Memorandum submitted by Professor Peter
Bradshaw, University of Huddersfield (PCT 9)
As one engaged professionally in the local health
economy and more importantly as a person with daily contact with
PCT staff I offer the following observations:
The proposed changes to primary care need to
be considered inter alia with the plethora of other NHS
changes that include notably, Choose and Book, Payment by Results
and Commissioning a patient-led NHS.
Funding—The fairest way of funding health
services is through general taxation and the alternatives are
inefficient economically and threaten what the NHS can proudly
claim to be the near universality of services.
The funding alternatives disintegrate the notion
of pooled risk on which the NHS depends. This allows purchasers
to determine arbitrarily who gets treated according to their ability
to pay and other concerns for profitability that override the
quality of outcomes for patients. These factors should provide
a focus for stringent analysis whenever the NHS is made to look
too expensive to afford.
Delivery—The NHS embodies a unique set
of equity principles regarding access to care based on clinical
need. Traditional ways of predicting health need and providing
services based on local epidemiological evidence took a knock
with the creation of the current PCTs. Yet with time and patience
the position is being retrieved in that population specific approaches
to meeting health needs are recovering from the abandonment of
Health Authorities in the last reorganisation. The proposed new
PCTs, unlike their predecessors have no such remit despite the
Secretary of State's minor retractions on the provider role of
PCTs. Prioritising decisions about financial entitlement and giving
them precedence over clinical decisions violates the principles
on which the NHS exists. In terms of the proposed models for PCTs
that are to be solely purchasers of care and treatment, the predictable
outcomes are:
— Fragmented and inconsistent staff
training, services and treatment outcomes.
— The delivery of poor continuity of
care with gross geographical inequities. This has all the potential
to undo so much good and to make the inequities of postcode lottery
in prescribing look a very minor matter by comparison.
— The subjugation of public health
improvements to the more pressing matter of buying treatments
as cheaply as possible.
Private Provision—Two interrelated concepts
arise:
1. Firstly the NHS has had a long flirtation
with private solutions to the provision of mainly non clinical
services and latterly for a restricted range of clinical services.
The rationale for this is that the NHS is capable of genuine free
market behaviour on the basis that contestability (this means
competition to Tory members!) enhances choice. The evidence is
that the NHS is only a very poor substitute for what Adam Smith
had in mind and the analogy that a free market in health services
can mimic commercial markets is a naïve and false analogy.
2. The second and related premise is that
the activities identified in 1 above produce superior economic
efficiency and better quality services. This is a similarly invalid
assumption.
The welter of empirical evidence from the USA
and the limited data on Independent Treatment Centres in the UK
reinforce the conclusion that the current proposals are an absolute
threat to universal access to services that is the hallmark of
the NHS. No privatised health system anywhere in the world has
been proven to deliver equity. There is similarly no assurance
that independent providers actually deliver value to the taxpayer
or that they are interested in only cherry picking the most manageable
and profitable patients leave those with more complex pathologies
to the NHS.
Despite the inefficiencies in the NHS that have
resulted from repeated unevaluated reorganisations, the service
still delivers a lot of care and treatment for a modest outlay
and this fact is the best indicator of value for public money
that we have.
Professor P L Bradshaw
Professor in Health Care Studies, University of
Huddersfield
31 October 2005
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