Choice Is The Real Key to Patient Power
If the money follows the patient, we can get away from the one size fits all model of healthcare, argues Nick de Bois.
3 Jul 2011, 17:20
In one of the countless meetings I had with my local Primary Care Trust over the past year, I decided to adopt a different response when they presented me with their case for the downgrading of my local hospital, Chase Farm. After they had delivered the PowerPoint I had seen for the fourth or fifth occasion I stated (for the fourth or fifth occasion) ‘I disagree and the public disagree’. I then put to them a question that I feel lies at the very core of the role of patients within health policy. I asked ‘Even if I and the public argue that you are wrong, will you admit your clinical case is flawed and substantially change your proposals?’. To which they replied, almost instantaneously, ‘No’.
So then, the quandary is, why are they even asking the question? Why are they holding meetings in town halls in which they tell individuals what they should believe, rather than asking them what they think? Why are they handing out consultation questionnaires which contain the same option written as three different statements? What is even more puzzling is that I have been criticised for daring to answer the question. The Times recently attacked me for standing in the way of the downgrading of Chase Farm, denying what they (unfairly) argued is a compelling case for downgrading services. Surely this entirely subverts what is meant by a democracy? If as part of the reconfiguration of services a PCT asks the public their views, and they answer resolutely to the negative, then the role of an elected representative is not to persuade the very people that he represents that they are confused.
So the two options for those designing health services, it would seem, are to consult effectively and take into account the opinions that are expressed or to not consult at all and press on with plans you believe have clinical (if not popular) backing.
However, there is a third way which, if the Health and Social Care Bill is fully realised, will solve this dilemma. If individuals have a genuine choice between health services, and the money follows them through the patient pathway, then there will not need to be a consultation that provides a single one-size-fits-all model of healthcare, resistant to change and innovation. An individual’s power to shape their healthcare will not come from their voice in a bureaucrat’s questionnaire, but the hospital or clinic they choose to attend.
Of course, we are not in a situation where this goal can be currently realised. To reach this desirable position we need to take three key steps. Firstly we need to provide clear and comprehensive data and evidence, in order to ensure that genuine choices can be made, and we need to make this fully available, in the same way online police maps now show local crime data. We have already begun to do this in health, with data released on the subject of mixed sex wards, but this needs to be taken further. Just as in order to find car insurance one can measure different providers on a range of different measures and make an informed choice, even without a degree in maths or finance, one should be able to choose their doctor or physician competently without a medical degree.
Secondly, our health service needs to deal more effectively with innovation and new providers. If we have a situation in a mixed health economy whereby patients are moving from one provider to another, we need to support that transition as opposed to financially propping up the struggling institution that has little patient demand. We will never deliver the efficiencies needed in our health service without accepting that we need to move on from certain outdated methods of delivery. Some may argue that the primary block to effective transition at present is politicians like myself, but that judgement is based on the current model of consultation and delivery. If a hospital was only visited by a small number of patients and due to this was no longer financially viable, then no politician would defend its retention as a local service as all his constituents would be covered by another provider. Clearly Chase Farm does not meet this definition, with a significant percentage of an increasing population relying on its A&E and maternity services.
The third necessity is a level playing field, to ensure that monopolies cannot grow and new providers can genuinely begin delivering public services. We have a Payment by Results system being explored in the area of drugs treatment and rehabilitation that means any new provider can receive Government payment if they reach a defined set of outcomes, with no barriers to entry. Although there are clear reasons why this becomes more difficult when transferred to a national healthcare system, we should be looking at how we can move to a system with multiple providers entering (and exiting) provision.
I should state here also that this can, and should, take place within a national, integrated health system which is free at the point of delivery and funded by general taxation. I should also state that all the above can also be delivered through the Health and Social Care Bill, which I will be scrutinising over the next few weeks.
I will also accept that I am not the first person to make these observations. Jonathan Powell, Tony Blair’s Chief of Staff, wrote that once Labour attempted to introduce a mixed system of provision in 2001 they saw how ‘a mixed economy allowed the system to be driven by the user and brought about real, sustainable changes’. We need to progress this organic transition to diverse provision and accept a truth which is difficult to accept in modern politics; that the way to truly ensure patients are given a voice in the future of the NHS, we don’t need to give them a megaphone, but simply put pound signs above their heads.
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