Giving NHS patients the right to choose where to be treated for free by any qualified healthcare provider, including private ones if they can meet NHS standards and costs, is one of the most potentially transformative policies of the Coalition Government. It will empower ordinary people to make the kinds of healthcare choices that, frankly, only the rich have been able to make thus far.

While few would disagree with the progressive aspect of this, the competition between providers needed to deliver the choice patients want has been controversial. This controversy has largely been manufactured, however, by vested interests on the Left who do not want other providers undermining their political control of the NHS. The reaction from the hard Right has been similarly ideological, with calls to go much further towards open competition without reference to any actual evidence on what works for patients.

The first thing to understand about competition in healthcare is that, like competition in all social markets, it has to be properly managed to be of real benefit to patients, rather than just creating budgetary efficiencies for the system.

For example, studies show that open price competition in healthcare, where providers can bid to run services and negotiate their payment for doing so, leads to lower costs and greater efficiencies, including shorter waiting times for patients. While that sounds great, the downside is that price competition can also lead to lower quality care as providers undercut each other in a race to provide the cheapest possible. While that may be good for NHS bureaucrats, it clearly isn’t in the interests of patients.

Thankfully then, this is not the central focus of competition in the current NHS reforms, which are primarily about patient services paid for at the NHS fixed-price tariff. Evidence both from home and abroad shows that competition at a fixed price, which most NHS care is moving onto, increases both efficiency and the quality of care patients receive. This is because providers have to compete on the basis of delivering as much benefit as possible for the fixed price paid.

The right regulation around competition is therefore crucial. The London School of Economics last year published a review of the effects of the competition and private sector provision introduced by the previous Government. It showed that while NHS patients benefited as well as private providers, it had a negative financial effect on some NHS providers in the market. This was because private providers were allowed to take easy, high-volume types of work, like simple hip operations, leaving complex and more expensive cases to NHS providers. Private firms were also allowed to negotiate far higher payments than NHS providers, even when doing exactly the same work.

It is important to note, however, that the expansion of private provision under the last Government was met positively on the ground. The Institute for Fiscal Studies very recently reported that, while the previous Government introduced private firms into the NHS, actively expanding private provision year-on-year since leaving office in 2010, patients were also actively choosing this option. It thus increased rapidly: by the time the present Government took office, one in five NHS hip operations was conducted by a private firm.

The sensible conclusion to reach from all this is that while competition expands choice and can benefit the NHS, it must be carefully managed, directed towards the interest of patients not bureaucrats, and fair to all providers. And this is exactly the aim of the present reforms.

Far from being the “market free-for-all” the more militant wings of the Left often claim, the competition elements of the reforms are designed to be targeted at patient benefit and closely managed to ensure that focus remains. Indeed, the specific problems mentioned above are explicitly outlawed in the Act which brings in the new reforms. The reason the Left lost credibility in the battle of ideas over NHS reform is precisely because their arguments relied far too much (and some still do) on pushing false caricatures. The reason the hard Right achieves no traction calling for more agressive competition is that the evidence doesn’t merit it.

There are some perfectly legitimate concerns remaining, however. One has been the effect of competition on ‘service integration’ – i.e., the need for different bits of the NHS involved in a patient’s care to be joined up, co-operating with each other. The Office of Health Economics recently undertook a major study which addressed this, concluding: “Competition can help the integration of care and there is no evidence that competition hampers integration.” Services provided in competitive markets will in fact ordinarily converge around consumers’ demands for convenient, joined-up services, which is why so many retail services are offered in bundles made up of different providers. The real question people should be asking is how long it takes competition to deliver this. As a transition measure, further initial system-led integration schemes should be used until the choice market matures.

Another area to focus on is local GP practices. As largely-independent enterprises, they’re effectively in competition anyway, but there is clearly more to do to make this market more open to patients’ choices. It is a scandal that the provision of decent information that ordinary patients can understand on the quality of GP services is so difficult to extract from the NHS establishment. This is due largely to fear of the huge variation in quality and outcomes it will expose to the general public. The job is, however, essential.

