The UK NHS funding model: historicalpolitical context

1
The UK NHS funding model historical-political
context
Christoph Lees Founder Member, Doctors for
Reform NHS Consultant
2
Sir William Beveridges vision for health
social care(developed in the darkest years of
WWII)
3
Key UK health political figures since 1940

• Sir Willian Beveridge
• Author of 1942 Beveridge Report on Health
  Social Care ex director of LSE and Liberal
  Politician
• Aneuran Bevan
• Labour Health Minister-founder of NHS, 1948
• Barbara Castle
• Labour Health Minister 1970s-attempted to abolish
  private care in NHS hospitals
• Margaret Thatcher
• Conservative Prime Minister 1979-1990 who
  introduced internal market in NHS and started
  purchaser/provider split with Kenneth Clarke
  (Secretary of State)
• Tony Blair
• Labour Prime Minister 1997-2007 presided over
  marketization of NHS
• Alan Milburn
• Labour health Secretary 1999-2003introduced
  ISTCs
• Alan Johnson
• Present Labour Health Secretary (2007-)

4
Political ideology1970s
HOSPITAL PAY BEDS
1093 As I have said, the Government have never
hidden their intention to separate pay beds from
National Health Service hospitals. It has been
part of our Socialist policy for years. I must
say that I find it a very strange accusation that
we insist on carrying out our own policy. What is
behind our policy? Why has the Labour Party very
deeply adopted this policy of separation? The
reason is that the whole ethic of the National
Health Service is inspired by the principle that
health care should be available to all, free at
the point of use, and that access to treatment
should be on the basis of medical priority alone
and not ability to pay. That has infused our
health service from the word "go".
The Secretary of State for Social Services (Mrs.
Barbara Castle)
http//hansard.millbanksystems.com/commons/1975/ma
y/05/hospital-pay-beds
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1980-1990 Internal market NHS General
Management Purchaser/provider split ECRs
(extra-contractual referrals) NHS trusts GP
fundholding Slow expansion of private
sector Abolished tax relief on private medical
insurance
Margaret Thatcher
6
Dont underestimate the feelings that still arise
in the health debate20 years on from Kenneth
Clarkes tenure as Health Secretary
http//www.wsc.co.uk/component/option,com_fireboar
d/Itemid,35/id,117668/catid,28/func,fb_pdf/
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nomenclature

• ISTC
• Independent Sector Treatment Centre
• PCT
• Primary Care Trust
• Commissions services on behalf of a local
  population
• SHA
• Strategic Health Authority
• 10 in the UK oversee services regulatory and
  public health role co-ordinate DoH initiatives
  facilitates commissioning
• DoH
• Department of Health

8
Nomenclature continued

• Primary care
• General practitioners (GPs)family doctors GPs
  with special interest (GPSIs)
• Secondary care
• General medicine, most elective surgery,
  paediatrics, OBGYN
• Tertiary care
• Neurosurgery, fetal medicine, hepatology
• Supra-regional services
• Transplant, metabolic

9
DoH
NCAA
Clinical freedom
NICE
NPSA
GMC
CHAI
Political Regulatory control
10
Managers
Politicians
Make the rules National health vs individual
health
Implement rules Maintain service within budget
Doctors
Patients
Duty to patient Champion individual care
whats best for me Individual care
11
What do doctors think is wrong?
disenfranchised
disempowered
disenchanted
Stifled by bureaucracy
Over-regulated
the doctor patient relationship suffers
12
The NHS good and bad

• ?
• Bureaucratic
• Expensive
• Stifles innovation
• Little patient choice
• Necessarily limits clinical freedom

• National standards
• National training schemes
• National healthcare coverage
• no quibble cover for devastating and expensive
  health problems

13
Reform The NHS in permanent revolution

• 1963 district general hospitals
• 1974 health authorities
• 1984 area health authorities abolished
• 1988 NHS trusts GP fundholders
• 1997 fundholding abolished
• 2001 NHS regions replaced by strategic health
  authorities
• 2006 Amalgation of SHAs (back to regions!)
• 2006/7 Introduction of tariffs PBR (payment by
  results)
• 2008 Darzi review Polyclinics

Extension numbers change, but its the same
people doing the same jobs!
14
Foundation Trusts supply side reform

