Believe it or not, Dr No is not a natural cynic. Indeed, when you think about it most doctors are not natural cynics. Much of our professional work requires the triumph of hope over experience. We have to see the best in people, and be optimistic about what we do: otherwise, our world, and then our minds, would fall apart.
Nonetheless, whether we like it or not, we doctors live in the real world, a world in which cynicism does play its part. If we want to understand that wider world, it behoves us to relax our optimistic blinkers a little, and at least allow ourselves a glance at life through the cynical telescope. We may not like what we see, but if we do not make that glance, we risk being blind to the full reality of the wider world, blind to large tracts on the tapestry of life, and blind too to the grim march of the Seven Princes of Hell across those darker tracts.
These emotions on divergent occasions came to Dr No not in the fever of illness, but as he meditated in the Sunday morning way upon two familiar, and he suspects related riddles. The first riddle is why should any doctor, whose first duty is always the care of his patient, ever want to work in private practice, where he must serve the twin masters of patient and profit, when there is a perfectly good NHS ready, able and indeed willing to let him serve the one true master – his patient? And the second riddle is this: why do the Tories, despite their protestations of love and affection, always want to reform (for which read marketise) the NHS?
The answer to the first riddle, once one has opened up the lens to the cynical wavelengths, is plain to see. It can only be, with very rare exceptions, all about the money. Those clinicians who sign up to Mr Anti Pasta’s Circle Partnerships could just as well, if they put their mind to it, gee up their local NHS hospital, and do their good works there. The pay is generous, the facilities to hand, and, were consultants to adopt the sadly missing but all too necessary shoot to kill policy on obstructive managers, NHS hospitals too could have fluffy white dressing gowns on the wards, and five star Michelin chefs in the kitchens. But – and here’s the rub – that would mean jumping through NHS hoop after hoop, tiresome and burdensome at the best of times, and all the more so, when Mr Pasta’s circles offer a seductive, easier alternative route to the money.
The short answer to the second riddle – why do the Tories want to marketise the NHS – is that it is about ideology. In the Tory pantheon, the faithful worship at the three high altars of choice, competition and market, for these are the divine forces that must surely rise up and drive out the devils of sloth, impudence and social conscience, and sweep aside those pesky peasants who stand in the way of a decent profit. These, then, are the ideals born in the tuck-shops of Eton and Harrow, and which form the backbone of economic subtlety that runs through the nice (and sometimes not so nice)-but-dim Tory rank and file, united as ever under the blue banner of economic prosperity.
But is that all there is to it? After all, the economic evidence of the decades suggests that the NHS is both cheap and efficient, and an opium to the people to boot: and what better way to keep those pesky peasants out of one’s hair? But, once again, once one opens up the lens to the more cynical wavelengths, other possibilities spring into view. What if, precisely because it is cheap and efficient, the NHS hides a fat economic cow waiting to be milked? What if there is unmonetised slack in the system, waiting to be creamed off?
What if UK health spending as a percentage of GDP has risen over recent years, as a result of Labour cash injections, to around 8.7% of GDP, but still remains short of the average for developed nations – 9.0% (OECD, 2008 data) – or countries like France (11.2%) or Germany (10.5%), and far far short of American spending, at 16%? Might there not be scope, indeed slack, in the UK system, to pad spending to match the OECD average, or even that of our higher spending European neighbours? And what if that padding should happen not in the public sector (Heaven forbid!), but in the private sector? The slack is surely there: UK private spending on health is low, at 1.5% of GDP, compared to an OECD average of around 2.4% (France and Germany both 2.5%).
Now, an increase in total health expenditure, but all of it deployed in the private sector, of 0.3% of GDP (8.7% to 9.0%, to match OECD spending) or, better still, 2% of GDP (to match French/German spending) might not sound very much in percentage terms, hidden as it is in the mist of relative numbers; but what if we convert those percentages in absolute money?
The UK GDP is around (2009 figures) £1.4 trillion (£1,400 billion, or £1,400,000,000,000). A 0.3% of GDP boost in total healthcare spending thus amounts to a mere £4.2 billion, while an extra 2% sloshes a more impressive £28 billion into the trough. UK private health spending, meanwhile, is currently around £22 billion (2008 data). So, if the Tories were to allow, even encourage, total health expenditure to rise from the current 8.7% of GDP to French/German levels, say 10.7%, that 2% rise, while ensuring all that rise occurred in the private sector, then the private healthcare economy would more than double, from £22 billion to £50 billion. And within that £50 billion, there is surely a tidy little profit to be had…
That really would be a corker of a bung for the Tories to pass to their private healthcare buddies. Even better, the bung has no effect on public NHS spending which, not being bunged, can remain tightly capped. All of a sudden, the Tory zeal to create a loose market based health economy starts making a whole lot more sense. Add ‘any willing purchaser’ – private health insurers – to ‘any willing provider’, and the runway is clear for the private healthcare jet to take off. Add a little squeeze on public NHS spending, such that the NHS starts to creak, and, with a little bit of luck, that private healthcare jet will soon be flying on full afterburner, winging those tidy profits to the great and the good.
And that is why, cynical as it may be of Dr No to say, he just can’t help wondering if it really is all about the money. It is also why the two riddles posed earlier are connected: someone has to fly that private healthcare jet. You can be sure that the pilot wont be Dr Finlay, it will be Dr Mammon.