Why single-payer health systems spark endless debate
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39196.414595.59 (Published 26 April 2007) Cite this as: BMJ 2007;334:881
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David Allen's response to my question about the organisation and
structure of such an experiment is very helpful and, again, interesting.
The answer suggests that the private PCT approach would vary
according to the area, which would demonstrate a potentially more
responsive approach to health care provision. However, it would also
indicate that some areas would inevitably not have the same 'choices'
available in other areas - based on geography and population density. In
other words, this suggested structure may work better in larger
conurbations (such as Greater Manchester) rather than rural locations such
as Lincolnshire. Does this sound rather similar to "Choose and Book"?
David Allen is correct in pointing out that United Health Europe
(Derby) is a primary care practice rather than a PCT. However, I used this
as example to illustrate public mistrust of private provision. While BUPA
et al may have high numbers of patients, I feel that there is public
support for the continuation of the NHS as the key healthcare provider and
commissioner for health care services in the UK.
With regards to the UnitedHealth Europe, there was no public
evaluation to my knowledge, however, there was public protest.
The original decision to hand the practice to the European arm of US
giant UnitedHealth Europe was overturned in court. Derbyshire County PCT
was forced to repeat its tendering process after a judicial review ruled
that managers had not properly consulted local patients before awarding
the contract for services at Creswell and Langwith in Derbyshire. Some
patients had been concerned that a private company might put profits
before patients and not provide continuity of services. Whether voluntary
sector/charity provision of care would receive the same response is
uncertain.
Changes to the provision of healthcare do seem to bring out high
feelings - closure of A&Es and restructuring of maternity units. There is
mistrust of such changes and, as demonstrated by the UnitedHealth Europe,
privatisation of services does not seem to popular. While this was a
frontline change, it is likely that there would be concern about changes
behind the scenes at PCT level.
I am unsure whether there have been any in-depth, widely held public
evaluations of such proposals. Perhaps there is a possible study to be
carried out.
Competing interests:
None declared
Competing interests: No competing interests
Fiona Reynolds asks some important questions of what I am proposing.
The precise organisational configuration for any location would depend, as
always in health services, on the population density and the
organisational costs, but the purpose of the exercise is to offer people a
choice of PCTs to be responsible for their care. So a private sector or
third sector PCTs could offer care to the residents of, say, Greater
Manchester, who would have the choice of their current NHS PCT or
switching to the new PCT. If the new PCT grew, above say 300,000, then
other organisations could be offered the opportunity to compete in Greater
Manchester, so residents would have a wider choice.
I think United Health Europe in Derby is a primary care practice,
rather than a PCT and does not (to my knowledge) receive all the DoH
capitation. I do not know of the public evaluation that Fiona Reynolds
refers to. Yes, there are a lot of people to convince, but the best way to
convince them is with evidence and that is why I am suggesting an
experiment.
Competing interests:
None declared
Competing interests: No competing interests
The survey Paula Whittaker refers to examined how the sample wanted
to set priorities for spending public money on health services for the
population as a whole. That is not what I am proposing. An individual
would only influence the allocation of their own capitation. I think an
elderly person might well choose a PCT which gave their needs high
importance.
PCTs focusing on the more proactive patients sounds familiar in the
current NHS and as Whittaker warns might well occur in what I am
proposing. Well, to start with, if these vunerable groups did not want to
change their PCT, then they would continue to have the care that they
currently receive. But if the government is not satisfied with the level
of care these groups are receiving then it is open to them to increase the
capitation for a group or to subsidies care for a group. It depends on the
group, but let us say that the government was not satisfied with the care
of the homeless in Manchester, then it could contract and fund care for
that group. The best solution might well be that there would be “niche
PCTs”, which would develop special skill in caring for particular groups,
nationally (?).
Whittaker is quite right, PCTs will, in all probability, identify the
most profitable groups for them and market themselves to those groups.
That says either the capitation fees for those groups has been wrongly
calculated and needs to be reduced and the money redistributed to other
groups or these PCTs have developed more efficient ways of providing care
for those groups and should be encouraged.
Selwyn St Leger has pointed out above some of the problems public
health has with my proposal and I have had some discussion with him on the
best way to provide Public Health, but if the government is not satisfied
with the general level of public health service to set targets for all
PCTs for some aspect or it is open to them to change the priorities and
redistribute the money available. But maybe I have missed the point.
