Now might be a strange time to consider taking lessons from the US health care system. The UK however is one of many countries which have closely studied the ‘islands of excellence in a sea of misery’ which is how US health care has been described. The islands of excellence include managed care organisations such as Kaiser Permanente which achieve excellent health outcomes, for example with regard to survival rates, hospitalisation rates and lengths of stay and where the rate of clinical and organisation innovation is unsurpassed. What can account for these differences in the rate of innovation between our countries? The answer may lie in financial incentives. Because health care is, unashamedly, big business in the US, the ‘bottom line’ is hugely important. The term ‘cost containment’ is acceptable there in a way that it would not be in the UK, with our mantra of care ‘free at the point of use’ which stems from the 1946 NHS Act. This has produced a disconnect that may no longer be helpful, between the care and the funding, which allows the status quo to flourish, and for the real money which is used to pay for services not to be ‘real’ either for patients or staff.

It may be the moment for us to put a caveat to that famous phrase, and to add ‘free only at the point of use’, because there is a price (and an opportunity cost) for each and every NHS consultation, test, intervention, treatment, operation and therapy. And these nationally set prices (the national tariff) are widely known about within the NHS management community as they form the basis for how hospitals are paid. Would it not make sense for these prices to be widely published and debated in the media so that patients and staff are aware of the costs of services? The objective would not be to deter, but to account to end funders (UK citizens as taxpayers) and to optimise the wisest use of a scarce resource. The public could request information about the invoices sent to their primary care trust for their treatment so that they could check for accuracy and value for money. The arguments about levels of activity and balance of resources across disease groups, primary and hospital care and mental health services could then be weighed by a wider group of patients, staff, public and media who would be more fully engaged in the costs and consequences of choices made by and within our health care system.