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Dr Raj Persaud FRCPsych




Aneuryn Bevan the Secretary for State of Health after much pain with the Doctors, pushed the NHS out on July 5th 1948 – the day the NHS was delivered to an expectant nation – so Bevan could be fairly described as the closest this child has to a proud parent.


Perhaps like all families there was a tendency right from the start, to view the newborn through rose tinted spectacles, born as it was with such high hopes. This child was after all going to rescue its kin, surrounded as they were with bombsites and obvious desperate need, following the greatest catastrophe the nation had ever faced. The NHS became a key brick in the architecture of constructing a nation fit for the return of its war heroes. It’s intriguing to note how foundational a role it continues to play in the UK’s psyche in terms of our vision of ourselves and the bedrock of our country’s key values.


Bevan honestly and fervently believed that the NHS would pay for itself after just a few years, because health would improve so dramatically thanks to the free provision of healthcare, the population would get healthier and therefore, logically, soon need less treatment.


What no one had bargained for as the obedient child matured into an unruly and demanding teenager, were the several unforeseen ways in which paying for baby rapidly became a fiscal nightmare, as is often the case with kids, anticipated savings never materialised.


Problem number one was that medical advances ensured more expensive treatments, combined with ever rising expectations of what quality of life should be delivered by scientific medicine, meant parents soon found themselves on a treadmill of writing ever bigger cheques.


Then the next problem; the population getting older in itself meant costs were going to spiral upwards, even without the added gasoline on the fire of inflationary medical technology. But the two hand in hand was, pardon the pun, a killer.


Indeed there was always a rather obvious and serious flaw in the over optimistic vision of the NHS’s parents all along – the better people’s health the longer they live – to cost you even more in the long run.


One famous statistic bandied around by health economists is that for developed countries something like the majority of health care costs are actually devoted to people in the last year of their lives.


Improving health implicitly means more, not less, expense. You are after all just postponing the inevitable and when it now arrives in very old age rather than youth – multi-system failure is then generally at fault – costing much more to the health service than the much more convenient way (for health economists) that the young tend to go.


This is just one of several key facts about healthcare which politicians prefer to collude with electors in sticking their heads in the sand over.


But those doctors that we might turn to expecting the truth about our prognosis, have also been ‘got to’ by the authorities, undermining the very essence of what an independent profession should be.


For example take Lord Ara Darzi who was a health minister and a practicing surgeon – surely we could rely on such an esteemed member of the profession to tell us just how bad things are before we are wheeled into the operating theatre?


But in an interview reported in The Guardian Newspaper the then Labour Secretary of State for Health clearly relished the analogy of this esteemed colleague with a ‘goat’ — a Government Of All the Talents. Did Alan Johnson have anything to fear from an independent opinion so senior in Health Care planning? Johnson is reported as responding: “We don’t have a goat problem in this department. Our goat is tethered.”


What is inherently paradoxical about the ‘tethered goat’ approach to what were traditionally regarded as respected independent experts, is that the mantra of patient choice in healthcare is also hobbled by it.


If patient choice is going to have any meaning a key issue becomes – how does a patient intelligently choose what to do about a medical problem, and for example, which Hospital or health provider to opt for when enduring a ‘need episode’ as opposed to being merely unwell?


Traditionally patients trusted Doctors with this kind of advice – but if doctors are merely tethered goats – who is the new shepherd of the flock? Or is everyone now merely following sheepishly what the Government recommends, in which case, whatever happened to patient choice?


This key moment – that of making an individual choice has profound implications on which industries and economies turn. It not only has obvious personal implications for whether the patient experiences recovery or not – but there are implications for the rest of us as it determines the kind of health service we are also exposed to.


If patients are not making good choices en mass then inefficient and poor quality health care providers will not got to the wall, and the health service will not improve with time.


Patient choice was meant to introduce the discipline of the market place, and this in turn was going to be the engine which drove quality and efficiency ever upwards, while also through competition, bearing down on spiralling costs.


This is why it was official policy that from December 2005, all elective surgery patients could choose from four or five healthcare providers. The government has even more recently committed itself to the radical idea that new providers from outside the NHS could compete for patients, as long as they demonstrated they adhered to NHS standards and prices.


Is this in fact the first omen that our 67 year old NHS despite having amazingly resiliently survived any disease it ever had to contend with, has now ominously developed something more mortal than a mere sneeze? Is it also possible that it is indeed ironically enough patient choice which is going to prove terminal for this case history, despite all those hurrahs at the recent birthday party?


Javier Garc´ıa-Lacalle, an Health Economist based at the University of Zaragoza in Spain, published a paper in the prestigious journal Health Policy entitled ‘A bed too far The implementation of freedom of choice policy in the NHS’ which ponders this question scientifically.


He has bothered to investigate rigorously the crucial question which lies at the heart of a lot of Government and Opposition humbug over patient choice – which is how exactly do patients choose when it comes to those thorny healthcare decisions?


