The year ahead in 2016: Healthcare and the PPPs

‘Public-private partnerships will be good for the entrepreneur but less convincingly so for the public’ - Dr Mario Tabone-Vassallo, consultant in A&E medicine

Inking a deal for the healthcare PPP at St Luke’s and Gozo General Hospital, where Barts school of medicine will host a medicine degree that will also use state health resources
Inking a deal for the healthcare PPP at St Luke’s and Gozo General Hospital, where Barts school of medicine will host a medicine degree that will also use state health resources

Much hot air is spewed out about the putative benefits of a private system or a private public partnership, as opposed to a public system. The claim that a public-private partnership would be more caring, more effective and more efficient than a public health service in the delivery of health care to the masses, is a canard easily disposed of.

Were private enterprise capable of both improving delivery of the three above requirements in addition to financial profit for investors, without costing more, it would be proof that a government is incapable of administering the health service. 

This is because the public health service would only be expected to achieve identical results without the added burden of generating a profit. Hence it should cost less and be easier to achieve.

I recently grieved when an elderly, English friend had his simple operation for a cancer of the colon cancelled at the last minute, at least five times to my knowledge, in a private hospital in London. This was because of a lack of intensive care beds. He was kept in the said hospital, imprisoned in his small room, for three months. He was only ‘freed’ the day his insurance cover was about to be exceeded.

He was told that his operation took five hours and needed five surgeons. This rather surprised me, since it was what I would have done within an hour, skin to skin as we are wont to say, with the assistance of just a junior doctor. He had been told that he would not have needed a colostomy but ended having one, despite the many scans he already had done elsewhere, having been repeated preoperatively. This all happened at a self proclaimed, ‘private’ centre of excellence, a world leader.

Of course, the most cost-effective treatment of many significant diseases or injuries would be a bullet between the eyes of the sufferer. Most patients, even if they recover well and return to employment, never really generate enough profit to make it financially worthwhile for the state to treat them. It is not financially efficient to treat most of those in need.

But we do not want just a financially efficient response to disease or injury, we want an effective and a caring one. 

To my mind, the NHS in Britain is, arguably, the one ‘product’ that most gives Britain a claim to fame. Being a product of humans, it was, of course, never perfect. But it was certainly better before they started meddling with it. With the maximum part-time contract, consultants had to offer most of their time to the NHS but were allowed some private practice. A very few abused it.

The powers that be thought of having private beds in NHS hospitals, aiming to keep the consultants nearer their NHS patients and also to make money by charging for the private beds. Many felt this made matters worse. What is more, it resulted in the irritant of two classes of patients in the same building. There were various other ‘innovations’. The most recent one was shifting the ‘power’ within the NHS to General Practitioners [GPs].

It has resulted in many stories of agency doctors being paid to do GP work out of hours while GPs pocket the savings. There have been complaints that agency doctors were overstretched, that some of them had difficulties with the language, if not also with the practice of medicine itself. What is certain is that some GPs may be grossing over £250,000 annually when many consultants, even with their private practice in London, do not approach that. That in itself would not matter if the service improved. But unexpected effects suggest otherwise.

For example, some of the smaller agencies may not hold a licence to stock drugs like diamorphine, because the licences would cost the agencies money and eat into their profits. Consequently, when one of such an agency’s doctors is consulted by a patient who needs diamorphine, a prescription would be issued. The relatives of the patient, often one with a terminal illness, would have to rush out at some strange hour to find a pharmacy that stocks the drug. These, particularly out of hours, might be few and far between and the relatives, not to mention the patient, would have to put up with this added distress and delay. To try and counteract this, general practitioners might choose to issue prescriptions for diamorphine before it is actually needed, so that it is bought and kept available, just in case. This would result in more dangerous drugs milling around, contrary to all stated aims.

These putative examples are from countries with a tradition of proven excellence and strict quality control. I dread to contemplate what might happen elsewhere. 

It is a lie to say that a public health service is free. It is paid for by the collected taxes. 

The concept of competition in the delivery of healthcare is insane. This is particularly the case when true competition is virtually inexistent, as in Malta. Auditing is what is needed. The pride of the professional, not to mention the ramifications on a putative private practice sideline, would then ensure the striving for the highest standards possible.

Despite the professed mantra of competition, this is just were it was not introduced; despite the mouse head in the salad. There is an obvious schizophrenic dissociation between what politicians say and what they do. In security and cleaning services the same obtains. Another disaster being assiduously prepared is in the care of the elderly. The farming-off of this service to monopolies or oligo-monopolies, is a disaster in the making, both for the exchequer and those in need of the service.

The prevention of disease most certainly is cheaper, more effective and more caring than its treatment once it is established. 

But what successive governments in Malta have been doing is leeching the life out of the public health service to subsidise the private one. We all read before the last election of very expensive surgical apparatus and instruments being ordered in the public health service and paid for by the public purse, only to be used in the private sector, at times virtually exclusively so. Believe you me, it is worse; this is just the very tip of the iceberg. This is the kind of private public partnership that is most certainly good for the entrepreneur but less convincingly so for the delivery of a good health service to the public.

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