Article published in Tribune October 2005

It isn’t difficult to get socialists worked up about proposals to privatise the NHS, but what are the real principles involved? There has been involvement of private suppliers in the unsexy parts of the health service for many years. Long term care for elderly people, and specialist mental health services have been provided by charities and profit making firms for years and no-one complained.

As Pat Hewitt says in her recent pamphlet it is important not to confuse means with ends. As far as we are concerned the end was expressed by Nye Bevan:

“The essence of a satisfactory health service is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged.”

That is a principle worth fighting for. And the means – that treatment be available free at the point of need – is necessary and worth defending, but it is not sufficient. The Black Report and numerous other studies provided the evidence on which Brian Abel-Smith argued:

“if socialists believed forty years ago that all that was needed to equalise health status between social classes was to remove the money barriers to access to health care, they were seriously mistaken”

Since 1945 medical treatment has become more effective and expensive. When Bevan wrote in 1952 the NHS was consuming £8 per head of the population. The figure now is £1280 and rising rapidly. Various methods of rationing have been adopted, chiefly queuing. People with resources are able to bypass these devices, either by buying private medical care or using influence not available to disadvantaged people to secure what they want.

The “Keep our NHS public” campaign asserts that “For nearly 60 years Britain has enjoyed a National Health Service that strives to be comprehensive, accessible and high value for money”. It may have striven, but Julian Tudor Hart’s Inverse Care Law applied then and now:

“The availability of good medical care tends to vary inversely with the need for the population served”

A campaign to preserve a mythical golden age deserves to fail, especially if it perpetuates privilege. While some could point to the existence of socialist states on the other side of the Iron Curtain it was possible to argue, as Tudor Hart did , that the NHS represented the possibility of socialism in a single industry. Now that is harder to sustain. The NHS exists in a capitalist system, and to be run effectively must recognise that. Most of us abandoned nationalisation and central control as principles in respect of other industries some time ago. It is not obvious that they should continue to be applied to the NHS. However the anti-privatisation campaigners are right that “There is no evidence that these reforms will improve the health service.” Furthermore there is good evidence from North America that for-profit health providers are less safe than not-for-profit institutions. It is not yet clear exactly what sort of choices Patricia Hewitt has in mind for the NHS, and it seems a novel sort of management that tells 250 thousand staff that their employers are to be abolished without any suggestion as to what structures will be established in their place. But for socialists the test must be the effect on health inequalities.

Experience in public health tends to suggest that systems with more choice will favour the middle classes. There is evidence from other public services that the details of the implementation of a choice system makes a great deal of difference to the outcome. Choice in the delivery of elective surgery has not caused much trouble. It seems to have played a part in reducing waiting lists and reducing the demand for private medical care. Choice in the delivery of care to people with chronic medical conditions will be more problematic. People who need an operation do not seem to care much where it is performed and have no opinion about how it should be done, so long as it is done soon. People who live with a chronic condition are in a position to have informed views about how their care should be delivered, and many of them see existing systems of care as insensitive and autocratic. A market in healthcare could be designed to reduce inequalities or to maximise profit, but the genie of choice once uncorked cannot be put back in the bottle.

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