It is sometimes said, by those who continue to regard the NHS as the best possible healthcare system, that as soon as there is an emergency or the need for intensive care, that private sector hospitals ship their patients back to the NHS. (See a comment along these lines in response to a posting this weekend.
The implication is that the private sector by its nature is, for some unspecified reason, wholly incapable of providing emergency care or intensive care. This, it is implicitly suggested, means that we cannot and should not ever rely on private healthcare. After all, what good is healthcare without these things?
The argument is, of course, simply ludicrous. Did St Bart's not provide emergency care before it was taken over by the NHS? Was St Thomas's incapable of looking after any but those who came for elective surgery prior to 1948?
Emergency and intensive care was provided by hundreds of private - or, to be more specific - 'voluntary' hospitals prior to the NHS. And in America, right now, private hospitals provide emergency care and intensive care. I visited the Mercy Hospital in Miami which actually had two kinds of accident and emergency cover. One was for minor accidents and the other for more major ones. Quite a good idea, perhaps. The Mercy Hospital, like the voluntary hospitals that used to exist in great number in Britain, is part commercial and part charitable.
Why, then, do British private hospitals provide little in the way of emergency cover?
I cannot give an authoritative answer but I will suggest answers that seem likely to me and would appreciate responses from those involved in medical care.
First, the private sector, while no longer small, is spread around the country. More important, its customers are spread around the country. So the hospitals lack the size - the critical mass - to be big enough to offer emergency care.
Full-scale emergency care requires a lot of equipment, facilities and staff to be on hand. Ideally such a hospital should have an MRI scanner, a CT scanner, x-ray scanners, several operating theatres, plenty of full-time staff, plenty of doctors on-call. There is currently no private hospital in Britain, as far as I know, that is big enough to provide all this (and doubtless other necessaries).
In London, meanwhile, there is a planning permission issue. The state will give itself permission to build great big hospitals. It can pay for them by closing down other hospitals and selling the land. For a private hospital to get permission to build something the size of the Chelsea and Westminster NHS hospital would be like a miracle.
Then there is the funding problem. At present, perhaps, many health policies do not cover emergency treatment at a private hospital. What about if someone arrives as an emergency but has neither funds nor a health policy to pay for the very expensive treatment? That would pose all sorts of problems. Why should a private company pay a fortune to create emergency facilities and then find itself under intense media and moral pressure to offer the expensive treatment for free, at a loss?
That is what the voluntary hospitals used to do. That is what they could and should do again. But the old voluntary hospitals, like St Bart's, were expropriated by the state. The biggest expropriation of property since the Reformation, as a GP said at the time. Do we have to create new voluntary hospitals? Yes, I suspect.
But how much better and more just it would be if the state gave back the hospitals it took away. How wonderful it would be if the Chelsea and Westminster became a voluntary hospital. Think of the donations and the goodwill it would receive. Think how the attitude of consultants would change to their work there. They would not demand large sums because it would then be work done largely or entirely done out of goodwill, as used to be the case. They would make their money out of private work.
Let no one get away with the nonsense that the private - or to put it more generally - the independent sector is institutionally incapable of providing emergency or intensive care. It is rubbish. It is shown to be rubbish by examples both from our own history and from what is happening abroad.
At the time of Tsunami, incidentally, some of the patients were treated in the Bumrungrad Hospital in Bangkok. It is a private hospital.
Posted by James Bartholomew • Indexed in NHS
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One of the the problems is Chris, that any suggestion that the private sector could do it better, is often immediately met with a defensive tirade like yours above. I should 'come out' right away and say that I am one of those 'Public Sector bashing Libertarians'; a perpective largely formed by my experiences as a former Policeman, member of HM Forces and consumer of the very Public Services which seem to me to be delivering ever less despite ever increasing taxation.
Like it or not, it is our money thats being confiscated by Government to fund the Public Services and I think that gives us a right to question how it is being spent. As an aside, visitors to the site might be interested in having a read of the 'Bumper Book of Government Waste' by Elliot and Rotherham, a 'right riveting' read which I would commend to anyone who still has any confidence that Government values the money it extracts from us.
As far as the NHS goes. Like many others I have benifited from Life Saving surgery, in my case provided when my Appendix ruptured a few years ago. Nevertheless, this does not invalidate James' observations about such treatment bring provided by the private sector. Perhaps private sector Heath provision could employ fewer administrators and more clinical staff, like yourself!
Best Wishes
Ray
PS - Appologies for the rather dense block above, but I dont seem to be able to insert the breaks for new paragraphs which appear in the composition block, but not the final post.
Posted by: Ray at June 27, 2006 12:33 AM
Ray,
I'm as angry as you are about how the Government wastes our money (the NHS IT fiasco and PFI being two glaring examples: as a taxpayer, why I am helping to support the profits of PFI consortiums when beds are being cut?).
