This was written on the 12th of september for Canvas, an online politics journal,
Mortality rates 45% higher in English Hospitals – is privatisation the answer?
Two weeks ago Channel 4 News ran a truly shocking story, which shook even the most dedicated NHS of supporters, including myself. Data they had obtained indicated that English hospitals were inferior to those in seven other developed nations. America’s much criticised insurance-based system came out on top, and was alarmingly sighted as a model for change in UK hospitals. “NHS death rates are one of worst in the West,” read the Daily Mail the next morning. By the end of the story, I for one was scared. Such startling figures genuinely made me question if whether I could trust the NHS with my life, and if growing old here, in my native country, is really as appealing as I once thought.
The source of the data was Professor Brian Jarman, and was collected secretly over more than a decade. Not only did it show our mortality rates to be the worst of the seven nations, it indicated that people over the age of 65 are five times more likely to die of pneumonia in hospital in England, and twice as likely to die from a blood infection (septicaemia) than if they were admitted to a hospital in the United States. Channel 4 claimed to have asked if anyone from the Department of Health was available to talk on the eve of the braking news. They weren’t, so they decided to continue with the on screen debate three against… zero. The defense of the NHS in the face of these damming figures was never heard.1
In the coming weeks, free market proponents in government who are currently pushing the ‘back-door,’ privatisation of the NHS will no doubt use this data to forward their agenda. The argument goes; in a system like the NHS, an absence of competition and meritocracy will invariably impact on efficiency and quality of service. As alarming as the figures were however, I quickly began to realise that the data did not prove in the slightest that the NHS is an inferior system to its privatised and semi-privatised counterparts in the other six nations. Firstly, the data is far from conclusive; It doesn’t appear to be peer reviewed, we know very little as yet about the sources and methodology used to produce these figures and nothing at all about the five other developed nations looked at – not even what nations they are.
This aside, the conclusions cannot be ignored; these figures appear to show rather unequivocally that English hospitals are under-performing. In particular, the fact that so many people seem to be getting Ill inside our hospitals indicates some hospitals may be sloppily run, comparatively undisciplined, or unclean. Much has been written about the hospital super bugs that have run rampant in British hospitals and about shock stories of dirty wards. In July of this this year a highly critical report into 14 hospitals with the highest mortality rates in the country by Sir Bruce Keogh described them as “trapped in mediocrity” ignoring concerns raised by patients and Staff.
This was echoed by professor Jarman who blamed the problems highlighted by his data on the ‘culture’ of the NHS.2 However, Keogh’s report suggested that geographical location was often a factor, in that isolated hospitals might struggled to attract the best staff. More common than that was the hindrance of quality care as a result of inadequate numbers of nursing and other staff, or an over-reliance on temporary and unregistered staff – in some cases ward staff were working 12 days in a row. Certainly, changing the ‘culture’ of the NHS will be no small task. It is one of the largest bureaucracies in the world; it’s the fifth largest employer on the planet. Public sector culture and the unaccountability and layered bureaucracy associated with it are undoubtedly factors in creating the problematic culture sighted. It has, for example, just abandoned plans to create the world’s largest single civilian computer system linking to all parts of the National Health Service. A change of culture may be needed, but changing this culture is not a simple as privatising.3
Market forces are not a quick fix and have actually been repeatedly shown to damage the NHS. Since Thatcher’s, “new public management” initiative in the 80’s, hospitals have begun to outsource cleaning (roughly 40% in 2008). The consequences have been; consistently less time spent cleaning each ward each day, higher staff turnover (less competent staff), and less control over cleaning for medically trained staff. I should like to point out those who might be thinking of giving the above argument that it is undoubtedly privatisation and market forces that have made our hospital dirty, not the other way around. Private cleaning firms were doing such a terrible job that by 2008 the Royal College of Nursing conference overwhelmingly voted for a motion proposing an end to contracting out cleaning to private firms.4
The marketisation of the NHS continued into the Blair years. The Labour Party thought they could create a market within the NHS without actually selling any of it off. Targets, quotas, and plans were put in place for most aspects of service. To meet the artificially inflated targets a number of NHS trusts allocated “The Hello Nurse,” whose sole task it was to greet new arrivals in order to claim for statistical purposes that the patient had been “seen.”5 NHS managers took wheels off trolleys too reclassified them as beds and reclassified corridors as wards in order to falsify Accident & Emergency waiting times statistics. From a wider view, hospitals are now paid by the quantity of work they do under a contract, so we see a phenomenon known as hospitals “over performing” when hospitals treat more patients than their contract allows. The “extra” patients are not extra “customers” for the hospital, they are patients with real problems that need to be treated, but the market that has been created in the NHS represents them as figures on a balance sheet and excess costs.
