Wednesday, December 26, 2012

NHS privatisation - we are right to be afraid

Just before Christmas David Cameron’s former speechwriter, Ian Birrell, wrote in praise of private sector involvement in the delivery of healthcare (NHS privatisation fears? Grow up). It is no secret that many members of the current government see the NHS, along with the BBC and the Royal Mail, as ripe for privatisation (or what you and I might describe as untapped opportunities for profiteering by their friends and supporters in large corporations). Yet Birrell’s enthusiasm for privatising the NHS overlooks two fundamental characteristics of private companies. They hate uncertainty (as their advocates tell us again and again) and they will invest their capital wherever they can be sure of making the greatest profits.

For health care to be attractive to them it is necessary to distort the delivery of care so much as to make it almost unrecognisable. As Margaret McCartney has set out in detail in her excellent book, The Patient Paradox, it must exclude anyone whose condition cannot be put into a tidy box and costed. Hence, the concern he voices for elderly and disabled patients seems at odds with the profit imperative to get rid of them, ideally to the social care sector where their care will be means tested. As we have shown in a recent paper, this is only part of a multipronged attachment on older people (or as certain politicians would say, sotto voce, those who have outlived their usefulness). Consequently, while no-one wants to see older people stuck inappropriately in hospital, we must consider the motives of those now suggesting that they should never be in a hospital at all. Recall that, in many cases, it is only possible to know that someone is entering the final few months of life in retrospect. The exclusion of old people from the health system will free space needed to screen the worried well until some harmless anomaly can be found and treated at a guaranteed profit.

Private providers will only contract with the NHS if the market is rigged in their favour, for example by capping their losses as happened in the deal with Hinchingbrooke Hospital, since condemned by the Public Accounts Committee. He invokes Germany as an example of a country where the private sector is heavily involved in health care delivery but seems unaware of the very different model of Rhineland capitalism in force there, with trade unions represented on supervisory boards of firms. The benefits of this approach over the Anglo-Saxon model we use have been set out at length by Will Hutton. The situation in our two countries is entirely different.

Birrell’s claim that “competition works in health, just as it works elsewhere” displays an ignorance of a literature stretching back fifty years. The theory was set out in 1963 by the Economics Nobel Laureate Ken Arrow and the empirical evidence gathered since then. He must surely know that the research he cites has generated results that are medically implausible and have been heavily criticised.

People with complex disorders, cannot be commodified. The abject failure of the market-based health system in the USA to improve health outcomes, despite spending vast sums of money, should give him pause for thought. On a whole range of measures, the NHS in the UK outperforms those in other industrialised countries. When someone is proposing something so completely at odds with the evidence, it is only reasonable to ask why and who will benefit?

1 comment:

richard.blogger said...

Here's an example of where the private sector is not effective.

Some cancers are close to the central nervous system and conventional x-ray radiotherapy, though effective with many cancers, may cause damage to nearby tissues and potentiall cause more harm than good. In these situations proton beam therapy (PBT) is effective because the beam is smaller and directional. However, PBT is very expensive. Each PBT installation costs around £150m, and at full capacity can treat around 750 patients a year (figures from DH). DH estimates that every year there are around 1,500 people in the UK with the specific cancers that can be treated with PBT but not with other forms of radiotherapy. Consequently, the DH has approved two PBT units for the UK (that is, all of the devolved NHS's will use these units). At the moment UK patients who need PBT are sent to the US at an average cost of £110k per patient, this cost will fall to about £40k with the UK units.

The US units are mostly commercial, consequently they need to have as many patients as possible to provide a return on investment acceptable to investors. Rare cancers are rare, and there is a much bigger and lucrative market with common cancers and so PBT is being marketed as a treatment for prostate cancer. The problem is that PBT costs about twice as much as conventional x-ray radiotherapy and yet there is no evidence that it is any more effective. There is competition in PBT in the US, but this is not, and cannot, bring the price down to that of x-ray radiotherapy. The flip side of private provision - convincing people that they need a treatment that they do not need - is pushing up the overall cost of healthcare in the US. And then there is the issue that if there are so many patients being treated inappropriately with PBT, will there be the capacity for those patients whose conditions can *only* be treated with PBT?

The DH looked into private provision of PBT in the UK but found that commercial companies were not interested because that they could not make a profit. The UK model of care that is appropriate to the condition, is cost effective and equitable: it cannot be beaten.