• Freedom to develop services
• Local election of hospital boards
• set clinical priorities innovate according to
  local needs
• ? central regulation and monitoring
• Financial
• Ability to borrow up to a set limit agreed by
  Treasury
• Retain budget surpluses
• Retain proceeds from sale of assets

15
A one tier NHS?-uniformity of standards

• Post-code prescribing
• Local provider may be anything from zero to
• Wide variation in access to and provision of
  regional specialist services
• Disparity in access to GP services

16
A one tier NHS?-uniformity of outcomes
in fifty years, health inequalities have widened
not narrowed Alan Milburn, 11th February
2003 people living in more deprived areas who
died of cancer used fewer resources than those in
middle class or affluent areas Wanless, 9.60
Interim Report
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A one tier NHS?-equality of access

• Highest earners
  private insurance or pay cash to
  go privately
• Articulate middle classes
  shop around within the NHS
• Disenfranchised
  in poor areas, poor access
  to information and transport make do

19
Equality No-one should go without high quality
care regardless of income Liberal socialists
Equality No one should get better healthcare
than anyone else Mechanical socialists
20
Choice, access and the private sector

• Expansion of choice to involve private sector
  will energise the NHS into delivering results
• Andrew Lansley (Cobservative Shadow Health
  Secretary), Westminster Hour, June 2004
• NHS current uniformity in provision has failed to
  guarantee equitable access to healthcare
• John Hutton (Labour Health Minister), Westminster
  Hour, June 2004

21
Laws applies his enthusiasm for economic
liberalism in a later essay on health, calling
for the replacement of the National Health
Service by a national health insurance scheme. He
envisages a combination of public, private and
voluntary providers, with people either choosing
to use a state insurance scheme funded by a
health tax on their income or joining an
independent scheme. Such is the status of the NHS
that any criticism of it is seen as near
blasphemous, yet the ideas Laws puts forward
operate in many Western European states which are
every bit as civilised as Britain and which enjoy
better health than we do. Nor is it ridiculous to
ask whether the NHS can continue indefinitely as
it is presently constituted if scientific
innovation continues but people remain no keener
to pay higher taxes to fund the resulting
increased costs. The Liberator 2004
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Money isnt everything

• Scotland spent 1,347 per head of population in
  2001 compared with 1,132 in England
• 20 more doctors per 100,000 pop. in Scotland
• Health outcomes in Scotland worse
• Waiting lists persist
• No patient choice
• The NHS Reforms Evidence so far Civitas, June
  2004

25
Funding increases
The NHS in 2010 reform or bust Prof Nick
Bosanquet, Henry de Zoete, Emily Beuhler. Reform,
December 2005
26
Funding and cost comparison
The NHS in 2010 reform or bust Prof Nick
Bosanquet, Henry de Zoete, Emily Beuhler. Reform,
December 2005
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Political Sustainability of Funding systems
Van den Broek et al. Stockholm Network Impatient
for Change (2004) /Tony Hockley Civitas
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The demand side funding schemes

• Tax Funded from Central Government UK
• Local taxation, local council provision Denmark,
  Sweden
• Private Insurance USA
• Tax private insurance subsidy Australia
• Social Insurance France, Germany, Switzerland
  EU countries
• Medical Savings Accounts (MSAs) public
  Singapore

29
Social Insurance

• Bismarck 1860s
• Socially equitable
• Universal coverage
• The poor have insurance subsidised
• Third party payer is not the Government and has
  no conflict of interest

30
The Swiss system Mandatory personal social
insurance cover Choice of insurer and
provider basic package far better than NHS
provision But 3400 per person!
Health Policy Consensus Group 2002
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Germany
Green D Irvine B, Civitas 2005
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Reform of the benefits catalogue

• choice of insurance coverage and providers
• individuals should be given the opportunity to
  determine the nature and extent of their health
  insurance coverage (as to services covered,
  deductibles, preferred providers, etc.)
• informed consumers need good information and
  consultation
• compulsory health insurance for all Germans
• basic safety net, limited on financially 'high
  risks'
• catalogue to be defined by the government

From Civitas 2005 Dr U Gotting, VFA
33
The role of government
consumers
govern -ment
transfers
diversity of tariffs (based on individual
premiums)
insurer
insurer
insurer
compulsory insurance
diversity of contracts (fees, quantity and
quality of services)
provider
provider
provider
control of competition, antitrust
From Civitas 2005 Dr U Gotting, VFA
34
Lessons from European models

• Government should not be single payer
• Government should not attempt to impose single
  provider
• Avoid compulsory link with employer
• Allow self sufficient people to be price
  conscious
• Provide dependent people with the mechanism for
  price consciousness but guarantee a not obviously
  inferior service

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The Swedish ExperienceStockholm, late 1990s

• Internal market established
• Some services privatised
• Unions initially hostile
• Result
• Far more patient choice
• Swedish nurses salaries increased
• Unions helped members establish franchises!

