Why is Public Health Care Always Best?


My name is Alex Scott-Samuel. I’m an honorary Professor in the Medical School at Durham University here in England, and also a clinical senior lecturer in the Department of Public Health at Liverpool University Medical School.

I’ve been asked to talk to you about health sector reform and let me first make it clear that this is not my main specialist area. My particular interests are health inequity and the so-called social determinants of health; but I do have an interest in health systems and in particular the National Health Service in the UK. And I should make it clear that, as we speak, the national health service is currently being privatized, particularly in England, by the current Conservative led government, and that I’m very strongly opposed to that. I believe that there is a lot of evidence to show that the National Health Service in England and in the UK is the most effective kind of health system in the world.

I know it is quite unusual in having a completely publicly owned and publicly funded health service, but until recently we’ve been lucky enough to have that and I feel very strongly that that is the kind of system towards which all countries should aspire, although politically of course it’s not always realistic. The system that we have is a decentralized system in the sense that there is local provision of family physicians who are known as General Practitioners (GP) so every person in theory has or is able to register with a GP from which they get healthcare free at the time of use. And there is a secondary care system of local hospitals but it is always the GP who is the first port of call and they decide after talking with you and examining you and so on, whether or not you need referral to secondary care or whether they can treat your condition within primary care. And in theory the majority of conditions are treated – obviously not the most serious conditions – but the majority of conditions can be managed within primary care, including of course quite a lot of serious conditions; once they have been reviewed in hospital they can be referred back for long term care by the family physician. So that is the basis of our system here. It’s a National Health Service, completely funded and provided publicly from taxation alone, not from insurance at all, and that I believe is the best kind of system and a movement toward that kind of system would be in the interests of any country.

I should point out though that having said we have decentralized care I don’t believe in complete decentralization of management, particularly in terms of quality and funding. I think in order to maintain the highest standards of clinical quality those need to be laid down centrally and as you may know we have a body called NICE, the National Institute for Health and Care Excellence, which lays down standards, based on the global evidence base, on how healthcare should be carried out by doctors and other health practitioners locally so they have to follow NICE guidelines. And NICE has published a large amount of clinical guidelines and I think that system is an excellent system and one to which all countries should aspire. In other words, local provision of services but with national standards carefully regulated, and centrally defined national standards of care quality.

I also believe that funding needs to be regulated from the center so that there is adequate funding in all parts of the country including disadvantaged and less attractive parts, so that high quality care is available to all people. Obviously there does need to be room for variation locally, but the maintenance of adequate funding and care quality standards from the center, I do think, is crucially important. I understand that you have a history of centralization and clearly that can make it difficult when decentralized family medicine is being provided and obviously to some extent that is a political matter but what I would say is the health service should not be totally controlled by politicians; ideally there should be some separation of the quality standards of health care from the political machinery so that clear standards can be laid down by professionals rather than political staff.

I understand you are also developing public-private partnerships and I have to say my experience and understanding of the international evidence is that private medicine is not a good thing and I think it is quite obvious why. The main purpose of private medicine or any other private sector activity is of course profit for the shareholders of that activity and that is perfectly legitimate. But clearly it is in direct conflict with the quality of health care which can be provided, which clearly needs an optimum number of staff paid at good levels of pay and conditions of service and so on. And the tendency of the private sector is to cut back on the quality of care in order to make greater profit for its shareholders. It’s understandable because that’s what the private sector is for, but it’s not the best way to provide health care, so if you have to have public-private partnerships what I would say is that you need to do the best you can in order to control the private elements of those partnerships so that it doesn’t interfere with the standards of care.

The other thing that I was asked to talk about is choice and rights, and choice is a word that’s used in many different ways and my belief, as I have said, is that the evidence demonstrates that if high quality care is provided by primary family doctors and secondary hospital doctors, if that is the main element of health care, then some degree of choice of course is a good thing. So, for example if you are a woman you may prefer to be seen by a woman doctor just to give that as one example. And some people prefer a doctor who comes from their own ethnicity or social class. I’m not sure that that’s a good thing. I think all doctors should be able to treat all patients but a degree of choice is, as I say, sometimes a good thing; but what I don’t think is necessary is a choice of hospitals in the same way we choose which supermarket to buy our food in. What I believe strongly is the quality of health care should be so closely regulated that there’s no space for hospitals to provide poor quality care. In other words, you don’t need to shop around and choose between hospitals. It’s important that there should be central regulation of standards so that all local hospitals and all local family physicians are providing high quality health care. So the choice is, if you like, reduced to a minimum but because of the uniformly high quality of care – not in order to restrict the quality of care which you receive. These uniformly  high standards that I refer to are obviously ideal aspirations.

I accept entirely it’s not always possible to achieve the highest standards. But, I hope I’ve made it clear to you that that’s how I think Iran should proceed. It should aspire towards the kind of service I’ve described and if you do that hopefully you will get good quality health services.

Goodbye – and good luck!

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