The wrong kind of reform

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The NHS needs reform. Reasonable satisfaction rates don’t make up for terrible outcomes and spiralling costs. However, the current reforms won’t achieve the coalition’s aims. They won’t improve health outcomes, nor will they make health services more patient-centred. The ‘pause’ will hopefully lead to consideration of alternatives to this problematic plan.

The alternative I wish to highlight stems from the government’s own aims and another of their admirable objectives: localism. The best people to ensure patient centricity are the patients themselves and we’re all the NHS’ patients. We can’t run it ourselves, but we can choose more directly who should run it for us by devolving it to local government.

Richard Grayson has set out an alternative based around this idea. He points to the system in Denmark which has one of the highest satisfaction rates in the world, and is run with counties controlling health services. Thus, when patients are unhappy with their services, they can vote out the councillors responsible in a much more direct way than central government. Patients can choose what services they want via councillors and how much they want to spend and be taxed. Thus people can also see how their taxes are spent and how it affects services they use. When people see the direct effects of their taxes, they are less resentful about paying them.

Applying this to the UK does have snags – some councils are too small to run broad services. In these cases one could look at merging the health budgets of several authorities together and having joint meetings. However, such problems aren’t insurmountable. The problems are also insignificant compared to the rewards of localism: allowing patients to decide about the services they use and to hold providers accountable. It would also save money – there would be no need for a gigantic layer of bureaucracy at the top, merely a supervisory and regulatory role for the Department of Health. It would also begin to address the ridiculous system of tax centralisation in the UK – Malta is the only EU country more centralised. Some might argue this would create a ‘post code lottery’, but there already is a post code lottery, only with none of the benefits of localism: different regions could experiment and innovate, providing pointers to other councils who could use pathfinder’s ideas to raise their own standards.

In comparison, it is clear that the current reforms do nothing to address the problems they aim to fix. The GP consortia don’t solve any problems. The GPs will be just as unaccountable as the bureaucrats. Similarly most GPs are simply not inclined to or trained for such a job. The reforms focused on competition also have problems, as there simply aren’t many competitors to choose from in many services. In complex treatments only the NHS and large companies such as BUPA could actually compete. Hardly an abundance of choice! Similarly there is the obvious problem of ‘cherry picking’.

The current reforms aren’t the cure to the NHS – only localism will meet the coalition’s aims. It will do so by injecting the NHS with the choice and control patients so badly need.

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