Why would we want to do this?

Really big questions over critical issues such as privatisation still remain unanswered: just how will the government prevent \”cherry-picking\”?

Experience of independent sector treatment centres shows that they cherry-picked patients with the least complex operations and left the NHS to deal with patients suffering multiple complications.

How will the government stop private health companies from picking the most profitable services and leaving areas such as mental health, patients with long-term conditions and elderly care to a financially weakened NHS?

No, seriously, why would we want to stop cheap and cheerful medical care in those cases where cheap and cheerful medical care is appropriate?

Think about it for a moment. Take some relatively simple procedure. Cataracts say.

We\’ve two ways of doing this.

1) A place which specialises in doing simple cataracts. They run an assembly line procedure, don\’t have vast amounts of complicated kit, they just slice and dice eyeballs all day long. Anything complicated, more than a simple cataract, is sent off to option 2.

2) A place which has lots of expensive kit and can do any and every possible eye operation. There staff chop and change between those various different operations and must be trained with and have all of that expensive kit all the time: even when they won\’t use most of it to do cataracts.

Now, option 1) would seem to be cheaper overall. Mechanisation, the division of labour and specialisation, is thought to reduce costs and or increase output for the same resources expended.

So, umm, what is the argument that we should not allow private companies to \”cherry pick\”?

We do in fact already do this all over the NHS. There are dentists who work in hospitals and they do all the really complex work, rebuilding shattered jaws etc. Fillings are done by the private sector with a chair and a drill, not an operating room full of nurses and kit.

Hospital pharmacies sort out the horrendously complicated drug mixtures needed by those with weird cancers and diseases. The private sector, the local pharmacy, issues the cough drops.

A&E does not do the primary health care for the population. A&E has lots of expensive kit, nurses coming out of the walls and immediate access to operating theatres for those who need their skulls reattached. A child with the sniffles goes to the private sector, to a GP.

We already contract out, we already not just allow but insist that the private sector should cherry pick. That we should not have all health care done in one place, but that those simple bits that can be done simply are so.

So what actually is the medical (as opposed to political) complaint that these people are making?

16 thoughts on “Why would we want to do this?”

  1. Tim

    It’s ideology (and not medical ideology) and vested interests.

    For some reason, recognising reality (i.e. How things are, NOW, really) isn’t an option.

    As you say, GPs (like all the other examples) are private operators. Some do it better than others. some make lots, others less.

    The NHS (hopefully) sets standards and controls them. That’s what I want them to be good at. right now they have a dodgy record. Bad stuff from both public and private operators has happened. The committment must be to find ways to guarantee the result and layers of management and lots more money are not the answer. That’s been tried and not been successful

  2. Much of that is sound, but are the simplifications of armchair economists (or retired accountants for that matter) all that needs to be said?

    You don’t think there is any risk that once Kwik-Hip’s fitters are churning their way through all the standard operational procedures (and the manager is arguing with Addison Lee about their quote for carting procedures that go pear-shaped up the road to find fully competent medics), that maybe, possibly, some people will be comparing their headline costs against those of the Royal Expensive Hospital up the road and keep shouting “it’s teh eevil socialised medicine bankrupting and serfing us – hand it all over to Southern Cross Medical Services, they’re private sector so they’re bound to do it better”?

    No risk of ideology and vested interests coming into play there?

    Tim adds: That is an amusing argument. We should give in to current vested interests because a change might create vested interests in the future?

  3. The very fact that you think surgical cases can be so easily & simply divided into routine and emergency speaks volumes. ISTCs were an expensive & frankly piss-poor means of hiving off low-risk surgery (especially given that re-admissions & post-op complications were usually handed straight back to the NHS). Not to mention the implications for both training (juniors getting flying hours), continuity of care and general capacity. Where I work, there’s no competitive relationship as such – the ISTC is just creaming off the tickbox stuff, whilst relying on NHS staff & infrastructure. It makes me laugh that us shopfloor grunts get accused of vested interest & ideological blinkers – and yet the suits at Cinven, Circle, Netcare et al are being given a free pass.

    And for the millionth time, platitudes about competition generally fail to capture the reality of acute care, but believe what you will.

  4. “Where I work, there’s no competitive relationship as such – the ISTC is just creaming off the tickbox stuff, whilst relying on NHS staff & infrastructure.”

    Ok, we probably want more competition than that but if the ISTC manages to do the tickbox stuff cheaper than the NHS it’s still a gain.

    “It makes me laugh that us shopfloor grunts get accused of vested interest & ideological blinkers – and yet the suits at Cinven, Circle, Netcare et al are being given a free pass.”

    are you seriously trying to tell us that PEs are never critiqued by anyone?

