Health systems should be publicly funded and publicly providedBMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3580 (Published 10 September 2018) Cite this as: BMJ 2018;362:k3580
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We thank Modi and colleagues for explicating the damages done by private sector involvement in the NHS (1). As junior primary healthcare researchers in Quebec, Canada, we would like to elaborate on an important question posed by this article: Given the evidence against private providers, why is a marketized healthcare model being introduced progressively? We consider that this question has relevance beyond the UK to public healthcare systems under threat of marketization worldwide. By reviewing evidence of progressive marketization and privatization of the healthcare system in Quebec, we argue that there is need for critical reflection on the instrumental value of the ‘public healthcare system’ narrative, in addition to Modi, Clarke & McKee’s explanations of lack of understanding of empirical evidence, personal self-interest or ideological belief as main contributing factors.
The Canada Health Act adopted in 1984 required provincial healthcare plans to be publicly administered, comprehensive, universal, portable and accessible (2) in order to achieve universal health coverage, for which Canada has been praised and is generally assumed as a defining national value of the country (3). However, similar to the 2012 Health and Social Care Act in the UK, which Modi et al. identify as the origin of the fragmentation and privatization of the NHS, Quebec has seen many reforms drastically change its primary healthcare (PHC) landscape under the last 15 years of liberal government (4, 5).
Evidence from these reforms suggests that the purported values of our public healthcare system, such as universality and accessibility, are being co-opted by a neoliberal marketization agenda to obscure processes of privatization. For example, using the pretext of increasing accessibility to and efficiency of PHC services, the last Quebec government pushed for rapid expansion of Family Medicine Groups (FMGs), which are completely publicly-funded, but the majority are privately-managed for-profit organizations (6). This expansion has unfolded at the expense of publicly-funded and managed CLSCs (Local community services centres or community health centres), which had the mandate of being the first point of entry to the healthcare system for all community members on their territory. Human and financial resources have been transferred from CLSCs to FMGs, with limited benefit shown in accessibility and continuity of care at the FMG level (4). FMGs only serve patients registered under the doctors working in the group, who can often "cherry-pick" their patients, restricting access to the most vulnerable ones who are left to the under-resourced CLSCs. Nonetheless, under the banner of accessibility, the government has been heavily subsidizing FMGs to take on more patients and to have longer opening hours, but most FMGs have not achieved these conditions yet (4, 6). Since they are solely accountable to their shareholders, however, and not to the government, answerability for the work for which they are subsidized from the public purse is kept well out of the public purview.
These processes of increasing private sector involvement in the Quebec public healthcare system follow similar patterns as those in the UK identified by Modi and colleagues, involving increased costs and erosions of accountability (1). However, these examples also reveal a need to interrogate where the values that underpin a "public healthcare system" serve to protect the system, and where they serve to obscure the processes of privatization that are dismantling it. We must safeguard against complacency with regards to the resilience of our healthcare systems and the values on which they have been built. Preventing the corrosion of universal health care will require careful examination of the instrumental value of "public healthcare": what is the contemporary relevance of this narrative and whose agenda does it serve to further.
1. Modi, N., Clarke, J., & McKee, M. (2018). Health systems should be publicly funded and publicly provided. BMJ, 362, k3580.
2. Canada Health Act. Justice Laws Website https://laws-lois.justice.gc.ca/eng/acts/c-6/page-1.html. Updated December 3, 2018. Accessed December 11, 2018.
3. Martin, D., Miller, A. P., Quesnel-Vallée, A., Caron, N. R., Vissandjée, B., & Marchildon, G. P. (2018). Canada's universal health-care system: achieving its potential. The Lancet.
4. Pineault, R., Borgès Da Silva, R., Provost, S., Breton, M., Tousignant, P., Fournier, M., ... & Levesque, J. F. (2016). Impacts of Québec primary healthcare reforms on patients’ experience of care, unmet needs, and use of services. International journal of family medicine, 2016.
5. Young, H. (2015). Quebec reforms: necessary or overkill?. Canadian Medical Association. Journal, 187(9), E268.
6. Plourde, A. N. N. E. (2017). CLSC ou GMF. Comparaison des deux modèles et impact du transfert des ressources, Montréal, Institut de recherche et d’informations socioéconomiques.
Competing interests: No competing interests
Modi and colleagues make a strong case against the private sector market in the NHS.1 That is absolutely correct. But NHS privatisation is a secondary cancer. The primary cancer is the internal market.
The internal market has turned our public hospitals into businesses in which, when there is a conflict between financial health and patients' health, financial health trumps. The Mid Staffs scandal was only the tip of the iceberg. All NHS hospitals are affected, as can be seen clearly in today's austerity climate, in which quality of care is sacrificed on the altar of 'efficiency savings' – all too often a euphemism for budget cuts.
The internal market was created by Kenneth Clarke under Thatcher to introduce competition in the NHS to increase efficiency. The mechanism was to effect a 'purchaser-provider split', which created bodies for health service commissioning separated from those for health care provision.
The internal market has resulted in high regulatory and transaction costs, health service fragmentation and bureaucracy, and opening the door to privatisation. Yet it has not demonstrably improved NHS performance and has not worked in its own terms. Even a centrist health economist like Alan Maynard concluded that the internal market is neither effective nor cost-effective and should be abandoned.2 And even the previous NHS Chief Executive David Nicholson on stepping down questioned the appropriateness of the purchaser-provider split and said he was 'interested' to see the reintegration of service commissioning and provision.3 And even still, scrapping the internal market may now be acceptable to the Conservative government.4
During the neoliberal heyday of the 1980s and 1990s market ideologues in international agencies promoted marketisation and privatisation of health systems.5 But the experience has been that competition in health care does not work for the public good and policy is reverting to the need for cooperation and integration. The purchaser-provider split has been abolished in New Zealand, as well as in Scotland and Wales.
In England the internal market has accentuated the fragmentation between primary and secondary NHS care and between health and social care. The potential savings from scrapping the market could be invested in integrated health and social care.
1. Modi N, Clarke J, McKee M. Analysis: forget the market: health systems should be publicly funded and provided. BMJ 2018;362:k3580
2. Maynard A. Head to head: should the NHS abolish the purchaser-provider split? Yes. BMJ 2016;354:i3825
3. Nunns A. Sir David Nicholson's latest bright idea for the English NHS. www.opendemocracy.net accessed 31/12/2017
4. Ham C. Editorial: a funding boost for NHS in England. BMJ 2018;361:k2741
5. Segall M. From cooperation to competition in national health systems – and back?: impact on professional ethics and quality of care. Int J Health Plann Mgmt 2000;15:61-79
Competing interests: No competing interests