Such is the argument deployed by the editor of the UK’s leading medical journal, Richard Horton, in analysing the implications of both the recent breast implant scare and the Health and Social Care Bill for the NHS.
Horton acknowledges that the specific case of PIP, and the industrial-grade silicone they appear to have used in breast implants, represents clear regulatory failures at the hands of the Medicines and Healthcare products Regulatory Agency (MHRA). The Health and Social Care Bill has very little to say about how the way in which medical devices are regulated and any changes to the way the MHRA operates following this episode will be independent of the reforms contained within it.
There is, however, a very strong link between the Bill and the PIP scandal, as Horton goes on to explain and as many others in our party and the medical profession have warned of for some time. That is the increasing reliance on private healthcare providers to deliver NHS services, and the implications for patient safety and the quality of care and what happens in the event that either are compromised.
It has to be stated (sad though that is, but the polarised nature of the debate on the NHS requires it) that there is no a priori reason why increased private provision of healthcare would necessarily cause a drop in standards – there are examples of both good and bad practice in both public and private spheres, and we must not overlook the fact that whilst health scares can and do happen in both arenas, the NHS delivers a very highly-rated service with world-class clinical care with the mix of public and private provision it uses. Although reforms are needed to the way the service operates, we as a party need to ask whether episodes such as the breast implant fiasco will become more common as a result of the particular reforms currently being advocated – whether extending the reach of the profit motive will compromise care quality and what happens if it does.
With the NHS moving increasingly towards being a purchaser of privately-provided services in a competitive market, questions must be raised as to how market participants are regulated and what happens when the market fails to deliver quality patient care. The answer from orthodox economics, lessons from which have been increasingly applied to the provision of public services under successive governments, has been to allow competition between providers but to give consumers choice and voice – the ability to choose better providers, and the vocal power to ensure they get the best service.
This philosophy permeates the Open Public Services White Paper too, and stems from the work of, amongst others, Julian le Grand, who advised the Blair government on health matters. The increase of choice through greater private provision, and of voice through the new HealthWatch bodies which are already forming, are central to the Lansley reforms.
Now is not the time to go into Kenneth Arrow’s impossibility theorem and its implications for the provision of healthcare in a competitive market – for another day perhaps. For now, suffice to say that optimising service provision through competition amongst providers moderated by consumer choice and voice may work in theory for the provision of routine, uncomplicated services, but for complex ones like healthcare which can quite literally be a matter of life and death, choice and voice may not be enough or even appropriate.
In the interest of not writing too much I will simplify the argument – consumers in the breast implant ‘market’ have made a choice (to have implants by PIP), and are now raising their voice to make their displeasure at the quality of service known. It may be that in the long run, this will allow future providers to configure a better service – but for those unfortunate women who’ve suffered anxiety and possible complications because of a poor standard of care, the post-hoc exercise of choice and voice comes far too late. To say nothing of the moral hazard (to borrow another economic term) created when private providers are allowed to walk away from their obligations to patients and leave the NHS to patch up the mistakes they make, as is the case here.
So whilst it’s not a case of “private bad, public good” (‘I think you’ll find it’s a bit more complicated than that‘ as some would say) Lib Dems who want to see excellent standards of patient care retained and improved should be wary of reforms that rely on choice and voice as the mechanisms through which this is achieved. The debate amongst Lib Dems must continue, especially regarding the risk to patient quality. Something for the re-launched Beverdige Group to consider, perhaps
* Prateek Buch is Director of the Social Liberal Forum and serves on the Liberal Democrat Federal Policy Committee
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27 Comments
I shall submit this article to the questions to which the answer is no awards.
The “moral hazard” argument is, I think, a little more complicated than “private providers are allowed to walk away from their obligations to patients and leave the NHS to patch up the mistakes they make”. There is a matter of legal responsibility, which I suspect will only be settled in a courtroom – particularly given Andrew Lansley’s stated intention for the NHS to attempt to recuperate costs from the implanters.
If the Government (in the form of MHRA) has approved these implants for use when they were unsafe, then it’s reasonable to expect the Government to accept responsibility for that failure – either by providing corrective surgeries through the NHS, or by reimbursing the private providers for providing same. I suspect the former is more cost-effective for the tax payer.
So it seems that the risk of “moral hazard” is already to be settled in court, and if the courts decide that the Government is not culpable, then the “moral hazard” of a private provider is eliminated; and if the courts do not, then the “moral hazard” of the Government’s failure to safely regulate and lay the blame on private providers, which as the author says is unrelated to the H&SRB, will hopefully be reduced.
