So – this is the day that Cambuffoon and his Lillie Langtry are to sprinkle drops of NHS blood on the oceans of commerce; and already the corporates are circling, to devour the NHS as a shark does its prey. Rich fat and valuable flesh will be stripped from bone, and all will go, save the profitless indigestible carcass of the weak, the poor, the chronic and the incurable.
These are the headline notes of the grim fate our government has in store for our health service. Already the rabble of the right is roused; and already the cry has gone up: The NHS is a wasteful and bloated sacred cow that should be slaughtered! The steely knife of market forces will excise all waste and all inefficiency on the trading floors of the agoræ, where ‘any willing provider’ can and will step up to the mark.
Now, Dr No is deeply sceptical of this ‘any willing provider’ rhetoric. It seems to him that being ‘willing’ is a rather strange measure of competence and good intent. We need only look to the financial services market – another damn market, and apparently a ‘regulated’ one to boot – to see that when there is allowance for an abundance of ‘willing providers’, not all ‘willing providers’ are necessarily competent; while others – ‘never knowingly unwilling’ loan sharks spring to mind – may reveal themselves, when push comes to shove, a bob or two short on the good intent front.
Dr No can’t help noticing that, rather surprisingly, his wariness of ‘willing providers’ appears to be at large in the most unlikely of quarters. Even his esteemed pro-market colleague Boots, who recently famously declared he would do pretty much anything, so long as it had a cheque attached, can now be seen to be, if not exactly back-pedalling, then at least wobbling, an uncertain mono-cyclist, in his enthusiasm for the market and its first cousin ‘choice’. One wonders if Boots has scented that ‘any willing provider’ will not just threaten, but probably destroy, the cosy duopoly that presently holds sway, NHS in the left corner, and Little Harley Street on the right; and that the minnows of Little Harley Street will have much to fear when the corporate pike come out to play.
The Boot may well now be on the other foot in Little Harley Street, but Dr No sees this as only one of any number of unintended consequences that will emerge from the Cambuffoon revolution. Consider GP commissioners. The corner shop chemists, for so long stuck in steerage, are now to be given control of the bridge. The forward argument – that as GPs they are best placed to know what is best for their patients – has that familiar no-brainer logic to it, even if, to most GPs, a spreadsheet is something one puts on a bed.
GPs, of course, are first and foremost providers of care; but they are now also to become the commissioners – buyers – of care. They will not just stand astride a part of the purchaser-provider split – they will have a foot firmly planted in each camp. They will be in a position to manipulate, perhaps even unwittingly massage, both the supply and the demand sides of the equation. Such a state of affairs, it seems to Dr No, risks becoming most cosy, not to mention distinctly anti-market, and strikingly anti-competitive – a Cambuffoon own-goal, a classic unintended consequence.
Naturally, it goes without saying that no GP would stoop so low as to commission care from his own practice, and trouser the profit. But general practice is a broad church. While many honest GPs are jobbing doctors, disenchanted and disfranchised by commissioning, there are nonetheless a few – only a few, mind – in whom the entrepreneurial flame burns perhaps a little too brightly.
Dr No can imagine how some of those in whom that flame burns so bright might enjoy the occasional congenial round of golf in which not only balls but patients get putted into holes; and handshakes close both game and deal. Practice A will commission out-patient ENT services from Practice B; and Practice B will commission out-patient dermatology services from Practice A. All very nice work if you can get it; all very cosy. All very Jobs for the Boys.
Dear Dr No,
I am touched by your concern about my finances, and glad to see you back out of purdah. My phrase was “I can tolerate most things that come with a paycheck attached”, and once again irony doesn’t always work on the internet. At both Borsetshire General and at Little Harley Street I do get a paycheck for seeing patients, heartsink or not.
My recipe for success in private practice is to behave ethically. Most GPs are fairly leftwing in orientation, and have mixed feelings about private practice, but they are the source of referrals. So if I behave well towards my NHS patients and do my best for them within the constraints of the NHS then I get the private referrals. The quickest way to antagonise GP’s and patients is to neglect the NHS patients, or to be rude to them. There are a few exceptions but generally the people who do well in private practice work harder than average in the NHS also, though other factors come into it. Women do not seem to have either the motivation or time to work in Little Harley Street.
I was lunching recently with our manager at Little Harley Street, he leads our negotiations with the emerging GP Consortia that seem Co-terminous with the old PCT. In many ways it is just a change of name. We have some contracts lined up, and I expect to do quite well out of it.
PFI is not a threat to my Private Practice, and neither is the advent of HMO type organisations such as United Health. Indeed I think they will drive customers up the road to Little Harley Street by destroying faith in NHS services.
I do think that there is a role for market forces in improving health care, but these health corporations are not market forces, but rather are private monopolies that demonstrate the worst of both worlds, and advantages of neither.
Dr Phil