Lies, damned lies, and electioneering statistics: privatising the NHS

Now the election campaign is in full swing, there has been a sharp rise in questionable statistics used in public discourse. This is distressing, as there is a risk people vote on the basis of misinformation. It seems that by using the same bogus assertions repeatedly, politicians of all stripes are able to eventually change the ‘facts’. The debate around the NHS has been the most dishonest. “Reverse the tide of privatisation in our NHS”

There has NOT been a tide of privatisation in our NHS. Privatisation if the process of transferring ownership of an organisation from government to the private sector. No shares have been issued in the NHS, nor distributed as vouchers to citizens. The NHS remains publically owned and funded, resources have grown in terms of real cash and people, and services are free at the point of the use. They must still provide services to all, whilst a ‘privatised’ company could choose to only serve those who pay.

Outsourcing isn’t privatisation, and is slowing

The government has encouraged competitive tendering of services, and outsourcing has increased, but only from 4.4% under Labour to under 6% with the Coalition. The rate of outsourcing has actually slowed under the Coalition. Regardless, outsourcing isn’t privatisation, maintains free at the point of use access, and can result in better services.

What about Hinchingbrooke Hospital?

Hinchingbrooke Hospital is the closest example to privatisation, as it is now run (though not owned) by a private company. The tender process for the hospital happened in October 2009, under Labour, further exposing their hypocrisy. Regardless, its core assets are publicly owned, and it still delivers NHS services free at the point of use.

An honest debate would consider alternative models that would improve services 

As an aside, it’s worth noting that Hinchingbrooke has gone from one of the worst ranked hospitals, on the verge of shutdown, to one of the best for patient happiness and waiting times.

A proper discourse on health care would focus on ways to improve the quality. We should examine the merits of private (profit and non-profit) providers, rather than being blocked by ideological labelling. We should explore how alternative models that don’t reply on as much government management, like in Germany or Singapore, could deliver better services for all.

Miliband's attack on profit is an attack on patients

Either Ed Miliband is struggling to understand the basics or his ideology is spiralling out of control. The latest Labour pledge:

Labour would cap the amount of profit private firms can make from the NHS, Ed Miliband will say as he launches the party's election campaign.

He will pledge to halt the "drive to privatisation" he claims has taken place in the health service since 2010.

The future of the NHS is "on the ballot paper" and only Labour can guarantee the funding it needs, he will say.

Under his plans, private firms will have to reimburse the NHS if they exceed a 5% profit cap on contracts.

Companies make profit by keeping costs as low as possible while producing a product or service that people want (and ideally choose) to consume. Apologies for the simplicity, but apparently Ed needs it.

Pledging to fix levels of profit that a company can make ruins any motivation for the company to bring costs down. Given the NHS’s current financial situation, Miliband should not be so quick to toss aside the importance of efficiency gains.

Nor should he be ignorant of private firm’s impacts on patient outcomes.

Private firms are hardly private when working for the NHS; they are still under the jurisdiction of NHS bureaucracy and are often dependent on public funds for their operations. But where private firms and independent sector treatment centres do differ from the public sector is in their record on patient outcomes. Research from 2011 showed that ISTC surgery patients are healthier and experience less severe recovery conditions than patients undergoing the same surgeries with NHS providers.

Furthermore, Circle's management of Hitchingbrooke Hospital turned a failing trust into one of the highest ranked hospitals for patient happiness and cut waiting times drastically; their recent failings were not a result of bad healthcare but rather bad business.

One of the reasons Circle reneged on its government contract is because it’s a struggle to make efficiency gains under NHS regulations as they currently exist; if Labour gets its way, this will become nearly impossible.

Miliband's attack on privatization and profit is an ideological attack on buzzwords; unfortunately, his crackdown could have real affects on patient outcomes.

Economic Nonsense: 33. Things like healthcare and education are too important to be privately provided

Healthcare and education are not only important; they are vital.  Most of us would prefer to live in a society that so organized itself that these services were accessible to all its citizens.  This is not, however, the same as saying that they should be produced and delivered by the state.  

When the state goes into the mass production of services it tends to put them into the political domain, where they can be influenced by ideological or interest groups.  Politicians can manipulate them to secure electoral advantage.  They can be effectively captured by producer groups such as teachers' or healthcare workers' unions, to the detriment the citizens who consume them and the taxpayers who fund them.

When the state does mass-produce services, they tend to be standardized.  It is easier to have a one-size-fits-all output than one that caters for individual preferences and allows a variety of choices.  The private sector, by contrast, tends to find different niches being filled by a variety of producers, allowing consumers to choose the level and quality that suits them.

