Is the private sector a good thing for the NHS?BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5865 (Published 30 September 2014) Cite this as: BMJ 2014;349:g5865
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Richard Smith’s article in favour of private sector delivery of NHS-funded services contains important errors and omissions (1). He cites a magazine article as stating that private companies are ensuring more consistent quality across practices (2), but in fact the article makes no such claim. He states that more than half of hip and knee replacements funded by the NHS are now done by the private sector, but in fact the report he cites shows that the large majority are still done by NHS hospitals (3). He cites an audit showing better results from joint replacements done in the private sector, but omits the authors’ comments that the differences could be attributable to differences in case mix that were not fully taken into account (4). He cites the 2014 Commonwealth Fund report as evidence that many countries with private hospitals serving the public sector have better outcomes than the NHS, but omits two important findings from the same report (5). First, all the countries with better outcomes apart from New Zealand spent substantially more per capita (range $3,800 - $5,669 per year) than the NHS ($3,405), which suggests that inadequate funding, rather than public sector delivery, may explain the NHS outcomes. Second, across all the dimensions considered in the report – quality, access, efficiency, equity, equity and outcomes – the NHS was ranked first overall. The NHS needs additional investment and a continued ethos of professionalism and public service, not replacement by the private sector.
1. Smith R. Is the private sector a good thing for the NHS? Yes. BMJ 2014;349:g5865
2. Soterious M. GP-led private company can take over 22 practices, watchdog rules. GP 2013 Aug 20. www.gponline.com/gp-led-private-company-22-practices-watchdog-rules/arti...
3. Arora A, Stoye G. Public payment and private provision: the changing landscape of healthcare in the 2000s. Nuffield Trust, 2013. www.nuffieldtrust.org.uk/publications/publicpayment-private-provision-2000s
4. Chard J, Kuczawski M, Black N, van der Meulen J. Outcomes of elective surgery undertaken in independent sector treatment centres and NHS providers in England: audit of patient outcomes in surgery. BMJ 2011;343:d6404.
5. Davis K, Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall, 2014 update: how the US health care system compares internationally. Commonwealth Fund, 2014. www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror.
Competing interests: Solutions for Public Health is a not-for-profit NHS public health consultancy. It has done contract work for UnitedHealth on quality indicators for healthcare.
Dependency of the Physician from private healthcare systems can generate conflicts of interest and undermine the doctor-patient relationship. Reinforced autonomy of the patients may help.
As Clive Peedell (2014)  says, the big idea of those that defend the privatization of the NHS “is that the injection of the private sector into the NHS will stimulate market competition to deliver lower costs, greater innovation, increased quality, and greater responsiveness to patients”. But this is only a myth.
1- Private health care systems are less efficient than public ones.
As John Appleby (2012)  says, in countries where the private healthcare systems are dominant, the cost of their healthcare system is greater: the USA spends almost the same on healthcare as all other countries in the Organization for Economic Cooperation and Development (OECD) put together. Total (public plus private) health spending in 2010 (as % of GDP) was in the U.K. 9.4% and the USA 17.6%.
According to the recent Commonwealth Fund Report on Health Systems , comparing 11 nation for factors that included quality, access, efficiency and equity of healthcare, the UK was rated higher than the USA, and the expenditures of healthcare (in 2011) were again higher in the USA (per capita, USA spent $8,508, compared with only $3,405 in the UK). These data, remind me of another statement of Clive Peedle: “private firms are profit maximizers, not cost minimizers”. Several papers published by The BMJ under the series “too much medicine” give good examples of inflated prices and waste.
2- Employed Physician, patient’s trust and possible conflict of interests.
Individual private medicine exists for centuries but was based on a private talk of the patient with his confidant doctor, and it was possible for the good physician to balance his own interests with those of the patient, under the regulation of medical associations to define ethic codes, limit fees and combat abuses. Physicians were liberal professionals, and when necessary they were free to choose (in accordance with their patient) the hospital in which to operate on their patient. With the increasing complexity of treatments and complementary examinations, there was the need to introduce a mutualistic third party payer, which was relatively peaceful until it interfered with the autonomy of the patient and with the freedom of the physician. The great problem was the introduction of economic groups and insurance companies not as payers, but as owners of health care systems with the control of both doctor and patient.