Of course. And getting this right is going to be difficult. However, it is fundamentally necessary to any liberal that “choice and voice” be the primary factors in everything in society. That’s a reasonable definition of liberalism.
Fortunately, the bill does not rely on this, and still involves extensive government monitoring and regulation of the healthcare industry. So your thesis doesn’t seem very relevant.
Dave Page – there is an interesting point though that if the private providers are to blame for this (and lets assume hypothetically that they are – if they in fact are not that in no-way means they won’t be in future cases) many of them are claiming they don’t have the money to correct these problems. This leaves them in a position where they can take a gamble (say on PIP implants) and if all turns out rosy reap huge profits, but if not they bankrupt a limited company, and the directors still walk away with a good pay package and not losing their money in the end. Requiring such companies to be insured against incidents seems the obvious step, but the worrying implications from PIP is that the companies claiming they can’t afford to fix it implies they were not insured – that is a worrying state in which to be using private providers. The NHS in comparison would need to be more cautious since it we can assume will not go bust and will inevitably end up footing the cost of any mistakes it makes.
@Dave Page – hah I do deserve a nomination, thanks for pointing that out 🙂
interesting argument on legal process, particularly in light of the cost and complications of legal battles currently being fought by the NHS (see for instance here http://www.thetimes.co.uk/tto/news/politics/article3283940.ece [£] and here http://www.guardian.co.uk/politics/2012/jan/12/healthcare-nhs-medical-insurance-bma?newsfeed=true)
So, it’s OK for the market to fail patients, in a manner that can lead to serious ill consequences to health, as long as there is redress through the courts? If my bins aren’t properly collected, or my parkland incorrectly managed, or even council’s backroom administration incorrectly processed, I would expect legal redress through the courts to be a good counter-balance. However I put it to you that in cases where patient care is compromised, legal means aren’t redress as they come far too late – well after the person concerned has lost their livelihood or even life. Sorry, but claiming that these matters should be settled in court just isn’t right.
@Andrew Suffield: choice and voice without the capability to exercise either or both isn’t liberalism in my book, and as good health is a primary capability without which most others are pretty meaningless, I strongly believe the role of markets in provision of healthcare should be restricted (not eliminated you’ll note) to clear cases of failure of public provision. As for the oversight role, despite extensive LD amendments to the way in which Monitor will operate there is still a pro-market bias in the way the trade-off between choice and service quality will be settled.
You are however right to say that the Bill doesn’t create a full-blown market as Government, or at least the NHS Commissioning Board (not sec of state) will retain oversight and monitoring role – which is of course as it should be at minimum.
@Scott – very good point, and one that needs to be watched as private provision increases. Of course there is plenty of innovative, cutting-edge treatment delivered in both public and private spheres, but the latter sector does it in an the knowledge that catastrophic errors will be picked up by the integrated services in the NHS.
The NHS, in England, will only pay to remove breast implants: it will not replace them. This will leave those women affected in a terrible position.
Under NHS reforms GPs will take control of purchasing care from hospitals, the private sector and charities for almost all treatments from hip replacements and stroke care, to paediatrics and rehabilitation. Who pays if things go wrong then, the GP, te private sector, the charity?
I’m not claiming that these issues should be sorted in court – just that it’s not quite as simple as private providers being able to “walk away” with no recourse. Perhaps this incident will highlight the need for patients who go private to check what they’re signing – and for GPs commissioning services to check the failure conditions as well.
@ Dave Page – fair enough, but in putting the onus on the patient you’re assuming they have access to and are able to understand perfect information regarding the service/procedure/device they’re signing up for. As this isn’t possible, there needs to be a mechanism that mitigates the risk – my point is that mitigation through the courts is not adequate in such cases.
Don’t these private clinics have liability insurance?
If the Government (in the form of MHRA) has approved these implants for use when they were unsafe, then it’s reasonable to expect the Government to accept responsibility for that failure – either by providing corrective surgeries through the NHS, or by reimbursing the private providers for providing same. I suspect the former is more cost-effective for the tax payer.
So just the existence of a regulator absolves private clinics? I don’t think so. Yes people should get corrective surgery on the NHS if they wish it but the costs should be recovered from the clinics. The clinics have a responsibility to use quality implants and insure themselves against liabilities for the whole package they provide, the implant, the surgery, the aftercare.