The state can fund education without producing it by giving people vouchers to cover the education of their child, or by routing the funding to the school of their choice, as is done in Sweden.  This leaves the schools independent and in control of the education they offer.  Healthcare can similarly be financed through insurance or refunds, without the state having to own hospitals and employ nurses.  Again, countries that do this tend to have more variety and choice.

Education in state-run comprehensive schools is not very good.  There are some good ones, but a great number that fail their parents and children by leaving them ill-equipped for life.  Healthcare in state-run hospitals varies hugely in quality, with recurrent exposés of inadequate care or neglect. 

Funding for state-produced schooling and healthcare depends on what politicians think taxpayers will tolerate.  Their output does not depend on what customers want.  Far from being too important to be privately provided, healthcare and education are too important to be publicly provided.

Nationalising the railways might be popular but perhaps not for the reason people think

Owen Jones tells us that Labour should, to beat the Greens, announce some really popular policy like re-nationalising the railways. And this might well be popular but perhaps not for the reason that people are assuming:

But there are three clear commitments Labour could offer to win over Green defectors. First, renationalise the railways. It would cut through like few other policies, and probably prompt some voters to break out in spontaneous applause. Polling demonstrates a publicly owned railway has near-universal appeal, winning over well-heeled Tory commuters and Ukip voters alike. But it also has a totemic quality about it: a clear demonstration that Labour has taken a decisive stance against the untrammelled market in the era of market failure.

The real complaint, we feel, about the railways is not over who owns and or runs them. It's over the price of them.

It's common enough to see people complaining that UK ticket prices are among the highest in Europe. And they are, as a result of a deliberate political decision. More of the revenue to keep them running comes from ticket prices and less from direct subsidy than in most other countries. And that's the correct decision too. There's Britons who don't use a train from one decade to another: difficult to see why they should be taxed to provide cheaper transport for others.

And that's why nationalisation won't make much difference. Because doing so isn't going to reverse that decision that, by and large, people who use trains are the people who should pay to keep trains running. The only way ticket prices will come down is if the taxpayer gets dunned for it. And why should we?

Hinchingbrooke Hospital isn't an example of bad privatisation; just an example of bad business

The first private healthcare provider to take over an NHS hospital just over three years ago is pulling out of its contract today, claiming it is “‘no longer sustainable under current terms’ because of rising demand and falling funding.” You can picture the foam forming around the mouths of hungry public-sector supporters and Burnhamites; in this ultimate battle to keep UK healthcare not only free at the point of use, but in public sector control, they’ve been craving a golden piece of evidence against the private-sector.

But Circle's contract termination isn't quite that.

Circle’s involvement with Hinchingbrooke Hospital is far from a traditional private sector model. Hinchingbrooke did not become a private hospital, but rather a privately managed hospital, that was still under the jurisdiction of NHS bureaucracy and, more importantly, dependent on public funds for its operations. Furthermore, there was nothing particularly competitive about the market, and while Circle did have an incentive to make some profit if it made a surplus, not much of its own money was at risk.

Circle’s contract with the government dictated that the hospital would be supported with public funds, give or take up to £5m worth of payments from Circle if public funds weren’t sufficient to provide necessary support for Hinchingbrooke.

Within a few years of taking over Hinchingbrooke Hospital, Circle Holdings took a failing hospital that “consistently ranked near the bottom of the 46 trusts for waiting times” – and that would have been shut down if it hadn’t been sold – and turned it into “one of the highest (ranked hospitals) for patient happiness”. Circle also corrected waiting time failures, leading the hospital to “(top) the list for short waiting times, seeing 98.2 per cent of patients within the required window”.

From ASI Fellow, Tim Evans:

Circle massively improved this hospital and the government should now do two things – 1. Recognise what a good job they have done and re-negotiate the contract to keep them on board - barring another company taking it over. 2. The government should announce that is wants more - not less - private and employee ownership of hospitals, clinics and other care facilities.

It is definitely the case that Circle brought to the table a much better management system and improved healthcare significantly for the hospital's patients. But these triumphs for both the hospital and its patients didn’t necessarily reflect a sensible business strategy. In fact, choosing to muddy the waters between public and private care under NHS supervision was a risky decision indeed.

From the ASI’s Dr Eamonn Butler:

I was very surprised that any private firm took on an NHS hospital. I spoke to private providers throughout the 90s and they all rejected the idea. An existing hospital comes with current buildings, equipment, procedures, personnel and above all culture. In schools a new head teacher can turn around a school, though there will be a lot of redundancies and redeployments along the way. In the NHS that is even more unthinkable, given the strength of the employee unions, including the doctors' trade unions, and the ease with which any changes can be dramatised as 'cuts'.

“Hinchingbrooke’s funding has been cut 10.1pc this financial year”, and having already spent £4.84m of the required £5m of its own funds, Circle claims it can no longer run the hospital in a successful, effective way.