By its duty of beneficence, doctors must prescribe the best treatment to the patient who trusted them. Since the promotion of public health is one of the social obligations of the state, in public health care systems, the doctor and the NHS (his employer) have in common the same goal: to promote the patient’s health.
In healthcare systems belonging to private groups in which the physician is employed (and dependent), besides the loyalty to his patient the physician also owes loyalty to his boss, and conflicts of interest may arise when private healthcare institutions maximize their legitimate interest in obtaining profits by minimizing their duty to provide good care to patients.
If the hospital belongs to an insurance company, an additional problem may arise related with confidentiality, because the patient may have doubts about the internal rules that “assure” data privacy, which can also undermine the relationship with his doctor based on trust.
For the above reasons, many agree with Relman (2007): “The continued privatization of health care and the continued prevalence and intrusion of market forces in the practice of medicine will not only bankrupt the health care system, but also will inevitably undermine the ethical foundations of medical practice and dissolve the moral precepts that have historically defined the medical profession”.
Private sector supply of new products and services is beneficial, but in a mutualistic model with liberty for the physician (in accordance with the patient) to choose hospitals, and with the possibility of patients freely choosing doctors and hospitals, even if these belong to a system different from that he has subscribed to. This is the beneficial and truly free market competition that improves a good relation price/quality. Private systems must restore the liberty that patients and doctors had before the holding of healthcare by the market.
1- Clive Peedell Is the private sector a good thing for the NHS? BMJ 2014;349:g5865.
2- John Appleby Rises in healthcare spending: where will it end? BMJ 2012;345:e7127.
3- Commonwealth Fund Report on Health Systems (http://www.commonwealthfund.org/interactives-and-data/infographics/2014/...)
4- Relman AS. Medical professionalism in a commercialized health care market. JAMA 2007;298:2688-70.
Competing interests: No competing interests
Dear Dr.? Smith
I take issue with your entirely interest based approach: private good public bad, reminiscent of one of Orwell's novels.
Specifically: "more than half of the hip and knee replacements now funded by the NHS are now done by the private sector"
Your argument is not only fallacious but also misleading, more reminiscent of Goebbels than Bevan.
Individuals providing this service:
1. Cherry pick the patients ASA1 and ASA2 patients only
2. Provide no training in this setting, they parasitse NHS staff
3. Ensure that correspondingly despite there being the capacity, they do less work on NHS premises, privately for example working a three shift elective system while letting lists in the NHS go fallow.
4. Treat no private sector complications in the private sector.
5. Inviduals providing the private sector service compete with their primary NHS employers for the same funds putting their own Trusts at risk of financial failure.
To make the whole system fairer maybe provbiding private care at the cost of the NHS should be legally prohibited and individuals prevented from putting their primary employer at risk. A true market would mean individuals having to make a choice they don't have to now. If NHS resources were used appropriately the private sector would long have been out of business.
Competing interests: 100% NHS Doctor
Dr Smith, I'd take issue with your paragraph:
"Successful organisations concentrate on their core business, which for hospitals means caring for patients. It thus makes sense to outsource catering, cleaning, and other non-core activities to the private sector"
Unfortunately it's not as simple as that. Catering and cleaning are as much part of caring for patients as anything else we do. Poorly-nutritioned patients don't recover from surgery, people pick up infections in dirty hospitals. It's odd that you categorise these essentials as non-core and not part of caring for patients.
Competing interests: No competing interests
Clive and I had fun in our debate at the Medical Journalists’ Association last night, and he won by about two thirds to one third of the 50 or so people present. But only one person changed her mind as a result of the debate: she thought I was weak.
The evening made me wonder about trying a very different process: dialogue instead of debate.
A debate—like head to head—is more for entertainment than enlightenment. Both of us made questionable statements, and the audience threw out lots of stories that seemed to them to prove their point.
Ironically, both Clive and I have the same aim—to keep the NHS alive. So instead of 60 minutes of wild statements we might have spent several days exploring every point, listening to each other very carefully. We would try to agree on what we knew for sure and on where we were uncertain. We would try and sift out what was opinion and what was a belief based on a deeply held value. As part of this process we might have clarified where we agreed and disagreed, where we needed more evidence, and how we might evaluate what was proposed. We might also have agreed what was inadmissible evidence.