36
How mixed healthcare funding might work

• Government
• Regulatory framework inspections
• Professional bodies
• Training, professional standards
• Public, not for profit private companies
• Provision of care
• Third party payers (mutuals, private insurers)
• Provide insurance pay providers

37
A possible UK mixed Tax social insurance
private insurance model

• Medium-high earners
• Can buy social insurance
• Or enhanced cover social insurance
• Or opt out and purchase private insurance,
  without penalty

• Low earners, retired, unemployed
• Guaranteed minimum package (social insurance)
• At least equivalent to NHS coverage now
• Premia payed for social insurance on sliding
  scale from tax revenues

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x.will lead to a two-tier service, destabilize
staffing damage the NHS
Where x Foundation Trust Choice Use of the
private sector
39
Private NHS Funding anomalies in the UK The
Doctors for Reform/Sunday Times Co-payment
campaign
40
Department of Health position The Department
has expressed strong opposition to these
payments. Alan Johnson, the Secretary of State
for Health, has said A founding principle of
the NHS enshrined in every single code of
practice most recently the 2003 code of
practice is that someone is either a private
patient or an NHS patient. They can be a private
patient and decide to resume their treatment as
an NHS patient, but they cannot, in one episode
of treatment, be treated on the NHS and then
allowed, as part of the same episode and the same
treatment, to pay money for more drugs (Hansard,
Column 724, 18 December 2007).
41
DfR TOP-UP CAMPAIGN (March 2008) Doctors for
Reform (DfR) launched a campaign to support
patients who have been prevented from making
top-up payments within the NHS. The aim of the
campaign is to set a precedent, by supporting an
individual case to judicial review. Raised a
fighting fund of nearly 40,000 to cover the
costs if a legal case were lost, acting in a
similar way to a legal indemnity broker. DfR
members and legal professionals will offer their
services free of charge to provide the medical
and legal support for the case.
42
Possible legal arguments include The
Departments own guidance (2003) seems to
anticipate that co-payment will occur Except in
emergencies, practitioners should not provide
private patient services that will involve the
use of NHS staff or facilities unless an
undertaking to pay for those facilities has been
obtained from (or on behalf of) the patient
(Department of Health (2003), A code of practice
for private practice). A number of articles in
the Human Right Act 1998 may be construed as to
place an obligation on PCTs to allow
co-payments. The National Health Service Act
2006 enables the Secretary of State to make
available new drugs for patients at a charge
(Section 255 (1)(C)). But also GMC places an
onus on Doctors to advise patients as to
treatments that are in their best interest. So a
Doctor may have a professional duty to act
contrary to DH guidance-this has not been tested.
43
Motion passed at BMA Consultants conference, May
2008
44
NHS Poll CATI Fieldwork May 28th-29th
2008 Absolutes/col percents Table 2 Q2. Suppose
you were diagnosed with a life threatening
medical condition and the most effective
treatment for this condition were not available
via the NHS. Approximately, how much do you think
you would be willing to pay yourself for such a
treatment?
30 would pay over 10K
45
Those that really suffer from not allowing a
mixed funding system are middle and lower income
earners the very wealthy can afford fully
private care. Equity and two tier service
arguments frequently lead to the opposite of
intended effect
46

• The expansion in the role of the private sector
  in provision of care for
• NHS
• and
• (2) fully private patients

47
Expanding capacity-rationale for ISTC programme

• We from the college and specialist associations
  have for the last 10, 12, 15 years been talking
  about separating emergency from elective work.
  Currently some 64 of consultant general surgeons
  are on call for emergencies when they are doing
  elective work. The NHS has to deal with
  emergencies at the same time as it does its
  elective work if you separate elective from
  emergency you will get good treatment.

