One important question overshadows healthcare reform. Is privatisation good or bad for the NHS?
The white paper, with this question part of a wider debate on a reform package announced by the new coalition government in 2010, suggested the NHS as a healthcare model was broke.
What is wrong with our health service that such a radical overhaul is needed? Is it that broke? News another seriously ill patient has been transferred from a private to a public hospital for treatment says something about standards of care in the NHS.
The remit of a good healthcare system is easy to define. It should be universal, meaning it covers everybody. lt should be affordable. It should be egalitarian, ones ability to pay and state of health not precluding you from care you need. It must be accessible, provide quality treatment and be cost effective.
On which of these parameters has the NHS failed?
Our health service consistently scores at or near the top of international studies on measures of healthcare delivery. It is probably the most cost effective system in the world for the quality and breadth of care it provides.
We spend far less (10% of GDP) on healthcare than does the US (17%+) which epitomises the free-market model that has privatisation and competition at it's core, and where tens of millions have no cover at all because they can't afford it..
We spend less than similarly placed European neighbours like Germany (12%) where tightly managed private stakeholders have a minority role in a Government controlled, quality, universal healthcare system.
But the NHS has one distinct advantage. It is a managed, democratic, single payer enterprise that puts people, not profit, first. And those who use and deliver it know this.
The NHS excels because it has not endured the excesses of the US private system where over specialisation at the expense of general practice, high dependence on technology, high administration costs, vested interests pushing separate agendas and the profit motive have all fostered a model which is more than twice as expensive as the UK's to run.
These excesses and inequities have been largely avoided in the UK because patients trusted doctors to make decisions. GPs and specialists worked well together without the supposed benefit of competition that evidence has shown increases rather than decreases costs.
Far from creating a supposed monopoly in healthcare provision this simple equation facilitated it's more effective delivery without compromising on quality.
Doctors, properly and well rewarded by the State had no incentive to treat or not to treat. They could be trusted to put patients first.
This balance, based on trust, may be challenged when GPs under a new commissioning system take control of budgets and 'incentives ' arise for referring or not referring patients to certain providers. Strains will also emerge as private suppliers compete for scarce specialist skills.
The free market healthcare model works well for some and provides quality care, but only when they can afford it. It cherry picks the healthiest, tends to ignore the poorest, the elderly and the chronically ill. It prefers clean treatments it can easily and profitably provide.
It discourages those, like mental health or chronic care patients that can be difficult to budget for. And it has been shown to be far more costly to administer than a single-payer system like the NHS.
Words like choice and information are also bandied around as justification for more competition and privatisation. They are increasingly creeping into the NHS lexicon as well, and rightfully so. But as Michael Moore's film Sicko graphically illustrates, private providers give you a choice of sorts, at a price with strings attached.
The NHS's traditional role as 'preferred' provider, which doctors first turned to when their patients needed tests, surgery, investigations or treatment, helped it develop a broad range of services and facilitated its growth as one of the most viable healthcare models in the world.
It is an integrated, not a fragmented, healthcare system. It relies on cooperation, not competition. It is highly cost effective and it is guaranteed.
Introduce excess, external competition and this model falls apart. Competition can lead to cheaper services for some procedures or services, such as providing cataract surgery or elective hip or knee operations which end on Friday afternoon.
But running emergency theatres and critical care units for accident victims on Saturday night is never going to be profitable, which is why the integrated healthcare model is preferable. It balances overall costs and guarantees continuity of service.
Health service reform is essential and ongoing but it should not be cloaked in politics. It must be based on evidence. And the evidence shows the integrated, co-operative NHS model is cheaper and works as well or better than nearly every major healthcare system.
There is of course much on the 2012 Health bill which is welcome. Productivity needs to match substantial spending increases over the past decade. Further integrating social care with medical care is a must and extra investment in primary care is essential.
But the NHS doesn't need more private sector help to achieve these goals.
The private sector wants good bits of the NHS however. If these are handed out on ideological grounds then the basic fabric of one of the world's best healthcare systems will be permanently, needlessly and seriously undermined. It could spell the demise of the NHS as we know it, forcing far more people to take out health insurance they cannot afford.
The private sector has a role to play within our health service, but only at the fringe. And that is where it must remain.
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