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Is it the beginning of the end for the NHS?

Are NHS reforms a one-off injection of competition or the first step to a US-style system? Gareth Iacobucci asks experts to look into their crystal balls

Are NHS reforms a one-off injection of competition or the first step to a US-style system? Gareth Iacobucci asks experts to look into their crystal balls

‘We predicted it would happen, and it is going to mirror all the excesses and worst aspects of US healthcare very soon.'

This is the view of healthcare academic Professor Allyson Pollock, who believes the Government's rush to involve the private sector in primary care is the beginning of the end of the NHS as we know it.

US giants such as UnitedHealth are already making inroads into the UK market, and are set to step up their involvement as the Government opens up the market to allow more competition for provision of GP services.

Professor Pollock, head of the Centre for International Public Health Policy at the University of Edinburgh, says expanding the role of the markets is ‘the antithesis of how healthcare should be delivered'.

But how right is she, and are we about to make the key shift from an internal market – with GPs as independent contractors – to a fully open market?

Professor Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, believes current Government policy marks a sharp break with the past, and risks fundamentally undermining the NHS.

He says: ‘The private sector has co-existed fairly happily with the NHS since 1948. This is because it has been relatively limited in scope, offering complementary services, rather than substituting for core elements.'

He notes that in many other European countries health authorities contract out primary care services, but their systems closely restrict who can enter the market.

‘The difference now is that the NHS is bringing in corporate providers, often from the States. This is the US model of provision, with much healthcare provided by chains.'

Fragmented care

Professor McKee believes the ‘massive lobbying power' of large companies will enable them to influence political decision-making – as he says happened with independent sector treatment centres, where firms were able to negotiate payment for a guaranteed volume of work.

He is also concerned current reforms will lead to private providers focusing only on relatively simple procedures, leaving the NHS to deal with the more complex cases.

‘The sector will fragment provision, leaving the unprofitable bits to the NHS.'

But other primary care experts believe fears the UK system will end up mirroring the US Health Maintenance Organization (HMO) model – where insurance groups provide health services for a fixed annual fee – are wide of the mark.

Professor Martin Roland, director of the National Primary Care Research and Development Centre, says it is ‘difficult to draw any simple parallels' between the UK and US. ‘I wouldn't say we're going down an American line, although some firms competing for business are American.

'Things will change, but I don't think the NHS will be fundamentally undermined.'

Professor Roland says the Government is no longer handing out contracts that guarantee volumes of business, which he says provided too little incentive to attract patients: ‘To stay in business, companies will have to provide what patients want.'

But he adds: ‘Things like continuity of care are less easy to measure. People feel these aspects may be lost in a salaried, private service, and they may be right.'

GPs are also finding it increasingly difficult to compete with the private sector for tendered APMS contracts. APMS looks here to stay – given that all the main political parties now support private involvement in the NHS – but can GPs bid for services with confidence of success?

Further reforms

Dr Richard Vautrey, deputy chair of the GPC, fears not. He believes the outcome of the tendering processes for Lord Darzi's 250 new polyclinics – all of which are being procured under APMS – will give a clear picture of the direction of UK healthcare.

‘The key will be how many private organisations win these tenders. If there is a significant inroad, the HMO model becomes a more realistic prospect.'

But with little political opposition to private sector provision, lobbyists are seizing the opportunity to push for further reforms of the NHS.

Helen Rainbow, senior research officer at public service think tank Reform, says Government plans need to be taken further to achieve better value for money.

‘We want a service that's a lot more accessible, fitting into changing demands, with access to GPs on patients' terms. There have to be moves towards greater efficiency, because demands are going to increase.'

Ms Rainbow says choice in the US has led to higher standards of treatment, and rejects concerns that the UK reforms may drive down quality. ‘If you look at current private contractors in the UK, they're providing a very high level of service.'

But Professor Pollock thinks it is only a matter of time before the UK begins to resemble ‘the worst aspects' of the American system.

‘Increasingly, we'll see decreased entitlements for care, ineligibility and patient and user charges. We've got greed and not need,' she says.

Some believe aggressive reforms will erode the core values of the NHS. Others point towards an ageing population and shifting patient demands to justify the growing involvement of the private sector.

Although the UK may still be some way from a US-style system, the involvement of companies such as UnitedHealth in the NHS has alerted GPs to the huge changes, and challenges, that lie ahead.

Different healthcare systems

The NHS: Provides healthcare to anyone normally resident in the UK with most services free at the point of use.

Social insurance: Favoured in continental Europe, in countries such as France. Funds are collected from individuals, employers and sometimes via Government subsidies. Patients choose a particular doctor or hospital, which then receives money from the insurance fund.

The Health Maintenance Organization model: The US model, in which medical insurance groups provide health services for a fixed annual fee. Patients pay fees to see their primary care physician, and can't see a specialist or access any other type of service without the primary physicians' approval.

Martin Roland

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