This post is not, as it happens, about the misadventures of a trench soldier in the First World War, but is instead about the perils of language: for, if there is one word that fogs today’s NHS reform debate, it is surely privatisation. Unions, the media – only yesterday, Channel 4 reported on ‘proof’ that the ‘government plans to privatise the NHS’ (only to fog matters further by adding a terminal question mark) – and bloggers may all declare loudly that the Tories are privatising the health service. At the same time, the Tories and the DoH (and, of course, our very own Sam) say they are not. Clearly, both sides can’t be right. Or can they? It all depends on what we mean by privatisation, and that is where privatisation fog, like the recent weather, can bring progress to a grinding halt.
And then there is general practice – largely provided by independent (ie private) contractors. Most GPs are either self-employed, or salaried (employed by other GPs). Very few are – the Armed Services are perhaps the only substantial example – directly employed by the state. Does that not mean that the health service is, in truth, already substantially privatised?
So (and yes Dr No knows starting paragraphs with ‘so’ was barracked on the Today programme yesterday, but here it is a legitimate use, as a consequential coordinating conjunction: Dr No’s thoughts and this post are a consequence of privatisation fog), Dr No proposes, at least in his own mind, to clear the fog by setting down what he understands privatisation to mean, and so clarify, at least for himself, whether both sides can be right in their claims over privatisation, or whether one, or indeed both, sides are, ahem, guilty of blowing a fog of misinformation over the debate.
Dr No’s first observation is that the word privatisation tends to be used globally, when in fact there are at least three entirely, apart from their mutual relation to the health service, separate sectors of the health service that are, as it were, in a position to be privatised. The first, and perhaps most important, is funding: who pays, and through what mechanism(s), with state funding through taxation at one end of the spectrum, to insurance based and self-pay funding at the other. The second sector is the purchasing and commissioning of health care: the sector that spends the money; and the third is provision: that which receives the money, and provides the service.
Because each sector in reality operates without direct intrusion from either of the other two, it is possible for one or more sectors to be variously privatised, without in any way affecting the privatisation content of the other sectors. The Channel 4 story, for example, which suggests privatisation of the (global) NHS, is in fact a story about privatisation of the purchasing sector. The Circle/Hinchingbrooke brouhaha is about privatising provision, in Circle’s case of secondary care. Neither, in any meaningful sense, can be said to represent a global privatising of the NHS Indeed, to present them as such is probably a mistake by those of us who do nonetheless fear the wider privatisation of the health service – a mistake because the Tories can, and vigorously do, claim that they will never privatise the (funding of the) health service.
And so, to answer the question posed at the start of this post: both sides can be right; and we, who defend a publicly funded, purchased and provided NHS would perhaps do well not to over-state our claims, and allege global privatisation, when in fact we mean sector privatisation.
Indeed, Dr No might even go further, and suggest that the privatisation word has become so fogged, so open to ambiguity, that its continued use generates, as the old cliché has it, more heat than light. And then there is the small matter of general practice, and the inconvenient truth that a large chunk of the NHS has been privately – and successfully – provided, ever since its very beginning.
So Dr No suggests it is time we dropped the word privatisation as the label for what we deplore about the Tory plans for the NHS. The word has, shall we say, lost currency, for the true beast in the Tory plans is not privatisation itself, but commercialisation: the transformation of a vocational service into a money making machine, wherein the primary purpose is not to provide a service, but to turn a profit. Indeed, such a distinction even allows us to solve the GP paradox: private providers they may be, but most, if not all, are vocationally, not commercially driven; and that is how they get away with it.
So Dr No no longer fears privatisation. Indeed, he is very happy that his esteemed vocationally driven colleague Boots and all his mates should stick their private scopes wherever they must. What he fears instead, what sends a chill shudder through his being, is the threat of health service commercialisation. For that, Dr No believes, is the true nature of the danger the Tories are pressing upon us.
Commercialisation, commodification of members of The Humankind when they are at their lowest ebb…..
Me and My Black Cat call the market you are talking about The Fourth Health Care Market.
There is also a Third Health Care Market that does our heads in!
http://witchdoctor.wordpress.com/seven-healthcare-markets/
We have identified Seven healthcare markets.
Seven is the magic number.
Dear Dr No,
I think your division of privatisation, like Gaul, into three parts is a useful one. I shall ponder on this. Even within these three domains there are degrees of what is involved in privatisation. I think that your dislike of Commercialisation is quite similar to my own use of the term Corporatisation. This is something that I have railed against on my blog.
