Maybe it was the wine. Or perhaps the warm afterglow of sharing a stage with Rob Webster, the NHS Confederation chief exec. Or, perhaps I am just stupid and/or never learn. Whatever it was that made me stick up my hand to ask Stephen Dorrell a question, I immediately regretted it.
Dorrell, the new Chair of the Confed, and former MP (“a pure Blairite” as he put it) had made a pre-pudding speech at a posh dinner after the NHS Partnership Summit, a gathering of NHS and independent sector organisations.
The man is a planet-brain, suave and funny with it. He had made the case for partnership working and explained how the NHS had always had a mixed economy (GPs, pharmacists, dentists, opticians, drug companies, kit suppliers and the rest can all be seen as part of the private sector). He proclaimed patients are “blind to who provides the service” as long as it is free at the point of delivery.
He was arguing, I thought, for us all to be braver about holding the difficult adult conversations about the role of the private sector in the NHS. This played to the vested interests in the audience.
Earlier that day, Simon Stevens had winged in, rushed his way through a Q&A session that we were not allowed to tweet about (why not?) and left for the 2.30 train to some other grand occasion. He had dealt with tough questions about tariffs and why the Vanguards did not seem to be ‘embracing’ the private sector. And he had left the participants restive.
Later, Rob and I had talked about what partnerships mean from a patient/user perspective. I had made my usual plea for patients to be partners at the decision-making table. And for them to be part of policy processes. And that applied both to difficult decisions about funding, and applied to ‘both sides’ - statutory and private organisations who need to take patients seriously at a senior level.
On the one hand…
On the one hand I am deeply suspicious of the ‘independent’ sector: I have campaigned furiously against the excesses of the pharmaceutical industry. They used to sell anabolic steroids to mothers of malnourished kids in developing countries. They produced thalidomide, dosed my mum’s generation to the eyeballs with valium, their business model is predicated on over-selling useful drugs and they initiated antibiotic resistance through widespread over-promotion.
I have railed against the excessive daily rates of process-driven McKinsey-ites. I hear rumours of secretive procurement deals between national agencies and the likes of Capita. I’ve met with smart suited folk from Deloitte, Optum, Virgin and KPMG. And they can talk the talk. But their swanky offices make me wonder. And when I hear stories of US corruption amongst some healthcare global giants who are over here now, I am pessimistic about the NHS. Corporate power coupled with secrecy are anathema to my values. And I dislike the current Government and its ideological arrogance. I don't think they are the long term protectors of my values in healthcare.
On the other hand: The NHS has no monopoly on cultural goodness, sweet and light. I have met bullies and idiots in the statutory, voluntary and private sector. People are people. And Bristol, Alder Hey, mid-Staffs and many more, happened on the NHS watch (though I am acutely aware that striving for FT status was part of the problem at mid-Staffs).
And Dorrell is correct – GPs are private businessmen and women. And powerful vested interests (hospitals, for example) will always fight their corner; meanwhile, funding and tariffs are not helping us re-invest in prevention, public health, social and primary care. It may be that a more ‘customer-focused’ approach – one that is habitual to many in the private sector is sometimes better than the paternalistic tendencies of the statutory sector.
In short, I am not a ‘pro-marketisation’ man and yearn for human values in healthcare. But I am not blind to the NHS’s failings. In all things, I am a soft-leftist. And often plain confused and uncertain.
However, what I am sure about is this: If we continue to play yah-boo politics with healthcare; if we shout more, we listen less; if we continue to play the abuse game: ‘if you are not for the NHS, you are against it’, we will all lose. There is an old African proverb: When elephants fight, the grass gets trampled.
In this case, it is patients and citizens – the users and owners of the NHS - who get trampled. Their real views, their real questions, get stifled. Because in the mysterious corridors of power, quiet deals will get done. The fear of holding difficult conversations drives negotiations underground.
During the partnership summit, I heard one person say that, in the absence of an over-arching strategy for public-private partnerships, stealth is key – that corporates need to argue that their mission is about quality and access (in essence, the Dorrell line), that they should avoid discussion of how they re-invest money in their business as it comes too close to an open discussion on profit; that they should focus all their attention on picking up local health economy contracts. One person admitted that in training their staff, they tell them not to use the ‘P’ word.
In my work, I have always stood for the need to have difficult conversations about complex stuff – and to bring patients and citizens into that tricky territory, so that they are equal partners in decision-making. What worries me is that debate on the NHS is so hot, so volatile that if you question the NHS, you are quickly labelled the enemy. And so you keep your head down.
It is safer not to raise your hand and ask questions. I have held my finger over the Twitter ‘send’ button with a tweet that says ‘Come on GPs, I don’t mind that you are private businesses. But get over pretending that you’re not’. And then deleted it. I have been a coward.
