For twenty years NHS reforms have made the NHS less efficient, more bureaucratic, less patient focussed and more costly.
There has been one explanation for this phenomenon: since the early 90s all NHS reform has tried to introduce two things into our health service. The first is the market, the idea being that this would create competition between suppliers. The second is patient choice, the idea being that this would create pressure on suppliers to really compete.
There have been two profound errors in this logic.
There is no market in healthcare - and can't be
The first is that there isn't a market in health care for all practical purposes in the UK for a number of very good reasons. First, we expect universal coverage. That's because we're decent human beings who live in a society in which compassion and empathy count for a lot. I like that. But it does mean that our health service is expensive because it covers the young, the old and the sick. Market based systems leave these groups as second rate citizens, at best. But the result is our health care is (relatively) expensive as a proportion of GDP (although cheap compared to the US, France and others). That's what happens when you treat the ill rather than the worried well.
But this means, secondly, that because we have universal provision and that costs a lot in absolute terms we don't have the resources to create spare capacity within our health system to allow for duplicated resources. So we don't have two hospitals in an area. And people have only been allowed to register at one GP surgery, and so on. There are two reasons for that: there are economies of scale when you have scarce resources in having just one hospital instead of two and not allowing people to seek the same service twice is a way of rationing scarce resources when there is no price to make them do so. So this all makes sense.
However, the result of there being few duplicated resources (big Cities apart) is that there is no safety net in the NHS. That means Failure is not an option in the NHS. Markets creates safety nets by ensuring everyone works at below full capacity so that when a market participant inevitably fails and goes out of business there is still the resource available to seamlessly take over the supply that the failed organisation previously delivered.
But we can't do that in the NHS, unless we want to dedicate vastly more of our resources to operating duplicate hospitals, all of them working at under capacity with resources going to waste. Since that's not an option I think almost anyone wants to propose, just as no sensible person wants to suggest creating excess capacity by denying first rate health care to the poor, young and old as the US does, then the sheer wastefulness of a market in healthcare in the UK is just not viable. In that case the reforms of the last twenty years have all been wholly inappropriately focussed.
Patients don't want choice
The other plank for reform - the desire to give patients choice - is as misplaced as the desire to create a market.
Choice also requires options to be available - but as noted, we can't offer choice in an area without duplicating resources - and that's costly and ineffcient (always) in the NHS.
So choice - especially in country areas means travel - and people don't want to do that. Many can't afford to do that.
In cities choice is also a poor option - because choice assumes that people know how to choose. Now of course neoliberal economists assume everyone has all the information they need to make perfect choices at all times and on all issues, but they're just fantasists. The reality is that people do not know how o choose between health care options - that's by and large why they go to see a doctor, because they want advice. And what they really want when they have advice that suggests that treatment is needed is not a choice, but the knowledge that the local place where that treatment will be undertaken is as good as it can be.
In other words, people don't want choice - they want excellence locally.
So where is Lansley?
Lansley is doing three things right now.
First he's driving the market ever deeper into the NHS - which can only result in monopoly profit as the NHS is captured for orivate gain by big corporations: his desired outcome, I am sure.
Second, he's promoting choice - even by GPs - when neither they r their patients have any information on the issues about which they're being asked to choose. So he is, yet again, banging the wrong drum.
Third, he's acting illegally. He has already said his reforms are irreversible as 90% of the UK has GP consortia. This is not true. First, there is no legal basis for these consortia - so I hope he is surcharged for illegally authorising spending on them. The Bill to create them has not been passed yet. Second, the GO consortia that exist have no powers as yet - and might also be subject to surcharging of the GPs involved as far as I can see if they spend illegally.
So Lansley's reforms are not just heading in the wrong direction - the evidence is he will ignore all obstacles like the minor issue of legality to drive them through, such is his desire to secure revenge on the NHS that once failed to diagnose him as having had a stroke. Unsurprisingly, he's carrying very few with him on his desired pathway to reform - including most MPs, even Tories.
And where is Cameron?
Now we here that Cameron has declared a 90 day moratorium on reform whilst a rethink takes place. I hope it's a real rethink - not just a case of making it inevitable that irreversible action illegally enacted must be retrospectively endorsed as Lansley is doing now.
What now?
In light of this moratorium and the fact I live with a doctor and talk to many of them I will over the next few days offer real insight into reforms the NHS does need. They're a long way removed from Lansley's.
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Another issue on the ‘choice’ theme is that the middle classes tend to be better at exercising their ‘choices’ than those less well off, with the inevitable result that they do rather better out of public services than the poor do.
One thing I haven’t seen much discussion of is how the privatisation would affect training,this is pretty much woven into the NHS framework andI can’t see how it fits with a competition based system.
@paul
It doesn’t fit in
No private provider has ever done any serious training yet – they just pinch from the NHS and claim they’re much more efficient
That’s called a) free riding b) being less than honest with your costings
My late father spent 40-odd years as a GP. On the initial reforms way back when, he was very clear on how he thought it would work out.
‘It’ll be a disaster’, he said. ‘The only reason the NHS works at all is that no-one is stupid enough to try to work out how much it all costs.’
He went on to suggest that soon the managers would outnumber the care-givers.
It is, of course, the Heisenberg uncertainty principal in action.
