This article Geoff Mawdsley appeared in the Scotsman.
The response in some quarters to Reform Scotland’s latest report, Patient Power, was misguided but wholly predictable. It also says much about the current state of the public policy debate in Scotland.
The report examines how we might improve the health care system in Scotland by learning lessons from other countries.
The central point is that Scotland should follow other European countries by making our system more responsive to the needs and wishes of patients. In particular, we propose that the NHS in Scotland should act more like the insurance systems in other European countries such as The Netherlands where the government sets out clearly the care to which patients are entitled. This makes the system more accountable to patients who have defined rights to health care. In Scotland, this would mark an important shift in emphasis and could be achieved within a taxpayer-funded system.
Further, we propose that patients should have greater control over the health care they receive through choice from a wider range of service providers. This would entail a clear separation of the commissioning of health care from its provision. Health Boards would become Health Commissioning Co-operatives run in the interests of patients and commissioning care on their behalf with the specific task of providing information to patients so that they can make informed choices about their care.
Existing health care providers would become independent not-for-profit trusts providing health care based on the approved NHS price for treatments. However, new approved providers from the public, voluntary or commercial sectors would be able to offer their services at these rates.
Much of the reaction was the familiar, knee-jerk response – that our proposals amounted to ‘privatisation’ or patients ‘opting out’ of NHS care.
It is certainly our aim to extend patient choice and open up the supply of health care to increased competition. But Patient Power is explicit that the NHS in Scotland would remain taxpayer-funded, with government continuing to play the essential roles of guaranteeing access for all regardless of ability to pay and regulating the health care system.
Equally, all patients would have access to the care currently available through the NHS. But for the first time they would know exactly what that was. This would have the added benefit of ensuring a more open debate in the future about what should and should not be provided through the NHS. This is particularly important given the advances in technology, particularly in relation to cancer care, taking place all the time. A leading cancer specialist, Professor John Smyth of Edinburgh University, called for just such a rational debate about how to ration limited resources in his speech to the Edinburgh International Science Festival on Monday 13th April.
This distortion of the positions of others is nothing new. It is typical of the way in which the defenders of the status quo seek to polarise the debate. They pretend that the choice is between our current public sector monopoly and outright privatisation when the evidence from other European countries shows that there are many alternatives in between.
The resort to easy slogans is doing nothing to encourage a rational debate about our future options. Too often, the defenders of the present public sector monopoly seem to think that there is no need to present any evidence as to why we should stick with the current system since the public sector is inherently superior to any alternatives because it is based on altruism. This ignores the fact that where there is a monopoly, those in the public sector can put their own interests first with impunity.
It is only by giving patients choice through competition that we can ensure that those providing a service serve the interests of the users rather than their own. In this respect, it has always struck me as odd that monopoly is regarded, quite rightly, as a bad thing in the private sector, yet somehow essential to providing vital public services.
As Reform Scotland sets out in ‘Patient Power’, other European countries have moved away from monopoly provision of health care because they believe that patient choice and competition drives innovation and quality. There is evidence that this has helped provide better value for money, particularly in relation to cancer care where the more flexible European systems have achieved far better survival rates than our own health service.
This is all evidence that is at least worthy of serious debate – particularly since, as in Scotland, these impressive outcomes are combined with a fundamental commitment to universal access for all.
In most European countries, central government plays an essential but more limited role than in Scotland. However, this approach has enabled these countries to have public services which meet the needs of their citizens as well as fulfilling broader social goals.
The type of health service we require to achieve such a balance is exactly what we should be debating here in Scotland.
Yet, instead of looking outwards and seeing what lessons we can learn in Scotland, too often the debate is insular and convinced that other countries have nothing to teach us.
The fact is that in relation to health care, most other European countries are moving in the opposite direction to us – away from centralised command and control and devolving power downwards to patients and local communities.
The question we need to ask is, are we right and all these other countries wrong or is it the other way round?