More from Eamonn:

What we need is more private, voluntary or charitable groups providing healthcare services on their own terms, in facilities that they themselves create and with staff that they pick by hand because of their skill, dedication and commitment to the enterprise.

Circle’s improvements to Hinchingbrooke Hospital should not go overlooked, and the Circle experiment should not be dubbed an example of private healthcare gone awry. Real privatisation puts the risk and responsibility on healthcare providers and those who hold equity - ideally including doctors, nurses, and hospital staff members - and then allows for public choice to dictate the winners and losers in the field. It's not backed up or heavily regulated by public funds.

If Circle's experiment has shown us anything, it's that private healthcare providers need more stake and control in their endeavours to produce good results.

More from Tim:

We have to move to 100% independent provision of hospitals through genuine ownership and property - not time bound and counterproductive government contracts.

In reality, Circle’s flirtation with public healthcare was not an experiment in the privatisation of the NHS, but rather an experiment to determine if public funds and oversight were compatible with private sector management. And in the case of healthcare, it looks to be a bust.

Bad arguments against selling the government's stake in Eurostar

The same bad arguments crop up again and again in political debates. The government is now looking, as it planned in the 2013 Autumn Statement, to sell off its 40% stake in Eurostar, for about £300m, as part of a general plan to get £20bn from privatising assets. In response, one popular argument is that the government is throwing away an asset, part of the 'family silver' that generates a few million quid each year for the exchequer.

But as I have repeatedly argued, this makes no sense. Instead of holding £300m in railway shares it can pay down debt, earning (approximately) the same risk-adjusted return. Even if they gave it away, they could just tax the returns from the private sector. As I said before:

A firm, in doing business, puts capital to use. It uses a mix of physical and human capital and devotes it toward achieving tasks in order, usually, to turn a profit. From this capital you get a return. Train Operating Company margins average about 4% over the last ten years. The average company got more like 10%. FTSE100 companies seem to enjoy higher returns. Of course, operating profits are not share returns, but they tell more or less the same story. The extra couple dozen billion the government would need to spend on trains could equally be spent on equities or anywhere else for more or less the same risk-adjusted return. The return they got here could be put into trains.

If the government returns that couple dozen billion to the population at large, the government can tax the income that the private citizens make on the wealth, at a glance dealing with the problems of governments holding wealth—principally: they are not very good at picking winners. Or they could pay off debt and reduce their repayment costs—since the risk-adjusted return of gilts is priced in just the same way as other assets.

This is just a general application of the problem of government's holding assets, which I have written about at length:

So maybe the government should hold some wealth, I can see the arguments for and I can imagine some arguments against. But if it holds wealth it ought hold assets as broadly as possible: because it’s not placed to take gambles on particular assets; because doing so may distort markets directly; because holding assets takes them off the market and reduces allocative efficiency; and because holding particular assets may distort the incentives facing policymakers. Thus we should praise Gordon Brown for selling off gold just as we should praise Vince Cable and George Osborne for selling off the Royal Mail.

To be fair, in this case the French & Belgian state stakes are going to stop this 'privatisation' leading to big allocative efficiency gains, but these widely-made arguments are still extremely unconvincing.

What would we consider a successful railway system?

Under many measures, the railways have performed remarkably since privatisation. It is not surprising that the British public would nevertheless like to renationalise them, given how ignorant we know they are, but it's at least slightly surprising that large sections of the intelligentsia seem to agree.

Last year I wrote a very short piece on the issue, pointing out the basic facts: the UK has had two eras of private railways, both extremely successful, and a long period of extremely unsuccessful state control. Franchising probably isn't the ideal way of running the rail system privately, but it seems like even a relatively bad private system outperforms the state.

Short history: approximately free market in rail until 1913, built mainly with private capital. Government control/direction during the war. Government decides the railways aren't making enough profit in 1923 and reorganises them into bigger regional monopolies. These aren't very successful (in a very difficult macro environment) so it nationalises them—along with everything else—in the late 1940s.

By the 1960s the government runs railways into the ground to the point it essentially needs to destroy or mothball half the network. Government re-privatises the railways in 1995—at this point passenger journeys have reached half the level they were at in 1913. Within 15 years they've made back the ground lost in the previous eighty.

But maybe it's not privatisation that led to this growth. Let's consider some alternative hypotheses:

Was it a big rise in the cost of driving?

Was it the big rise in GDP over the period that did it?

Was it just something that was happening around the developed world?

Was it purely down to extra cash injections from the state?

Has it come at the expense of safety?

Has it come at the expense of customer satisfaction?

Has it come at the expense of freight?

Is it all driven by London?