- Email: [email protected]
london UK to embrace private-sector involvement in NHS?
DISPATCHES
UK to embrace private-sector involvement in NHS?
he pledge came like a bombshell at the start of the election. At the launch of Labour’s manifesto, Tony Blair declared there would be “no ideological bar” to wider use of private companies in the delivery of the UK’s national health service (NHS). This was the political equivalent of Margaret Thatcher calling for the nationalisation of banks. Labour, which invented the NHS in 1948, has traditionally been vehemently opposed to private practice, seeking all manner of ways of reducing its influence. This has ranged from reducing the number of private beds in public hospitals in the 1970s to its latest plan to require all NHS consultants to serve 7 years before they can take on part-time private work. The new move therefore startled everyone. The new plan would still provide free care, according to need, at the point of use but there were few further details at the launch. 8 weeks on there is still no clear plan. Ministers then confirmed that the government wants to contract out some of the 20 planned 24 h treatment and diagnostic centres to the private sector as an experiment, though in the furore that followed, they emphasised in their retreat that this would only be “the management” of the unit. Clinical staff would still remain part of the NHS. Even here there is no real clarity. Clinicians can be managers too. William Hague, the Tory leader, last week challenged the prime minister to reconcile his two contradictory positions: in favour of privately run surgical units; but under no circumstances allowing any clinical service to be run by the private sector. As the Tory leader noted: “Being managed is the same as being run.” The answer he got failed to clarify the position. Since the launch of the idea, it has waxed and waned. Leaks have been met with counter leaks. Even people right at the centre of government remain unsure of what is planned. The ironies are enormous. A Labour government, which fought the 1997 election promising to save the NHS from the Tories’ sharp-elbowed internal market, has fought the 2001 election promising to widen and increase competition by including private operations—a move the Tories would never have dared contemplate. British opinion polls traditionally showed that the NHS was more popular than the royal family—even when the royal family was at the height of its popularity. Now there is no clear
T
THE LANCET • Vol 358 • July 7, 2001
message about making more use of the private sector. Some polls have shown the public does not mind as long as they are provided proper care; others have found deep-seated opposition. It depends on how the question is asked. But an opposition bandwagon to the change is gathering strength. It embraces Labour activists, intent on taking on ministers at the party’s
Rights were not granted to include this image in electronic media. Please refer to the printed journal. PA Photos
LONDON
Tony Blair—welcomes private-sector input
annual conference in October; medical leaders exhausted by the many management changes in the past decade; and union bosses. In addition, big party names such as Neil Kinnock, the past Labour leader, and his former deputy, Roy Hattersley, are opposed to the ideological switch. And many senior health managers are concerned by the way the row over widening the private sector’s role will divert attention from crucial internal reforms needed to achieve the government’s 10-year modernisation plan.
“This was the political equivalent of Margaret Thatcher calling for the nationalisation of banks” Union bosses, who traditionally have been the bedrock of Labour’s support, were given a Downing Street dinner last week, but the key leaders emerged still unsure of how far and how fast the prime minister intended to move. The two biggest unions this week attacked the government’s “cocktail of confusion” and have even agreed to meet the Liberal Democrat leader to explore ways of blocking Labour’s plan. Concerned by the rising tide of opposition, the health secretary has been trying to draw boundaries where the manifesto said there would not be any. He has set out four separate areas where private—and voluntary—sector involvement could be widened: the new 24 h fast-track surgery units; reducing non-emergency NHS waiting
lists by using the private sector’s spare capacity; expanding the private finance initiative (PFI) to take in family doctor premises, mental health, and social service facilities; and running IT systems and NHS buildings. Areas added subsequently by others include managing the new primary care trusts, which will be commissioning hospital services for family doctors; regional pathology centres; and intermediate care. One major setback for the government was the publication last week of a special commission into public– private partnerships by the Institute for Public Policy Research (IPPR), Labour’s favourite think tank. Pre-election leaks suggested it would include a call for a widening of private-sector involvement in health. But it was much more cautious, expressing grave doubts that current public–private partnerships (PPPs) had provided value for money in health. It specifically rejected the idea, pushed by ministers, that PFI (raising private cash for public hospital building) had created “extra” investment. The report suggested PFI was not “offering significant gains” and there was “little hard evidence” of innovation resulting. Indeed, for a government committed to evidence-based policy-making, there is little evaluation of any PPP project. The report insisted that nothing should be tried on a broad front until properly piloted and assessed. It went on: “There has been a tendency to spray the demand for ‘private sector involvment’ across most new government initiatives without proper consideration of what the different partners would have to offer. This has fuelled partnership fatigue rather than unleashing new energy and innovation.” It is clear that the euphoria raised by the launch of the government’s 10-year health plan last July—the principles of which were endorsed by 24 of the country’s top medical, nursing, and managerial leaders—has by now evaporated. Labour’s commitment to move towards a world-class health service by the next election (2005 or 2006) is in serious trouble. Public expectations have been raised to a dangerously high level. Public opinion polls still show wide dissatisfaction with the current service. Labour’s majority is the second highest in its history, but it knows it will be in serious trouble if it does not deliver the promised better public services. Malcolm Dean
45
For personal use. Only reproduce with permission from The Lancet Publishing Group.
