Evidence not ideology
Authors: Allyson M Pollock
Journal: BMJ (2005)

Editor—The argument is that the BMJ shouldn't have a position on the privatisation of health care and the NHS, but it should simply be a forum to allow the issues to be debated.1

But neutrality on this issue is wrong. It means abdicating the responsibility of a scientific publication to weigh evidence and argument based on evidence. A very large accumulated body of evidence underpins the establishment and development of a publicly owned and operated health system in the UK, evidence that advocates of its abandonment have yet to supplant with valid evidence of their own.

The fairest way of funding health services is through a progressive tax based system. The alternatives—social insurance (employer, employee contributions, local authority taxation), private and voluntary insurance, and user charges—are all, in that order, increasingly regressive and inefficient. Above all they introduce the potential for disaggregating and fragmenting the risk pool, allowing funders to pick and choose who gets coverage according to ability to pay and profitability. Increasingly this evidence is obscured by the mantra that the NHS is “unsustainable” and “unaffordable.”

Just as the method of funding matters, so too does delivery. All universal services have the goal of equity and universal coverage and have to be organised in such a way as to incorporate the principle of equal distribution in terms of need, not ability to pay; and, in the case of health services, to separate clinical decisions from issues of funding. The principle of not allowing fragmentation of coverage and mechanisms also extends to populations, treatments, services and training, public health support, and information.

Hitherto, health care has been organised and funded according to the needs of geographical populations for services, giving responsibility to administrative tiers responsible for meeting the needs of all patients and populations within their areas and ensuring that services are in place to provide them. Redistribution is the key to ameliorating inequalities and has to be designed both into funding and into delivery. Thus the flow of resources has been linked to needs and services, through the Resource Allocation Working Party and prospective budget setting. Politics often disrupted this process, but this was due to failings in democracy and accountability, rather than to failure in organisational design.

The abandonment of these principles is constantly justified by two claims or theses: that it doesn't matter who delivers care so long as it remains publicly funded; and that private sector delivery introduces choice, contestability, and diversity, leading to greater efficiency. In neither case is valid evidence presented.

The claim that private provision leads to greater efficiency is refuted by evidence from both the United States, where it is most general, and now from this country, by the example of the independent sector treatment centres. The claim that it doesn't matter who provides care is also refuted by the evidence of the past 25 years of privatisation in the UK. Health secretary Patricia Hewitt's claim that the outsourcing of elective care will come to no more than 1% of the NHS budget is evasive and wrong. It is designed to allay the fear that it will be more, but the claim flies in the face of all economic logic, recent history, and common sense. The privatisation of clinical provision now being pushed through is no different. It is in the nature of private companies never to be content with a given market share.