Competing interests:
None declared
Competing interests: No competing interests
David Allen raises several interesting points, though I would
appreciate a further explanation of some of the detail. He states:
“If a private PCT did not offer as good if not better services than
the existing NHS PCTs then most probably the private PCTs would not get
any custom…With patients choosing their PCT, it is the public who choose
from what is on offer. What is on offer will be based on decisions of
managers and health professionals. That is the nature of a market.”
A PCT generally covers a large area, for example, Manchester. Is
Allen suggesting that the private PCTs would cover smaller geographical
patches, or that several private PCTs would offer the same services to the
same area as a competitive market? In either case, this almost sounds like
GP commissioning.
If he is suggesting that one private PCT covers this large
geographical area, how do patients choose their PCT? Move house to a new
area? This is no different to the current situation, only with a private
provider rather than the NHS.
Services are already being tendered out to third parties and, in some
areas the private sector already provides primary care (United Health
Europe in Derby). This has largely been very unpopular with the public. It
seems that choice of provider is really not an issue – just good care at a
local facility, preferably the NHS. Despite negative headlines, there is
still great public loyalty to the NHS and fear of privatisation.
David Allen may have to convince an awful lot of people.
Competing interests:
None declared
Competing interests: No competing interests
In response to David Allen's comments. Research has shown that the
general public in Britain prioritise treatment for younger people over the
elderly, and life threatening illnesses over preventative measures(1). My
concern is that the needs of vunerable groups, such as the homeless and
elderly, will not be prioritised by third sector PCTs, because these
groups are unlikely to exercise their right to choose thier PCT, and so
PCTs will focus on trying to secure the custom of more proactive patients.
Legislation to not allow PCTs to cherry pick cheap patients will not
prevent PCTs from marketing themselves to this group. Public Health,
despite being extremely cost-effective in the long term, will also fail to
be prioritised if PCTs are concerned with producing short term results to
attract new patients.
References
(1) Bowling A. Health care rationing: the public's debate. BMJ
1996;312:670-674
Competing interests:
None declared
Competing interests: No competing interests
Selwyn St Leger correctly points out that not everything can be
trusted to the market that I am suggesting. In a list based system there
needs to be an area/population based body responsible for some of the
public health functions. However, I think (and I stand to be corrected)
some public health functions; such as vaccination and some health
promotion, should still best be the responsibility of a patient’s PCT for
medical (continuity of care) and economic reasons(most efficient use of
health care and patient resources). The Government could specify some
targets for PCTs, as at present; 90% vaccination rate, smokers less than
30%, etc. As St Leger says the provision of this public health service
could be contracted out.
Selwyn St Leger is also correct to point out that by having several
competing PCTs the advantages of a single payer health system, would be
reduced, but as St Leger says this advantage does not seem to have been
exploited under the current arrangements. Whether the NHS would be more
effective at benefiting from being a SPS depends on whether the DoH is a
more effective negotiator than, say, Boots.
Competing interests:
None declared
Competing interests: No competing interests
I am becoming increasingly convinced that market players, such as
those proposed by David Allen, are potentially more efficient at
delivering services than well intentioned bureaucrats. The limited NHS
internal market introduced by Mrs Thatcher's government was, at least in
Manchester, beginning to work as intended when the rug was pulled from
under our feet by the present government's ill conceived desire to tinker
yet further with the NHS.
However, I remain to be convinced that everything can be entrusted to
markets. I suggest that the basic public health functions (e.g.
communicable disease control, childhood immunisation programmes,
environmental health, and mass health promotion) are best organised on a
collective basis. That's not to say that the agencies responsible
shouldn't be contracted out but they shouldn't be competing after the
tendering stage; they would require strategic oversight such as is applied
to the gas, water and electricity utilities.
A minor worry about David Allen's otherwise excellent suggestion is
that the potential advantages (not currently adequately exploited) of a
single-payer health system would be lost if there is a multiplicity of
commissioning agencies; perhaps an overarching purchasing agency could be
set up?
Competing interests:
None declared
Competing interests: No competing interests
Dr Whittaker raises some important issues. Privatisation means
different things to different people. The first major privitisation was
the sale of British Telecom (and I do not think many people would argue
that that was not a success). BT was sold on the stock market. I am not
proposing that for the NHS. Nor am I proposing copying the US model of
health care. I am proposing experimenting with inviting some “private and
third sector firms to set up or manage existing PCTs”. I am suggesting
that on the basis that the market, while not perfect, has a track record
of finding the combinations of outcomes which most satisfies the wishes of
customers.
I agree that “tenders should not be granted on purely economical
grounds, (but) to achieve the best health outcome for the population”.
