Sunday, May 29, 2011

NHS Reform and The Evil Market Boogyman

There is no doubt that the government's proposed NHS reforms have proven to be controversial. Originally backed by Lib Dems, Andrew Lansley has now lost their backing as the party descends into panic mode after the poor local election results. Without the support of the Lib Dems the reforms stand little chance of getting on the statute book.

It seems the main sticking point for the Lib Dems is the extent to which the market will play a role in the provisioning of a free-at-the-point-of-use service.

But, what is this evil market that is threatening our fantastically efficient and effective NHS, in the minds of the left anyway? If you read the Guardian or watch the BBC you'll be under the impression it is some kind of malign mechanism that is designed to sap whatever is good out of anything that comes into contact with it. A diabolical agent of the right wing, whose only purpose is to destroy the NHS and replace it with a US style health care system, where only the rich can afford decent treatment and the poor will be left to die in agony on the streets (because they'd have sold their homes to pay for what inadequate treatment that could pay for).

It suites those on the left, the statist planners and advocates of entrenched public sector interest, to characterise the market as a thing, a device, usually portrayed as an ideological paragon at the heart of the plans of frothing mouth right wingers hell bent on suppressing the poor and enriching their banker mates in the city. But, if you haven't already dismissed this as ridiculous (genuinely) idealogical nonsense, think on a bit more.

What is "the market"? It is nothing more than the choices made by you, me, our neighbours, their friends and family, in fact everyone. It's not an extraneous body with an agenda of it's own. Why shouldn't our needs as patients be put at the heart of our health service?

In Britain we have come to expect a free-at-the-point-of-use healthcare system. There are some powerful moral arguments for it and it appeals to our sense of fairness, that everyone, regardless of ability to pay, should receive the best healthcare available. We call the system the National Health Service and we are all very attached to the concept. And quite right too.

Free at the point of use it maybe, but cost free it certainly isn't. The cost to all us tax payers runs to over £100 billion a year. It has the income of a small nation but with the burden of expectations of a very large, complex and demanding one. As multiple reports over the years prove (including this one), the NHS is neither efficient or effective in delivering the standard of care we expect. As someone who has had a love one almost die of malnutrition on an NHS ward, I know for a fact that reform is needed.

The model we use currently is predominantly based on services being delivered by state owned entities and staff. New Labour's early reforming zeal attempted to introduce a more modern and competitive environment but met the same seemingly immovable forces of self interest in the form of public sector unions and others, such as the doctors' union, the BMA, who mobilised to scare the general public and the Prime Minister of the day into believing change was too risky. Old Labour fifth columnists like Gordon Brown and Ed Miliband made sure these voices were heard and moved to scupper all subsequent attempts at reform that threatened their friends and party funders and (as they saw it) loyal Labour voters in the public sector. Sadly, history may be repeating, with Cameron replacing Blair and Clegg replacing Brown. Cameron may not be worried about upsetting Labour voters in the public sector but he is worried about re-contaminating the Tory brand with the poisonous idea, no matter how untrue, that he wants to privatise the NHS.

So, we're spending enormous sums on an organisation built on the 1940's concept that centralised state planning and provision is the only way to provide a national health service free at the point of use. This approach has failed to deliver consistently excellent service as expected. There's been much tinkering at the edges to attempt to improve things but nothing that has been in any way adequate. And now the money's running out. David Cameron is committed to maintaining real terms funding and is avoiding real NHS budget cuts. However, after a decade of fiscal incontinence that has seen the NHS's budget more than double, the organisation has lumbered from poor productivity to worse. Some, politically motivated performance targets have been met (especially around elective appointments) at the expense of professional medical judgement in many cases and overall quality of care has dropped.

What's needed is choice. For example, GPs should be able to assess the performance of local care providers and send patients to the most appropriate one dependent on their needs. If that happens to be a private outfit rather than a public one, so be it. As far as the patient is concerned, it is free. The only difference would be quality. Where appropriate the patient should be provided with adequate information to be able to make informed decisions of their own about where and how they are treated.