Mr Bernard Ribeiro, Former President, Royal
College of Surgeons
48
Independent Sector Treatment Centres
(ISTCs) -Rapid throughput high turnover low
complexity day surgical/diagnostic
workload -Facilities financed and run by private
sector companies with minimum length contracts
from local PCTs -Medical staff initially not NHS
(additionality) -Now many NHS consultants
involved -treat NHS patients only with no top
up allowable -not for private patients
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Independent sector treatment centres (ISTCs) the
beginning

• April 2002 DoH announced a programme of NHS
  Treatment Centres to create additional elective
  surgery capacity and relieve pressure on the
  acute sector.
• December 2002 a decision to commission a number
  of independent sector treatment centres (ISTCs)
  to treat NHS patients for relatively simple,
  highvolume surgical procedures. The first ISTC
  began operating in 2003

51
Second phase ISTCs

• March 2005, DoH announced second and substantial
  phase of procurement of additional elective
  surgery and diagnostic capacity from the
  independent sector. This was contentious for a
  number of reasons
• several professional groups had been concerned
  about the quality of care provided by the ISTCs
• doubts as to whether the ISTCs provided value for
  money.
• In January 2006, HoC Health Committee announced
  an inquiry into ISTCs

52
Treatment centres

• July 1999ACAD, Europes first dedicated elective
  treatment centre, opened at Central Middlesex
  Hospital
• April 2002NHS Treatment Centre programme
  announced in Delivering the NHS Plan next steps
  on investment, next steps on reform
• December 2002ISTC programme announced in Growing
  Capacity Independent Sector Diagnosis and
  Treatment Centres
• September 2003first ISTC contracts signed
• October 2003first ISTC opened at Daventry
  (Birkdale Ltd)
• March 2005second phase of ISTCs announced

53
ISTC phase 2

• There has been confusion about the scale and
  nature of Phase 2. When the Secretary of State
  gave oral evidence on 26 April 2006, she told us
  that ITNs had been issued for 12 elective
  schemes, in two tranches, and that responses had
  been received for five of those bids.
• However, the Health Service Journal reported the
  next day that Phase 2 had originally comprised 24
  schemes, of which seven had subsequently been
  scrapped, with only 17 proceeding

54
Goals of phase 1 ISTC

• Increase capacity
• Reduce spot purchase prices in the private
  sector
• Increase choice
• Introduce best practice and innovation and
  diffuse these through the NHS, and through the
  challenge of competition from ISTCs, stimulate
  reform and improve efficiency in the NHS

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1. Increase capacity

• ISTCs have not made a major direct contribution
  to increasing capacity, as the DoH admitted. It
  is far from obvious that the capacity provided by
  the ISTCs was needed in all the areas where
  Phase 1 ISTCs have been built, despite claims by
  the Department that capacity needs were assessed
  locally

56
2. Reduce spot purchase price in the private
sector

• ISTCs have had a significant effect on the spot
  purchase price in the private sector and on
  charges in the private sector more generally.

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3. Increase choice

• ISTCs haveincreased choice, offering more
  locations and earlier treatments. However,
  without information relating to clinical quality,
  patients are not offered an informed choice

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4. Innovation

• ISTCs have embodied good practice and introduced
  innovative techniques, but good practice and
  innovation can also be found in NHS Treatment
  Centres and other parts of the NHS. ISTCs are not
  necessarily more efficient than NHS Treatment
  Centres

59
Innovative partnerships of clinicians have
developed from original ISTC contracts
Circle is Europe's largest partnership of
healthcare professionals. Our purpose is to
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We exclusively focus our efforts on what we are
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our patients. We empower our people to do their
best. We are unrelenting in the pursuit of
excellence.
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60
Through challenge, stimulate reform and
innovation

• The threat of competition from the ISTCs may
  have had a significant effect on the NHS. This
  factor may be the most important contribution
  made by the ISTC programme. However, the evidence
  is largely anecdotal. Waiting lists have declined
  since the introduction of ISTCs, but it is
  unclear how far this has happened because the NHS
  has changed in response to the ISTCs or because
  of additional NHS spending and the intense focus
  placed on waiting list targets over this period.
  We are surprised that the Department has made no
  attempt systematically to assess and quantify the
  effect of competition from ISTCs on the NHS.
  Given its importance, the Department should have
  ensured that this was done from the beginning of
  the ISTC programme in 2003

