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Be brave, and hand the purse strings to patients

There was a terrible amount of opposition to the Government's proposals for clinical commissioning.

Why? Where has it got us? Back to where we were in 1992, doing total purchasing under the fundholding regulations – that's where. The real opposition should have been to the financial cutbacks. Ministers must have been laughing their heads off.

So if you think commissioning is radical, just look at what's coming next: patient-held budgets. This means the individual is handed the fund to buy their chosen package of healthcare. They are already being piloted around the country – for instance, where I work in Southwark, we are testing them out with patients who have long-term conditions.

I can see the profession's reaction now. ‘Patients don't know what is good for them.' ‘They will buy rubbish such as alternative therapies and then run out of money.' ‘It will destroy the NHS.' ‘Hospitals and practices will go bust.' Why would anyone introduce such a mad system? Because the NHS is still run as if it is for the benefit of the service and not the consumer.

I commend Bernard Shaw's play The Doctor's Dilemma (currently on at the National Theatre) to all of you. It opens with a receptionist trying to get a patient seen first by a medical student and then by a series of doctors. Our colleagues all have more pressing things to do.

The play was written in 1906. From the public's perception, however, it looks much the same today. Just think of the impact the recent industrial action over our pensions
has had.

Why should the purchaser/provider interface be between general practice and secondary care? How can this possibly be relevant? I have heard arguments that only doctors can set and enforce clinical standards. I agree, but they should be a matter of key performance indicators in hospital contracts in just the same way as they are in our contracts.

How would we feel if, when we went shopping, someone else held the purse strings? Would it not severely limit our choice? Don't we complain that the public wastes resources through DNAs and inappropriate use of A&E because they do not pay for them and don't recognize their value?

Though they are not without their problems, I believe patient-held budgets have multiple advantages for all players in the NHS. They will give the public leverage for the first time. If any of you have had to seek healthcare in a private system, either here or abroad, you will recognize how patient-focused those systems are – no waits,
for example, but rather appointments ‘when it would suit you'.

What about when the money runs out? If the budgets are not big enough, it will be the public clamouring for increased resources. For the first time, there will be benefits to the individual in taking responsibility for using the service appropriately.

This could really impact on the DNA rate and also on the self-care agenda. I don't have to tell you over 20% of GP consultations are for minor, self-limiting conditions. Do any of us really get any pleasure out of dealing with these? Yes, they may give us a breathing space between complex problems, but with the patient paying we would charge more for complexity. We would get our first real opportunity to be rewarded properly for
using our skills.

One benefit we can already see in my CCG is the ability for co-payments. In long-term care, we have an obligation to deliver a total package of care to patients eligible for NHS services and also to provide that at an economic cost.

Time and again we deny patients who wish to be looked after in their own home because the cost is much greater than being cared for in an NHS facility. Under the traditional funding model patients could not supplement the budget. Under patient-held budgets, they can.

I know which system will suit me better when I need it.

Dr Simon Fradd is a GP in Southwark, south London, clinical lead at NHS Southwark CCG and non-executive director of Concordia Health