The drive for private involvement in the NHS ignores the fundamental principles of healthcare

Does the NHS need to learn anything from successful private companies, as prime minister Tony Blair seems to believe? Is the NHS just a brand name with a series of franchised operations, or is it still something different from UnitedHealth?

Health is not a commodity that can be produced by means of the investment and deployment of capital and labour resources. Health can only be produced by engaging people and encouraging them to take active control of their own well-being. The public sector has not proved to be good at engaging the poorest communities ? but the record of the private sector is even worse.

Of course, the production of healthcare can be seen as a business - one in which capital is invested and from which people earn their living. But has it anything to learn from the private sector? But the fundamental reason the market will not work in the NHS is that it is centred on growth and failure. Selling more goods and services more profitably than your competitors is the only criterion for success in the market, but in public services, success is more complicated.

There is a more immediate political reason, too. The market works well when companies can set up and go out of business in response to customers' demands. The government has not yet explained what will happen if a foundation trust fails.

As Audit Commission acting chair Sir Michael Lyons told the NHS Confederation conference last month, a market-based system would generate 'waves of extinction sweeping through public services', which would not be tolerated in a system which remained 'collectively funded and publicly controlled'.

The (un)importance of choice

Can commercial organisations help the service 'rebalance' policy from a 'national sickness service' to a national health service, as government adviser Sir Derek Wanless put it? For commercial organisations, empowerment is about individual choice. But in reality, choice will never be very important in the NHS because elective surgery is only a small part of what the NHS does.

For people who are acutely or chronically ill - that is most hospital patients - choice is irrelevant. That is not to say that some lessons could not be learned from commercial providers. Just because they are not paying customers, there is no reason why patients should be made to feel that their time is of no importance and that their comfort has to take second place to that of the staff.

But most patients do not want to feel that their local hospital is in competition with the one down the road, especially if that road is 50 miles long. There are only a few urban areas where there is a choice of convenient providers. The vast majority of the population has only one hospital which is convenient.

And can commercial organisations help us to lead healthier lives? Given that much of our unhealthiness is directly attributable to our poor diet and lack of exercise, both of which are encouraged by unscrupulous firms, it is hard to see how.

The central difference between the NHS and commercial organisations is surely that the NHS is, or should be, under democratic control and operates primarily for public benefit, not private gain. Despite spending record sums on the NHS, politicians are still blamed for its problems.

The challenge for reform is to establish systems for local and regional decision-making under democratic control, which are robust enough to enable devolution of power and responsibility. Giving the commissioning responsibilities of primary care trusts to democratically elected unitary local authorities seems to be a good first step.

Martin Rathfelder is director of the Socialist Health Association.