Explaining why private firms so often drive down standard is simple; when a private corporation wins a contract for ten years say, there is no competition for ten years, the motivation to drive costs down and increase profit margins can increase. The same has been seen to be true with rail companies running poor services and private catering companies selling harmful, but profitable foods in school. In the case of the NHS, the historic conception of the public servant proudly giving themselves and their talents to people and nation was permanently tainted. Public service became self service and so emerged the popular image of the petulant NHS working mindless ticking boxes and chasing bonuses. These systems of free choice and opportunity did not perform as the game theorists predicted, because the players cheated.
In an industry trading in the commodity of people lives, market incentives can only result in people being treated as objects and patients as customers. Customers who might one day be judged on their ability to pay, not their medical need. Even if I concede that our hospitals our are made worse by, and our death rates higher because of, our system being public sector run this does not mean that our health-care system is inferior. The primary end of any health care system should be to preserve as much life as possible – not simply to provide excellence to those who can afford it. And it is to this most important end that the NHS continues to excel in comparison to the American system.
A good demonstration of this is that whilst a woman entering an English hospital to have a baby might have a higher chance of not leaving, a US government report conducted under George W Bush found that if just routine clinical care and social services are offered, women can reduce infant mortality rates by a half to a third. This basic care is offered in the UK, by default, and things should remain that way. As is so often asserted, prevention is far more effective than treatment and by providing universal healthcare no one in this country skips vital treatment, vaccinations or check ups simply because they can’t afford it. This is why, even if sadly our hospitals perform comparably poorly; our health care system is still better. More live are saved and less money spent overall. (According to sums done by ‘Liberal conspiracy’ blog the US spends 15% of GDP on health care annually, we spend just 8%. So humanity and morality aside, a free market does not even create economic efficiency in this particular ‘industry.’)6
In the Channel 4 report, the viewer was taken to the Mayo Clinic Hospital, one of the best hospital in the world, where a doctor explained that the success of his hospital was due to putting, “the needs of the patient first.” The simple fact that he had to clarify this, that profits and payment did not rule, is telling enough. It seems obvious to me that America should have many of the very best hospitals in the world – it has a market system creating a pyramid of excellence with a few truly exceptional institutions at the top and others providing more affordable care of differing standards to those lover down. Not to mention that America is also the wealthiest of the large developed nations. To compare English hospitals to those in one of the richest yet unequal societies on earth is to miss the very point. It would be great to have the best hospitals in the world, but it’s even better to have a universal health services that can save as many lives as it can, regardless of who the patients are.
I haven’t been secretly collecting data for a decade like Professor Jarman, but I’d also like to make the logically valid point that maybe part of the reason more people die in English hospital is because more dying people end up in our hospital here. Unlike in America where, as Jeremy Hunt put it on a recent live broadcast, “they have a long tradition of letting people die at home.” This might be because they are one of the 31million American who completely lack health insurance, or even more tragically, because the crippling worry about the financial burden to be left of the shoulders of their loved ones – consider the plot of Breaking Bad had it occurred in any civilised nation but the U.S.
We’ve seen this government allow universities to set their fees up to a staggering £9000 a year. This has undermined the meritocratic values the right so vehemently professes to uphold – the best universities will now start filling up with those who can afford it, not those with the best grades. Further damage to the health care system could create an injustice even more ugly. If we go the American way not only opportunities, but people people’s very survival, will depend on their financial status within this market economy. Our health care system is necessarily inferior, but remains the moral superior. In spite of Channel 4’s harrowing and sensational report, I won’t be leaving the country any time soon.