There are fundamental facts which this discussion has barely touched upon, and these involve the intrinsic nature of the market and market commodities. The market does not respond to need or desire or urgent situations of people, no matter how desperate – it responds to buying power. Market mechanisms are fine when you’re talking about the manufacture and sale of widgets, burgers and cars – these are morally neutral objects. But when market mechanisms are applied to public service provision something goes badly wrong; in order for these mechanisms to work, the public service being provided must be commodified and in doing so the proponents of such a process are in effect saying that public services are as morally neutral as a burger, a widget or a car.
Which we know is not true. Public services – health, education, policing, justice system, etc – are not morally neutral but fundamental to our wellbeing, both individually and collectively. Entrusting them to the market and its profit-driven morality goes beyond folly into moral and intellectual bankruptcy. It is a sad thing to see people who describe themselves as Liberals eagerly touting such ill-conceived notions and working tirelessly to bring them about, regardless of the harm done to the weak and the powerless.
Or is that part of the plan, a means of weaning the population off the postwar social democratic public welfare structures put in place by Labour? After all, we can’t have people dependent on the state when there are some perfectly good corporations for them to be dependent on!
But surely this is missing a fundemental point. There is no evidence so far that the implants do any damage, which is why the private clinics are (in some cases) not removing them.
The ‘poor standard of care’ does not come from anything the clinics have done but from (as you say) poor regulation. I can’t see how this is an argument about less private provision in the NHS.
@Mike Cobley no-one is suggesting that healthcare provison should be ‘trusted to the market’. having a wider variety of providers giving free care is very different.
‘The market responds to buying power’ – I’d go along with that summary. However, when it’s a democratically elected government that has the vast majority of the sector’s buying power, that makes the market respond to democratic forces. When it comes to healthcare, the democratic voice strongly favours universal socialised healthcare. I don’t see why the market wouldn’t respond to that.
(I’m totally undecided about the NHS reforms.)
Someone who works in the private sector is no less moral or as concerned with quality than someone in the public sector. I work for a private company which provides health and social care software services to councils and NHS Trusts. Yes companies and their employees need profit to earn a living and develop products but that does not mean we don’t care about the people using our services; if we didn’t care about providing a quality service we wouldn’t last very long and no one would use us. Neither public nor private sectors hold a monopoly on quality or incompetence.
Any debate about public versus private provision should be based on actual experience and detailed analysis of public or private providers or users of services rather than the prejudice that often seeps into these discussions.
Simon McGrath Posted 13th January 2012 at 1:26 pm………..|But surely this is missing a fundemental point. There is no evidence so far that the implants do any damage, which is why the private clinics are (in some cases) not removing them……….
Not quite true
The expert committee makes it clear that the issue of safety has not been settled because inadequate data has been provided. It says:”On the currently available information, the group considers that the statistical evidence on the rate of ruptures for PIP implants compared with other implants is incomplete and this risk cannot be assessed accurately. For this reason it is unable to come to any view on comparative rupture rates.”
The UK appears to say we don’t know so we’ll wait. A completely different position from that in France, Germany, the Czech Republic and other countries who are recommending removal of the implants as a precaution
@Duncan Stott – “…when it’s a democratically elected government that has the vast majority of the sector’s buying power, that makes the market respond to democratic forces.”
I’m sorry but that argument is laughable. The very politicians/ministers who determine the current swathe of radical upheaval are heavily influenced/lobbied by the private sector providers who benefit from said marketisation. That doesnt even take into consideration the financial waste associated with private sector provision, namely management salaries and bonuses, company profit margins and shareholder dividends (if such companies have traded stocks).
And @Richard Shaw – I appreciate that you personally consider yourself no less morally engaged in the wellbeing of patients but as you say, you do not work for the NHS (non-profit) but for a company operating in the healthcare marketplace; you may not have encountered situations where cost-benefit pressures bear down upon treatment type and/or outlay but such examples are myriad. You say that the “debate about public versus private provision should be based on actual experience” – I couldn’t agree more and one only needs to turn to the American experience to discover an avalanche of cases demonstrating the heartless nature of market-based healthcare provision. Indeed, several large American healthcare providers and insurers are involved in the private sector penetration of the NHS – and the record of their shabby, greedy mistreatment of ordinary Americans does not stand up to scrutiny.