A ‘competition panel’ set up by the previous Government published in 2010 a study showing the more competitive pressure GP practices faced – i.e., the easier it was for patients to find and choose local alternatives – the better quality the care patients received was. But this competitive pressure is currently very low. While people can easily look up the quality of local schools via official league tables, they still cannot find out something as important as which GP practices are good at managing diabetes or a child’s asthma. So few ‘shop around’ or switch providers. Better GP information should be an urgent priority and would lead to a transformation in care quality, as well as choice.

Given the clear benefits to patients of properly managed competition, the most important job is to make it happen fairly, in an appropriately managed way, backed by better information for patients – and above all, quickly. The NHS is still stuffed with ideologues who oppose change on the basis of their own vested interests. We can only hope that Monitor, the Commissioning Board and all others overseeing the NHS changes will be alert to that and prepared to act against it as champions of patients, not the system.

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30 Comments

  1. Shibley says:

    selective use of evidence leading to a distorted argument

    statement about Monitor not very meaningful

    people oppose change because of flaws in the argument – author shows little comprehension of how complex strategic change in management relies on stakeholder involvement

    poorly developed link between ‘patient choice’ and competition

    no mention of the formidable legal concerns about competition under European and odmestic law

    in summary a very unimpressive article

  2. patshu11 says:

    I suspect this was meant for the Conservative Home website, how did it end up here? Or is it April 1st already? if it really is being hosted by the SHA they should think about removing the word ‘socialist’ from their title

    Here is some info re Sean Worth

    Worth was a key figure in the Andrew Lansley’s health reforms, and a former head of the Conservative policy unit before the election. He has had a ringside seat in the first two years of David Cameron’s attempts to reform public services.

    http://www.guardian.co.uk/politics/2012/jun/19/tories-speed-up-public-sector-reforms

    1. Martin Rathfelder says:

      We invited him to write. We don’t agree with all he says, but we think we need to have a proper debate. Anyone who disagrees is most welcome either to post comments or to write a post themsleves.

  3. Joe fd says:

    Well at least this puts paid to the idea that the Act is not about competition first and foremost. There is nothing here to evidence the claim of “transformation”, unlike the managed (but long overdue) changes in acute stroke care in London for instance.
    The trouble is that managed contestability can be marginally effective, as recent evaluations suggest. But the legislation introduces – or rather, formalises and mandates – real competition rather than contestability, and gets rid of system management functions. That is why the so-called Hard Left like GP organisations (who don’t have vested interests in NHS hospitals) and academics (beyond the usual suspects) are worried about this un-evidenced step into the real and un-managed market.

  4. llcooljoel says:

    Would have been lovely to see the author support all of his assertions with some actual evidence, other than a quote from a government department. As it is, we can only consider this an ideological and political article rather than a robust argument in favour of NHS privatisation.

  5. Mike squires says:

    If it is good for the NHS why not defence as well ?
    Managed competition between the army and G4S et al as to who should invade Iraq.
    Fantastic idea.
    These 19th century ideas about the benefits of competion peddled by the extreme right have no place on a socialist website. We get the same kind of arguments put everyday in the press. It is a waste of space to duplicate these arguments.

  6. Ronan O'Leary says:

    Thank you Sean for taking the time to write this for us, it is an interesting piece. I must say, however, that there is very little detail. I think this is one of the problems with the H&SCB – no one really knows what you are going to do.

    A lot of what you say is neither ideological or difficult for left leaning people to stomach, particularly what you write about GPs. We, arguably, already have the worst form of market system in primary care. A cartel of private organisations funded on a for profit (GP salaries) basis with few mechanisms for patients to chose or move between suppliers. This should be an anathema to the Left but the attempts at reform by both Governments have been so ham fisted that we are now fighting to maintain a suboptimal system because we are scared that we will end up with a US style shopping mall style of primary care. Whether the Conservative proposals are a move towards this or away are impossible to tell, like all of the H&SCB the detail is so complex it is impossible to predict where we will end up.