And I have also wanted to tell the big private sector corporatists to get real – yes, they may be able to argue that they are ‘customer’ (aka patient) focused, but if they want to be trusted they need to get their act together – be honest about what happens to the money and where it goes, and start committing themselves to real honesty and transparency.
And during the clever Dorrell speech, I suddenly saw a chink of light. There are two different conversations to be had and two different facets of this debate: One is about what makes for a good service for and with patients, users and carers. The other is about accountability to citizens as taxpayers.
This is blindingly obvious in some ways, but if we continue to talk about patient AND public engagement, we mix them up. What Dorrell was saying, I thought (while sipping a fourth glass of wine that had somehow appeared) was let’s just focus on the former, as a rationale for letting the private sector in to more business.
Raising my hand
As I raised my hand to make the point, I had an almost out of body experience. I saw my arm go up in slow motion, and something told me to put it down again. A voice in my head said ‘no, no, this is going to be too hot to talk about, this will make people splutter in their pudding’, Maybe I’d get hit. And a second voice said ‘you’re too drunk to make sense anyway, so don’t worry about it’. I ignored both voices.
I said that, while I could understand that patients (sometimes) are “blind to who provides the service” I, as a citizen and taxpayer am not. And while I know GPs are part of the private sector in some ways, there is something about the scale of some parts of the private sector that make that analogy meaningless. My local coffee shop is not Starbucks. My local greengrocer is not Kellogg.
I said that if the private sector wanted to be part of mixing it with the NHS, they needed to have the balls to defend where they are coming from, to talk about profits, talk about what they put in and take out, argue the case, and have the guts to have the difficult conversations.
And that, if those ‘defending’ the NHS want to have that debate as grown ups, they also need to come clean about their vested interests, assumptions and values too – that not everything in the garden is rosy. And that, patients need their voice too – not as the baying public, easily swayed by one side or the other that claims to speak on their behalf, but as people who use and pay for the service. With facts at our disposal, and assumptions made plain.
Beneath all this, there are some important subsidiary questions that need teasing out (but I was too drunk to ask them at the time): One is about scale - are larger businesses bad for patients? Does the very scale of some private sector corporations mean they are inevitably divorced from being able to provide the personal and local touch that my GP practice would?
However, being big is not necessarily a bad thing. Hotels chains can be vast corporate entitities, but their quality of service isn't too bad. And, small businesses (like GP practices?) are not always so brilliant at some aspects of care (I'm thinking my own mental health experiences). I have seen great 'patient-centric' work in the private sector (by big and small organisations) and pretty duff stuff in the public sector (by big and small organisations). And vice-versa.
New primary care models (Federations and the like) are developing too, partly because the old models aren't fit for for purpose. And they're going to get big!
So is it about the business model? Can any organisation that has shareholders be anything but conflicted in its purpose, constantly seeking to maximise return and looking to prune costs at the frontlne? I've heard several people in the private sector argue that there's something different going on: that they truly believe they can deliver better care across the system and are inherently better at 'joining up' primary, community and secondary care; that often they are making losses, or tiny profits; or that they reinvest what they have to a degree that we just don't know about.
For each of these sorts of questions though, we need to tease out the ideological asumptions from the evidence. We certainly also need to ask these sorts of questions more openly.
Holding my breath
And then I held my breath and waited to be pounced on by one side or the other. And, guess what? It didn’t happen.
Dorrell took my point on board, I think (though his verbal dexterity coupled with my tipsy state meant I had a hard time following what he said). Then two people from the private sector said I was right. That they needed to be more honest about their own role, and more open about their profits and how they invest and what their shareholders get out of it. That they needed to build real trust.
So, I was proud of my courage, reasonably sure I was making sense, and uncertain whether any of this will make a blind bit of difference.
I am almost as nervous about this blog, as I was about the pudding intervention. And I am sober tonight. I try to avoid getting into debates about politics and policy, as I am not an expert, nor am I certain of my views.
In an old Peanuts cartoon, the bullying Lucy berates mild-mannered Charlie Brown. She ends up listing his faults. These include accusing him of always sitting on the fence, never making up his mind, always seeing both sides of things, being too damn wishy-washy. That he should stand up for himself and his rights. To which he shouts: "I demand the right to be wishy-washy"
I am sure the evangelists on both sides will seek to justify the rightness of their own position. And that’s fine. But I am after two more important things – firstly, an honest debate about the future funding of the NHS and health and social care and beyond that, how we pay for people to stay healthy. Secondly, for patients and citizens to have a say in all this. If we continue the yah-boo political gestures, the debate will continue to be driven underground and the decisions continue to be made secretly. So, it is important to stand up for the right to be wishy-washy.
Please take this blog in the spirit in which it is offered. Not as pro-one side or the other. Talking of spirit, where’s that wine bottle?