Consumer choice in health

Article by John Spiers in the Yorkshire Post about the Darzi review

Another NHS report! Should we be dazzled by Darzi? Does Lord Darzi of Denham’s report on the future of the NHS - the 84-page Final Report of the NHS Next Stage Review, High Quality Care for All fundamentally alter the picture so that the customer is in charge?

Lord Darzi, an eminent key-hole surgeon and in 2007 ennobled as a Parliamentary Under Secretary of State, has certainly significantly shifted the focus of concern. There is a new emphasis on quality and on outcomes including patient’s reports of their experiences. The focus on compassion, cleanliness, dignity and respect is vital, too - if still rather astonishingly necessary after 60 years of the NHS and after years of unprecedented investment. In launching his report at Westminster Lord Darzi said that “For the first time, patients’ own assessments of the success of their treatment and the quality of their experiences will have direct impact on the way hospitals are funded”. This admits some key principles into the debate. He has, too, introduced some financial incentives for providers to respond. These are important issues, and his leadership here is very welcome.

However, we should rigorously apply the tests of consumer control, of competition, and of fully informed customers where the individual is empowered to make choices and the medical professions are empowered in a new rapprochement in a market. We should then assess what is being offered, whether it will work, and what still needs to be done.

Most importantly in the extension of patient choice, does the new vision pass individual financial empowerment to the individual? No. It does not. It proposes to extend personal budgets, but it still does not go far enough. Instead, we have another pilot. Here, 5,000 individuals and families with long-term medical conditions such as diabetes, multiple sclerosis, motor neurone disease, and asthma will be given personal health budgets to give them greater control over the care they receive - “with a view to a national roll-out”. In addition, all 15 million patients with long-term conditions will receive personal care plans. But if the financial incentive principle is right, why not extend it into every nook and cranny of health and social care now? We have already seen the significant gains in social care from the pilots in personal budgets.

Second, does Primary Care Trusts and GPs have to seek the willing revenues from individual holders of health savings accounts? No. They do not. Notably, PCT monopolies - which are state created cartels - remain undisturbed, even if patient’s have the right to choose their GP. The necessary incentives for primary care practitioners to respond to customer power are not there.

Third, does it introduce sufficiently powerful incentives for both purchasers and providers to be more effective by making local choices in response to financially-empowered customers? No. It does not. Indeed, the report follows on nine regional reports - Our Visions - by Strategic Health Authorities which are incessantly prescriptive. The final Darzi report introduces some financial incentives, however. From 2010 onwards NHS Trusts - with an average district general hospital now having an annual turnover of £250m - will be paid according to the outcomes of treatment they achieve, using indicators including surgeons’ death rates. These have been successfully already pioneered by cardiac surgeons, as we saw earlier in this book. There will also be surveys on how well patients feel after treatments. Some £7m to £9m in bonuses will be paid by central government to the best healthcare units and GP practices. This would be 3 to 4% of an average district general hospital budget. These are, however, relatively small sums. If the principle is right, why not enable the entire budgets of units to be open to challenge? Why not pass the power to the consumer, and to the consumer’s representative, a competing patient guaranteed care association? The incremental financial impact could then be as a consequence of purchasers making decisions, on behalf of their members whose willing support they must seek. Instead, government will pay or deny financial bonuses.

Fourth, does Darzi introduce financial incentives to self-care, and thus directly impact on the crisis of chronic care, and of the accumulating problems of obesity, alcoholism and life-style? No. It reminds patients of their “responsibilities”. And a new Coalition for Better Health will try to persuade you to eat more healthy food and take more exercise. From 2009, too, three million people a year aged between 40 to 74 will be invited to take a free blood test to check whether they are at risk from one of the big killers - heart diseases, stroke and diabetes. There will also be a ‘Reduce Your Risk’ campaign. These initiatives may have some impact. But past experience is not encouraging.

Fifthly, does it create a Disclosure and Information Commission, to publish audited information to guide consumer decisions? No. It does not. It proposes a National Quality Board, to advise government and publish annual reports on standards of care in England. This is a beginning, but it does not propose issuing the detailed information on performance which we want and which will fully inform patients and link their knowledge to financial clout. All NHS bodies will be required by law to publish “quality accounts”, which set out the quality of care they are providing. How specific will this be? How will people then be able to decide who decides? Unless consumers become customers holding tax-based funds they will not have the necessary clout

An NHS constitution is promised. But how will this ensure that you can command a necessarily personal, intimate, timely service when you want it? To achieve this we must be much bolder. We must unleash the power of customers and of competition.

John Spiers, IEA Health Fellow

see also
Sixty Years On - Who Cares for the NHS? by Dr Helen Evans

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