Further privatisation is inevitable under the proposed NHS reformsBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2996 (Published 17 May 2011) Cite this as: BMJ 2011;342:d2996
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I find it hard to take Clive Peedell seriously sometimes. According
to him he wasn't criticising privatisation. But his article can hardly be
read as "the government is secretly planning to privatise the NHS, but
that's not necessarily bad".
And, apart from the need to assume a conspiracy, not many would
accept the definitions of privatisation he proposes. Giving organisations
more freedom to decide how to do their job is not privatisation any more
than allowing clinicians freedom to make clinical decisions is privatising
them. FTs are not privatised on any reasonable definition of the word.
Allowing NHS trusts to compete with each other isn't privatisation either.
Whether competition works (and he kindly saves me the task of
referring to the most recent evidence that it does) has little to do with
privatisation unless you believe it is a prelude to selling off the NHS as
part of a long term conspiracy. And this government are not well organised
enough to run a conspiracy.
The opposition to NHS reform should also be more honest about what
sort of NHS they want. If they really believe that an organisation that
size can be centrally controlled with centrally set operational processes
and that this will be good for patients, then make the case and show the
rest of us why that mode of management worked so successfully in communist
economies. Some of Peedells' privatisation criteria (giving more autonomy
to hospitals = privatisation) imply exactly the sort of stalinist
organisation that few in the NHS would really welcome. If that isn't the
model of the NHS he want to promote, then a) he should be clearer about
what he does want and b) not use criteria derived from a central planners
manual to determine which aspects of reform count as privatisation.
I agree with many opposed to reform that the government
should pay for our care. I agree that we should judge any reform by its
impact on outcomes. I disagree that central control of all provision and
no competition is a good way to achieve improvement.
Competing interests: No competing interests
More importantly Black fails to provide a robust response to the majority of the points made within my article. Rather he states:
"The rest of the case seems to consist of taking a bunch of criteria from some central planning advocate and applying them to the health bill. None of this addresses the central question of whether the reforms will produce better results for patients."
However, the article is not about whether the reforms will provide better results for patients (which for the record, I strongly believe will not be the case, along with the majority of the medical profession and the health policy community). It is about whether the politicians are being honest with the public on the issue of privatisation of the NHS. The article shows that they are not being honest and Stephen Black helps to prove this argument because he actually broadly supports the reforms because he thinks they will improve care by greater use of competition and the private sector. Of course, he provides absolutely no evidence to support his case. I'm sure he would quote the recent work of Cooper and Propper, but the role of competition remains highly controversial at best, as the work of Peter Smith for the OECD has shown.
Black also states that this Government is not bent on privatisation, but this ignores their economic policy, which is supply side in nature. Reducing public expenditure and replacing public services with the private and third sectors is crucial to their plans for economic recovery.
Finally, as for his comments about the well being of patients, that is the raison d'etre of my working life as a cancer specialist. It is also the reason why I strongly believe that the sooner the management consulting industry is removed from the health policy community, the better.
Competing interests: Author of original article
One of the commonest criticisms of the government's programme of NHS
reform is that it is "ideological". Clive Peedell's argument on
privatisation illustrates that this criticism applies equally to the
opponents of reform.
In his entire rant against reform, for example, he fails to mention
the wellbeing of patients even once, giving the impression (presumably
unintentionally) that he would oppose anything that looked like
privatisation even if it it demonstrated better outcomes.
The overall logic of his argument seems to flow like this: we know
privatisation is evil and therefore any move in that direction must be bad
for the NHS. This isn't so much a real argument as a trick to appeal to
the innate prejudices of the majority of his audience (so rhetoric rather
than logic). But even then some of the steps in his case are extremely
For example, one of his criteria for identifying privatisation is
"Self management, wherein providers are given autonomy to generate and
spend resources." Correct me if I'm wrong, but I thought that most doctors
and managers regarded "self management" and "autonomy" to be good whatever
their view on privatisation. It is only die hard stalinist central
planners who think the world would be better when all hospitals and
doctors had to follow a single recipe written by a distant Whitehall
And are Foundation trust freedoms bad? Is borrowing money from the
private sector to pay for hospital investment bad? Or would a public
sector PFI scheme be better (note that PFI isn't the same as borrowing
from the markets and that FTs have mostly shunned PFI schemes compared to
non-FTs. I'm in agreement that PFI is mostly a bad idea but it is the
trusts with more freedom and accountability that have shunned it.) And the
old private patient cap on FTs was a very poor way to focus them on NHS
activity and ended up just reducing their flexibility to bring private
investment back into the NHS when the hospitals had more capacity than
local PCTs wanted to pay for.
The rest of the case seems to consist of taking a bunch of criteria
from some central planning advocate and applying them to the health bill.
None of this addresses the central question of whether the reforms will
produce better results for patients.
If competition among NHS hospitals (FTs or not) encourages them to
become more efficient and deliver better outcomes for patients (and recent
evidence suggests it does) then why should it be bad? If new providers--
even, god forbid, profit making ones--enter the market and offer better
outcomes for the same price, why should we prevent patients choosing them?
Unlike Clive Peedell, I don't believe in conspiracies and don't think
the government is bent on "privatisation". The key reforms are about
competition which will mostly be among NHS providers. But even if this
wasn't true, I would judge the reforms by their results for patients not
by whether they conformed to my ideology of how things ought to be run.
Competing interests: Has advised government on issues related to "privatisation".