61
Additionality

• Phase 1 ISTCs were inititally forbidden to
  employ anyone who worked for an NHS secondary
  care organisation, or who had worked for such an
  organisation within the previous six months

The DoHrecognised that the additionality
principle has hindered integration and proposes
to restrict its application. It proposes to allow
NHS consultants to work noncontracted hours in
ISTCs
62

• Additionality has also been seen as having an
  adverse effect on the quality of care Many
  foreigntrained doctors do currently work in the
  NHS and are integral to the workforce. However,
  they have been integrated into the system over a
  long period of time. By contrast, there are
  overseas surgeons employed in ISTCs who have no
  experience of working in the UK or in the NHS.
  They might be unfamiliar with processes within
  the NHS, surgical techniques or equipment, and
  might have language problems. Some surgeons
  working in ISTCs, albeit a decreasing number,
  have come to the UK to work for a weekend or a
  few weeks, and are therefore often unable to
  follow up, or even be aware of, complications

63
Governance complications and quality

• There are examples of poor care in ISTCs, as
  there are in the NHS. However, in the absence of
  the necessary comparable data from both NHS
  Treatment Centres and ISTCs, there is not the
  statistical evidence to suggest that standards
  are different. The Department should have ensured
  that such data were collected from both providers
  and published in order accurately to assess
  quality of care, complication rates and other
  quality measures. We are concerned that currently
  only eight of the 26 KPIs are clinical
  indicators. We welcome the Healthcare
  Commissions review of the quality of care in
  ISTCs which the Chief Medical Officer has
  requested.
• Given the difficulty in making comparisons, we
  are dismayed at the strident and alarmist tone
  of some criticisms of clinical standards in ISTCs
  on the basis of anecdotal evidence, highlighted
  by the BOAs questionable claim that there are
  revision rates of 2.3 in ISTCs

64
ISTCs and training
Even though Phase 1 ISTCs perform a relatively
small number of procedures, there can be a
significant local effect on the training of
junior doctors
65
ISTCs staff pay/benefits

• Private providers do not match the pension
  provision made by the NHS.
• A DoH official explained that NHS providers
  benefited from state aid in a number of ways,
  which put them to some degree at a competitive
  advantage compared to independent providers, and
  staff pension costs was one of these advantages

66
ISTCs-value for money

• In view of the high degree of uncertainty about
  the wider benefits and costs of the ISTC
  programme, we recommend that the (National Audit
  Office) investigate them, in particular the
  extent to which the challenge of ISTCs has led to
  higher productivity in the NHS.

67
Phase 2 ISTCs 2006-

• The DoH has agreed that in Phase 2 there should
  be improvements in respect of
• Integration of ISTCs with the local NHS
• curtailment of additionality
• Training

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conclusion

• concerns that..expansion of the ISTC programme
  will destabilise local NHS trusts, especially
  those with financial deficits. ISTCs should only
  be built
• where there is a local need
• and after consultation with the local health
  community

69
recommendations

• not convinced that ISTCs provide better value
  for money than other options such as
• more NHS Treatment Centres
• greater use of NHS facilities
• outofhours or partnership arrangements

70
The NHS does offer private care in private beds

• Constituted 9.8 of total independent NHS
  private income combined in 2006/2007
• Lowest proportion on record
• Probably related to ISTC programme taking effect
• May be related to greater uptake of private
  insurance

71
Private hospitals

• Not co-located with ISTCs
• Run by private companies and charities
• Some are bidding for ISTC type work
• Though different business model
• Patients referred by GPs (or self refer)
• Patient completely removed from NHS
• bespoke service
• Patient chooses surgeon, where, when operation is
  done
• No upper limit to fees billed
• Though there is upper limit on what insurers will
  pay
• proper market in London-wide variety of charges
  made by consultants and the market will bear this

72
Medical indemnity for private practice

• Provided by medical defence organisations
• Based on net private income specialty
• Ranges from 500 to 47,000
• Payable for doctors in private practice but not
  ISTCs (liability covered by agreement with NHS)

