Choice, markets and competition in the NHS
What can we learn from the evidence?

Dr Ruth McDonald, Manchester University

3/2/06

Scoping review

Expert workshops
International literature
Do patients want to be able to choose their health care provider?
How do they respond to choice of provider when choice is available?

Scoping review

The impact of choice on efficiency?
The impact of choice on equity?
The impact of choice on quality of care?
Choice and individual treatment decisions?
Information and choice?

Choice of provider

Not a high priority for NHS patients
Elective care - recent experiments suggest attractive to some groups of patients
Primary care – evidence scarce, though evidence of loyalty to practices
Ability to exercise choice dependent on age, gender, socio-economic status and nature of treatment
Choice of provider
Relatively little enthusiasm by patients in other European countries (though waiting times shorter)
Choice likely to be more important where existing service very poor, waiting times long & support for choice offered.
Patients offered choice
Primary care – little evidence want change provider, though scarce capacity
Secondary care – LPCP high uptake in context of lengthy waits
Ease of access, reputation, quality & wait most important for patients
Fundholding – limited changes to providers

Efficiency

PBR – standard tariff & efficiency
Tariff based systems & gaming, perverse incentives, cream skimming
‘DRG’ creep
Increased expenditure on health care
Impact on services provided on goodwill basis (e.g. advice)
Administrative costs
Equity
GPFH mixed evidence – no impact, 2-tier service
LPCP no evidence of inequalities but did not consider patients not offered choice who were likely to be older & sicker
USA – relatively advantaged populations benefit from choice & better access to information

Information

Public release of info little impact
Some evidence influences providers, but mixed and small effects
Poor performers withdraw from reporting process may account for impact
Poorly understood by public/patients

Information

Choose on other characteristics (proximity, personal knowledge, friends & family)
More affluent patients more likely to use information, leading to inequalities in access
Perverse incentives – avoid treating sicker, high-risk patients

Key questions for policy makers

Equity – what measures being taken to create level choice playing field for disadvantaged groups?
How much choice? Treatments of limited efficacy?
Increased capacity – increased costs, impact?
Clarity between payer and user choice (and voice and choice)

last updated 6/02/06