Hybrid' health protection: the challenge of the National Health Service

The National Health Service and the companies that make it up are traditionally used to thinking in terms of a mixed system, in which public and private facilities coexist and part of the private supply is financed by the public system. The conceptual framework of reference is a clear distinction between what the public must guarantee - the essentials, that is, the Essential Levels of Care (LEA) - and what is left to private funding because it is not essential or appropriate. In this perspective, private healthcare consumption, which accounts for about a quarter of total expenditure and has been stable for years at 2.2 per cent of GDP, when it does not appear clearly inappropriate, is read as a sign of a limitation of the public system.

It is not the case here to argue analytically why this conceptualisation is no longer appropriate and risks steering the actions of the system and companies in directions that are not consistent with the collective interest. A few observations help, however, to intuitively grasp the transformations taking place. The distinction between essential and non-essential is easily applied in the so-called acute paradigm, in which public intervention aims to restore a state of health altered by an event.

In chronicity, on the other hand, this distinction becomes more blurred: the objective is to improve or not worsen the person's capabilities, but it becomes more difficult to define the correct amount of resources and to identify inappropriate consumption. In concrete terms, 70% of rehabilitation services are privately financed and 70% of physiotherapists work in the market. Similarly, in 2023, for the first time, private specialist visits surpassed public ones, and it is hard to imagine that all of them are useless or can be brought significantly within the public perimeter. Lastly, it must be emphasised that the increase in scientific and technological opportunities physiologically increases the number of services that are useful for health, but not so useful as to justify, within a framework of limited public resources, the supply by the SSN.

It is in this context that the hybridisation of the health protection system must be placed. The concrete patient pathway no longer sees the episodic consumption of a single service, but a set of services consumed, often systematically, in different parts (public and private) of the system. Private consumption is no longer, if it ever was, only inappropriate, but also reflects individual preferences for appropriate consumption with richer ancillary elements (times, places, ...) than those offered by the public. In short, a hybrid system is one in which it is increasingly difficult to think of public and private consumption as separate worlds.

Hybridisation would require a rethink in the NHS and in companies in at least three directions. The first is a broadening of the terrain on which an effective capacity for governance must be exercised: from public consumption alone to all healthcare consumption (public and private). In fact, the SSN has hitherto looked only at the public component, with the idea that private consumption did not contribute to satisfying the population's health needs. The second is the integration of public and private consumption. In many cases, from prevention to rehabilitation, citizens alternate public and private services and, in the absence of explicit coordination, duplication and waste end up multiplying. Lastly, the issue of the public supply of private health services should be fully addressed, starting from the good reasons that should push some public companies to position themselves on the private market as well, overcoming the current unsatisfactory configuration in terms of free practice. These are some of the reflections that have characterised the debate and discussion within the SDA Bocconi DASP Network. These are shared trajectories within a system that reveals heterogeneous patterns in the mix of consumption between public and private services.