Garcia-Lacalle points out the UK Government’s own rating scheme for hospitals which is supposed to assist patient choice achieves a unique combination of being too crude (there are only four possible scores: excellent, good, fair and weak) combined with too complex – how a vast array of data is boiled down to this four point scale remains impenetrably mysterious.


One obvious reason choosing a hospital for your operation is not like buying a car is that many will simply opt for the nearest clinic. And there are not likely in the near future at least to be many independently competing clinics near you because the cost of entry to this bazaar is so prohibitive, it’s difficult to see how competition can shape the market.


Another problem with the way healthcare is currently organised is Government seems inordinately fearful of electoral consequences of letting failing hospitals ‘go to the wall’ and tend to bail them out so that failure currently doesn’t have the sobering consequences other markets endure.


On the other hand previous research does confirm that if the local hospital becomes too inconvenient for other reasons – like it develops too long a waiting list, then patients are willing to endure long journeys to overcome these inconveniences. However yet again the research found this kind of decision turned on the provision of high quality information about alternatives.


However the leap of faith that both profession and government need to make is to trust patients to make the right choices by themselves without direct interference. If patient choice is to have any real meaning it really has to be the patient that chooses – not for example the Primary Care Trust nor Care Commissioning Groups, which is in fact who chooses on behalf of the patient now. It’s the PCT or Care Commissioning Group which actually purchases services from Hospitals and GPs.


This is a bizarre way of structuring the health service because it’s not the PCT nor the Care Commissioning Group that actually receives the treatment it pays for – no that remains the ‘joy’ of the patient. If the patient happens to reside in an area where a large powerful PCT or Care Commissioning Group can flex its muscles then the patient may benefit from this purchasing power in ways those residing in neighbouring PCTs or Care Commissioning Groups won’t.


Also suppose a Care Commissioning Group finds itself in financial difficulty because of it’s over-spend on surgery – mental health care patients will suffer from the inevitable retrenchment of contracting – again where is the patient choice in that?


Another intractable problem is that Care Commissioning Groups at the moment purchase via block contracts – for example all their counselling services for a year are bought from a provider and competitors have to sit on their hands and wait for a Care Commissioning Group to realise it made a mistake before getting to tender again for the contract. Plus if the Care Commissioning Group is getting something on the cheap it doesn’t really care that patients suffer – what is the mechanism by which patient dissatisfaction is meaningfully and impactfully fed back to Care Commissioning Groups?


The stark reality that in point of fact patients are being presented with ever diminishing choice, no matter what the spin doctors would have you believe, is confirmed by another problem at the heart of the present Government’s incoherent policy on health care. Bodies it has created like NICE (the National Institute for Clinical Excellence) actually work directly and relentlessly to restrict patient choice, by preventing access to a plethora of the latest treatments through the NHS. NICE’s bizarre decisions leading to outrage from patient groups and doctors on numerous occasions, because basically it disguises rationing decisions as technical or clinical ones.


On top of the predicament of NICE’s restrictions, is the added layer of patient non-choice that different Care Commissioning Groups decide to fund contrasting treatments – the famous postcode lottery. At the moment for example if you have wet age related macular degeneration then peer on a map to choose where you live carefully, as that will now determine how blind your local Care Commissioning Group allows you to get.


The real key to patient choice is to ‘show them the money’ to coin a phrase from the Tom Cruise hit movie ‘Jerry McGuire’. Let patients have their own personal health budget which they then choose how to spend – they suffer the consequences of bad choices and will rapidly learn how to deploy their health budget to maximum efficiency. Perhaps money saved one year by better health can be carried over to future years – encouraging people to look after their health so that they store up credit for future emergencies.


Healthy people who didn’t spend their health budget might earn interest from a ‘health bank’ and also could donate their saved credits to look after ill relatives who need a ‘top up’. At last the NHS would be giving people a direct benefit for looking after their health.


Let patients decide if they want to invest their health budget on drugs which NICE would ban them from – it’s the patients’ health – the average citizen may well make better choices over their own lives than any paternalistic government.


Lacalle found from his new study entitled ‘A bed too far The implementation of freedom of choice policy in the NHS’ that most of patients’ overall quality assessments about hospitals were based on their experiences of how they were treated, in terms of issues like how much better they felt, politeness of staff and convenience. But the problem is that having a delicious coffee served by a polite receptionist in a pleasant waiting room, and even how you feel immediately after a particular procedure, may not correlate with how competent the surgeon lurking behind the next door really is.


On the other hand those valiant doctors and nurses who provide an excellent service against all the odds and despite their NHS management would now at last be rewarded for their hard work. All that dead wood in the NHS would finally be exposed and disposed of.


