A mixed public-private healthcare system reduces the effectiveness of healthcare for everyone
The British public are worried about their much loved NHS. They have been told there is no money, demand for expensive medicines and technologies cannot be contained, and the elderly are an intractable burden. And so when they see services struggling, staff vacancies growing, and services cut back, they are perhaps persuaded that drastic change is warranted.
But on even superficial inspection, current changes seem inexplicable. The 2012 Health and Social Care Act ushered in the provision of care by “any qualified provider.” As a consequence, according to figures from the NHS Confederation, in addition to NHS (i.e. publicly owned) providers, some 853 for-profit and other independent sector organisations now also provide healthcare services in England. Consequently, a growing proportion of public money is not going into frontline public care, but into profit margins.
The multiplicity of providers also fragments care pathways, a situation particularly damaging to children with long term or complex conditions. The new accountable care systems, in which all health services will be integrated under a single contract, have been presented as a solution. But this brings the possibility that all healthcare contracts across large parts of the country may be awarded to for-profit providers. What could justify this if money is so scarce?
There is no evidence that healthcare is better when delivered by non-NHS providers. Indeed, evidence to date indicates that care is compromised when organisations with no prior experience of local contexts take over from NHS providers. But what too of the growth in private for-profit healthcare covered by out-of-pocket payments or insurance? Some say this will take the pressure off the NHS, but just a little thought reveals the flaws in this analysis.
In the UK the overwhelming majority of doctors work in the NHS; take them away and the NHS, already reeling from the adverse impact of Brexit on migrant workers, suffers further. Profit-based providers, reimbursed from public funds or insurance premiums, contain expenditure by delivering strictly to contract or restricting provision according to the letter of the small print, and maximise returns by encouraging out-of-pocket expenditure—as exemplified by billboard adverts now proliferating around London. The NHS treated young and old, rich and poor according to need. A mixed public-private healthcare system ultimately reduces the effectiveness of healthcare for everyone, because it leaves the poor vulnerable to restriction and the rich to overuse of diagnostics and treatments, as shown clearly elsewhere in the world.
The NHS was not perfect but for almost 70 years it has, uniquely, showed that a nationalised service can deliver high quality, equitable, efficient, effective care successfully; provide freedom from fear of ill health to an entire population; and command the respect of the public and the lifelong dedication of a committed workforce. This was the UK at its very best, a global leader. The NHS doesn’t need to be discarded, nor does it need to go back in time; it needs to evolve.
The NHS needs visionary leadership to translate its founding principles into 21st century healthcare. It needs investment coupled with equitable cost containment, for example through the further development of pioneering mechanisms initiated by the National Institute of Health and Care Excellence. Realising the potential of NHS data does not need to be the prerogative of the private sector, but should be seen as providing the UK with unprecedented opportunity to improve population health and drive efficiencies through robust measurement of quality, safety, and outcomes—in other words, identifying what works and what doesn’t. The UK has also long punched above its weight in biomedical and life sciences research, but it now needs to address its weakness in exploiting this for public gain. And wiser public-private partnerships than the NHS has hitherto seen could stimulate innovation directed primarily at health and wellbeing from infancy into old age, rather than disease and profit.
It makes sense on grounds of equity, effectiveness, and cost efficiency to retain UK healthcare as a primarily publicly funded, delivered, and accountable service. Discuss the scale of the current counter-direction of travel with members of the public and most jobbing healthcare staff, and the commonest reaction is shock. Discuss this—in private—with senior doctors, managers, and civil servants, and they wring their hands ruefully, acknowledging the conclusions and likely consequences. The government must be honest, the media must explain, the public must protest, and the professions must speak out. If we do not, future generations pondering upon the demise of the NHS will be legitimate in asking whether our silence reflected ignorance, denial, fear, or self-interest.
Neena Modi is Professor of Neonatal Medicine, Imperial College London and President of the Royal College of Paediatrics and Child Health; the views expressed are her own.