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Dr Raj Persaud FRCPsych



Headlines this week include that NHS trusts in England are suffering a total deficit of more than £800m for the current financial year, meanwhile the BMA attacked Government proposals of seven-day GP surgeries, plus the health service ombudsman reported hundreds of thousands endure painful, undignified or lonely deaths because of “appalling” end-of-life care right across the health service.


The NHS represents the last bastion of centrally-planned Soviet style spending – given the glaring failures, why do we persist with it?


Why not instead give each citizen their own annual health budget? This could be in the form of health vouchers or coupons.


This would make rationing more transparent, and it would make health something each individual takes more personal responsibility for. The efficiencies of the market now discipline a system currently hampered by massive wastage, incompetent management and irresponsible use by many.


Each citizen would immediately be taking more responsibility for their own health, and yes, they could spend their health coupons or vouchers as they liked – as long as it was on healthcare. If they stayed healthy they could save for a ‘rainy day’, or donate to other family members as necessary.


Assuming the current annual NHS budget is £115.4 Billion, and there are roughly 60 million citizens in the UK, then that works out as £1923 per year for each man, woman and child, if they were allocated their own health budget each year.


This doesn’t seem that much – but then again if part of a standard family of two adults and two children then a family would then have £7693 to spend each year on their health.


If you are 52 years old then you might have been given almost £99,996 pounds (obviously fudging the issue of past NHS budgets being smaller) to date over your lifespan to look after your own health, which is quite a big number.


A direct incentive to properly manage your condition(s) now emerges. You are much more likely to develop an interest in preventative health strategies, plus become more meticulous over taking your medication and following medical advice, if you know that society is not going to bail you out forever, should you become irresponsible managing yourself.


There would be massive savings in terms of removing layers of bureaucracy and administration by getting rid of all that central planning. People could possibly leave their unused health credits in their wills to future generations. This means families could start to pressurise the slothfully corpulent in their midst into better fitness.


Major health charities like Diabetes and Cancer organisations, might organise with patients to construct their own specialist systems for particular disorders.


Economics-wise, the problem of markets is that they perpetuate the existing allocation of income and wealth. They under-provide for the poor because the underprivileged do not have market power. This radical idea immediately gives more clout to the impoverished by allocating the resources they need to demand and afford a better service.


Many studies demonstrate that the middle classes get more from the NHS than the poor – they know how to work the system, how to make the right noise and complaints. The NHS does not empower the less well-off – it bosses them around. The post code lottery is associated with the distribution of income.


For example, the Royal College of Nursing report that a man in Kensington and Chelsea can expect to live 86 years, whereas in Hendon in Sunderland, male life expectancy is just 69. Nonetheless, Sunderland will only get 57 per cent of the per head public health funding which Kensington and Chelsea attracts.


Empowering citizens requires giving them the resources to demand great health care. Your own personal health budget means greater control of health choices and trade-offs. This is superior to a system determined by some bureaucrat trying to hit the latest arbitrary health target.


The leap of faith that both profession and government need to make is to trust patients to make choices and accept the consequences. If patient preference 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 nor the National Institute of Clinical Excellence (NICE).


Care Commissioning Groups and NICE remain a bizarre way of structuring the health service, because it’s not the commissioners that actually receive the treatment they contract or legislate for.



If the Care Commissioning Group is getting something ‘on the cheap’ regardless of quality, it doesn’t really care that patients suffer. What is the mechanism by which patient dissatisfaction is meaningfully fed back to Commissioning?




Let patients decide for themselves as they are the ones who suffer the consequences of good or bad decisions. For example, if they want to invest their health budget on drugs which the NHS (via NICE) would ban them from – it’s the patients’ health so let them choose. The average citizen may well make better decisions over their own lives than any paternalistic state.



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. Now there is a direct personal incentive 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 or even health insurers.



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.


The uncomfortable truth is that all health services ration health care – just some do it more explicitly than others.


So 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 Care Commissioning Group?(6) Yourself – if you are given a personal health budget?(7) Your elected political representative?



Follow Dr Raj Persaud on Twitter:

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:

Books by Raj Persaud are available on here:

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