    With respect to hospitals, I am in Melbourne at the moment. I am certain that we have a lot to learn from the private sector moreover, private and public sectors can co-exist to deliver high quality health care. There are two important caveats, it is expensive and certainly not cheaper than the NHS, and, secondly, it is very difficult to measure quality across the system. It is possible in individual hospitals to delivery and measure very high quality services but very hard, I suspect, to compare institutions. That is not to say that we are good at this in the NHS, but a system of mixed providers will be worse.

    I personally think that is time that the Left moved on from this argument. The real debate about health in the UK is why people get sick and why they don’t get the same standard of care, this is where the Left should be fighting. It doesn’t matter, in my view, who owns the building where care takes place provided it is high quality, universally available, and free at the point of delivery. We should really focus on why certain groups have such poor access to care and concentrate on legislating to help these people rather than fighting a battle which ended in 1997.

    1. sean worth says:

      Agree with pretty much all you say, Ronan.

      I’d just say competition is best and quickest route to dealing with issues like the access and variation problems you cite, especially in poorer areas – where, frankly, it’s often been hard to attract good doctors and even juniors / trainees to go to. You can help by paying a premium for tackling those problems, but I see competition as a faster driver of progress if targeted for a social cause.

      1. Ronan O'Leary says:

        “Agree with pretty much all you say, Ronan”

        Oh no!

  7. Creating a competitive market among the power utilities worked so well didn’t it. We have the Prime Minister actually threatening power companies because their tariffs are too complex for ordinary consumers to make informed purchasing decisions.

    Creating a competitive market with train companies worked so well didn’t it. We’ve had services having to be taken back into public custody as absurd non-economic bids lead providers to the wall.

    Competition doesn’t deliver what it’s cracked up to provide. And, frankly, when I’m sick and in need of care I want the BEST care … not the URL for a comparison site.

  8. sean worth says:

    I really appreciated the invite to post here. Don’t understand complaints that the editor has asked for this piece from me, though. As an explicitly socialist blogsite, I didn’t expect him or any of your members to agree with all I say, but this blog looks like it’s been pretty open to debate up to now?

    I would certainly not agree with the privatisation free-for-all implied by comments – got to be very managed, targeted competition to give people more provider choice. Research clearly shows patients want it and it raises standards as long as you don’t allow a race to the bottom through agressive price competition. That is not a ‘selective’ read of the evidence.

  9. Mark Burton says:

    How remarkable to find that the SHA website is being used as a platform for ideology that is readily accessible pretty much everywhere else.
    Socialists need to be confident in the superiority of collective and cooperative approaches to health and health services. That means a critical analysis of choice itself. Some aspects of autonomy are indeed important – the ability to influence treatment decisions, the interactions in healthcare spaces, the configuration of health services, and the determinants of health and well-being – but these are not about choice, even though the first two in particular are about the experience of individuals and are therefore things we want to influence as individuals. The second two are about critical, political, collective autonomy. But understanding this need for autonomy as choice is mistaken and capitulates to a market inspired vision. We have seen the destruction that choice has made to other elements of collective provision – parent choice in schooling wrecking the comprehensive model and weakening the collective voice of parents when the middle classes leave a school, or the right to buy in social housing radically depleting the stock of cheap accommodation and fuelling the housing bubble.
    But make no mistake, this is not about choice or patient power but about opening up our commonly owned health service as sites for profit accumulation. The same neoliberal strategy as New Labour followed but intensified and shorn of its mitigating provisions.

  10. most patients i know are not interested in competition. what they are interested in is being able to see someone who has a friendly smile on their face, who knows what they are talking about, can tell them whats wrong with them and help them to sort it. they want all this local to where they live, they don’t want to go miles away for treatment or to have to go miles away to visit family or friends in hospital. whether or not competition will transform the NHS is yet to be seen, the drive to the bottom is what we are seeing regardless and reduction in services to the people who most need them. i oppose all this as i have paid my national insurance all my working life, from 16 to present (52) This was part of what it was paying for to give me access to health services. in my time this has been reduced i used to get free prescriptions, free eye tests, free glasses, free dental treatment access to GP and hospital as required. no i only have the last 2 which they are trying to take away too. so what exactly am i paying for and will i be expected to pay private health care insurance on top of what im already contributing. no one has been able to answer any of this for me yet. although i have personalised this, this is happening to everyone in the country. the government and david nicholson with his 20 billion of savings are driving the nhs services into the ground and telling everyone how wonderful private care is, however circle (running hinchingbrooke) has recently had a bail out from them, but they are not bailing out NHS hospitals, they are quite willing to sell them off to however they can get to take them. i can see that anyone can post on here, however people having to pay for health care or having health care rationed im sure is not a socialist principle or am i missing something.
    sorry my post is so long but i do get fed up with all this nonsense about patient choice, its a red herring.

