Much of the political opposition particularly from the left, however, has focused on the proposed extension of market, or private sector, involvement in the delivery of health care. While this must generate concern, placing as it does a market and profit-oriented motivation in to the organisation of health care, it is just one aspect of the fragmentation of the provision of health services that the Tory proposals will bring and there is a real risk that simply opposing private sector health providers operating with the NHS will distract from the more serious dangers that the Tory reforms pose.

The bigger danger in the Tory reforms is alluded to in the comments from the RCGP and BMA, the potential to fragment local health services. One major element of the reform is the abolition of Primary Care Trusts and Strategic Health Authorities and the move to GP commissioning of local health services. This view of commissioning leans heavily towards the idea that commissioning is the purchasing of services from existing providers, and in doing so it fundamentally misses the point about commissioning. Commissioning isn’t simply a clever name for buying health services, it is a term heavily used through public service, particularly in social and health care, to represent a planned approach to the development of the capability to provide services over time as well as the establishment of specific services or service contracts.

This is very different from a purchasing approach to service provision which assumes a wide market of service providers is available from which a selection can be made. Commissioning of public services needs to look at the current, developing and potential needs of a population and then develop service strategies that will enable those needs to be met, often with services that do not currently exist and to which the market is unlikely to respond until demand and funding is proven. In health this is a key role of the PCTs and SHAs and a role which GP consortia will be very ill-suited to perform; 500+ GP consortia will be hard pushed to develop the kind of strategic thinking needed to forecast and develop health services for the next 10 never mind 20 or more years and, given that new health services can take a long time to come to fruition, the need for a strong link to both research and public health and the increasing need for integrated services between primary, secondary and social care broader strategic thinking is more important than ever. It is not enough to simply focus on the availability of existing care paths in a single given locality, to do so can jeopardise health care for the future.

The focus opposition from the left has placed on the Tory desire to open up the NHS to the wider market only deals with one part, potentially just a symptom, of the bigger danger in what the Tories have proposed. Private and independent providers operating within the NHS system are not necessarily the issue. There have been independent or private sector providers working in the NHS delivering patient care since the NHS began. GPs are independent partnerships delivering NHS care under contract to the NHS. The NHS has always ‘contracted out’ general practice. We rarely question the fact that dentists are essentially private practices that take patients under contract with the NHS. The use of independent treatment centres or private hospitals to deliver routine, particularly orthopaedic, surgery in recent years has been one of the major factors in driving down waiting times. Private sector providers have delivered good health care services, provided extra capacity in the health system and have enabled extra investment in new facilities that might not otherwise have been possible. Some innovations in health care, such has mobile diagnostic units have come from private sector providers.

Another accusation levelled at private sector providers is that they have profiteered at the expense of the NHS. In fact, in recent years NHS tariff pricing has meant standardised pricing for procedures between the NHS and the private sector and the private sector’s profit margins have been squeezed quite hard by what the NHS is willing to pay per procedure. The private hospitals make very little money out of operations, virtually all the fee going to the medical staff (particularly the consultants operating in private practice), the hospitals’ revenue predominantly coming from what they rather interestingly call ‘hotel services’; the extras that patients might choose during their stay – perhaps one of the reasons early discharge from a private hospital is not a priority.

Well managed and carefully directed, private sector providers can provide a very useful service within an NHS context. We should not be afraid of their involvement or existence. They will always be there as senior doctors preserve their right to operate in private practice as well as through contract with the NHS. The problem with the private and independent providers is that they will respond directly to the expressed and perceived needs in the NHS; they will not necessarily invest in the longer term strategic developments of care services unless it is part of their medium term business strategy. They are also very selective in the care types and services they are interested in providing. Too much service contracted to the private sector may end up with the NHS provision being limited to high cost, high complexity services or long term chronic care debilitating its ability to maintain consistency of service or staff.

The biggest danger, however, is in the break-up of the NHS’s ability to plan adequately for the future and the potential disjoint that could come as a result of the implementation of separate operating structures for primary and secondary care as well as social care with no strategic oversight or coordination.

The separation of public health from the commissioning of health services also makes services targeted at prevention rather than intervention much more difficult and much less likely to occur. The movement of public health to local government at a time when local authorities are facing the biggest cash cuts in funding they have potentially ever seen is a sign that the Tory-led government just doesn’t understand the importance of public health and the importance of coordinating services between social, primary and secondary care. Public health-led strategies around obesity, diabetes and heart disease, for example, also require involvement from other care providers and a more fragmented organisational and operational approach to health, each with different objectives and budget pressures will make coordination and collaborative working much harder. This is not an area where market forces and price competition are going to help anyone, but it is these kind of services that should form and inform the future of our health service.

The Tory vision of the future will make the delivery of an integrated health and care service much more difficult if not impossible to achieve, less likely to succeed and take us back to a health system of haves and have nots and where no-one is adequately planning for the future. Rising waiting lists and rising costs might just be the tip of the iceberg.