NEWS FOCUS: The modern patient has come a long way from the submissive, respectful individual of yesteryear. How should health providers respond in an era of greater expectation? Lynn Eaton reports

Patients, so the NHS has been told for the past 20 years or more, should always come first. From a royal commission in the late 1970s to the growth in the patient movement of today, the NHS has struggled to come to terms with what the rhetoric of 'putting patients first' actually means.

And just as the government - fresh into its second term - moves towards what it views as more patient-friendly healthcare provision, someone has moved the goalposts yet again.

That, at least, is the gist of a report published this week by the Institute for Public Policy Research.

'People are becoming more informed and less deferential, ' says its author, IPPR senior research fellow Liz Kendall. 'But, clearly, the system hasn't kept pace with the changing needs and aspirations of changing groups. '

The NHS has to start understanding how patients' needs and expectations have changed, she argues. But it should not lose sight of the fact that many, particularly older patients, will still expect a more paternalistic form of care.

Society is changing, though, with inevitable consequences for healthcare. In future, for example, more and more people are expected to be living alone.

Certain diseases, such as cancer, are increasing as people live longer. More 'lifestyle' drugs, such as Viagra, will come on the market and operations could soon be carried out by robots.

Meanwhile, information about health service performance will continue to improve and patients will become increasingly vociferous about the services they want.

'What patients clearly want is time, ' says Ms Kendall. 'If we are moving towards having more and more specialist nurses, who is left to provide the thing that patients most want and value?

That doesn't appear to be informing the current debate about workforce issues. '

The NHS also needs to recognise that not everyone will want the same level of information at the same time - for example, not everyone has access to the Internet, or they may not want to use it.

Although the government is talking of kite-marking approved health information sites, Ms Kendall suggests a more helpful approach would be to teach children in schools how to access websites that have been peer reviewed.

But the report suggests that basic sources of information such as leaflets found inside drug packets are one very useful source of information that could be made far more patientfriendly.

Patients are increasingly likely to want to take control of their illnesses, she says, arguing the case for more information to be made available on self-help groups and self-management of long-term illness.

The report also suggests - albeit in one line buried in the final pages - that schoolchildren should be taught how to deal with common ailments, such as colds. The near-throwaway remark has been seen in some quarters as a recommendation that young children should treat themselves, to reduce pressure on GPs.

'I am so annoyed with that, ' says Ms Kendall. 'We were not saying they should be diagnosing and treating their own conditions.

People need more information about health, and one idea is to start young so that when they grow up they know about some of these issues. '

But while she is keen to encourage more knowledge, she fights shy of a consumerist approach to health, arguing for a 'citizenship'model instead, where patients have responsibilities, as well as rights - a now familiar New Labour mantra.

'The slow but inevitable decline of paternalism in the NHS provides an important opportunity to drive forward a new agenda: one that not only genuinely empowers patients by promoting greater choice but also encourages and enables them to take on some responsibilities in return, ' Ms Kendall says.

But will that work in today's apathetic society, where less than 60 per cent of the population bothered to vote in the general election?

'It is very difficult to start talking about patient responsibility when people feel the system is letting them down, ' says Ms Kendall.

'But we have to start addressing that, otherwise expectations will have been raised to such a level that it is bound to fail. '

The Future Patient: recommendations at a glance

The move towards a more consumerist health economy needs to be matched by patients taking responsibility for their own health.

Doctor-patient relationships must change, moving towards sharing information and decision-making.

The government should ensure that high-quality healthcare information is available as a core service in the NHS. Every trust, including primary care trusts, should have a senior member of staff responsible for ensuring relevant, high-quality information is available to patients.

A patient support service should be set up as a central point to filter inquiries about a particular illness on to the relevant patient group.

NHS performance indicators should be published by an independent organisation.

Self-care should be encouraged.

Information should be relevant to various patients'needs.

The Future Patient by Liz Kendall. IPPR central books, 020-8986 5488.£7. 50, plus£1. 25 p&p.