Dr Phil Hammond, broadcaster and GP returner in Bristol

What do most people want to be when they’re sick? A customer or a patient? Ironically, in this new age of consumerism, they may not get the choice.

Tony Blair, in his speech to the Labour party conference last month, expressed confidence that the NHS is “safe in the patient’s hands” – which means they’ll all have to shop around for the best treatments,holding doctors to account and resisting expensive, unnecessary over-investigation. Consumers rule, OK?

This is the theory behind the health savings accounts (HSAs) that were launched in the USA a couple of years ago. They allow customers to invest tax-free into their own HSA which combines with insurance policies to cover larger medical bills.

And the analysis of their uptake and use so far is interesting. HSAs have been purchased by a wide range of people, both young and old. And when patients (sorry, clients) are given responsibility for holding the purse strings they become far more discerning about what they want and what they don’t want.

Those with chronic conditions are 20% more likely to comply with ongoing, preventative treatment regimens because they don’t want to shell out on the cost of emergency care.

As a result, health insurers have decreased the cost of premiums to HSA customers to reward them for their more responsible behaviour.

Clients needed fewer investigations and hospital visits (both inpatient and outpatient) and were much happier about doing home monitoring. And despite spending less on their healthcare,they didn’t appear to become less healthy.

Unsurprisingly, clients became much more interested in the costs of healthcare, something they’d never been before (until the bill arrived). They also had a lot more choice about where they could go for treatment, and their HSA was completely portable across the United States.

HSAs have also forced providers to cut their costs and develop interactive decision aids for customers to help them make the best choices.

Could it happen over here? In part, it already has. Dr Foster, the healthcare communications company, is helping PCTs develop information guides with previously unobtainable information, like whether your local orthopaedic surgeons use NICE-approved hip prostheses and submit their results to the National Joint Registry. New Labour hopes ‘choose and book’ will shift the balance of power (or blame) onto patients.

But for all the Government’s reforms, it still has the feel of a Stalinist organisation experimenting with consumerism but not really wanting to relinquish control. Unless patients are given control of the money, and the information and help to use it wisely, the self-serving NHS culture will never change.

Of course, some patients will make far better choices than others and health provision will remain as unequal as ever.

But whatever model we end up with, patients need to be given financial incentives to look after themselves and stay healthy. The HSA model, where money doesn’t follow the patients but arrives with them, may be part of the answer.

Guidelines in Practice, October 2005, Volume 8(10)
© 2005 MGP Ltd
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