There’s been a lot of discussion about the potential for a trade agreement with the USA and its possible impact on the NHS. “I think everything with a trade deal is on the table,” Donald Trump has said. “When you’re dealing in trade everything is on the tabl,e so NHS or anything else, a lot more than that, but everything will be on the table, absolutely.” The response of those who want there to be such an agreement has been to say that it won’t matter – a “storm in a teacup”, one IEA spokesperson commented. US firms are already providing services in UK health care. Services can be provided by a range of providers; what matters for the consumer is that the NHS continues to offer services that are free at the point of delivery.
This view may be disingenuous, because there is a strong financial incentive not to see the problems. It is certainly mistaken. The usual complaints from the left are that profit-making firms are extractive, and that competition consumes resources. Either might be true, but the problems run much deeper than that. There is now abundant evidence of what happens to public services when ‘competition’ or part-privatisation is introduced. I have just had a paper rejected which makes the arguments in some detail – admittedly it’s too tendentious for an academic journal – but I can sketch out a couple of points here.
There is no system, anywhere, that is wholly public, any more than there is a system that is wholly private. The NHS has had an uncomfortable relationship with the private sector, but its successful functioning relies mainly on two pillars: that the private sector is small and select, and that the services are sufficiently integrated to ensure that really serious cases can be taken over by the national service. Both of those are at risk from creeping commercialisation.
The fundamental problem in any mixed system is that commercial providers get to choose what they cover; public providers, committed to meeting the needs of a population, do not. Commercial providers select those areas of operation which they are undertaking to provide – that is how markets work. That means that in general they will select those activities which deliver the best return per unit. It follows that some things will be left out; when they are, the public services will have to deal with them as provider of last resort. (Take a simple illustration, delivering post and parcels. If private firms can subcontract for the profitable bits, they choose the easy runs – between major cities, or within busy areas. In the case of private health care, that has generally meant a preference for relatively low-risk elective surgery, while long term psychiatric or geriatric care don’t attract the insurers or the services.)
Taking those points together, that must also mean that public services have a higher cost per unit than the private services – the difference is built into the process. Politically, there are constant complaints that public services don’t work as well as private ones. Of course they don’t; they have to take on the bits that private providers leave behind.
That’s the unavoidable part of the problem. Some other things follow in the wake of that structure. They may be avoidable, but they are still difficult.
- There is a continuing incentive for private providers to cut corners – skimping on service, paying less, holding to the letter of complex contracts.
- The public sector has to develop processes for sub-contracting and compliance, which are expensive and uncertainly effective.
- When private providers get it wrong, and services collapse, the public services have to pick up the pieces.
There’s obviously a lot more to be said about competitive structures, but that’s why I started out trying to write a paper on it rather than a blog entry.