Friday 6 February 2015

Labour's NHS trap

It all seemed so clear. The battle lines were drawn and the trenches dug. As Andy Burnham came on Newsnight on Thursday night to talk about the NHS, Labour had prepared a well rehearsed argument, something well liked by its faithful and seemingly cutting through to the public: ‘The Tories are privatising the NHS’.

The Labour leadership believed that this argument resonated with rank and file members and offered the simplicity of clear ideological division. Tories equal private, Labour equals public. In addition, the argument has ‘recognition value’ as marketing experts would say, harking back to a pre-Blair time when Labour was against privatisation of public services. It also linked in with other policies, such as public ownership of the railways, a potential battleground with the Greens challenging Labour from the left.

As Burnham started the interview, the position fell apart fairly quickly. Kirsten Wark’s point of attack was Labour’s own record of ‘outsourcing’ and the fact that, under the last Labour government, private business amounted to 4.4% of the total NHS budget. Now, it stood at just above 6%. Hardly the ruthless Tory privatisation wave Labour claimed, Wark argued. Yet it seems that it was current levels of outsourcing that broke Burnham’s argument. More likely, Labour appears to have misjudged the depth of knowledge (or lack thereof) about the NHS within the population. The main confusion at the heart of Labour’s argument about the privatisation of the NHS was that, from the perspective of ordinary people, it is little more than a deliberate obfuscation.

People encounter the NHS as patients. The patient doctor relationship determines the perceptions and views of people on the NHS. That relationship is governed by clinical guidelines designed by NICE and Labour’s privatisation argument somehow suggests that this could change.

Yet, the complexity of health care delivery through the NHS in the UK means that privatisation anxiety makes little sense. GPs in the UK are in fact private enterprises. Aneurin Bevan’s National Health Service Act in 1946 made them so. Yet, this is not what Labour trained its guns on. Its main artillery was pointed at the health economy around the patient doctor relationship. It claimed that, somehow, because of private involvement, doctors would have to take profit into consideration when making clinical decisions.

This is a difficult argument to sustain for two reasons. On one hand, doctors are bound to make decisions in line with clinical guidelines, and profit is ostensibly not part of the picture. Yet, on the other hand, efficiency (and consequently rationing) is and has always been part of the NHS. In fact, NICE guidelines take into account both the effectiveness and the efficiency (in terms of life years saved) of medication and interventions before approving it. So, in a sense, considerations of efficiency have always been with us. The notion of a fully resourced health care system is a utopian make belief. Doctor’s clinical decision making process will always need to navigate patients’ expectations, in other words: say ‘no’ at times.

The real issue is whether, within the health economy that is grouped around the clinical patient doctor relationship, competition would drive down costs or increase costs for the NHS, or the tax payer. This argument is worthwhile having and Lord Darzi has made an important contribution to this recently. Everything, from pharmaceuticals to protective gloves, is after all produced within the market economy of the UK and to advocate a unilateral withdrawal of the NHS from this health economy is like saying we should bake our own bread at home. It may be wholesome and nutritious but hardly ever enough to feed a large family.

So, Labour’s argument about privatisation offers a false dichotomy. When articulating an anxiety that profit considerations would encroach on the patient doctor relationship the argument is ostensibly false. Doctors are bound by clinical guidelines. If taken to refer to the health economy around medical care, the argument is little more than a common place. The NHS always operated as a public service within a market economy. An autarkic healthcare system, insulated from economic pressures, is a pipe dream.

Boxed into the argument about privatisation and sensing its failure, on Thursday, Burnham tried to move the discussion on to the issue of integrating health and social care. It is a valuable idea and one that has been around for decades. It cannot have escaped him though that the earliest protagonists of health care integration are Kaiser Permanente; you guessed it: a private US insurance company with nearly $50 billion in revenues and more than $1.6 billion in profit. Health care may just be a policy field that proves impervious to ideological battles. And that may be a good thing.

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