Two tier NHS : we already have many tiers surely due to funding and 
practice variations?

On Jul 26 2011, Tom Foubister wrote:

>Dear all,
>
> I would like to follow up on Joe and Uwe's mention of tiers. We have in 
> this country a mild two-tierism - it's mild because those who use the 
> second tier continue to have a very strong stake in the high performance 
> of the first tier. The proposed reform threatens to make this two-tierism 
> less mild.
>
> But the issue does not relate primarily to the delivery side - allowing 
> private facilities to provide NHS-funded care to NHS patients. Although 
> the development of private sector capacity is relevant.
>
> It relates primarily to purchasing - to the transfer of NHS funds to 
> groups of GPs, and to allowing these GP groups to contract private 
> companies with purchasing expertise to run things for them - companies 
> like BUPA or (the US company best known here) United Health.
>
> The following scenario is entirely plausible, perhaps likely: you receive 
> a letter from your GP group (say, "BUPA-NHS") saying "we can make it 
> possible for you to have your NHS care delivered more quickly, and in 
> more comfortable surroundings. We can also make it possible for you to 
> access some services and some drugs not available through your NHS 
> policy. All this security for a modest monthly premium".
>
> This second scenario is at least plausible: responsibility for user 
> charges policy is eventually devolved to GP groups (justified by talk of 
> local knowledge, local needs, local priorities etc etc), with changes 
> doubtless being subject to approval by the centre. Here, the letter might 
> say: "due to NHS budgetary constraints, it has been necessary to increase 
> our charges. This will allow us to continue to provide care of the 
> highest quality. You will be interested to know that we are offering a 
> low-cost insurance policy to cover these charges, meaning you have to pay 
> nothing at the point of use".
>
> And then, of course, there will likely be the straightforward: "Welcome 
> to BUPA-NHS. Please take a brochure explaining how you can avoid the NHS 
> altogether".
>
> The thing is, there's little profit (or 'surplus') to be had from running 
> NHS purchasing (not if you want to be popular at least), so if companies 
> like BUPA are doing this, they will be ensuring their core business 
> benefits somehow. At the very least, private health insurers and 
> insurance - still a pretty marginal thing here - will gradually become 
> normalised, and the marketing potential will be limitless.
>
> This is all speculation, but if things are going to become more 
> 'privatised' (whatever we choose to mean by that) I think this may be how 
> it will happen. So bit by bit, many will begin to think of it as utterly 
> normal to use the new or old second tier; their stake in a high 
> performing NHS will be weakened because they no longer need it to be 
> quite so high-performing (at least not at the cost this would entail); 
> and the idea of equal access to high quality care will come to be readily 
> accepted as being something 'unaffordable'. There will be less insistance 
> on the NHS 'keeping up'.
>
> So in the end the new purchasing arrangements may eventually change the 
> way people feel about the NHS (and the values the NHS embodies), and the 
> NHS may become precisely that, the 'NHS policy'. I hope I'm wrong. But it 
> does seem that the NHS is indeed to suffer under the strain of growing 
> social inequality, and that it won't be permitted to get in the way of 
> wealth's gradual trickle up. We'll see.
>
>Tom
>-----Original Message-----
>From:         "Maynard, A." <[log in to unmask]>
>Sender:       Anglo-American Health Policy Network <[log in to unmask]>
>Date:         Mon, 25 Jul 2011 11:20:12 
>To: <[log in to unmask]>
>Reply-To:     "Maynard, A." <[log in to unmask]>
>Subject: Re: Doctors to launch public campaign against proposed NHS reforms
>
>PS ISTCs doing elective surgery (mostly hips and knees) had an initial 
>premium but now trade at national tariffs
>
>Rudolf Klein wrote:
>>  
>>  
>> I think that some semantic precision may help to clear up Jo's 
>> misapprehensions about the NHS.  By privatisation I mean the transfer 
>> of the NHS provider function to private, for profit enterprises ( 
>> which GPs have been ever since the inception of the nHS, incidentally 
>> ).  This not happening, though in future more for profit providers may 
>> attempt to enter the market: but note that it took what was in effect 
>> bribery ( i.e. paying premium prices ) to attract the Independent 
>> Treatment Centres ISTCS introduced by Labour in order to cut waiting 
>> times. So I don't anticipate an explosion of private activity but only 
>> a modest increase from a very low baseline. What Cameron & co. do want 
>> - and are publicly committed to ( see the recent White Paper on the 
>> public sector ) - is to transform  NHS producers ( and the school 
>> system ) into not for profit social enterprises.
>>  
>> The process began under Labour with the introduction of Foundation 
>> Trusts and is to be accelerated. There are lots of governance problems 
>> about this transformation, but it is not privatisation. Indeed the odd 
>> thing is that the NHS has been the only health care system in the 
>> western world, since the collapse of the Communist Empire, where 
>> hospitals are owned by the State. Now it will be more in line with 
>> systems like the Netherlands or Spain where hospitals have a variety 
>> of legal forms but essentially are not for profit.   
>>  
>> Incidentally note that postcode prescriibing is not a function of how 
>> the NHS operates. Geographical variations in medical practice 
>> charaterise all health care systems : see Wennberg and the Dartmouth 
>> Atlas.
>>  
>> Regards to all,
>>  
>> Rudolf
>>  
>