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Market principles have no place in the NHS

The Government has based its reforms on the premise that everything within general practice is measurable and has a monetary value. It is wrong, says Jobbing Doctor

‘A cynic knows the price of everything and the value of nothing’, So said Oscar Wilde. Generally, there are three main sources of quotes that we use in daily life – the Bible, Shakespeare and Oscar Wilde.

We are in an era of measuring. We have ways of measuring all sorts of things, and the pseudo-intellectuals will witter on about the ‘metrics’. I hate that term.

The whole upheaval we are about to embark in the NHS upon is underpinned by the costs as they are measured. There seems to be a widely-held view that if you can measure something, it will make it better. This is matched with the equally fallacious view that the market will always make things better.

I saw a patient recently with an intractably difficult problem that nobody, as yet, has been able to ameliorate. I was at a loss as to how to deal with it, and turned to the hospital letter, and this seemed to be a list of increasingly erudite investigations that had not elucidated the problem, nor had it dealt with the symptom.

So I spoke to my colleague, her consultant, who was also mystified. We (who both know the patient) mused on possible strategies, and decided a joint plan forward, that was to be orchestrated by me. This was done in a spirit of mutual respect and trust. There was collaboration at a high level. You can’t measure that. You can’t cost that, either.

The new NHS changes are predicated on a simple precept: that using market mechanisms will drive down costs, remove inefficiencies, and will favour quality. Market systems are beneficial if the transactions are simple and measurable. Health economists say that health transactions are simple and measurable. I say that they are neither.

Market forces generally drive down quality, achieve ends at the lowest possible cost, and the inefficiencies (such as they are) are replaced by skimming off profits. They replace nurses with health care assistants, doctors with physicians’ assistants, police with community service officers, teachers with teaching assistants, and so the litany of dumbing down continues.

If the only tool that you have in your toolbox is a hammer, you tend to see every problem as a nail. If you are a zealous marketeer, then you tend to see every problem being solved by using the market. The use of markets is the mantra of the moment. There is no other.

Personally, I would do very well in a healthcare market. I have a great deal of experience, I have a good reputation, and I have a loyal following. If I followed the market model, I would dissolve my partnership, employ lots of younger doctors at cheap rates, delegate every task down to the lowest level, avoid expensive patients, practice in a nice middle-class area. Thank you very much. In two years I could be a millionaire.

I didn’t go into medicine to earn vast swathes of money. My attitude to money tends to be the same as Wilkins Micawber in David Copperfield: provided income exceeds expenditure, I am happy.

I am not happy about the way in which the NHS is going. The measuring, the management, the diktats, the markets, the costing, the protocols. These are the tools of the market. You can have a market in healthcare. But it will have winners and losers.

The interaction I had with my colleague was, I hope, valuable for my patient. That professional conversation cannot be measured or costed. The marketeers would have it that it can.

As Oscar Wilde (again) would have said: ‘There is no sin except stupidity’.

The Jobbing Doctor is a general practitioner in a deprived urban area of England.

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