“That doesnt even take into consideration the financial waste associated with private sector provision, namely management salaries and bonuses, company profit margins and shareholder dividends (if such companies have traded stocks).”
a brilliant explanation of how the Coop undercuts Tesco and sainsbury’s
Jason – women who have their implants removed on the NHS but not replaced are not left in a “terrible position” just left with normal breasts!
That might seem harsh but the NHS makes rationing decisions all the time. Women like me who through no fault of their own have had to have an emergency caesarean are not offered a “tummy tuck” on the NHS afterwards; nor should they be.
@Simon McGrath:
Yes, because healthcare is the same as grocery shopping.
Oh dear, is that really the level of discourse we’re left with now?
Ruth Bright….. Posted 13th January 2012 at 5:21 pm
Jason – women who have their implants removed on the NHS but not replaced are not left in a “terrible position” just left with normal breasts!
What about those with reconstructive surgery. A scottish report suggested about 5% of PIPs were used in such cases.
…….That might seem harsh but the NHS makes rationing decisions all the time. Women like me who through no fault of their own have had to have an emergency caesarean are not offered a “tummy tuck” on the NHS afterwards; nor should they be…..##
I would prefer to see ‘upgrades’ in such surgery rather than ‘drag down’ other surgical procedures.
@Mike Cobley
What I gathered from your comment is that you believe:-
– because the NHS is “non-profit” it is therefore immune from and therefore, I suppose, does not have to consider the cost of different medicines or treatments when approving drugs or commissioning services. And I suppose by extension the same goes for any “non-profit” organisation. Money doesn’t matter and no compromises on service provision are required.
– because the NHS is “non-profit” there are no cases of malpractice, incompetence or otherwise poor quality care provision. As proof of the specialness of “non-profit” status you have invoked the dreaded “A-word” as an example, rather than exploring the existing relationships between public/private service providers and private/public consumers in the UK.
Apologies if I sound snarky but I don’t appreciate being patronised or having a genuine point about evidence being dismissed by namedropping the U.S.
jason – it might be pie in the sky but what is preferable to upgraded surgery is to address society’s revulsion for female bodies that are made “imperfect” by childbirth, gravity, the passage of time or the consequences of disease.
Richard – you are correct in pointing out that the NHS is not immune from cost considerations, but what I`m saying is that these considerations do not have the same institutional impact as they do in a private sector business. I suppose I’m defending the NHS as I would prefer it to be rather than the over-managed, pseudo-market hobbled organisation that it has become. Oh, and I never made mention of malpractice, incompetence or poor quality provision, but I would say that the worst of those would be where there is no provision at all. I think it is perfectly valid to cite the behaviour of US health corporations; they have their lobbyists and laws and regulations have been altered in their favour, thus one has to wonder what they want from the UK government. Don’t you?
Don’t mind a touch of snark, and I hoped that my urge to argue the point doesnt come over as patronising. Perhaps I should be snarkier.
“@Simon McGrath:
a brilliant explanation of how the Coop undercuts Tesco and sainsbury’s
Yes, because healthcare is the same as grocery shopping.
Oh dear, is that really the level of discourse we’re left with now?”
Of course not. I was replying to the point by Mike Cobley that private companies will inevitably be more expensive because they have to pay dividends etc.Which is nonsense.
Great discourse. Thank you. It what i would expect from LibDems around a vital issue. I think we need to go back to some basics in healthcare before talking at all about markets, etc. What, really is the role of a hospital? How does that differ from a hospice, a GP clinic, a nursing home? What about Primary Care? Can we use it to engender a feeling of community, an attitude of compassion and consideration, duty even. How does the whole fit together with the responsibility of taking care of yourself, as well as others?
We have shifted into recommending solutions before we have looked at purpose in a HUMAN sense. A bit of epistemology in this regard could go a long way.
Ruth Bright Posted 13th January 2012 at 7:13 pm…………
jason – it might be pie in the sky but what is preferable to upgraded surgery is to address society’s revulsion for female bodies that are made “imperfect” by childbirth, gravity, the passage of time or the consequences of disease……
And in the meantime? I find it hard to believe that you really mean to imply that reconstructive surgey is of so little consequence.
To follow your argument, there should be no corrective surgery on children with treatable ‘craniofacia’l defects. We should explain to them that we are addressing, “Society’s revulsion for bodies that are made imperfect”.
.
jason – for adults I mean exactly that. The NHS cannot afford to do everything.
I am very pleased to say that our priorities differ.