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Commentators have written "It is time now to ask the public if a market-based health service is what they really want." The question, surely, that interests the public is whether they have good access to high quality value for money healthcare that serves their needs.
It has been shown many times that who provides a service is a very much lower order issue for the public. So the debate is about which model (more "commercial" or more "state") is most likely to satisfy what the public really wants.
There are three basic elements in healthcare - insurance in case you need it, provision when and where you need it, and promoting public health.
If people do not have a commercial relationship with their healthcare insurer their influence on the services available to them is limited. At present, we pay for insurance through taxation and the money is mainly channelled through monopoly Primary Care Trusts reporting to Strategic Health Authorities and thence to the Department of Health - a state model (despite the greater role for local authorities being pursued by the government). Choice and competition between insurers and some element of direct payment for cover (excepting those who cannot afford it) have, within a strict framework of government policy and regulation, been proven elsewhere to raise outcomes and satisfaction levels. This more commercial model would mean PCTs should, over time, be transformed into competitive, accountable healthcare insurers with an element of direct payment to complement what will for the foreseeable future be very significant tax-based funding.
If clinicians and managers are not fully engaged in the success or failure of the healthcare provider they work for - if in other words there is not a full performance culture - they will not maximise value for the public as patients and as taxpayers. Gerry Robinson's recent TV programmes were a good demonstration of that. More needs to be done to incentivise clinicians and managers to behave as they would if they were acting for their own account (as GPs do). The more commercial model would mean that clinicians and staff should be given a greater stake in the success or failure of the organisations that employ them.
If people pay nothing for the treatment they receive they do not always act in the same way as if they did. The international evidence is that an element of direct payment results in higher patient satisfaction levels. The more commercial model would mean that, over time, people (again excepting those who cannot afford it) should start to make some level of payment for treatment on NHS terms, although most costs will for the foreseeable future continue to be financed via the PCTs (and their successors) through taxation.
Such moves towards a more commercial model under strict government policy and regulation have been shown to improve the quality and value for money of healthcare in many other countries. Rejecting them because they represent a "market" solution is surely folly and I don't believe the public would favour a solution towards the state monopoly end of the spectrum if a better way could be demonstrated. Current government reforms are moving towards the more commercially accountable model, even though Ministers cannot always bring themselves to articulate it clearly or take it to its logical conclusion.
Adaptation of a Letter to the Editor from The Times (January 2007)
It has been shown many times that who provides a service is a very much lower order issue for the public. So the debate is about which model (more "commercial" or more "state") is most likely to satisfy what the public really wants.
