What the PIP breast implant fiasco tell us about the market for healthcare

A couple of days ago I suggested that the private sector don’t appear to be trustable to clear up their own healthcare problems, and so it would make sense for the government to step in, but to make sure the private sector end up paying for the extra operations. This still makes a great deal of sense.

It isn’t really relevant that the surgery in this case was cosmetic – a lot of people have got moralistic about predominantly women engaging in medical care for problems that weren’t life threatening, and saying that this means that any problems resulting aren’t a problem for the rest of us. I’m afraid I don’t buy this. It seems to me that if people are in a position where they may face illness in the future, or considerably uncertainty now, then the NHS should intervene. However, this should be at the expense of the private sector, who have been content to take profits for the surgery, but now don’t seem to wish to engage with the longer-term obligations of providing healthcare.

Healthcare is not a service the same as cleaning, and does not provide products like DVD players. With cleaning, if I like the service I get from a cleaning company, I pay for it. I’m in a position to judge whether it’s been done to the level I want, and once I’ve paid, the transaction ends. With a DVD player I have consumer rights for the device to work for a reasonable period of time after purchase, and to expect customer service if it does not.

Implant surgery is a service in that someone is doing something for another person, but also a product in that something physical is being put into their body. The key thing is they are not equipped to judge fully the quality of the service (operations can go wrong for reasons which the surgeon was not to blame, or right despite the bungling of the surgeon), or to understand fully the consequences of the product (they have to take it on trust to a large extent that the implant was a good one). In addition, people are not in a position to write-off their loss (as they might do with a DVD player that they don’t like) as getting rid of an implant involves going through the surgery again – with all the problems of last time (not being able to really judge the quality of the surgery or the standard of the new implant).

The reason why it’s a bad idea for healthcare to be dominated by the profit motive is that there are perverse incentives for clinics to try and save money by providing the minimum in terms of surgical qualification, and to find the cheapest implants. PIP appear to have been supplying implants there were much cheaper than the rest of the market – and we now know why – but without adequate questions being asked.

Harley Medical have suggested it was the government’s responsibility to allow PIP implants to be used in the UK, so the government is morally responsible for them being removed. I don’t entirely agree. The people that bought surgery from them could not have been expected to understand the trade offs involved in accepting PIP implants, and, had the product been successful, Harley Medical would have been very happy to take the profits that would have resulted. They presumably have the expertise to judge the quality of the implants they were using (I’m sure their surgeons had views on them), and took a decision to use the cheap PIP ones. Should the government have passed them for use in the UK? Maybe not. But on the best information the government had at the time of approving them, I expect they met the minimum requirements for sale (based, we now know on false information). However, the government didn’t make any profit from the sale of the implants, and the private providers did – so they are responsible.

All of this highlights that healthcare is not the same as buying a service such as cleaning, or a product like a DVD player. The consequences are far greater, and the incentives for providers should not be out of line with giving the best standard of care possible and trying to evade responsibilities afterwards.

The problem is, we are about to enter a period where the government wants to considerably expand private provision in the NHS. I fear this won’t be an isolated case. In the future public providers will be expected to pick up the problems caused by private sector cost-saving or failure again and again. Is this really a good deal for the public?

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One Response to “What the PIP breast implant fiasco tell us about the market for healthcare”

  1. Richard Blogger (@richardblogger) Says:

    BMW have just recalled 235,000 Minis due to a faulty water pump. Apparently the pump could overheat and cause an engine fire. There is a real, but not an immediate danger, hence the recall. I don’t know for sure, but there is a good likelihood that BMW didn’t make the pump. However, for the sake of their reputation, and good customer service – with an eye to repeat business – BMW have decided to recall all Minis and offer to replace the pump free of charge.

    How involved is the government in this recall? I suspect very little. Even if there had been a spate of engine fires and personal injury, the government would not be involved (although the HSE would investigate).

    The PiP implants is a similar consumer issue: if the implant has not ruptured then it is not a clinical issue, but the women were sold substandard devices, and for the sake of their reputation and customer service to get repeat business, the clinics should offer to *replace* the implants for free. When there is a clinical need (eg the implants have ruptured) the NHS should always be there to *remove* the devices. Who pays? Well if the implant has ruptured then it is an NHS responsibility, otherwise will you have to charge the car manufacturer if the NHS treats someone with injuries due to a crash caused by a fault in the car? Much too bureaucratic and probably more costly to administer than the cost of the care.

    I am reticent about the NHS removing the implants when they have not ruptured and then the NHS charging the clinic. For a start NHS hospitals have 18 week targets and plan patient throughput accordingly; the extra theatre time can affect these targets and affect other patients. All of the people on the waiting list for elective care have clinical conditions and many will be in pain or discomfort, how can anyone justify such people finding their treatment time being affected by the demands of the worried-well?

    Would women with implants themselves be affected by the RTT target? I am not sure since if the private clinic is being charged then the work will effectively be carried out as a private patient in an NHS hospital. They may find that they get put to the very back of the queue, since there are many people with higher clinical priorities. The income also means that the trust’s private patient income cap may be affected. Some NHS Trusts are worried they won’t get FT status because their PPI is higher than they would be allowed under the PPI cap.

    Lots of issues, so it is much better if the clinics are made to offer redress. (Personally, I would have told them that they could not insert any more implants until their previous customers have been addressed.)

    The implants are not permanent, they have a limited lifetime (about a decade). The women who have them should be aware of that (if not, then they have another complaint against the clinic) and so should have been aware of the need to have them replaced at some point. So I also wonder why there is the heightened demand.

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