The NHS is not the saintly institution of the popular imagination
This slavish and often misguided devotion to the NHS is akin to ‘death by a thousand cuts’ for an institution we claim to love, but regularly abuse, whether it be in the form of lack of responsibility for our personal health, inappropriate A&E attendance, or not turning up for appointments.
What we need is a sensible discussion about the NHS’s future, which includes its relationship with the private sector.
The myth of NHS being the envy of the world was exposed in Kristian Niemietz’s book Universal Healthcare without the NHS, which found: “In international comparisons of health system performance, the NHS almost always ranks in the bottom third, on a par with the Czech Republic and Slovenia.”
The current pandemic gives further strength to Niemietz’s argument for laying the foundations for a new era of cooperation between the private and state sectors.
It is still early days, but a preliminary analysis of how Covid-19 impacted on different countries shows those who have already integrated private providers into their healthcare systems have been far more successful in tackling the pandemic than the UK. Just look at the huge difference in excess mortality rates between the UK and Germany, which is home to a huge private healthcare industry.
GPs as purchasers of healthcare services
So, what would be the first steps towards addressing the thorny issue of greater private sector involvement? Niemietz is right when he advocates that a good starting point would be GPs, who are already technically private providers contracted by the NHS.
In the 1990s, a Fundholding initiative allowed individual GPs to independently purchase services for their patients. This compares to the current system of GP-led clinical commissioning groups (CCGs) which commission services as a group.
Fundholding was a genuine example of how effective commissioning can be.
It gave GPs like me control of budgets involving hospital care for patients allowing us to negotiate directly with providers. The clinical knowledge we bought to this process allowed us to become far shrewder purchasers than our administrative counterparts.
I cut out the ‘middleman’, saving money and providing better care, because I knew more about my patients and their needs. This included getting hospital consultants to come to my surgery, allowing patients to be seen closer to home.
I was subsequently encouraged to start moving towards private sector involvement in the tendering process.
Unfortunately, this didn’t happen with Fundholding, which was brought down by a cabal of NHS managers who saw their hegemony being threatened along with some GPs reluctant to try something new.
Over the following decade, I had much closer dealings with local health authorities.
It was fascinating to see them undergo so many name-changes involving confusing acronyms – FHSA, PCG, PCT and CCG – while maintaining the same arteriosclerotic structure run by the same people under different hats, often ineffectually so.
A positive case study – and its undoing
There were exceptions to the rule.
I was fortunate to work with an inspiring chief executive in my role as a cardiology lead with my local Clinical Commissioning Group (CCG), who agreed private providers could tender for a community cardiology initiative.
Our goal was to provide a cheaper, more patient-responsive service than our local hospital and its eye-watering cost-loading mechanisms.
Our choice of a small private firm with state-of-the-art equipment and a sound managerial structure led to achieving excellence, value for money and improvement in procurement.
Soon independent consultant cardiologists joined the service and eventually a Harley Street company with a high-definition cardiac scanner – unique to the UK at the time – was contracted to carry out secondary cardiac diagnostics.
Here’s how that private sector contract worked.
A patient presented at my surgery with a heart condition and would be seen within two weeks (as opposed to eighteen) by a cardiologist, supported by first line cardiac diagnostics.
If they required a more detailed investigation, we would arrange for a taxi to take them to our private contractor offering the latest state-of-the-art scanning equipment (and back home again).
The cost per patient was £800 compared to the £1,200 hospital bill for the same service but with inferior scanning equipment (never mind the taxi).
The initiative won six national awards along with praises from two health secretaries, the Prime Minister and a visit from the then Mayor of London, Boris Johnson.
With hindsight, it would appear that we were already successfully following Niemietz’s strategy for an orderly transition towards a pluralistic healthcare system, as outlined in chapter 5 of his book.
But then the empire – aka the NHS bureaucracy – struck back. They had no intention of letting the status quo be upset and systematically set about dismantling the community service.
Our private contractor, whose diagnostics had exposed the archaic equipment used in one of the most prestigious London teaching hospitals, came into their crosshairs first.
The independent cardiologists, who had reduced waiting times to two weeks and hospital outpatients to near zero, were replaced by hospital consultants and it did not take long before waiting times rose again.
The dismemberment of this once nationally renowned service is a textbook example of how to eliminate the private sector threat and sacrifice primary care in favour of secondary care and the NHS’s own hospitals.
Sadly, CCGs’ blind obedience to this doctrine makes a mockery of the claim that they are ‘clinically-led statutory NHS bodies responsible for the planning and commissioning of health care services for their local area’. NHS England is the real powerbroker with ultimate control over CCGs, and 97% of its senior ranks are filled with people who have previously worked in secondary care. This is where their allegiance remains.
Consolidation of power at the centre and total submission of GPs has been secured with the introduction of Primary Care Networks and the collaboration of the Local Medical Committees and the British Medical Association, the only unreformed trade union left in the UK. With GPs leaving in droves and record practice closures, we are fast reaching the end game of turning GPs into salaried doctors under hospital management.
Greater involvement of the private sector is the only way forward if the NHS is going to survive. Niemietz has rightly identified GPs as the best placed health workers to initiate changes to achieve that goal, but this requires a supportive policy framework; it takes mavericks to ‘drain the swamp’ and empower GPs by enhancing their independent status.
It will be unpleasant work and senior NHS management has a vested interest in ensuring it never happens as these merciless high priests have consolidated their powers.
The lions might be led by donkeys but it doesn’t have to be like that. If the public had a greater realisation of the fact that the NHS is not the saintly institution they imagine it to be, but an institution which contains a strong self-serving element, an institution which looks after its own first – change would become possible.
Carl Jung famously said that ‘that which you most need will be found where you least want to look’. Where we need to look now is the market, and the private sector – however loud the misguided protests may be.
Dr Kosta Manis is a member of Bexley CCG in south east London. He has been a GP, and a regular contributor to healthcare policy debates, for more than 30 years.