all the local consultants and will send them to ‘just the right person’. This is understandable but mistaken. Firstly there are usually several hundred consultants at any one hospital in Britain – keeping up to date with who does what, let alone who is best at what is impossible for GPs.

But even if you’re GP does happen to know who is best, they then have to manipulate Choose and Book, the new mega system to support ‘choice’ which makes it intentionally hard for GPs to use to refer to a particular named consultant. Intentionally because it’s much easier to manage waiting lists when all referrals for a particular specialty or service come into a single pool. So choice is sacrificed to shorter waiting times.

The NHS has traditionally got round this by saying that all services meet minimum standards so you don’t need to find the best. Recently the lameness of this response has triggered an interest in PROMs – Patient Reported Outcome Measures. If we don’t know who is ‘best’ then we’ll ask you, the patient. So PROMs aim to measure how you felt before an operation and then again some weeks afterwards.

The Darzi report, which is this year’s bible on how the NHS should develop, says that we should use PROMs right across the system in the hope this will help people choose who they want to see. And give a valid answer to the question that managers are also very interested in, namely ‘which of our doctors are good?’ (And, by implication, which are less good).

Trouble is that whilst PROMs are useful they are very far from perfect. To make valid judgements about outcomes you need to have a big enough sample and make sure that inputs – the casemix of people seeing different consultants or teams – is the same. If one team specialises in difficult cases their outcomes will be different to those handling easier cases. And of course you need a reasonable number of cases for each procedure and each surgeon. The danger therefore is that PROMs will just mean many more surveys for patients plus a whole new industry processing the answers and tweaking the answers to try and get a ‘true’ picture.

For our part we think that the emphasis on choice is in some ways – literally – misplaced. The 'choice' policy puts the question at the wrong point in the process. Ill people make poor shoppers, and whilst they most definitely want to be involved and informed in decisions they usually want to be looked after rather than labouring under a mountain of 'choice' decisions. Once patients have experienced a particular service (and hopefully are feeling better) they have very decided views about what they liked and what could have been better. Using these views as a quality driver makes much better sense – and is what we try to do at Patient Opinion.

How to give patients accurate, useful information to help them make better choices is an important question that keeps coming round and round like a bad penny. PROMS, Choose and Book, Information Prescriptions, NHS Unlocked, IWantGreatCare all represent different approaches to this problem. Sadly trying to find who is the ‘best’ doctor for some condition or operation is a simple question that can only ever have frustratingly complex answers.

Among all its myriad wonders, one thing the web does well is enable every voice to count. Even the voices of people who don't usually have a voice.

That's been one of the key values driving the Patient Opinion team. And now we're pushing this a little bit further through our partnership with Homeless Link, with our attempt to bring the voices of homeless users of health services into the heart of the NHS.

Will it work? We don't know, but we think it's worth a try. Remember, On the Internet, Nobody Knows You're a Dog.

James has been busy creating big pictures of Patient Opinion postings, and Paul has talked about our recent work with Rotherham Trust, where staff made promises to themselves. We will be publishing those promises on the site in the next few days, but in the meantime here is an interesting combination of our last two blogs.

Here is a Wordle of 50 promises that Rotherham staff have made.

The other day we blogged about "the big picture" of the last 100 postings on Patient Opinion.

So a few people said: "well, OK, but what about the responses from the NHS?" And, obviously, we couldn't resist. So here's a Wordle of the last 100 responses posted on Patient Opinion.