Unless you have spent the last two decades in North Korea or in Josef Fritzl’s basement, you will be familiar with that scene from the opening credits of the Simpsons, where it initially appears as if Maggie Simpson, the toddler, is driving the car. Later, we see that Maggie’s steering wheel is just a toy; the one who is really driving the car is her mother Marge Simpson. Maggie just turns her toy wheel in whichever direction the car is already heading, and believes she is in control.
People who see private healthcare providers as a threat to ‘our NHS’, on the grounds that the NHS is ‘democratically accountable’ while these private firms are not, are in a position very much like Maggie Simpson’s. They, too, are under an illusion of ownership and control. Their logic is simple: As long as the health service is wholly publicly owned, it is ‘our NHS’, because ‘the public’ – that’s us, right? The public, that’s people like you and me, so ‘we’ own the NHS collectively. Outsourcing parts of it to private providers means losing control over them, because these parts would no longer be ‘ours’.
Dear NHS worshippers, sorry to be a killjoy, but look, the NHS is not ‘yours’, and never has been. You have no control over it. You feel like you are in control when you spin your little toy wheel, but try steering the car in any direction other than the one where it is already heading, and see what happens. The ones who really drive the car are the political class and the medical establishment. ‘Democratic accountability’ is a mirage. All it really means is that healthcare managers answer to bureaucrats, who answer to other bureaucrats, who also answer to other bureaucrats, who, after some more detours, answer to some politician. That’s democratic accountability. Feel powerful now?
Accountability through the political system is about the weakest form of accountability one could imagine, and in healthcare it is even weaker than in other areas. We can go to the ballot box every five years or so, but we do not vote specifically on healthcare policies, we vote for jumbo policy packages of which healthcare is but a small part. More importantly, even if healthcare was the decisive issue for an election outcome, it would still only give us control over macro variables. We can vote for a party that credibly promises to deliver the kind of healthcare policy we support, but there is only so much of a connection between those system-level decisions and our actual experience of healthcare delivery on the ground.
Now let’s have a look at the least democratically accountable NHS facility in the country, which is Hinchingbrooke hospital, the only NHS hospital that is wholly operated by a for-profit private company. When that transfer was arranged in 2011 the Guardian issued dire warnings:
‘The government's decision to sign a 10-year contract worth £1bn for an untested private company to manage the heavily indebted Hinchingbrooke hospital really is the triumph of hype over experience. […] The Hinchingbrooke contract is a gamble with high stakes, and with only slim chances of success: yet remarkably it's already being discussed as a model for other struggling trusts. Don't ask for evidence, just go with the private sector hype. That's the future under Lansley's NHS.’
Elsewhere, the same newspaper cited Unison’s head of health policy, Christina McAnea, who feared: ‘Introducing profit into the NHS risks putting patient services under strain. This is a very real fear for patients at Hinchingbrooke hospital. If the company is allowed to expand into the NHS as the government brings in its reforms through the Health and Social Care Bill this, it appears, could put many more patients at risk.’ The paper also cited Valerie Vaz MP of the Health Select Committee, who warned: ‘It is difficult to comprehend how Circle can maintain a proper standard of healthcare while maximising profit; as a company they would have to make a profit, but that can only come if costs are cut – such as a shorter stay in bed to recover, one less nurse. That must compromise patient care.’
In the meantime, Hinchingbrooke, formerly a basket case in terms of both medical and financial performance, has been turned into an award-winning hospital. It is not accountable to us in our role as voters, but it is very much accountable to us as patients. If the company fails to attract patients, it will sink, and lots of people will lose lots of money. That’s the accountability of the marketplace. We don’t drive the car, but we can exit it any time and choose another one with a better driver, and the drivers’ livelihoods depend on our decisions. Down with accountability, long live accountability.
Will the NHS purists now become a little bit less fundamentalist, after the Hinchingbrooke experience? Of course not. They will do everything to prevent the possibility of repeating that success story. (In fact, they have just done that.) That’s what incumbents do. They protect the status quo, because it means protecting the position they have secured for themselves against newcomers and outsiders.
In other sectors, this happens for the usual Public Choice reasons: the beneficiaries of entry barriers are well-informed and coordinated, while the paymasters are busy with other things. Healthcare is different. In healthcare, we are not just passive bystanders in this game. It is worse: We actively support the incumbents in their fight against newcomers, because we think the former are answerable to us, while the latter want to take our toy steering wheel away.
The Simpsons series uses a so-called floating timeline, a device to ensure that the characters don’t age. Therefore, baby Maggie never reaches an age where she would realise that something’s not quite right with her steering wheel. Let’s hope this is where the Maggie Simpson metaphor ceases to be applicable.
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