Defensive tirade: maybe, but only because of what I see - day in, day out. I'd like a realistic debate about the challenge of healthcare funding, especially given the changing demographics - but with a proper acknowledgement of what it is that the NHS actually does well. Before it gets thrown away. I'd like Patricia Hewitt to understand that the laudable goal of shifting treatment into the community does not entail an automatic reduction in acute capacity. I'd like the British Public to understand that if all the hardworking Filipina Staff nurses left tomorrow, the NHS would simply collapse. Without making like a nanny state, I'd like to close the loop of destructive lifestyles and preventable admissions. I'd like people to cycle to work (fat chance). I wish that we looked after our elderly properly - both in the community and in hospitals. Why can we afford a new generation of nukes - and not afford to care for the WWII generation? I'd like an end to dogmatic mudslinging - as an (ex?) forces member, would you describe an AMS Field Hospital and QARANC nurses as "unproductive and inefficient", simply because War is left up to the State? That's kind of how I feel everytime I look at A+E & ITU staff nurses going the extra mile - and then read ill-informed newspaper editorials, still less comments about the evils of socialised medicine by people who haven't been near an arrest trolley in their entire life (not this blog, I hasten to add). Etc etc etc etc.
This article (about Ireland, via NHS Doc Blog - sorry can't do the linky thing):
http://www.irishhealth.com/index.html?level=4&id=9394%2013/06/2006
...sums up it up better than I ever could (and maybe a useful source for answering some of Mr Bartholomew's questions).
Regards
Chris
Posted by: chris at June 27, 2006 01:21 PM
James,
I have to disagree with you on this one. I work for an organisation - the CBI - which does support the use of the private sector in health. Indeed I spend much of my time promoting this! However, I can't agree with you that emergency care should be provided by the private or voluntary sector. This isn't for ideological reasons - I think private companies have a huge role in improving the NHS - but rather because of the practicalities.
You began your piece by reflecting on a comment made about the private sector shifting its patients back to the NHS whenever a complication arises. I haven't read the comment, but if that's a criticism of the ISTC programme (and it is an oft-quoted one) then there are good reasons for ISTCs referring patients back when things go wrong. The point there is that they're not equipped to deal with emergencies, so its hardly surprising that they have to pass patients on to NHS trusts. I think thats an inevitable and not unreasonable consequence of the way the programme is set up - ISTCs are meant to deal with routine conditions that often had long waiting lists under the NHS.
You're right that the voluntary hospitals did provide emergency care before 1948. But provision was patchy and unorganised. In some areas, where there were large streams of funding and several hospitals, there may have been overcapacity. In other areas, there was hardly any provision at all. There was no one organising and co-ordinating it. You only need to look at the situation for where the voluntary sector provides mental health services today. I was only this morning speaking to someone from Mind who said that the provision, for example, of advocates for the mentally ill, who get them access to public services, is almost absent in some areas.
The trouble is that, as someone almost suggested in another comment, healthcare is far from a perfect market. First of all, the cost of treatment at one sitting can be very high (a standard admittance charge to ER in the US can be 600 dollars) so people have to take out insurance. In the US, this means that 'high risk' patients - such as those with heart disease, for example - pay extremely high premiums and have to come together in risk pools. It also means that, because there are 43 million uninsured Americans, the state has to provide some emergency services in the form of Medicare.
The second point is that, as you suggest, emergency care is an area of healthcare with a very high sunk cost.
You asked why the private firms, BUPA, BMI and so on don't provide emergency care. I think the answer, you'll find, is that in contrast with elective operations, there simply isn't significant demand for it in the face of the extremely high costs of providing the service. Doing so would add a huge cost to insurance premiums and probably make private healthcare unaffordable, except for a few.
I think what you have to do, (I apologise if you have done elsewhere) is set out the positive case for why the private/voluntary sector should take over emergency care. For me, there are a few points that make me conclude that it shouldn't:
1) this is something that the NHS actually does quite well. Waiting times for emergency care are now down to an average of below 4 hours. I, unfortunately, had the experience of going to an American ER last summer (where I had to present my Barclaycard on entry) and waited all night.
2) the NHS provides emergency care equitably and manages provision well geographically so that most people have access to A + E close enough to where they live. I'm not saying the situation is perfect, but its certainly better than 1948, and certainly better than the private or voluntary sector could do due to the distortions in the market
3) Despite the rising cost of healthcare over here, insurance premiums are rising even faster in the states. If we think we aren't getting much from the increases in health spending over here, then I'm sure 43m people in the US see the situation to be much worse.
Still - interesting site - I stumbled upon it earlier, and I'd be happy to carry on the debate.
John Wilkes esq.
Posted by: John Wilkes at July 18, 2006 09:43 PM
It's amusing how you write off opposing arguments as ludicrous!
I suggest a trip to Australia where despite large numbers of people having private health insurance, a minimal amount of emergency work is done by the private sector.
Why, becuase there is less profit in it!
All systems whether public or private are essentially geared around the way they are set up and run. As Emergency medicine is expensive, inefficient and unprofitable to run- private companies shy away from providing a decent equitable service for their customers. They leave it to the state system to deal with this unprofitable work.
