Emma Cartwright describes how having to pay for health services has given her more control over her care

As someone who was diagnosed with type 1 diabetes at the age of 4, I grew up being a frequent user of the NHS. I attended all of the hospital appointments I was advised to without ever giving it much thought. Once every six months I would see a consultant where I received my diabetes MOT (height, weight, blood pressure, HbA1c). During these appointments I would also usually see a diabetes specialist nurse and a dietitian. And once a year I would also have my feet checked and attend an eye screening appointment.

To me, this was normal and merely part of what I had signed up to since my diagnosis. Although I never failed to miss an appointment, I certainly wasn’t present during them. I nodded, smiled, and agreed with everything the health professional told me, but I never felt present or engaged.

Until recently, I had never questioned the fixed cycle of appointments, despite the fact that on many occasions I would leave with no more information than I had started with. Yet having recently moved to Singapore, where I am now required to pay for every appointment, test, and prescription I need, my perspective has begun to shift.

Most of my healthcare is subsidised by health insurance, so the amount I pay is actually very little (e.g. $20 for an appointment with a GP) compared with many other countries. The normality of seeing chip and pin machines at all GP and hospital reception desks has taken some time to get used to. However, the most shocking thing for me has been the change in my engagement with the healthcare I receive. The prospect of having to pay (even a small amount) for something has changed me from a patient to a consumer, which has altered my perspective on my healthcare.

Since leaving the UK, I feel much more in control of the healthcare I receive. Rather than attending an appointment because I have been given one, I now arrange appointments when I have something I want to discuss or need support with. I now go to my appointments with my questions, wants, and goals, rather than attending to tick a box. This has also led to me taking more responsibility for my health as I am in control.

I have always been someone who looks for value for money and now I seek out value in my healthcare. I now make sure I know exactly what I am paying for. This prompts me to ask about every test I am recommended. Why do I need this? How often do I need this? What does this test tell me? Meanwhile in the UK, most of the time I would provide my blood sample with no idea what was being tested, why, or what any of the results meant. I never felt the need to know as I assumed my doctors would be making the best decision for me based on clinical evidence and their knowledge of me.

I have also noticed a change in the relationship I have with my healthcare team. In the UK I had, mainly, a fantastic diabetes team. In Singapore, however, the health professionals seem to seek to go beyond the basic level of care. They strive to ask me what I want from them, how they can better support me, and what else they can provide to help me. I wonder if this is because they are all too aware that if I leave appointments feeling unsatisfied or hear of another doctor providing better care, I am free to go elsewhere.

The local hospitals host conferences and events aimed at patients, providing talks and support. These events allow the health system to “show off” their services and their interest in supporting patients. I see them as opportunities to learn about my health and meet other people.

Finally, this change from patient to consumer has really allowed me to get the personalised healthcare that suits me. As someone living with diabetes, you can’t always predict when you’ll have a difficult spell or need extra support. I could go for months with no major problems, concerns, or questions. During these times in the UK, I would still find myself sitting in the waiting room of an appointment, racking my brain to think of an issue to discuss with the clinician. In other periods, when things were more challenging, I would have to collect and store up numerous problems or questions until my next appointment, which might be a few months away.

Now I am in control of my care, I can choose to make appointments when I need them (or when I want to have my regular tests done). This feels more like the personalised care I kept hearing discussed in the UK, but never truly experienced.

In the UK I was a patient. I followed the guidance I was given by the professionals. I never questioned their advice in what tests I needed and how often. In Singapore I feel like a consumer. I have been given full control in the care I receive. I make all of the decisions, which means I have also taken on the responsibility. Other people might find this a burden as it can feel like a lot of pressure. I worry that if I started to get complications, I would blame myself more than if I had been within a structured system of appointments. With no one else to blame, I wonder if I would question whether I had managed my health and appointments correctly. But for me, the better engagement and control I feel over my diabetes is worth this added responsibility.  

Emma Cartwright is currently completing her PhD in health psychology at Nanyang Technological University in Singapore. Emma was diagnosed with type 1 diabetes at the age of 4 and is a patient editor at The BMJ, editing the “What Your Patient is Thinking” series. 

Competing interests: Emma Cartwright is a freelance patient editor for The BMJ.