Here’s a nice diagram of the privatisation’s main actors.
Quite a gruesome bunch.
One big problem with privatisation will be that there will be a direct public sector comparison available in Scotland and Wales. Probably the closest economists will ever get to science.
I, for one, am very glad to be north of the border just now, with our old fashioned health boards.
Is there anywhere in the world where the health care system actually ‘works’ without people talking about it as a disaster?
In Canada, it’s 100% public, no private allowed, and people complain about long waits, and dealing with rationed treatment that’s unfair.
In America, it’s 99% private, public is starved to non-existent, and people complain about lack of access and exorbitant HMO profits.
I always thought the NHS struck a reasonable balance between the two. Is there a system that works better than the NHS?
Apparently Cameron and Clegg are having a ‘listening’ session about the NHS reforms later in the week. I expect they will ‘listen’ in much the same way that Cable has ‘listened’ and then do precisely what they set out to do in the first place – subject the NHS to full market forces. Most people in the UK want good NHS provision locally and have no wish to travel long distances to receive treatment.
Where I think the NHS does need reform is in its provision for the elderly. Observing the hospitalisation of an elderly relative in an acute hospital in Cambridge (where he has been for almost two and a half months and has improved very little) I am not sure that the current configuration of services is suitable for our ageing population. I would be interested to know how policy formation to deal with this issue will be dealt with under the reforms, and will any of the policy forums be open to the public. I doubt this as Lansley does not wish local politicians to be involved in commissioning bodies. This surely is a dramatic example of the democratic deficit which is so prevalent in UK policymaking.
It will be interesting to see where the patient care records end-up.
I opted-out as soon as I heard about it, but with the massive private interest in bleeding the nhs dry of funds I expect that soon it will be a forced opt-in with data.
I doubt that those with no funds, old, or chronically ill will do well in this not-quite-private-but-nearly health service….my GP has just retired [early] because he didn’t have enough time for his family now, and considered he would have a lot less time soon.
Correct me if I’m wrong but the French seem pretty pleased with their system. However they can self refer to specialists and it’s very expensive.
Another reason why the Market approach won’t work is the nature of product on sale. It’s not very reliable especially in the group that need it most – the people at the bottom of the income scale (wealth=health).
That’s why the private sector in the UK works at all. Their clients respond to healthcare in a more predictable and therefore cost effective way.
The private sector works in this country because they also use nhs facilities, albeit at a cost.
Check-out how many high-dependency and intensive-care beds are in use by ex-private patients
If you haven’t done so already, pl sign/circulate/RT http://saveournhs.org, a refreshingly politically unaffiliated petition from a self-confessed group of ‘internet geeks’ who care about the NHS. Results go direct to MPs, so an unavoidable reminder of public opinion on the issue.
Lansley plans weren’t even in ‘coalition agreement’, but have been, according to director of Adam Smith Institute, in Tory pipeline for 20 years. OK, Lansley wants to abolish the PCTs that hadn’t been invented back then but, though a big detail, that’s not the thrust of the proposals. PCTs are simply in the way of ‘any willing (private) provider’ undercutting NHS services. NB Shirley Williams excellent on Monday’s World at One BBC R4 news. Puts Labour to shame with its lack of clarity on issue.
But as worrying as the proposed changes themselves is the undermining of the democratic process which is going on in parallel. See, eg, from Telegraph 2 April:
‘NHS reforms ‘gone too far already to be undone’: http://bit.ly/hNhgW8.
As Lansley’s Health and Social Care bill hasn’t yet been passed by parliament (and might fall at its 3rd reading if the 57 LIbDem MPs reject it) how can the ‘reforms’ have gone ‘too far’? Part of the answer lies with some GPs/PCTs playing the ConDem game (former have already begun to form themselves into groups/’consortia’, the latter to disband. Ironic that doctors could be said to be complicit in this undermining of the democratic process.
if a Market is introduced in health care it is in the interest of the economy and the Market to have sick and dieing people. as in US a significant portion of GDP comes from health care. therefore in the US the more unhealthy people are, the more obese, the sicker they the more treatment they need is good for the market and good for the economy.
this not the way forward for a healthy society.
@Paul
Lansley’s plans for training is a bit of a mystery. Training amounts to almost £5bn of NHS spend so it is very important in funding terms. However, that does not the capital cost of teaching facilities and the fact that (to put it politely) when a patient is treated by a consultant with a trainee, the patient does not get 100% of the consultant’s time (private patients would not put up with that, but we NHS patients do because we recognise the future benefits of highly trained staff). So NHS training costs a lot.
The basis of Lansley’s policy is a document called the “NHS Autonomy and Accountability” which you can find on the Tory website. In this they say that all providers receiving NHS work will be responsible for training. That policy document was published in 2008, so has that policy surfaced in the H&SC Bill? Have we seen the private sector announcing the building of a private teaching hospital? Nah!
Instead, what we are seeing are inaccurate figures from KPMG saying that the NHS has a 14% advantage over the private sector (mostly the cheap to implement NHS pension scheme) and hence the private sector should not be “disadvantaged” (the suggestion is that NHS hospitals should pay the government for these “advantages”). Was training included in these KPMG figures? No! Yet more dishonesty from this government.