But then again you are only interested in public sector waste! On your website you have a whole section on public sector waste while you ignore private sector waste! Very convenient, it says more about your bias than anything else.
I'm sure you believe in privatising, deregulating and a flexible labour market- while all the problems these antidemocratic policies bring, you just blame on the individual and their dependence on the pathetic welfare state that remains.
It's a weak and ridiculous argument.
Public and private systems can both be good and bad, depending on many factors. But you paint the picture of public bad and private good, a kind of anti-intellectual argument for two year olds to understand!
One question- why do states with more generous welfare systems not exhibit greater degrees of dependence? Is it because your argument about dependence on welfare is deluded right wing garbage? I think so.
Posted by: ben dean at July 23, 2006 04:17 PM
HI JAMES
Just finishing your book.
On the issue of private emergency service: One need look no further than the remarkable ability of tow trucks. They arrive at the site of a motor vehicle crash BEFORE the ambulance or police!! How can this be?? Commerce motivated by profit and competition has always been the most efficient at delivering any services or goods. A private emergency department would run rings around anything the public hospitals can dish up. The government directly and indirectly make it impossible for them to exist by the many layers of bureaucrats and regulators who stand in the way.
(We can't have rich people getting better medical care than poor people... now can we!)
Best wishes,
DOCTOR GEORGE QUITTNER
PRIVATE FAMILY PHYSICIAN
Provider No. 457755K
90 AVENUE ROAD
MOSMAN 2088
AUSTRALIA
P: 61 2 9968 2222
F: 9968 2266
M: 0407 968 007
www.MOSMAN-DOCTOR.com
Posted by: DR GEORGE QUITTNER at July 26, 2006 09:31 AM
It's worth recalling that the private sector does still provide major emergency services, via e.g. the AA and the RAC, and, in one area at least, on a charirable basis. To quote from one of the RNLI's publications:
"The Royal National Lifeboat Institution is a registered charity that saves lives at sea. It provides the 24-hour on-call service to cover search and rescue requirements out to 100 nautical miles from the coast of the United Kingdom and Republic of Ireland and a seasonal beach lifeguard service on appropriate beaches in the south west of England.The RNLI is independent from Government and continues to rely on voluntary contributions and legacies for its income.
The RNLI is largely a volunteer organisation. Many thousands of people give their time, their skill and their commitment so that the RNLI can achieve its purpose of saving lives at sea. It is because of the willingness of RNLI volunteers that such a high proportion of the RNLI’s money can be spent on first-class lifeboats and equipment, not on wages. The RNLI sets great store by the voluntary spirit of the whole Institution and would resist any change to this."
Posted by: Philip Talmage at July 31, 2006 07:08 PM
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If you were taking umbrage at my comment about "simply the blaming the NHS" - may I point out that I agree with the statement that many elderly patients would benefit from increased post-op high dependency care. And whilst in "recovery", they usually do. It's transferring them back onto under-staffed, under-resourced wards that is a major part of the problem. Things get missed. Yes, there is a lack of critical care capacity: like everything else, it is - effectively - rationed. Patients requiring "planned" post-op ITU beds quite often have their surgery cancelled because emergency admissions have taken precedence. The situation in PICU (kids' ITU) is just as bad, if not worse. There are certain criteria for bed allocation ("too sick" - i.e. futile admission - "too well" - i.e. needs HDU, maybe not ITU) + some trusts have made good and forward-thinking use of "step up/step down" beds, critical care outreach staff (i.e. ITU nurses who support general wards) etc etc.
It might not be fashionable amongst public-sector bashing libertarians, but I think it is fair to say that the NHS - lumbering as it is in other respects - is actually pretty good in an emergency. That is threatened by New Labour's ill-thought out reforms and its obsession with the political chimera of "choice" (I'm not denying the power of the market here - just pointing out how crass the notion is in certain contexts. If I've got a bowel obstruction - I damn well want somewhere local and dependable, not a "choice of 5 hospitals"). Important as charity is (see Great Ormond Street) - and however much it eases the conscience - I don't want to have to rely on it to cover emergency surgical lists on a friday night.
Some of the affection (well, what remains of it) for the NHS is based upon more than socialist daydreaming. NHS Critical care staff do a damn good job and the taxpayer does well out of them. The problems mentioned in the study you cited are capacity issues- not efficiency issues. Of course the private sector can provide good ITU care - if there is a market for it (and there undoubtedly is - although guess where they'll have to get the nurses from....) It's just that, thus far, commercial healthcare groups and other private interests seem to be more interested in cherry-picking "easy" surgical cases and ludicrous PFI re-financing deals - whilst excellent NHS services are being fragmented. It might be a cliche to suggest that shareholder value becomes more important than post-op elderly patients going into shock - but it certainly feels that way... That's what angers some of us at the coalface. That, and the tabloid level of national debate. We need a realistic debate about funding (ask Dr Crippen about "free at the point of use"...)-not dogmatic public-sector bashing or empty political promises.
(student nurse)
Posted by: chris at June 26, 2006 01:54 PM