UK to embrace private-sector involvement in NHS?
he pledge came like a bombshell at the start of the election. At the launch of Labour’s manifesto, Tony Blair declared there would be “no ideological bar” to wider use of private companies in the delivery of the UK’s national health service (NHS). This was the political equivalent of Margaret Thatcher calling for the nationalisation of banks. Labour, which invented the NHS in 1948, has traditionally been vehemently opposed to private practice, seeking all manner of ways of reducing its influence. This has ranged from reducing the number of private beds in public hospitals in the 1970s to its latest plan to require all NHS consultants to serve 7 years before they can take on part-time private work. The new move therefore startled everyone. The new plan would still provide free care, according to need, at the point of use but there were few further details at the launch. 8 weeks on there is still no clear plan. Ministers then confirmed that the government wants to contract out some of the 20 planned 24 h treatment and diagnostic centres to the private sector as an experiment, though in the furore that followed, they emphasised in their retreat that this would only be “the management” of the unit. Clinical staff would still remain part of the NHS. Even here there is no real clarity. Clinicians can be managers too. William Hague, the Tory leader, last week challenged the prime minister to reconcile his two contradictory positions: in favour of privately run surgical units; but under no circumstances allowing any clinical service to be run by the private sector. As the Tory leader noted: “Being managed is the same as being run.” The answer he got failed to clarify the position. Since the launch of the idea, it has waxed and waned. Leaks have been met with counter leaks. Even people right at the centre of government remain unsure of what is planned. The ironies are enormous. A Labour government, which fought the 1997 election promising to save the NHS from the Tories’ sharp-elbowed internal market, has fought the 2001 election promising to widen and increase competition by including private operations—a move the Tories would never have dared contemplate. British opinion polls traditionally showed that the NHS was more popular than the royal family—even when the royal family was at the height of its popularity. Now there is no clear
T
THE LANCET • Vol 358 • July 7, 2001
message about making more use of the private sector. Some polls have shown the public does not mind as long as they are provided proper care; others have found deep-seated opposition. It depends on how the question is asked. But an opposition bandwagon to the change is gathering strength. It embraces Labour activists, intent on taking on ministers at the party’s
Rights were not granted to include this image in electronic media. Please refer to the printed journal. PA Photos
LONDON
Tony Blair—welcomes private-sector input
annual conference in October; medical leaders exhausted by the many management changes in the past decade; and union bosses. In addition, big party names such as Neil Kinnock, the past Labour leader, and his former deputy, Roy Hattersley, are opposed to the ideological switch. And many senior health managers are concerned by the way the row over widening the private sector’s role will divert attention from crucial internal reforms needed to achieve the government’s 10-year modernisation plan.
“This was the political equivalent of Margaret Thatcher calling for the nationalisation of banks” Union bosses, who traditionally have been the bedrock of Labour’s support, were given a Downing Street dinner last week, but the key leaders emerged still unsure of how far and how fast the prime minister intended to move. The two biggest unions this week attacked the government’s “cocktail of confusion” and have even agreed to meet the Liberal Democrat leader to explore ways of blocking Labour’s plan. Concerned by the rising tide of opposition, the health secretary has been trying to draw boundaries where the manifesto said there would not be any. He has set out four separate areas where private—and voluntary—sector involvement could be widened: the new 24 h fast-track surgery units; reducing non-emergency NHS waiting
lists by using the private sector’s spare capacity; expanding the private finance initiative (PFI) to take in family doctor premises, mental health, and social service facilities; and running IT systems and NHS buildings. Areas added subsequently by others include managing the new primary care trusts, which will be commissioning hospital services for family doctors; regional pathology centres; and intermediate care. One major setback for the government was the publication last week of a special commission into public– private partnerships by the Institute for Public Policy Research (IPPR), Labour’s favourite think tank. Pre-election leaks suggested it would include a call for a widening of private-sector involvement in health. But it was much more cautious, expressing grave doubts that current public–private partnerships (PPPs) had provided value for money in health. It specifically rejected the idea, pushed by ministers, that PFI (raising private cash for public hospital building) had created “extra” investment. The report suggested PFI was not “offering significant gains” and there was “little hard evidence” of innovation resulting. Indeed, for a government committed to evidence-based policy-making, there is little evaluation of any PPP project. The report insisted that nothing should be tried on a broad front until properly piloted and assessed. It went on: “There has been a tendency to spray the demand for ‘private sector involvment’ across most new government initiatives without proper consideration of what the different partners would have to offer. This has fuelled partnership fatigue rather than unleashing new energy and innovation.” It is clear that the euphoria raised by the launch of the government’s 10-year health plan last July—the principles of which were endorsed by 24 of the country’s top medical, nursing, and managerial leaders—has by now evaporated. Labour’s commitment to move towards a world-class health service by the next election (2005 or 2006) is in serious trouble. Public expectations have been raised to a dangerously high level. Public opinion polls still show wide dissatisfaction with the current service. Labour’s majority is the second highest in its history, but it knows it will be in serious trouble if it does not deliver the promised better public services. Malcolm Dean
45
For personal use. Only reproduce with permission from The Lancet Publishing Group.