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Broken healthcare: Lure of private medicine

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With increasing healthcare demands and challenged capacity, does private health offer a better alternative to social insurance? Or does private healthcare put profits before patients? Recent experience in the UK and elsewhere is examined.

Universal Health Care v Private Provision

UHC has two main principles: (1) cradle-to-grave health care funded by or on behalf of the state for all citizens regardless of age, status, income or means, and either subsidised or free on demand at the point of care, and (2) state funding drawn from the population and employers.

The latter is either from general taxation or, more usually, by a combination of general taxation to fund capital and payroll demands, plus compulsory national social insurance or nominated health insurer for all those of working age, typically deducted from wages at the source.

A National Health Service (NHS) is charged with delivering UHC.

There is no set NHS template, and different schemes exist, all with greater or lesser involvement of state or state-backed insurance schemes and patient contributions.

Cyprus has its version in GESY.

Generally, NHS systems have proven effective and very popular with patients.

However, most countries continue to face NHS challenges from ageing populations, increased demand, pandemic crises, staff shortages, and new and often expensive treatments.

In some countries, especially the UK, such challenges have translated into chronic delays in treatment and long waiting lists, often running into years.

Some countries have rejected UHC, e.g., the US, which spends at least 1.5 times the per capita on health care relative to European countries.

Despite such outlay, the US ranked only 22nd in the global list of actual health care outcomes, resulting from a highly fragmented system, differential standards, insurer disavowals, and patient inability to pay premiums owing to poverty or unemployment.

US Census data for 2016 showed that some 28.1 million citizens had no health care insurance.

By 2020, the figure was still 27.96m or 8.6% of the population.

This article examines the tensions between the two competing ideologies.

NHS Future in Doubt

Under the new Health and Care Act 2022, services ‘free at the point of use’ are now open to much greater private competition.

In dentistry, so many dentists have quit NHS provision to go private that some localities now have no NHS dentists.

Will GP practices do the same, or will they cater for both NHS and private patients but with an access and delivery bias towards private patients?

The dilemma for governments, including Cyprus, is how to maintain and improve health care provision in line with medical advances and public demands and how to pay for it all. Will the new 2022 Act result in the much-vaunted ‘salvation’ the present UK government asserts?

Or will it degenerate into a ‘dog’s dinner’ – a dysfunctional systemic mess from which the only beneficiaries will be private doctors and surgeons, insurers, private corporations, their investors, and financially secure patients, while the mass of patients without adequate finances will be taken back to a primitive pre-NHS reality on a par with third-world health care?

A Climate of Amoral Calculation

Right-wing politicians argue that private providers are much faster and more cost-efficient and are entitled to be profitably paid for their services. Moreover, as respectable and ethical enterprises, they would never extract excessive profits or engage in underhand or lazy practices to the detriment of patients.

Unfortunately, the evidence is that they are not all such paragons of virtue, e.g., the notorious case of surgeon Ian Paterson, who was jailed for 20 years.

A ruthless pursuit of profit encourages, if not ensures, a heavy reliance on amoral calculation by some of those engaged in private health care.

Not all private healthcare provision is incompetent, poor value for money, fraudulent, or worse, damaging or dangerous for patients.

The long-standing public/private partnership arrangement that characterises the UK’s NHS should be able to continue both in principle and practice, so long as there are stringent monitoring, control, and independent auditing systems in place, reinforced by both NHS and government determination to stamp out unethical, harmful and, especially, criminal conduct.

The UK’s Care and Quality Commission will not be robust enough for these oversight tasks. The level of independent auditing (and corrective action) cannot be ‘tick-box’ or superficial ‘window dressing’ if it is to have any benefit, let alone credibility.

Avoidance of Failure

The required headline preventive elements include:

Compulsory liability/surety bonds amounting to, say, 10% of pre-tax turnover imposed on all corporate entities and their individual board members that seek to provide services to the NHS.

Compulsory financial and character ‘due diligence’ screening on all corporate entities and their senior personnel that seek to provide services to the NHS.

Compulsory fit-for-purpose registration and competence certification of all insurance entities and their professional and sales staff engaged in offering Private Medical Expenses Insurance.

Regular compulsory independent validation audits and verification audits (to national criteria, standards, and certified auditors) of all corporate policies, strategies, operations, and management systems about the contracted provision of services to the NHS.

Regularly review the implementation speed and effectiveness of remedial recommendations in compulsory audit reports.

Judicial penalties for corporate wrong-doers (both organisation and individuals), including, say, 10% of pre-tax profits and, where appropriate, jail sentences and/or fines, asset confiscation, compensation orders, directorship bans, and compulsory ‘name-and-shame’ orders.

Control analogues exist.

The UK Competition and Markets Authority has already imposed massive fines, compensation orders, and directorship bans on ‘racketeer’ raiders who have inflated monopoly prices for critical pharmaceuticals supplied to the NHS.

The UK Online Safety Bill will likely impose broadly similar controls on online platform companies and senior executives.

In health care, the emphasis must be on prevention and fairness now rather than a future corrective reaction based on bad experience.

 

This is an abridgement of ‘The UK’s NHS is Broken: Is Private Medicine the Answer?’ by John Broadway and Alan Waring, published in Fair Observer, 26 October 2022.

Dr Alan Waring is Adjunct Professor at Centre for Risk and Decision Sciences (CERIDES) at the European University Cyprus. He is author of several books on risk & contributed to The Risk Watch Column in Financial Mirror 2004-2016