Back to index of Nerve 16 - Summer 2010

There has been continuous pressure to alter the NHS public service to a market with both private and public sector organisations, all running as businesses and competing for patients. All NHS staff are only too aware of the constant changes and upheavals these changes have produced. Is this the right policy for a vital public service? Will it deliver better, more accountable, more cost-effective care as is so often claimed? What is happening elsewhere in the world? And why has there been so little informed debate about all this in our media?

Healthcare Sell-off Worldwide
A bad idea imposed without public debate

By Andrea Franks

I was fortunate to attend a most interesting conference on all this a few months ago.
A carefully researched Oxfam paper ‘Blind Optimism’ (on Oxfam UK website) recently looked internationally at evidence for ‘what works in the provision of effective and equitable healthcare’ as in recent years the EU, IMF and World Bank have increasingly promoted the involvement of the (mainly for-profits) private sector for provision of health and other public services. Will the private sector bring welcome additional investment to cash-starved public services in poor countries? Is privately provided healthcare really more efficient and cheaper? Does quality improve? Is the private sector more accountable? Is this the way to reduce inequity and reach the poor?

The answer to all these, it seems, is ‘No’. The Oxfam researchers concluded: ‘The evidence available shows that making public health services work is the only proven route to achieving universal and equitable health care.’

Costa Rica and Colombia, countries with a similar GDP, provide an interesting comparison. In Colombia a healthcare market system has been introduced with growing private sector involvement. Insurance cover is increasingly expensive and much of the population is now effectively excluded from care. By contrast, the Costa Rican health service is a unified and integrated system which is publicly provided and accessible to all. Life expectancy and infant mortality are now similar to those of the US, but at 1/9 of the cost.

Financial considerations often distort the priorities of healthcare providers in ways which are not in the patients’ interests. In Chile the Caesarian section rate is 72%, the highest in the world. This is not because Chilean women are unable to give birth naturally but because hospitals are paid so much more for a surgical delivery.

In any profit-driven system, patients seen as ‘unprofitable’ may be deprived of essential treatment, while others will have unnecessary tests and procedures which benefit only the healthcare provider.

In the developing world, many well-intentioned foreign aid programmes, increasingly delivered by the private sector, target a single condition such as malaria. In Congo, there are 52 disease-specific programmes, each with its own administrative structure, but no general healthcare system. As well as being unnecessarily expensive, this does not provide effective care for the whole population.

Private-for-profit hospitals in Greece, and also in Canada, have been found to have a higher mortality rate than public hospitals, and higher costs. In Germany the increasing numbers of private-for-profit hospitals have been found to have lower staffing levels than public hospitals, lower salaries for staff and more complaints.

The most expensive healthcare in the world is of course in the US, where an influential group of doctors, ‘Physicians for a National Health Program’ is campaigning for a ‘Medicare for All’ option which goes considerably further than Obama’s modest reform. The healthcare insurers, whose profits rose by 56% in 2009, are spending huge sums on campaigning against any reform. Meanwhile, 46 million people have no insurance at all, while 62% of the 900,000 personal US bankruptcies each year are caused by medical costs, even though 78% of those concerned were insured. Those who have seen Michael Moore’s ‘Sicko’ will know some of the ways the insurers manage to deprive patients of care they need. It is alarming that these same organisations have now been invited into the NHS to help with commissioning care and have influence over large sums of public money. In sharp contrast with the US picture, the publicly provided Cuban health service, covering everyone, costs 1/27 as much per head as the US system.

When New Labour was elected in 1997 they promised to get rid of the healthcare market, but in power they did quite the opposite. Why has there not been real debate in the media? How has all this been allowed to happen?

There are now so few specialist journalists in the UK mainstream media that few have the necessary background knowledge to report thoughtfully on health policy. Deadlines are usually extremely short, leaving little time for research. This usually means that Department of Health press releases are reported uncritically, and statements promoting the healthcare market and private sector are not challenged. When a policy is implemented with no press release, few people are likely to hear about it. The alarming involvement of the healthcare multinationals in NHS commissioning received very little publicity for this reason.

There is much international evidence that fragmented, marketised health services with providers working for profit provide worse and much more costly care. If the NHS is destroyed it will be almost impossible to restore it. The current financial crisis, with the pressure to cut public spending in the UK as in other countries, may give a brief opportunity to publicise all this and to restore an integrated public service.

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