This piece argues for a publicly-funded healthcare system that is also mostly provided by the public sector as well. It suggests that competition in provision is wasteful and unlikely to work to improve the system, and alternatives to drive the system to get better have to be sought instead. In short, that the reforms proposed at present are wrong for all manner of reasons.
To understand this argument, I think coming up with a list of propositions that I believe in (and which seem to me to be logical) need to be made clear first, in order to show that the conclusion above logically follows from it.
Proposition one: That access to healthcare is a social issue, and access to it should be based on need rather than ability to pay.
The vast majority of industrialised nations have universal access to healthcare in some form or another, and ruling out citizens from accessing healthcare because they cannot afford it seems inhumane. This leads on to:
Proposition two: That it will always be necessary to have public provision in healthcare, and so imagining that private medicine can replace it is foolish.
To guarantee all citizens access to healthcare in all areas (both geographically and treatment), public provision is necessary. To imagine that private provision can swoop in and plug gaps where set-up costs are so high, and the need to guarantee standards is so important, is delusional. Public provision is necessary in order to achieve guaranteed provision. This need for public provision also leads logically to the idea that the Secretary of State for Health should ultimately be responsible for the NHS, but does not mean that all private provision be removed – it can be a supplement to public healthcare, and even provision healthcare to the NHS to reduce waiting times or provide excess capacity (but not without difficult questions about why public provision is not covering this being asked).
Proposition three: That funding healthcare from the public purse, through general taxation, is desirable because it is both efficient and redistributive.
It is efficient to pay for public healthcare from general taxation because it gives the government considerably leverage in keeping costs down (as well as economies of scale in purchasing). Even senior Conservatives (for example Nigel Lawson) have come around to this viewpoint. I would also regard funding healthcare through taxation being distributive as being desirable because of the increased sense of societal solidarity it will hopefully lead to – and goodness knows we need this at the moment.
Proposition four: That healthcare provision is often complex in terms of both organisation and treatment, and it is therefore difficult for patients to make judgements about how to access services that are based on clinical considerations.
Healthcare provision is complex both organisationally and in terms of the treatments on offer. Expecting patients to navigate their way through local health provision is silly – it needs someone clinically competent who understands local provision and can find the best care for their needs. Where patients are forced to make decisions they are likely to engage in what Daniel Kahneman calls ‘substitution’ and choose on the basis of a factor that won’t lead to clinical improvement – such as car parking spaces. This won’t drive up clinical quality, but might lead to some perverse effects (the logical thing for hospitals to do would be to build multi-story car parks instead of providing better services).
Proposition five: That there are no simple organisational fixes to providing healthcare, and politicians, management consultants or policy wonks who suggest otherwise are ideologues
We have had sixty-five years of the NHS. It’s a big, complex system that is hugely difficult to organise and manage. We’ve tried all manner of fixes in the past – it’s about time we realised that there is no optimal size for commissioning, and that more bureaucracy or more market mechanisms are not going to work. Improvements are going to be a long slog, and depend most of all on clinicians and managers working hard locally to make things better. Imagining there is an organisational panacea to resolve all the competing demands on healthcare systems is never going to work. It’s much harder work than that.
Proposition six: That trying to get healthcare providers to compete with one another will not work as public provision is necessary, because patients cannot make clinically-informed choices, usually do not want to travel, and duplicating provision in clinical specialties is wasteful. We therefore need alternatives to improving healthcare.
If patients usually can’t choose the services they need, how about getting someone else like GPs to do it? This is unlikely to work either because it implies that there is duplication of provision (and so waste), and is hugely wasteful for GPs as well as it asks them to stop looking after people and commission services instead. Most patients want to be treated locally, so trying to get competition between localities is unlikely to work.
We therefore need alternative ways of driving improvements in healthcare. In any case it’s going to be hard work. Professional bodies need to step up to the mark and do rather more than they have in the past to scrutinise clinical data and improve practice. Managers need to ask harder questions about outcomes as well. Imagining there is an organisational fix that will somehow magically make it work isn’t going to work.
In all then, improving healthcare is a difficult business. Public provision, in my view, is a crucial and necessary component of a strong healthcare system, and assuming private provision can replace it unproblematically is unrealistic. Funding healthcare is both more efficient and more equitable than any other system. Improvements can’t come through market mechanisms as patients can’t make informed choices, and it is surely wasting the time of clinicians to ask them to commission services. Making improvements to services needs to be more robustly dealt with by both clinicians and managers than it often has done in the past, but will be hard work. However, imagining that there are simple organisational fixes is just about delusional. NHS reform based on ideology, as I would suggest the present reforms represent, simply won’t work.