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.