While we would all want our doctors and allied professions to be vocationally motivated, all of us do need to pay the bills at the end of the month. I wonder how this mixture of pure and impure motivations can be stable, in either the private or state sector. It may have much to do with valuing and being valued by others, and mutual respect. I wonder how we can ensure this. I suspect that much of the alienation of Doctors from the GMC, Trusts and health care management is leading to a loss of the things that make vocational motivation possible. It is this that I am getting at when I refer to privatisation as a distraction from the real ills of modern medicine. It may be that this commercialisation and commodification are manifestations of the pathogen rather than the pathogen itself.
Good Lord! I seem to be agreeing with you on something. I have much to think on for my next post, though have a few busy days before I can bring my ideas together.
While we all get blogging fatigue from time to time, it is posts like your one above that make it worthwhile. Just as when doing research it is the findings that do not fit with pre-conceptions that lead to advances, as they help re-form paradigms.
Best wishes
Boots
PS WD: have you yet revealed what healthcare markets six and seven are? or is that only for cauldren initiates?
Dear Dr No,
I think your division of privatisation, like Gaul, into three parts is a useful one. I shall ponder on this. Even within these three domains there are degrees of what is involved in privatisation. I think that your dislike of Commercialisation is quite similar to my own use of the term Corporatisation. This is something that I have railed against on my blog.
While we would all want our doctors and allied professions to be vocationally motivated, all of us do need to pay the bills at the end of the month. I wonder how this mixture of pure and impure motivations can be stable, in either the private or state sector. It may have much to do with valuing and being valued by others, and mutual respect. I wonder how we can ensure this. I suspect that much of the alienation of Doctors from the GMC, Trusts and health care management is leading to a loss of the things that make vocational motivation possible. It is this that I am getting at when I refer to privatisation as a distraction from the real ills of modern medicine. It may be that this commercialisation and commodification are manifestations of the pathogen rather than the pathogen itself.
Good Lord! I seem to be agreeing with you on something. I have much to think on for my next post, though have a few busy days before I can bring my ideas together.
While we all get blogging fatigue from time to time, it is posts like your one above that make it worthwhile. Just as when doing research it is the findings that do not fit with pre-conceptions that lead to advances, as they help re-form paradigms.
Best wishes
Boots
PS WD: have you yet revealed what healthcare markets six and seven are? or is that only for cauldren initiates?
Because the government needs the NHS, it’s part of the vision of a Big Society. But there will be top ups, however, the NHS will always be there to provide a free at the point of need service for the poor.
As for KPMG’s involvement in the NHS, this is old news, nearly a year ago, find the link here;
http://chezsams.blogspot.com/2011/01/my-scroll-january-2011_27.html
But although I too thought that it was for privatisation at the time, I now think it is for not only monitoring cost and performance, but to streamline commissioning, monitor and eliminate fraud. KPMG follows a flow chart when designing programmes, and although GPs will be tightly scrutinised by that programme, it will make commissioning a peace of cake for them too, but no harm, no privatisation.
Boots – Dr No suspects that we agree on many many (but not all!) things.
Dr No certainly agrees that commercialisation and coporatisation are closely linked, with perhaps coporatisation being a subset (characterised by its distinctive corporate nature) of commercialisation.
Dr No has no problem with doctors wanting to pay the bills as well as treat their patients. He even thinks they should be well rewarded for what they do. And so dual motive, vocational and financial, can co-exist. The question is which is primary.
A simple test is this. Dr No has a menorrhagia clinic with ten patients. When he sees each of those patients, and considers the option of hysterectomy, does he make that consideration solely in the patient’s best interests, or does a fleeting consideration of his upcoming mortgage payment come into it?
We know that hysterectomy rates vary, and can be higher in countries where a financial motive might be more likely to come into play. The beauty of the old-fashioned public NHS, untainted by commercial considerations, was that whether Dr No did ten hysterectomies or none, he still got paid the same, and so was entirely free to decide solely in the patient’s best interests.
PS have unpublished what I presume was an accidental double posting – hope that is OK.
Sam – Dr No wasn’t suggesting this is new news, rather using C4’s presentation of it as an example of how suggesting a global privatisation of the NHS is in fact misrepresenting the situation, and so does not help the debate. We need to know what we are talking about before we can talk about it.
You already know Dr No’s views on the likely influence on the incidence of fraud when the private sector dolphins and sharks join the public sector pool. Sooner or later the water will go blood red.
Dr No is not entirely sure all GPs will enjoy being flow charted and streamlined by KPMG. It may feel rather like managed care, and managed care may (or may not) save costs, but it certainly reduces clinical freedom.
looks just like Richmond Park last Sunday. (Nothing to do with the post.)
I suppose the best term is “soft medical fraud” as it may not affect the conscience as much as blatant medical fraud like doing a kidney transplant when nothing was wrong.
I certainly try to highlight the situation in the States and Medicare and Medicaid Fraud can be blatant and soft. they both cost money. Taxpayer’s money.
Just look at our own dental fraud!