One key objection from the lobby who don’t trust people to spend their own money most wisely, is that at the moment, given the information available to them, patients may not be the best judge of their doctors, (something doctors themselves have long been convinced of – Harold Shipman was popular with his patients) and if that is the case, then consumer choice is not going to assist us, in the way it does in other markets, in providing a better health service for all.


Perhaps this is the area that Government working with ‘untethered goats’ of experts in medicine, could play a valuable role – by providing accessible yet in-depth information about, and constantly investigating, healthcare providers so that patients end up being better informed. New websites would be formed which helped patients analysed the data and lead them to better decisions so that patient choice became much more meaningful. Just as we consult products like Which? Magazine similar enterprises would be established which also helped the market become more efficient.


The Care Quality Commission would at last have some competition – its reports on hospitals and clinics could now be properly evaluated alongside a welter of patient personal experience which would accumulate on patient choice websites.


The personal patient testimonial available to all via the web would now enter the game in helping other patients make decisions about who to entrust with their lives.


But how to decide what that budget per patient is going to be if everyone is allocated health vouchers or credits? At least transparency in this number gives the electorate a chance to vote on a figure – as proposed by different parties – which has real meaning to each individual. At the moment learning what the latest total NHS financial statement is becomes as personally meaningful as being told what NASA’s latest budget is.


Richard Heijink a Health Economist based at The Netherlands’ National Institute for Public Health and the Environment along with colleagues has recently published a study in the Journal Health Policy which investigated whether it was possible to calculate what it cost to treat an illness depending on which country you were in.


They found some remarkable convergences as well as divergences – for example the average spend per head on the treatment of mental illness was US$67 in Germany while this cost leapt to US$ 184 in the Netherlands. Exactly why costs of illnesses vary between countries might be accounted for by a plethora of national differences in treatment approaches and priorities, but it’s precisely this kind of data which could be used by the Government to set a budget per patient which each citizen then deploys as they see fit.


Perhaps the most profound objection to this idea is this; suppose you find yourself suffering from something like Diabeters or Schizophrenia, which are both chronic disorders probably destined to consume much more resource than the average annual health budget allocated to each citizen.


A way round this might be that once diagnosed you are allocated an additional budget per disease which is calculated on what it should cost to treat that disorder. Again, a direct incentive to properly manage your condition now kicks into place, because you are much more likely to be careful about taking your medication and following medical advice if you know that society is not going to bail you out forever should you become irresponsible in the management of your illness.


Doctors working in the NHS can regale you forever with countless stories of feckless patients who cavalierly disregard medical advice only to suffer complications or relapses which the ever present NHS patiently and endlessly picks up the bill for.


This featherbedding fosters a lack of personal responsibility when it comes to the population looking after its health which in turn costs the state exponentially.


Another key advantage of this new proposal is that patients might notice resources depleting towards the end of the health budget year and exercise their own self-restraint – rather than have it exercised for them by faceless bureaucrats as happens now.


Yet another is that those who looked after their health and saved their health budget might keep it in a kind of Government Health Bank, where they earned interest and which they might be able to spend on the health of relatives or friends in need – a direct incentive to keep being healthy and to maintain and promote your own health.


Perhaps communities would get together to pool their health credits and thus benefit from contracting arrangements with local health providers.


In other words the National Health Service would at long last live up to its name – a service that encouraged and promoted national health – rather than being an institution focused on disease – which is kind of locking the stable door after the horse has bolted anyway.


Giving each citizen their own health budget which they then take responsibility for spending is the only mechanism yet proposed by which personal safeguarding and promotion of health is incentivised, outside of a private health care system.


Ironically it’s possible that only long after its sixtieth birthday that the NHS finally grew into earning its original name – becoming at long last a Health Service as opposed to a Disease and in point of fact Diseased service.


The uncomfortable truth is that all health services ration health care – just some do it more explicitly than others. Sometimes long waiting times are merely a form of rationing. Targets are a way of setting priorities, but that also means that something is not being targetted, and therefore it’s likely to be rationed.

Who would you prefer to ration your healthcare?
(1) An administrator in the NHS?
(2) Your local GP?
(3) Your hospital doctor specialist?
(4) Your health insurance company?
(5) Your local community through a kind of local council or Primary Care Trust?
(6) Yourself – if you are given a personal health budget?
(7) Your elected political representative?




Javier García-Lacalle A bed too far: The implementation of freedom of choice policy in the NHS. Health Policy Volume 87, Issue 1, Pages 31-40

Richard Heijink, Manuela Noethen, Thomas Renaud, Marc Koopmanschap, Johan Polder. Cost of illness: An international comparison Australia, Canada, France, Germany and The Netherlands. Health Policy 88 (2008) 49–61


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Raj Persaud and Peter Bruggen are joint podcast editors for the Royal College of Psychiatrists and also now have a free app on iTunes and Google Play store entitled ‘Raj Persaud in conversation’, which includes a lot of free information on the latest research findings in mental health, plus interviews with top experts from around the world.

Download it free from these links:

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