However, perhaps the greatest challenge relates to preparing for the future. As Donald Rumsfeld famously said “there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns, the ones we don’t know we don’t know. And … it is the latter category that tend to be the difficult ones.” So when we are thinking about the competing strengths of public and private provision, a key issue must be which allows more flexibility to adapt to future challenges. Then there are the things that we can predict, such as the need to train the next generation of health professionals and the need to engage in research and development to generate new knowledge. Again, we need to ask which is better at investing in these future needs.
The Independent Sector Treatment Centres raise different issues. Here the evidence is rather less, largely because they have consistently failed to supply the data that were required from them. Consequently, a cartoon accompanying one of Allyson Pollock’s paper in a recent issue of the BMJ compared them to a black hole, with money and patients being swept into them but no idea what happened afterwards. One problem is cream-skimming. They only take the straightforward cases, leaving the NHS to look after the rest. Yet bizarrely, give the lower costs that result, the government pays them 11% more per case! (and this is on top of various other subsidies plus a guarantee to buy back the premises at the end of the contract). It then doesn’t even check whether they have performed all the procedures they have been paid for – a reasonable estimate is that they have performed about 70% of the contracted work but of course they received 100% of the payment.