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A trial without evidence - Health Policy Today, 15th July 2008

Health Policy Insight associate editor Tom Smith on the debate of the day

At 9 am this morning, BBC Radio 4 hosted a programme on the cost of the NHS and the involvement of the private sector.

This involved Allyson Pollock (AP) and Paul Corrigan (PC) setting out their alternative cases; and former Lib Dem health spokesman Dr Evan Harris and businessman Sir Gerry Robinson responding. The concept of the show was for Harris and Robinson to listen to the arguments and then make up their minds (as if they didn’t have a view already). Kings Fund chief executive Niall Dickson was on hand as referee.

Allyson Pollock has a very clear view.  She outlined her thesis: the government’s aim is to privatise all of the NHS, including general practice; the aim is to hand over the NHS £100 billion budget to American firms to provide and commission.

“Now what you will hear today is that it doesn’t matter who provides care, but it really does”, Pollock told listeners.  Market mechanisms introduce transactions costs into the NHS.  “The logic of having shareholders is that they are risk-averse.  So they will avoid the very ill patients. We’re beginning to see that process with the closure of services”.  The nature of markets is that they sell things to people that they don’t actually need, and then she linked this to the copayment debate.

Rather than question some of the argument, Gerry Robinson seemed to turn therapist. “I’d like to ask Allyson”, said Gerry, “Just why are you so antagonistic?”

“I start from the evidence, Gerry”, replied AP, “and all the evidence suggests that markets distort, they add costs.  “No universal system in the world is based on markets”.

Gerry agreed, “it is difficult for the public sector to deal with the private sector”.  

Then it was Dr Evan Harris’ turn to probe the ‘experts’.  He asked / told Paul Corrigan, “shouldn’t you have waited until commissioning was more developed before involving the private sector?” Turning to Allyson Pollock, he told / asked how would she square her arguments with the presence of GPs who, after all, are private businessman.

“That’s a total misrepresentation of what GP’s are”, said AP.  “They had a direct contract with the Secretary of State, were strictly regulated and couldn’t refuse patients and now all these things are gone”.  She said GPs are not commercial firms.

At this point, we had a good question, from the presenter, Branwen Jeffreys.  She asked, "Allyson, if GPs are not bad businesses or commercial, if they form together in larger groups, do they then become bad firms?”

AP ignored the question, and talked about the takeover of primary care by “American!” firms.  

Continuing with his psychoanalyst's tone, Gerry Robinson asked AP, “do you really see GP entrepreneurs as akin to US firms?”

And then Paul Corrigan jumped in to make the valid point that a lot of the argument is about semantics:  “Allyson says surpluses are okay, profits bad.  If practices are run by Americans, they are bad; but if run by English people, they are okay”.

Gerry Robinson said he felt that a difficulty “is the ethos that American firms bring up in our minds”.  He asked Paul Corrigan, “Paul, you must have some fears?”

PC said he didn’t, because “in this country people don’t have to worry about whether they can afford it”.

Evan Harris said he “bristled” when Allyson Pollock says “all the evidence points this way” because there is so little evidence.  “I’d like to ask Paul Corrigan if there is any evidence for the reforms”.

PC was clearly flustered by this approach. "I don’t know what has been published”, and then, recovering, said,“a lot of these reforms are new and haven’t had an opportunity to make an impact yet”.

At this point our 'jury' reacted to the 'expert witnesses' – and a jury trial seemed to be the model for the show.  

Gerry Robinson concluded that we should keep the private sector out of the NHS until we really understand the implications and plan the scheme properly. He said he wanted to believe that the private sector could help, but wasn’t convinced the NHS could work effectively with the private sector.

Evan Harris said he wanted to agree with PC that the private sector could make a difference, but he had to agree with AP.

Taking the 'trial' metaphor, it's interesting that unlike a court of law, prosecutors of reform must prove there will be no harm while detractors only need to place a shadow of doubt.

It is an indictment of the quality of debate that it is possible to do this by saying “America” at different points, and by painting a dark scenario of the future.