A patient approach: Putting the consumer at the heart of UK healthcare

In recent years, the healthcare debate has been dominated by allegations that the 'privatisation of the NHS' was in full swing. But this is not a new phenomenon at all. For as long as the health service has existed, there have been periodic outbreaks of 'NHS privatisation fears'. Public attitudes to healthcare could be described as a combination of 'macro-level absolutism' and 'micro-level pragmatism': When people are asked about their commitment to the NHS in the abstract, support is almost unanimous and strongly felt. But when people are asked whether treatment should be provided privately or publicly, the majority are either indifferent, or even in favour of private provision. Supporters of a competitive, consumer-driven health system should try to build on this pragmatism. There will never be a democratic mandate for a privatisation programme involving healthcare facilities in the UK, but there already is an appetite for choice and pluralism. In the pluralistic systems of France, Australia, Luxembourg, Japan, South Korea, Germany, the Netherlands and Switzerland, patients enjoy free choice among a range of providers, including a large private sector. These systems record some of the best health outcomes in the world, without any obvious downsides relative to the NHS. The quasi-market reforms of the mid-2000s have already taken us some way towards a pluralistic system. Going 'the whole hog' would not require a revolution. It merely requires building on those reforms, and straightening out inconsistencies in them. The whole concept of 'catchment areas' should be abolished. Patients should be able to register directly with any Clinical Commissioning Group (CCG) they see fit, and choose freely among primary care providers. Meanwhile, CCGs should be able to operate nationally, and to merge and de-merge with other CCGs, as well as provider organisations. CCGs would effectively become social health insurers, and the sector should be opened to private insurers as well. The 'Payment by Results' (PbR) formula should be reformed in such a way that funding truly follows patients. In particular, PbR tariffs should cover a proportion of fixed costs as well, and they should be set in such a way that the vast majority of providers could economically survive on the basis of these activity-based payments alone. This should be coupled with a strict no-bailout clause. Hospital bankruptcies, mergers and takeovers would become a normal occurrence. CCGs and other financing agencies should be able to offer selective rebates for patients who voluntarily accept co-payments, deductibles, or inclusion in a 'managed care' plan. The default option would still be a situation in which healthcare is free at the point of use, but people could change that default option in exchange for a tax/premium rebate. CCGs and other financing agencies should be required to build up old-age reserves for their members while they are young, and draw upon those reserves in later years. This would mean a transition to a pre-funded health system, in which, on a lifetime basis, each generation 'pays its way'. The new system would continue to offer universal and equitable access to healthcare, regardless of ability to pay. But the role of the state would largely be limited to guaranteeing that access. Healthcare would otherwise be provided in a competitive marketplace.