Morality not markets: a manifesto for the NHS; Response to Pollock, Frith, and Cox.

We would like to thank Pollock (1), Frith (2) and Cox (3) for their interesting analyses and suggestions on our article “Morality and markets in the NHS”. A number of important themes arise: the lack of either practicality or morality of a healthcare market or privatisation; the need for values to be supported (where possible) by legislation; and the crucial importance of humanity and compassion in healthcare. Healthcare will be a key issue in the upcoming UK general election. Practitioners frequently distance themselves from politics, concentrating instead on their primary duty to individual patients. However, it is increasingly relevant that the doctors of 2015 recognise their duty to society, as well as to the individual. From the advent of General Practitioner (GP) fundholding in the 1990s to the latest Clinical Commissioning Groups, rationing by healthcare professionals on behalf of the government has become more explicit. In balancing their duties to individuals, communities and society, doctors should be encouraged to speak out about issues that influence patient care. This should not be confined to whistleblowing, but should include engagement in the broader political process. The need for doctors to speak out in this way is heightened by what Allyson Pollock describes as the “managed decline” of the National Health Service (NHS). As she reiterates, “The NHS will last as long as there are folk left with the faith to fight for it”. Despite continual frustrations with the political process, doctors, amongst others, are well-placed to understand many of these issues and to defend the NHS. We applaud Pollock for making an explicitly political response to our article. If universal healthcare is to remain, it should be enshrined in law, which would require reinstatement of the legal obligation placed on the Secretary of State to provide healthcare, either through repeal of the Health and Social Care Act or through new or revised legislation which reinstates this fundamental principal of responsibility. Pollock emphasises the importance of what is set in law and statute as being the framework from which everything else is derived. This principle can be applied to Frith’s comments about the NHS Constitution. In response to our suggestion of a valuesexplicit approach, Frith suggests that this already exists, at least theoretically, in the form of the NHS Constitution. The Constitution reiterates the intended purposes of the *Correspondence to: Barnabas J Gilbert, Email: [email protected] Copyright: © 2015 by Kerman University of Medical Sciences Citation: Clarke E, Leaver L, Gilbert BJ. Morality not markets: a manifesto for the NHS; Response to Pollock, Frith, and Cox. Int J Health Policy Manag 2015; 4: 327-328. doi: 10.15171/ijhpm.2015.78 Received: 20 March 2015, Accepted: 3 April 2015, ePublished: 4 April 2015 NHS, as a publicly accountable, comprehensive service available to all according to need, and makes explicit its values and commitments. However, Frith asks: “How useful is the Constitution in practice? How is compliance with the Constitution to be policed?...What does ‘have regard’ to the constitution actually mean...?” (1). One could also question the extent to which the NHS Constitution succeeds in placing reciprocal responsibilities on the public to make best use of the NHS (or to defend it). The Health and Social Care Act was passed without a mandate, described by Pollock as “lacking in any meaningful [public] consultation”. This undermines the central message of the NHS Constitution, that “the NHS belongs to us all” (4). The duty to “have regard” for the NHS Constitution, which was set out in the Health Act 2009 and extended by the Health and Social Care Act in 2012, has clearly been flouted, damaging the utility of the NHS Constitution. As we have touched upon, the Act further undermined the Constitution by removing the obligation of nationwide healthcare provision by the Secretary of State, which may further increase inequalities in provision. We agree that repeal of the Health and Social Care Act may help to enshrine morality in law, as proposed by Pollock, and would also improve congruence between the message of the Constitution thrown into question by Frith and the values underlying the operation of the NHS. In practice, owing in part to the nuances of the political process and in part to a desire to uphold important and positive aspects of this legislation (for example, greater involvement of clinicians in decisions about local commissioning, and an attempt to improve integration between health and social services), new or revised legislation may be a more likely and sustainable outcome. All three authors agree that there are “moral limits of markets” (5) and that their application to healthcare is ethically wrong. Frith highlights twin forces at play, both of which are exacerbated by the Health and Social Care Act – the use of market forces and privatisation. She explores the profound ethical implications of the latter, using the example of the privately run Hinchingbrooke Hospital. She emphasises that patient care is threatened both by conflicts of interest and by a lack of long-term accountability within the private sector. In addition, both Pollock and Frith highlight practical problems that stem from the use of markets in healthcare, including detrimental effects on cost effectiveness, inequality of provision and fragmentation of services. Frith explains that the principal justification for a healthcare market, namely its ability to drive up quality while reducing costs, is misconstrued, and Pollock agrees that healthcare markets