    “And for the millionth time, platitudes about competition generally fail to capture the reality of acute care, but believe what you will.”

    The same thing was said about manufacturing by the marxists. They were wrong then and you are wrong now.

  5. The same thing was said about manufacturing by the marxists. They were wrong then and you are wrong now.

    Whatever. There’s more to healthcare than tractor production, though I suppose it makes for pleasingly simple soundbites.

  6. “There’s more to healthcare than tractor production, though I suppose it makes for pleasingly simple soundbites.”

    Why yes there is – the soothing hand of the nurse helping you drink that glass of water, or gently feeding you your lovely NHS dinner, when you are too weak to feed yourself.

    Oh silly me I forgot, the NHS doesn’t do that nowadays, it just lets its geriatric patients starve and die of thirst (link: http://www.bbc.co.uk/news/health-12464831)

  7. There’s more to healthcare than tractor production, though I suppose it makes for pleasingly simple soundbites.

    Have you ever manufactured tractors? Or for that matter, micro chips?

  8. Manufacturing microchips is a disastrous route to financial ruin. It’s lucky that mercantilist Asian governments sponsor this endeavour because it sounds modern and hi-tech, so that people in the UK can make copious amounts of money designing microchips and having them manufactured for cock-all money overseas.

    While I’m sympathetic to Tim’s point here, lost_nurse is right about the difficulty of differentiation and the fact that in the UK system as currently constituted, people who become emergency cases when undergoing private surgery get the emergency treated for free under the NHS. If we were being fair, then the bill for emergency healthcare should be sent to the private provider (not the individual, obviously – that would be grossly unfair – but it would significantly impact on UK private healthcare prices, which are currently ridiculously low because the NHS takes negative outcome risks).

  9. John B – manufacturing microchips may be financially disastrous, but I also understand from my engineering mates who went down that direction that it’s darn complicated.

    Whether it’s as darn complicated as supplying healthcare is another matter, I don’t know anyone who has both manufactured microchips and run a major hospital (or manufactured tractors and run a major hospital), but I was curious as to whether lost_nurse has, and would therefore be qualified to compare them. My own personal experience is that any sector is complicated, once you get into it.

  10. Philip Scott Thomas

    ..people who become emergency cases when undergoing private surgery get the emergency treated for free under the NHS.

    Really? For free? So since one of the perks of my job is free health insurance, I should no longer have to be paying towards the NHS, right? Oh, wait. It’s not free after all. There’s still a whacking great chunk of my paycheque going to fund it, regardless of whether I use it.

    Or maybe the problem is a theological one: that by going private I’ve left the One, True, Holy Flock of the NHS and become anathema and so not deserving of the NHS’s loving ministrations that I’m also contributing to .

  11. “people who become emergency cases when undergoing private surgery get the emergency treated for free under the NHS. If we were being fair, then the bill for emergency healthcare should be sent to the private provider”

    That would be fair if the private provider is negligent, but that’s not what you mean, is it?

  12. Cherry-picking seems fine, so long as the price paid is based on that cherry-picking.

    The problem (and quite possible, knowing how piss-poor civil servants are at contracting) is that private hospitals will be doing the easy jobs but charging the average price.

    But that’s not a problem with the proposal, just a matter of getting a few people with commercial experience in to do the negotiating.

  13. Richard’s got it in one. That’s how the payment by results national tariff works… Answer: differentiated pricing. Simples!

  14. I like the casual way you talk of cataract operations. They are especially fun when they go wrong or somebody in training gets to train on you.

  15. Have you manufactured tractors

    Nope, but it’s the standard device for comparing the NHS to manufacturing in the former USSR. I would agree that any sector tends to be complicated once you get into it.

    if the ISTC manages to do the tickbox stuff cheaper than the NHS it’s still a gain

    Jolly good – will they be paying for workforce training and ITU capacity (useful if things go south)? No doubt the trend towards having fewer-but-larger major trauma centres is also plain ‘wrong’ – because it contradicts your cherished notions of market competition and diversity of supply. This isn’t even a defence of monolithic NHS provision – it’s a defence of cooperation, which is how things tend to get sorted in real (and very messy) world.

  16. Despite my first sentence, I was not attempting to be balanced or comprehensive, I was – as we say – “just saying”. Because sometimes the simple answer is simplistic.

    And, for clarity, I was trying to suggest that there are also vested interests on the marketeers’ side right now – it’s all got to be taken into account and it’s anything but a simple academic exercise.

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