In separate but similar arguments over recent days, the PM and his health secretary have boiled down their complex health bill to one defining word: competition. After months of impenetrable jargon, Tory cards have been placed on the table in dramatic fashion.
They are legislating for a market in health, ran the new Cameron-Lansley argument, as they consider it the best route to meet the healthcare challenges of this century, and it can't be delayed as those challenges are urgent. In deciding to back the bill and face down cabinet opposition, the PM has clearly decided that making a bold, pro-competition case is his best course of action. It could be a defining moment for a man who used the NHS to define himself politically.
So the battle-lines for the final parliamentary reckoning are drawn and the choice is clear: a market-based or planned healthcare system. Cameron's intervention has brought much-needed honesty and clarity to the government's message. All the early focus on clinical involvement in commissioning, which did not need a bill, only served to confuse. Cameron's up-front approach has disarmed those warning of a "hidden agenda".
But it is a high-stakes move and the Labour Party must now develop a considered and well-argued response. This fight will not be won on an emotional appeal alone, but on the evidence. So what is the government's new line? In the Health Service Journal, Andrew Lansley argued that a market-based approach to health was necessary to bring forward advances in healthcare. He wrote: "If we allow more informed and more demanding patients and health professionals to agitate for these new treatments and technologies to be made available – rather than accepting the misplaced belief that a centrally-planned system based on past patterns of delivery can do it better – then the NHS will find itself facilitating rather than frustrating innovative care." He didn't go quite as far as calling the NHS a "60-year mistake", as some in his party have, but it is quite clear he sees his bill as representing a clear break with the first 63 years of the NHS. "There is little we can learn from examining the past", he writes to emphasise the point.
There are two central claims in the Cameron-Lansley analysis to which the opposition needs to provide clear answers: first, that a market system will drive more efficient use of resources; and, second, that more competition between providers will improve quality and safety of services.
On the first point, there is a welter of international evidence to disprove the government's case. Right-wing critics of the NHS like to throw accusations of it being a "black hole" with poor productivity. Of course, there is waste in the NHS, as there is in any healthcare system. But evidence from around the world shows that the NHS model is a highly efficient way of delivering health cover to a whole population. Uncomfortably for the right, it suggests markets in health end up costing more, not less.
The Commonwealth Fund's most recent comparative study of health systems clearly shows that market-based systems, or countries that have a more mixed economy in health, spend more as a proportion of GDP on health than we do on the NHS for a roughly equivalent level of coverage and service quality. For instance, France spends 11.8%, the Netherlands 12%, Germany 11.6% and the USA 17.4%. We spend 9.8% on the NHS. This is why the fund regularly judges the NHS to be the most efficient healthcare system in the world.
Why is this? One of the main reasons is the centrally planned nature of the NHS model. The structure provides the precious ability to set standards and entitlements to services at a national level. Market-based health systems do not afford a similar ability to control costs at national level, and allocate resources in a fair and consistent way.
For instance, through the Department of Health's annual operating framework, and the decisions of bodies such as Nice, England is able to make careful decisions about service priorities and treatments based on evidence. In Lansley's world, with customers "agitating" at local level for new treatments, that ability is lost. Control of costs and fair access to treatments are replaced by a huge postcode lottery.
This ability to plan and co-ordinate also provides the answer to the government's second claim on service standards. Unlike other services, healthcare is both an essential emergency service and highly complex. Services are rarely delivered in isolation but across clinical networks. It is certainly true that, in market-based systems around the world, we find pockets of real excellence. In the US system, for instance, it is possible to find some of the world's most advanced and innovative examples of care. But, alongside it, we find very poor or non-existent care. The question we must ask is not which system produces the best individual examples of treatment, but rather which is best for everyone. On this test, perhaps the centrally planned NHS wins hands down? [FlamingNews]