I think the proposals have been rushed out and not communicated to key stakeholders in healthcare or to he general public very well. Taking time to pause and refocus is sensible. But, if the reforms are watered down or delayed until the next parliament we will merely end up with an organisation that has grown to rely on massive year on year budget increases to achieve bare minimum standards, if even that at times, facing the prospect of budget increases at barely inflation levels only. It won't know how to adapt. Services will be cut instead of unnecessary bureaucracy, productivity will carry on falling, outcomes will continue to lag behind international standards, cost efficient prevention will still play second fiddle to expensive cure etc etc.

Those that oppose the market playing a larger roll in the provision of healthcare are opposing the NHS becoming more responsive to our actual needs. They prefer to promote their ideological belief that only the state can provide adequate healthcare, despite all the evidence to the contrary.

All that patients care about is that their treatment is of the highest possible quality and free. Who provides it is irrelevant.


  1. Here's the thing.

    The current proposals offer no guarantee of better service, or lower cost. I think I would be more in favour of them, if they had chosen a more German approach (i.e. market competition, but fixed prices, etc). But they aren't, are they. What they will do is make the private health companies very rich (you know, the ones that have 'donated' almost a million pounds from them over the last 5 years).

    What we have learned by letting 'the market' into the NHS. People cut costs far more in the private sector. This is why the superbug that's roaming around our hospitals only started rearing it's ugly head after the cleaning had been 'outsourced'. We've also learned that private companies provide worse service at the same cost for the eldely ( ). We've also learned that dentists (who operate as private companties with the NHS) routinely overcharge ( ). We've also seen the overall percentage of NHS money spent on admin double since the invention of market like entities like PCTs. This is without mentioning things like 40% of people defer dental treatment due to the costs.

    As with the privatisation of British Rail which has resulted in more expensive journeys for travellers, and yet a bigger bill for the tax payers. The main worry is that letting the market in (without severe constraints like in Europe) will just reduce quality, and increase tax payer cost.

    The skeptisism about the market is completely due to the actions of the market within the NHS, and within things like British Rail.

    You'd have to be an idiot not to realise that. Sorry.

  2. Please don't be sorry. Your comment merely confirms the point I'm making about the average leftist's view of 'the market'. You view it as a thing rather than what it is, which is the needs and decisions of individuals. You confuse the proposed reforms with the introduction exclusive private provision, but you make a valid observation on the importance of regulation in a service as sensitive as health care.

    Your assertion that anyone who disagrees with your view is an idiot is sadly typical of the arrogance of the left (not all those on the left I hasten to add, but too many). But that is something I've learnt to find amusing rather than offensive nowadays. (No doubt you will say you are not of the left and are above such simplistic categorisations. Another sure sign that that you are indeed of the left).

    I agree that more attention needs to be placed on how the market is controlled. I'm not advocating free reign for private provision of health care and nor are these proposals. Indeed price control is something they explicitly highlight as a failing of Labour's reforms that allowed private providers to pick off certain services at the expense of overall outcomes. These proposals allow choice, with GPs (in the main) choosing where to send their patients to get the best outcomes. As a broad principle, I don't see how you can argue against it. The details need thrashing out much more openly and comprehensively than they have been. Hence the pause for thought. I hope they come back with improved plans. But the plans broad aims should be kept, in my, admittedly, idiotic opinion.

    It's fair to refer to the scandals in the care of old people and, I would add more recently, in Bristol of mentally ill people. But to suggest that this abuse is related to whether the abusive staff are public sector or private is ridiculous. It happened at least as much if not more when all these services were publicly run. The only difference being that the survival of the organisation and/or its senior management didn't depend on avoiding such incidents. The company running these institutions will now have serious difficulties in winning further contracts and even maintaining current ones. It is a disaster for them, or at least it should be as long as public sector service procurement has the choice to move providers. If not, more market is needed, not less.

    As for the comparison with British Rail that really undermines your point. Why not choose BT? Why? Because you know their services are cheaper, more efficient and customer service immeasurable superior to how it was when it was nationalised. No more do we have waiting lists for a phone; a phone that comes in one of a limited number of designs etc... No, you pick a badly privatised model. One that replaced public monopoly with a private one. Again, that is not what is being proposed for healthcare. If the public sector providers in the NHS provide superior service to the private providers, as you suggest they do, then they will dominate and set the standards.