Also, while using their private sector expertise to develop efficient
services, the private sector PCTs will need the expertise of those who
know about purchasing health care, including public health doctors. The
objective is to get the best health care for the money available. However,
presumable if a PCT did not do that then customer/ patients, partly
informed by a DoH prescribed annual report on the service PCTs offer,
would take their custom to where they thought they would get better
service. If a private PCT did not offer as good if not better services
than the existing NHS PCTs then most probably the private PCTs would not
get any custom.
The crux of the matter is who should determine “the best health
outcome for the population”. In the current model it is politicians (or
their surrogates) on the advice and recommendations of managers and public
health staff. With patients choosing their PCT, it is the public who
choose from what is on offer. What is on offer will be based on decisions
of managers and health professionals. That is the nature of a market.
It is an interesting point whether the choices made by
customer/patients would result in poorer health care. I am not quite sure
what Dr Whittaker is specifically referring to, but quite possibly
customers might choose to spend more, say, on elective surgery at the cost
of less immunisation. This might mean that under some outcome measures
“the health” of population might be worse. That is one reason why we need
an experiment to test the impact of these changes. It would also question
what is meant by the “best health outcome”. It could be that the
government would need to set targets for all PCTs for some aspects of
health.
I am not sure whether Dr Whittaker wants patients to “have power to
demand expensive treatments”, but in a market the power to change the
service lies in customers switching to a PCT which offers a service they
prefer. In which approach would “vocal patients” have more impact? I think
it might well be the current approach.
As Dr Whittaker says, the homeless, drug users and the very elderly
are among the groups which are the most expensive, and although their
capitation payment is likely to be higher than the average, the increase
may well not compensate for the increased cost of care. This may well
deter PCTs from providing care for these groups.
Although we have to consider whether equity is everything and whether
in the interests of getting complete equity we should sacrifice providing
a better service for most, I am concerned that all groups should be
treated equitably. That is one of the key strengths of the NHS and I am
anxious that it should continue.
First, private and third sector managed PCTs would have the same
obligations as current PCTs; including a legal requirement not to cherry
pick the cheapest patients, but to be open to all patients who present.
Secondly if the government thinks any care group is not getting
adequate care and the health gap is getting too big, then it is open to
the government to increase the capitation for that group to make it more
attractive for PCTs to offer more care for that group or to subsidies care
for that group.
Since “mega-phone decision making” would not work in a market system,
it is possible that the least articulate groups which concern Dr Whittaker
(and me), by being able to change their PCT, may well find their influence
increased.
I hope that has persuaded Dr Whittaker that the idea is worth further
consideration.
Competing interests:
None declared
Competing interests: No competing interests
Other respondents to Professor Reinhardt’s article are keen to
privatise PCTs on the grounds of greater efficiency (the same argument
that was used for privatising our power and water companies). The NHS is
criticised for high costs and wasting money, but compared to the USA we
actually spend much less of our GDP on health (9.4% compared to a massive
16% in USA). Private PCTs would introduce greater competition, but not
necessarily greater health purchasing expertise. Tenders granted on purely
economical grounds may not produce the best health outcome for the
population. Private PCTs will reduce their costs by tightly rationing the
services they offer, so patients will have less power to demand new
expensive treatments such as herceptin. Disengaged groups such as the
homeless, drug users and the very elderly are unlikely to exert their
right to choose their PCT- it’s these groups that use up a
disproportionate amount of PCT resources- but their needs will fall lower
down the agenda as PCTs attempt to win the business of vocal patient
groups. Competition for patients’ business may lead to some more satisfied
patients, but it might have the side effect of further widening the health
gap.
Competing interests:
None declared
Competing interests: No competing interests
Re: What lessons are there for the UK and the NHS from Professor Reinhardt article? 2 May 2007
Fiona Reynolds is correct in saying that the proposed structure would
differ in different parts of the country. So does the NHS at the moment.
Whether the proposed change would work better in some areas than others
(as does the NHS at the moment) is very hard to say, before it is tried.
It also depends what we mean by “work better”.
I agree people distrust the private sector. Despite the great
affluence that business has given this country in the last 50 years people
distrust commerce and the private sector. A lot of that is irrational as
the “More or Less” programme on Radio 4 on 30th April showed.
http://news.bbc.co.uk/1/hi/programmes/more_or_less/
People remember the accidents at Clapham, Ladbroke Grove, Hatfield,
Potters Bar, etc, and some think that privatisation has made the railways
more dangerous. In fact the railways are safer after privatisation than
under British Rail. With information coming in unsystematically, we are
not good at assessing risk.
That is why we need to experiment, so we can acquire information.
Competing interests:
None declared
Competing interests: No competing interests