Private Provision in the UK National Health Service

Abstract

The two papers by Professor Pollock and Mr Boyle are probably the most significant yet in the ‘controversial topics’ series. The health policies of the Blair Government, especially those of ‘privatisation’ of the NHS, will have untold consequences for us all, whether patient or surgeon. Professor Pollock provides a cogent and strident defence of the NHS: in particular, she derides the phenomenal costs to the UK tax payer of remuneration of executives and shareholders of the private providers which are due to absorb up to 20% of NHS hospital diagnostics and treatments and, correctly, she points to the high level of administrative costs associated with healthcare in the US. She highlights the incredible and lengthy debacle of PFI hospital contracts, in which substantial sums of HM Treasury money are siphoned off for up to 20 years or more. Professor Pollock lambasts those in office in all major medical institutions – first, for complacency in not defending the principles of the NHS and now complicity in the benefits of remuneration from private provider work. Mr Boyle, a central figure in the private service provider ‘Centres of Clinical Excellence’, challenges the record of the NHS in providing choice, the poor rate of delivery of care, poor figures for preventable mortality and maldistribution of access to healthcare in the UK. He believes that the example of variety of providers, (as occurs in other countries) provide real choice for NHS patients: he infers that ‘consultant’ owned and run units not only enable consultants to regain control of their professional lives, but will encourage the responsibility to train. Independent-sector hospitals have reduced waiting lists and increased access to healthcare for many, but at what price? Independent-provider healthcare companies have secured millions of pounds worth of payment from the UK Department of Health, yet fulfilled only a proportion of the contracted work. How much of the profits from these companies remain in the UK – European, American and South African companies have taken the lion share. Is there a real choice or does ‘choice’ of an independent provider come with a supplementary payment (inducement) to the GP? Does the overseas model of plurality of providers give us a good example of better healthcare delivery? Any surgeon who has worked in the US can attest to the difference, not only in quality but also access, in that free-market health economy in which some of the worst practices reside alongside some of the best. In Australia, where increasingly surgeons have ownership of hospitals and clinics, observation indicates that selection for surgery in the doctor-owned establishments may be tainted by the fact of financial loss, should the patient choose an alternative provider down the road. Independent-sector providers undertaking high-volume, routine, quick-fix surgery should provide an ideal training ground. Why, therefore, are these providers so reluctant to initiate training as part of their contract? Presumably because training cuts into the profit margins. Why has it taken so long for the UK Department of Health to recognise the need for training in these institutions? No one could question that the NHS has lacked capacity, but much has been achieved to increase patient throughput by changing surgical practices. Hitherto, the NHS has been a non-profit organisation – any profits now made as a result of payment by results are returned into the system, even by Foundation Trusts. It remains to be seen whether NHS hospitals providing services for the less glamorous aspects of medicine will be forced to make cuts on account of loss of income from elective surgery to the private provider. One must question the fiscal integrity of a government that permits billions of pounds of taxation to be siphoned off by executives and shareholders of large, private, healthcare providers when similar resources could be provided by the NHS at a fraction of the costs, especially when the government has guaranteed an almost risk-free investment environment for these companies. The majority of NHS surgeons regard their work as a public service duty: becoming established and gaining the respect of GPs and the local population takes time. Are the short-term employment contracts of private providers a good foundation for continuity of care, especially considering procedures such as arthroplasties? Private providers are here to stay: their reputation has been besmirched by the secretive manner of their financial contracts with the UK Department of Health and some ‘mistiness’ concerning clinical outcomes. Whilst state monopolies are generally thought of as being inefficient, the example of de-regulation of the railways has not been the greatest of successes of privatisation; ask the passengers if the fares and services to the West Country are to their liking? Perhaps British Rail was not so bad after all! TCB Dehn Consultant Surgeon