73
UK population covered by private insurance
7.4M
6.9M
3.6M
1M
1960
1980
2000
2007
Lee Donald Associates/ Laing Buisson
74
Why do people in UK access private healthcare?
The industry has to be optimistic following two
years of growth at a time when the UKs public
health service has undoubtedly improved, and
economic growth has started to slow. Private
corporate healthcare cover solutions remain a
strong and growing preference and private medical
insurance for individuals retains many desirable
features that cant be matched by a budget
restricted NHS. After a period of massive
investment, the NHS is highly unlikely to
continue its rate Health Care Cover UK
Market Report 2008. Laing Buisson, 29 Angel
Gate, City Road, London EC1V 2PT. Tel [phone]
9123, www.laingbuisson.co.uk.
75
Consequences to the NHS of having a healthy
private sector

• About 12 of UK population have private health
  insurance/employer schemes (7.4M/pop 60M)
• (Laing Buisson 2008)
• 15-20 of all elective surgery is performed in
  private sector
• Significant saving to NHS as most of these
  patients would be NHS eligible
• New techniques are often adopted from highly
  competitive private sector to the NHS by doctors
  working in both sectors
• Prostatic green-light surgery
• Urgent angioplasty
• Laparoscopic surgery
• Keeps NHS on its toes from clinical/quality
  perspective

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77
Dual practice in the UK

• NHS contract ISTC/G-supps
• Doctor also works in an ISTC
• NHS patients treated in an independent
  facility-contract is between PCT and ISTC
• Doctor makes no fee for service charge
• NHS contract private practice
• Doctor also works in private hospital/clinic
• Patients often eligible for NHS care but pay
  cash or are privately insured

78
Alternatives to dual practice in UK

• Never seriously considered politically
• Existed since inception of NHS for consultants
  (secondary tertiary care) and some NHS GPs
  (primary care)
• Purely pragmatic
• Probably would not have been a feature of a from
  scratch design
• Preserved a degree of medical autonomy
  independence
• Would have met stiff opposition from public and
  profession
• Affects autonomy of patients to choose spend
  their money as they see fit
• Many politicians and advisers have private
  healthcare, as do trades union leaders!
• Would have been seen as anti-competitive and
  negatively impact on patients self determination
• In London, health is significant earner for not
  just healthcare economy (Middle East, Africa)

79
New Consultant Contract 2003 consultants
undertaking private practice

• No bar to NHS consultant performing private work
  elsewhere or (in agreement with NHS) on-site
• According to new consultant contract must however
  offer an extra PA (programmed activity4 hours)
  to the NHS first, taking him from 10 to 11 PAs
  per week
• This was designed to reduce consultants
  defecting wholesale to the private sector
• In effect, hardly any NHS Trusts enforce 11 PA
  rule
• they cant afford to
• there is no need to

80
BMA code of conduct for private practice (March
2006) General principles

• NHS consultants and NHS employing organisations
  should work on a partnership basis to prevent any
  conflict of interest between private practice and
  NHS work. It is also important that NHS
  consultants and NHS organisations minimise the
  risk of any perceived conflicts of interest
  although no consultant should suffer any penalty
  (under the code) simply because of a perception.
  
• the provision of services for private patients
  should not prejudice the interest of NHS patients
  or disrupt NHS services
• with the exception of the need to provide
  emergency care, agreed NHS commitments should
  take precedence over private work and NHS
  facilities, staff and services

http//www.bma.org.uk/ap.nsf/Content/CCSCContractp
rivMS
81
BMA code of conduct for private practice (March
2006) conflict of interest with NHS

• Consultants should declare any private practice,
  which may give rise to any actual or perceived
  conflict of interest, or which is otherwise
  relevant to the practitioners proper performance
  of his/her contractual duties. As part of the
  annual job planning process, consultants should
  disclose details of regular private practice
  commitments, including the timing, location and
  broad type of activity, to facilitate effective
  planning of NHS work and out of hours cover

http//www.bma.org.uk/ap.nsf/Content/CCSCContractp
rivMS
82
BMA code of conduct for private practice (March
2006) Scheduling of work and on-call duties