In retrospect—and you can see it in the articles—we were talking across each other. Clive was talking about the “marketization,” while I was making a more mundane point that the private sector already does much in the NHS (not least provide general practice and half of all hip and knee replacements) and has the potential to do more. For me use of the private sector does not necessitate a “market,” as the first 40 years of the NHS show.
The debate over competition, which the BMJ has already included in its head to head series, (1 2) is a much more complex debate, where evidence is lacking. I touched on it my article and effectively reached the Scottish legal conclusion of “unproven.” But we might explore in our dialogue why the main political parties all agree on some form of competition and whether it would be possible to return to a command and control NHS.
If we’d had a dialogue we would have at least agreed exactly what we were talking about; and, as I’ve argued before, (3) http://blogs.bmj.com/bmj/2014/07/31/richard-smith-all-problems-are-ultim... we would have defined terms in a way that would have been desperately boring for the audience but helped with achieving enlightenment rather than entertainment.
British institutions—not least Parliament, elections, and the law—tend to be based on debate rather than dialogue, possibly because our attentions spans are short and getting shorter.
But it is perhaps time to rediscover the Socratic Dialogue, which Wikipedia defines thus: http://en.wikipedia.org/wiki/Socratic_dialogue
“In the dialogues Socrates presents himself as a simple man who confesses that he has little knowledge. With this ironic approach he manages to confuse the other who boasts that he is an expert in the domain they discuss. The outcome of the dialogue is that Socrates demonstrates that the other person's views are inconsistent. In this way Socrates tries to show the way to real wisdom.”
The NHS touches deep emotions and beliefs in a quasi-religious way, probably because it is an arena for the fundamentals of life—birth, death, pain, and suffering. This makes calm dialogue about the NHS particularly difficult.
Yet we need dialogue not debate about the NHS—because it matters so much to all of us. How can we make it happen?
1 Stevens Simon. Is there evidence that competition in healthcare is a good thing? Yes BMJ 2011;343:d4136
2 Mays Nicholas. Is there evidence that competition in healthcare is a good thing? No BMJ 2011; 343:d4205http://www.bmj.com/content/343/bmj.d4205
3 Smith R. “All problems are ultimately linguistic problems.” BMJ blog: http://blogs.bmj.com/bmj/2014/07/31/richard-smith-all-problems-are-ultim...
Competing interests: RS is employed by UnitedHealth and has shares and share options. He runs a philanthropic programme in low and middle income countries for the company and has no responsibility for UnitedHealth (now Optum) in the UK or for any of the commercial activities of UnitedHealth. He also has equity in Patients Know Best, a company that links records from all parts of health and social care and gives control to patients.
Frankly, both the models are good - it is not Sir Humphrey Appleby non-committal answer of a civil servant.
As a basic research scientist deeply involved and worked closely with clinical colleagues (UK, Europe- West, East, USA, Canada), my conclusion is simply the following.
"The field of golden research of promise for treatment affecting huge numbers of patients is fiercely competitive: biotechnology for blood transfusion, BM, stem cell transplantation and gene therapy,
Apart from the pressure for grants, lure of honours, glittering prizes, with a shrewd eye for commercialisation with the administrators, the minute consideration of "$s enters, the whole thing goes skewed and faulty". Companies are floated and the interests of the company and shareholders have a skewing effect and become paramount.
Public sector (apart from the example of Railways, social services) is also affected seriously for lack of vigilance and monitoring constantly the performance of the clinical and administrative staff. Some hospitals-dragging their feet and not acting speedily, suppressing information, passing the buck is not good-risks to whistle blowers and safe guarding their interests has not improved
The real problem for both the systems is the great need for constant unbiased-watchful eye and constant monitoring of the performance that is 'quantitative' and evidence based.
My comments have been based following work/observing happenings and practices in the clinical environment actively since 1960 and in hospitals, research Labs UK, Europe (Paris, Karolinska-Stockholm, Freiburg, Munich, Cologne), USA: Washington DC, New York, Yale, Brookhaven, Bethesda, Seattle, Portland-Oregon), Eastern Europe (Rostock through to Budapest), guest of the Academy hospital in Moscow, St Petersburg, Beijing, Chengdu. I have no vested interest.
Competing interests: No competing interests