Book of the Month: Patients, Power and Responsibility
Authors: Angela Coulter
Journal: Journal of the Royal Society of Medicine (2003)

Despite Government rhetoric about putting patients at the centre of the health service, British people still have limited choice and little control over what happens to them in their encounters with the NHS. John Spiers' basic thesis is that patients cannot be truly empowered unless they are given direct control of the resources to purchase their own healthcare. In Patients, Power and Responsibility1 he outlines a radical proposal for changing the structure and funding of the British healthcare system which he claims will lead to greater equity, fairness, social solidarity and personal responsibility.

In Spiers' reformed NHS the patient would become a fundholder with entitlement to a voucher to purchase essential core services. The Government would relinquish responsibility for purchasing and providing services, its role being reduced to that of regulator and guarantor of access, choice and competition. Taxation-funded compulsory insurance would cover the guaranteed care package with universal protection for catastrophic and costly medical events, but with a voluntary element enabling people to negotiate a specific package of care and provision for ‘top-up’ insurance.

The basic package—Spiers calls this PGC (‘patient-guaranteed care’ or ‘pretty good care’) would be clearly specified and purchased by competing cooperative insurers (‘patient-guaranteed care associations’) from a diverse range of providers. Patients would be free to choose between these purchasing associations and they would receive financial incentives to adopt healthy lifestyles or to take charge of their own chronic disease management. The healthcare system would operate according to market principles using legally enforceable contracts with providers who would set their own prices and publish information on their quality standards.

The suggestion that an insurance-based system with vouchers for patients is a better way to pay for health services has been heard before in the UK. Indeed a similar idea is currently being floated by Norwich Union Healthcare and the National Economic Research Associates.2 The starting assumption is that tax funding will not deliver the sustained increase in resources that will be required to provide good quality healthcare in the future. Proponents argue that a centralized tax-funded system is necessarily less efficient and less responsive than one based on a competitive insurance model.

Spiers admits that many of his ideas are not new, but he makes a cogent—although ultimately unpersuasive—case for considering this option. The style is ideological and polemical, but Spiers has read widely and he demonstrates his erudition with extensive quotation from a diverse range of sources including political and economic theory and literature. He has a particular penchant for the views of American libertarians such as Virginia Postrel, but Charles Dickens, Matthew Arnold, Isaiah Berlin, Noel Coward and many others are also cited to support his case.

Spiers believes that the State should be an enabler rather than a provider of services. Individual consumers should be allowed to spend their health credit as if it was their own money and patients must be trusted to determine their own best interests. He objects strongly to the notion that resources should be distributed according to professionally defined ‘needs’ or that government should attempt to manage demand and ration services. His special betes noires are the ‘stasists’ who think they know our interests better than we do ourselves. In this camp he includes Sidney and Beatrice Webb, originators of the Fabian tradition that had such a strong influence on the development of the British welfare state, the centralizing, managerialist tendency of recent governments, the public sector unions, and my erstwhile employer the King's Fund.

Proponents of radical change tend to exaggerate the defects of the status quo and romanticize the alternatives and Spiers is guilty of this. For example, he claims that taxation-funding has created wide inequalities in access to care in the British NHS whereas in the European social insurance systems ‘the poorest are treated immeasurably better’, yet no evidence is supplied to support this assertion. In discussing the merits of European systems he implies that Bismarck social insurance systems empower consumers to a much greater extent than systems which rely on taxation-funding, although again there is little evidence of this.3 He fails to discuss other health systems—for example, those in Spain and Sweden—in which reliance on taxation-funding has led to reasonably equitable provision of a high standard of healthcare.

In Spiers' brave new world the poor would be guaranteed ‘pretty good care’. However, what he has in mind is guaranteed access to the basic package only, with additional services purchased out of pocket or through top-up insurance. The rich would still be able to purchase more and better quality services than the poor. He offers the current organization of optical care in Britain as an example of how a voucher system would work. People in receipt of income support, children, pensioners and people with special health difficulties or complex prescriptions are entitled to NHS vouchers to be spent in privately managed opticians' shops. Rich and poor purchase their sight tests and glasses in the same marketplace and consumers are free to purchase additional, non-essential services if they can afford to pay. This sounds quite reasonable—few would argue that public funds should be used to subsidise the cost of expensive fashion frames—except that in practice NHS contributions no longer cover the full cost of sight tests and opticians are having to cover the difference by increasing charges for glasses and contact lenses.4 A report from the National Consumer Council found that some older people are now deterred from having sight tests because they are concerned about the cost of glasses.5 Erosion in the value of the voucher is an ever-present risk and in a privatized system this inevitably impacts more on the poor and disadvantaged.

Spiers is scathing about attempts to ration services based on normative criteria or professional needs assessments. Yet this would be an inevitable feature of his proposed system because the core package or minimum standard of care would have to be defined if the Government, or an independent regulator, was to guarantee universal access to ‘pretty good care’ with funding from the taxpayer underwriting this. Reference to ‘needs’ and ‘norms’ would be unavoidable if the system was to be seen as fair and patients would need some form of protection from market failure.

Where Spiers does hit the mark is in pointing to the limitations of the Government's current efforts to promote patient involvement and choice. Increases in lay involvement on committees and provision of limited choice of treatment location to those undergoing elective surgery, while welcome initiatives in themselves, will not achieve the fundamental changes that are needed to tackle the dependency culture that a paternalistic system has created. I agree with many of his goals—guaranteed prompt access to a core package of quality care for all; encouragement of personal responsibility; incentives to take account of patients' preferences; a system which empowers individuals—but I don't agree with his proposed means.

The NHS has suffered from too much structural change, most of which has made little difference to patients. We do need to focus effort on changing the balance of power between those who use health services and those who provide them, but a voucher system is not the answer. The scenario described by Spiers seems most unlikely to come about in the foreseeable future unless the current direction of travel turns out to be a catastrophic failure. As Spiers himself admits, there is no groundswell of public opinion calling for a change in the funding system, least of all for an increase in direct payments by patients. It would be a brave political party that put abolition of the NHS at the top of its agenda during an election campaign. Meanwhile, more funds are being found for the NHS from public resources, serious effort is under way to increase capacity and quality, and patient empowerment and choice are higher up the policy agenda than they ever have been. The current reforms must be given a chance to work before we start planning the overthrow of the entire system.