• 2.3 where there is or could be a conflict of
  interest, programmed NHS commitments should take
  precedence over private work. Consultants should
  ensure thatprivate commitments do not conflict
  with NHS activities included in their NHS job
  plan.
• 2.4 Consultants should ensure in particular
  that- private commitments, including on-call
  duties, are not scheduled during times at which
  they are scheduled to be working for the NHS
• - there are clear arrangements to prevent
  private commitments disrupting NHS commitments,
  e.g. by causing NHS activities to begin late or
  to be cancelled- private commitments are
  rearranged where there is regular disruption of
  this kind to NHS work and- private commitments
  do not prevent them from being able to attend a
  NHS emergency while they are on call for the NHS

http//www.bma.org.uk/ap.nsf/Content/CCSCContractp
rivMS
83
Dual Practiceare there lessons from the UK?
84
Canada is the only nation other than Cuba and
North Korea that bans private health
insurance Wall St Journal 2005 Many Clinics
all across Canada are illegal for profit ABC
News, 2007 Canada remains the only
industrialized country that outlaws privately
financed purchases of core medical
services New York Times 2006 71 of
specialists and 53 of GPs feel funding is
primary impediment to care National Physician
Survey, March 2008
Canada is different...
85
The equity argument-Canada

• The rich by-pass public services and obtain
  private treatment in Canada or the US anyway
• Making everyone suffer the same waiting times
  hasnt improved services by consumer pressure-
  those who can, do find ways of getting around it
• Shouldnt equity be about allowing the lowest
  earners and disenfranchised have access to good
  quality care?

86
Advantages for Doctors and the service removing
the impermeable barrier between public and
private practice would probably increase the
number of procedures carried out, without a need
to invest in more infrastructure. This would also
be a significant retention factor for specialists
who have been trained at great expense in
Quebec's faculties of medicine."
Dual Practice endorsed by the public survey
commissionedin Québec in 2006, 90 of citizens
were in favour of allowing physicians to practise
in both the public and private sectors, as long
as a certain quota of services was maintained in
the public sector.
Mixed public/private provision As far as the
place of the private health sector in the
delivery of health care services is concerned,
the QMA feels that this is desirable as long as
it is clearly defined and would translate into
improved accessibility to services.
Montreal, February 2008
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(No Transcript)
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The legal position in Canada

• Chaoulli and Zeliotis vs Quebec (2005)
• Quebecs prohibition against private health
  insurance for medically necessary laws violated
  the Quebec Charter of Human Rights and Freedoms.
  Chief Justice McLachlin said
• Access to a waiting list is not access to health
  care

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Quebec-Bill 33

• Minister may take measures to allow patients
  access to services (even outside province) if
  waiting time is unreasonable
• Similar to NHS PCTs can refer patients to
  private providers or non local hospitals where
  services are insufficiently responsive
• Procedures may take place in centres outside
  hospitals with doctors either completely opted
  in or opted out
• Sounds like ISTCs
• Provision to stop doctors opting out
• If this is happening, then there must be a
  serious imbalance between the sectors that needs
  to be remedied rather than stopping doctors opt
  out
• Limited expansion of private insurance to
  previously core areas
• Procedures must then be undertaken by fully
  opted out Doctors. Why not allow all core areas
  to be covered?

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UK Dual practice compared for patients
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UK Dual practice compared for doctors
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Key dangers of introducing dual practice-an
outsiders view

• May impact negatively on public-funded capacity
  as doctors only provide private procedures
• Drive up costs
• Exodus of doctors to private sector
• May introduce perverse financial incentives to
  public sector

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Key dangers of introducing dual practice-an
outsiders view

• May impact negatively on public-funded capacity
  as doctors only provide private procedures
• Unlikely if Provinces fund/commission small
  number of public only centres to prevent
  cartel/monopoly developing develop services
• Doctors will want reputation from public practice
  to drive private practice
• Drive up costs
• Unlikely more capacity in public and private
  sectors will probably drive down costs and
  increase competitiveness (as long as monopoly
  doesnt develop-see above)
• Exodus of doctors to private sector
• Unlikely most doctors will want to be employed
  in both sectors
• May introduce perverse financial incentives to
  public sector
• Unlikely if robust codes of conduct in place with
  disciplinary sanction

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Key advantages of introducing dual practice

• Likely to drive down costs drive up efficiency
  in both sectors
• Doctors may be more willing to remain in public
  sector if they can supplement income in private
  sector
• Where shortage of doctors and resources exist,
  encourages maximising use (sweating) of staff
  and resources
• Will improve choice for patients and increase
  private/personal component of health funding
• Minimal effect on taxes
• Will reduce pressure on public sector