Article for House Magazine, the NHS 60th Anniversary edition.

Individual patients should get more than choice; they should exercise control.

As the NHS ages, it changes. Some say ‘change fatigue’ in the NHS means we should call a halt to any further change. In my view, the NHS needs more change, not less.

For all the huge improvements of recent years – falling waiting times, better outcomes, higher standards – too many patients still too often feel they are treated like numbers, not individuals. The accent is still on tackling illness, not on improving health. And too many elderly or disabled people still find themselves unable to get the seamless service they want from health and social care.

The NHS today is in transition between a 20th century model and a 21st century one. The far-reaching reforms of the last decade are moving the NHS from an old model – state control, monopoly provision and a provider-dominated culture – to a new one where the citizen is in control with a mixed economy of provision and a user-led culture.

The issue now is whether the journey is completed or truncated. Our ambition should be a new paradigm for healthcare – one which gives power to patients. Tentative change cannot deliver that. It is clarity, courage and consistency that are now needed.

First, power should move from the centre to the local. Government should continue to be a key player in health – in setting strategic direction, creating capacity for improvement and raising and distributing resources. But the centre itself should be running less, not more. So proposals like that for a national NHS Board should be rejected. Accountability, instead of being upwards to Whitehall, should be downwards to local communities.

The creation of primary care trusts and NHS foundation trusts has begun to shift that balance of power. Next, foundation trusts should become universal across the whole NHS and be given greater independence, so that provider organisations are autonomous but operate to common standards and incentives. Responsibility for commissioning local health services should be moved from primary care trusts which are not elected to the best local councils, which are.

Second, the transition from public sector to public services should be completed. Of course, competition pure and simple cannot bring about improvement in what are complex services delivering multiple outcomes to their users. And there are services where competition is inappropriate or impossible – hospital A&E services are a case in point.

But where it can be applied, managed competition gives organisations a sharp reason to focus on delivering better services to users. So there should be a level playing field where public, private and voluntary sectors are able to compete to be providers. Commissioning and providing should, wherever possible, be separate functions. And services which fail to meet a minimum standard of provision should automatically face external competition.

Third, change should be driven less from the centre by standards and targets and more from below by incentives and users. The move should be away from assessing inputs and activity rates towards measures that assess outcomes and experiences. The payment of providers, for example, should, in part, depend on how NHS patients themselves assess how local services are performing. These disciplines should apply in community, primary and mental health services, just as they should in acute care.

Fourth, individual patients should get more than choice: they should exercise control. NHS patients are already able to choose their hospital. The next stage is to let them choose forms of treatment through individual budgets that they control. For example, parents who have children with special needs could choose to have a budget – worth the annual cost of the conventionally provided service – so that they can personalise care according to their specific family circumstances. And patients with chronic conditions – starting with those in the most deprived areas – should be able to do the same.

The forces that are driving change in health care call for a new form of accountability. Not to politicians. Not to providers. Not even to professionals. But to patients. In the end, it is their health, not ours. It is time to fundamentally change the distribution of power in health care – to put the patient in control.