    At the end of the day, no one should care whether they are treated by a doctor in the pay of the private or public sector. All that matters is outcome. An unreformed NHS will not be able to cope in the coming decade. I hope the review of the reforms will produce something more compelling to the key players in healthcare but Cameron mustn't let vested interests derail real reform like they have so often in the past.

  3. Yes, sorry about the idiot comment, and thanks for the reply.

    The problem is that the term 'the market' isn't simply "the needs and decisions of individuals" any more. Especially not in this context. It carries with it a lot of assumptions for the delivery of care, pay of staff, acceptability of huge profits, rather than cost savings to the system, and placing of profit above patient and staff. I think competition with in healthcare systems is best done with competiting not-for-profit bodies, but that's not what's on offer here, is it?

    Why did I choose British Rail rather than BT? Because the geography of healthcare provision limits the potential for competition, and failure in way that the geography of the rail network limits the potential for competition, and failure. So it's an entirely fair analogy, unlike that of BT. It's also an example of 'the market' delivering a more expensive service than it was when it was owned by the state.

    I've not even touched on the huge amount of money donated to the Conservative party over the last 5 years by the private healthcare sector. It's precisely this conflict of interest that makes me fundamentally not trust The Conservatives on this issue. This is in addition to the clear contempt for the parliamentary system Lansley's shown by implementing the bill before it's been ratified.

    There are key things that we need to tackle to reduce healthcare costs, such as obesity, which if not tackle will doom the NHS far more than not imposing an expensive top down re-organisation (which I note that Cameron promised not to do in the run up to the election) during a time of recession.

  4. Thanks for your reply and apologies for my tardy response.

    You're assuming the Market acts as some individual entity that somehow makes decisions about staff pay, quality levels of care and that profit and cost savings are mutually exclusive. You seem to be suggesting that non-profit making providers are excluded from competing in proposals when they aren't. There's room for all kinds of providers, state, private and non-profit. The more the merrier.

    Staff pay need not be uniform from John o' Groat to Lands End. I agree that those working in social care do seem under valued. But equally I don't see pay as the a direct contributory factor in the recent abuse cases. Unless you're suggesting the low paid are somehow naturally more predisposed to abusing the vulnerable? I don't accept that low pay justifies immoral behaviour. Graeme Archer's blog post makes this point well -

    If we had proper competition, being provisioned by competent people and regulated effectively, quality of care would be the main commercial selling point. Value for money would come in to it, of course. But value in the true sense of the word. The cheapest provider doesn't necessarily provide value for money as any private sector vendor manager would tell you. Scandals like the ones we've seen recently would be commercial suicide.

    Because value in the private sector equals increased chance of commercial success, running below par care homes/health services is a recipe for commercial failure, as Southern Cross proves. As The Economist suggests, their business started going tits up due to running below average care homes. (

    I can't agree with your rationale for picking British Rail instead of BT (for example). We're talking about providing health and social services here. You correctly identify the limitations of the rail privatisation as being related to the geographical nature of the infrastructure such as train tracks and stations etc. No such limitation exists for health and social services.

    As for private healthcare providers donating money to the Tories this is a red herring. The Tories genuinely believe in the liberalisation of public services and always have. It is no more suspicious that private companies should choose to support them than the public sector Unions choosing to support the guardians of state owned monopoly services, the Labour party. In fact less so. The Tories are not in hock to the private health care providers like Labour are to the unions, the source of 87% of all their donations, not to mention the main sponsor of their leader!

    I agree that more needs to be done on preventative measures such as tackling obesity, amongst many other things. And providing more power to GP in the form of purchasing power would do nothing to damage those efforts, in fact it would encourage them as GPs would benefit from reducing the number of needless expensive referrals.

    It's true Cameron promised no top down reform of the NHS, but I always interpreted that as meaning they would reform the NHS into a bottom up organisation, which is what these reforms are (were?) about.

    I say were because I'm only just catching up on the results of the reform consultation. Let's hope the results improve the proposals rather than just cripple them in the name of consoling the left wing of the Liberal Democrats after their poor local election results.