Democracy, healthcare and the modern era
As more and more of Europe moves towards multiparty politics, it is becoming increasingly common for coalition governments to decide healthcare policy. The results of the UK election will be known when this editorial is in print – but will it really make a difference to those practicing orthopaedic surgeons in the UK?
It is somewhat ironic that the US healthcare economy is being pushed further towards an affordability model (with, amongst other initiatives, 'Obamacare' and reforms to insurance) whilst the NHS is being pushed ever so slowly towards a 'free market' approach – potentially repeating the mistakes of our American cousins.
There can never be such a thing as 'market forces' in state-funded healthcare. The basic principle underlying the reforms of the coalition government (GP commissioning, etc) and the previous administration of patient choice and alternate providers, are based on a fallacy. In order to function, private business must both make profit and pay shareholders. Businesses tend to do this by making economies of scale (small margins, large volume), cutting costs (such as outsourcing manufacturing) or through attracting more customers with a quality product. All three approaches can be seen in spades in the various private companies involved in NHS healthcare delivery.
The 'economy of scale' model can of course never work when competing with an NHS hospital which is always a much larger institution, and usually able to deal with the full range of healthcare problems. Alternate providers are therefore stuck with either trying to cut costs through outsourcing (overseas surgeons, cheaper prosthesis, reducing follow-ups) or taking the simplest cases with the highest potential margins and attracting patients through a better environment and surgeons through higher wages.
All of this is terribly destabilising for the NHS and causes vast imbalances in local health economies, with NHS trusts forced to take on the most difficult work with the highest risk. The recent change in General Medical Council rules is aimed at seeing fair play between surgeon and patient when offering a 'private' alternative. It seems to me that this guidance doesn't in fact go far enough – there are plenty of NHS providers of care who are paying shareholders dividends and (in some cases) offering shares and bonus incentives to consultants who work there. All of this takes money out of the system. In a system that has a fixed budget and is struggling to make ends meet, this really doesn't seem all that sensible.
The largest reform of the UK healthcare provision since the start of the NHS was ushered in with the Health and Social Care Act, spearheaded by the Conservative portion of the coalition government which put the budget for healthcare delivery in the laps of primary care doctors. So far this has made very little difference to what is the biggest problem in healthcare the world over – profiteering by big business. The British Orthopaedic Association has attempted to address this with the development of Clinical Champions – an attempt together with the existing network of regional advisors to influence funding in favour of those healthcare institutions providing gold standard of care to all patients without cherry picking.
Whatever happens on polling day (7 May), I doubt little will change in healthcare provision, but I hope it does. We as a profession globally will likely need to take more and lead more both locally and nationally, to influence the system in which we work and protect the provision of care for our patients.
