The British government's increasing reliance on private sector involvement in the NHS is the subject of heated debate, as the once-proud service faces an uncertain future, writes Ben Quinn, in London
For some, Nigel Lawson wasn't far off the mark when he described Britain's health service, the NHS, as "the national religion".
In a nutshell, the then chancellor for the exchequer had captured the iconic status of an institution, founded in 1948, to provide state-sponsored care "from the cradle to the grave".
Lately however, the troubled service has increasingly taken on an additional new role - that of a political football, with Britain's two leading political parties claiming to be its saviour.
The latest round was last week's budget, when the current chancellor, Gordon Brown, announced that the NHS in England will get an extra £8 billion sterling over the coming year.
Describing the move as the service's biggest cash increase ever, Brown went on to outline how extra health spending for the whole of the UK is to rise by £10 billion.
Only days earlier, Conservative leader David Cameron continued to stake his party's claim to be the true protectors of the NHS, accusing Labour of ripping the heart out of the service and turning it into a "vast inhuman machine and pen-pushers' paradise".
Britons once drew immense pride from the system, confident in the knowledge that theirs was a system in which, as one commentator put it, "the judge and the janitor could have beds on the same ward, and receive the same standard of care".
Recent decades have been marked by a period of radical change, when, depending on one's political perspective, the NHS has either benefited from badly needed reform or suffered from being fragmented into hundreds of competing entities, as a result of creeping privatisation.
Critics of the increasing role played by the private sector charge successive Labour and Conservative governments with creating a situation where healthcare is moving at a fast pace back towards being a commodity, rather than a right.
On the other side of the ideological divide, the private sector is looked upon as a means of delivering and managing services efficiently, saving costs as well as offering "patient choice".
But amid the political battles, the NHS debate continues to offer valuable lessons for Ireland, itself at a crossroads of sorts in terms of what model of healthcare system it wants for the 21st century.
Just last week, a glimpse of what the future might hold for Irish healthcare users was provided by the announcement in Britain that retailers, such as Tesco and Boots, will be invited to lodge bids to open GP surgeries at stores in areas where doctor numbers are low.
In the meantime, many of the challenges for Britain and Ireland's health services are the same, combating the spread of MRSA being one such challenge.
Others are more specific to one country or the other, the problems surrounding the NHS "deficit" being perhaps one of the most crucial.
At its centre are NHS trusts - public corporations that receive government funding to provide healthcare services, but are required to break even at the end of the financial year, when their budgets must not show a deficit.
NHS accounts recently showed that a third of NHS trusts were forecasting deficits totalling almost £1.2 billion, a revelation that prompted the health secretary, Patricia Hewitt, to promise last year that she will resign if the NHS in England does not break even financially by this month.
Against a backdrop of continuing job cuts and departmental closures across the country, headlines now talk of a health service "cash crisis", while discontent among health workers has reached a level not seen since Margaret Thatcher's premiership, with protests by doctors, nurses and support now a regular occurrence.
Many condemn the government's increasing reliance on private involvement and, in particular, on Private Finance Initiative (PFI) schemes, which use private funds to build new hospitals.
For some, PFIs go to the heart of the current ills in the NHS, a concern with particular relevance to the Irish experience, given the fact that the State's capital budget for the health service this year includes a provision for investment by the private sector.
In the UK, the intellectual case for such arrangements have been widely discredited since at least 2000, according to Allyson Pollock, head of the Centre for International Public Health Policy at the University of Edinburgh and a fierce critic of PFI schemes.
In England, where private consortia have raised money on the government's behalf in return for contracts to design, build and operate hospitals, responsibility for paying back the debt, interest and shareholders' profits has rested not with the government but with individual hospitals, which must pay for them out of out their annual budget for patient care.
Pollock asserts that PFIs have proved to be more expensive than normal governmental procurement because the private sector cannot borrow as cheaply as the government can, while consortia involved in the schemes must generate profits and pay dividends to shareholders.
Painting a disturbing picture of the impact of PFI schemes on hospital trusts, she says: "The cuts in hospital operating budgets, that have had to be made to fund the higher costs of PFI hospital building, are the real reason why the NHS hospitals' cleaning and catering standards are reduced.
"NHS-provided transport is no longer available, waiting times refuse to fall, seriously ill patients are parked for hours on trolleys waiting for a bed, and cuts are made in the ratio of nurses to patients and consequently in the quality of clinical care."
According to Pollock, the once-outstanding effectiveness has been sacrificed to "market dogma" for so long that Britain has begun to lag behind comparable countries in survival rates for conditions such as heart disease and cancer, and even in rates of infant mortality.
But for the British government and its supporters, involving the private sector was a logical step to take when New Labour came to power in 1997.
Labour MP Howard Stoate, one of a handful of GPs in parliament and a member of parliament's powerful Health Select Committee, says: "When we took office there was a very large number of very rundown and outdated facilities and hospitals.
"There were unacceptably long waiting lists and there wasn't any obvious way of getting those waiting lists under control, the way things were.
"The first thing we did was to start putting in some serious cash . . . but it became increasingly obvious to ministers that just relying on expansion of the NHS and on the length of time it takes to rebuild things was going to be too slow.
"That's where the discussion started about whether we could start using spare capacity available in the private sector, because traditionally private sector hospitals had been under-utilised."
According to the MP, the introduction of a "payment-by-result" system has addressed concerns that taxpayers were paying a premium for private sector involvement, in other words, that the private sector was more expensive than the NHS.
Under the scheme, hospitals now are paid a fixed price, set according to the national tariff, for each patient treated.
To some, the system has echoes of the internal market introduced by the Conservatives where "the money followed the patient", but the new approach goes further, in that it extends the payment system to private companies providing treatment for NHS patients.
As evidence that traditional problems are now being overcome by successful New Labour policies, Stoate points out that there was no "winter beds crisis" in 2005 while waiting times are now at their lowest level ever.
However, concern is growing for the future of the NHS even among those who champion increased competition. According to a study by the right-wing think tank, Reform, the service faces a "make-or-break" year.
It blamed vested interests for hampering change and called for increased patient choice through more competition.
Entitled NHS Reform: The Empire Strikes Back, the report argued that deficits needed to be written off, and measures introduced to ensure value for money, as well as strict financial discipline.
According to one of the authors, Prof Nick Bosanquet of Imperial College in London, the department of health has been so busy fire-fighting that it has lost sight of developing a means of ensuring value for money.
Among other concerned voices, James Johnson, chairman of the Medical Association, said recently that he believes there is only one year left to "save" the NHS before the Government starts to question its future.
"Don't assume there's anything automatic about the system we have at the moment continuing in perpetuity," he says.