Chris Lancelot: Public and private - not a case of good and bad

I do wish people would think more deeply. Many have been brainwashed into believing that, in healthcare, 'NHS' means 'good' and 'private' implies 'bad', 'selfish' or 'profiteering'. Even doctors who rightly believe in evidence-based medicine appear to have swallowed this assumption whole.

The GP Record, by Fran Orford
The GP Record, by Fran Orford

There is a myth abroad of 'the noble NHS doctor' and 'the dedicated nurse', working for nothing but the good of their patients. Applied to such people 'profit' is clearly a dirty word, which sullies their heroic status.

And it's all a fairy story. We all work for profit - because we've all got to eat. Whether we work for the NHS, for a private company, or as independent contractors, we all work to make money. But aren't private companies a drain on the public purse, set up to make a profit from the taxpayer? Don't they waste money by comparison with the NHS?

Not necessarily. As the economist Milton Friedman has pointed out, when spending money, the less directly we are involved the less care we take. If we spend our own money on ourselves we take great trouble to purchase exactly the right thing at the right price. When spending our own money on a friend (say, for a present) we usually spend less time choosing. And if we spend someone else's money on a third party, our level of concern diminishes even further.

Public organisations fall into Friedman's third category. Their individual managers don't benefit from spending public resources carefully. Instead, their only possible gain is to their ego: the one who can create the biggest empire or hold the largest budget wins. No wonder large public ventures frequently overspend and underperform.

This is why the central NHS is so frequently overmanaged, overspent and inefficient. Conversely, it's also why primary care has long been recognised as the most efficient area of the NHS - because as independent contractors we benefit personally and financially when we deliver more care, more cost-effectively.

'Public' may mean 'non-profit-making' - but it can also mean 'inefficient' and 'wasteful'. Indeed, in some areas of healthcare 'private' may be a more economical user of resources than 'public' ever was. This is where the mantra of 'public is good, private is bad' disintegrates.

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