  11. Shibley says:

    I’d especially like to thank Sean for the very decent manner in which he has replied to these comments, and for accepting the invitation to write for us. In no way do I think Sean is “wrong” – I just feel it’s only part of the debate, which I hope to fill in at greater length sometime else. Happy new year!

  12. Welcome to the SHA website. I hope you receive a hot response! Here is my contribution.

    The evidence for the effectiveness of competition is very weak. The two studies that appear to support it in the hospital field are highly contested, not least by the OHE. There is virtually no evidence that quality or productivity were increased as a result of competition in the 80s and 90s. No basis on which to build a huge infrastructure, expensive in so many ways. The policy is driven by ideology, not evidence.

    Private companies carry risks in a state enterprise. They will follow profit, so they will leave if the bottom line dictates; money goes to shareholders, not to patients; they are likely to drive down costs by paying less and offering poor service. We have evidence of all of these in the very recent past.We think it reasonable that private companies be used if the NHS cannot improve a particular service itself – or if a private company offers innovation that the NHS cannot adequately copy.

    Let’s have choice, but let’s focus on where the evidence shows it works – in supporting clinicians and patients to choose together the best treatments and management for that person. Shared decision-making improves care.

    I don’t see marketisation being targeted. CCGs are effectively being forced into AQP and into the privatisation of NHS planning through the CSUs. They will see that they will in effect be forced to tender out services when it is quite unnecessary to improve patient care.

    Health is not a commodity, healthcare is not like shopping. We don’t want this for our NHS.

    Brian Fisher
    Chair of the SHA

    1. duncanenright says:

      This is spot on. Thanks.

  13. judithwardle says:

    The major problems I see with answering ~Sean’s piece are 1) that it was our Labour government that led us down the path of false logic about “choice” and 2)his piece is a mixture of examples of that false logic and coherent and sensible ideas. I suspect he does not know that “few would disagree with the progressive aspect of this” is just not true — lots of leaders of the voluntary sector as well as Labour Party members have written in detail about how patients were tricked into believing that “choice” would give them a better service; and calling the idea “progressive” assumes a value judgement that many would oppose.
    Just a few of the relevant factors: my choice could deny you your choice because the service you need may be forced to close without the infrastructure and financial support of the entire facility — applies to community NHS services as well as bigger hospitals. Can we please not accuse the “left” of vested interests — I think that means people who want to keep their jobs and working conditions; but mud-slinging helps no-one. Let’s stick to mature debate.
    When Sean talks about “delivering as much benefit as possible”, he needs to define “benefit” — as a member of a NICE appraisal committee I understand the complexity of arriving at that definition.
    Yes: 1 in 5 hip operations are conducted by a private firm: part of the easy pickings; but some of those operations were shoddy or unnecessary and the total effect was bad for some major orthopoedic centres.
    I’d like to see that evidence about “integration of care” because I don’t believe it, and anyway what does it mean? across primary/secondary/tertiary or with social care or across different disease areas for those with complex conditions? — National Voices is currently working (with the Commissioning Board) on a document about what “integrated services” means for the patient.
    See what I mean? this is an enormous subject, and can only be conducted with totally honest thinking and “evidence-based” references.

  14. Michael Pollard says:

    Totally agree with the previous posts – there is far more evidence to show that competition and privatisation does not work for the benefit of patients. What works for Toyota, except when they have to recall thousands of faulty cars, is not appropriate for healthcare where lives are at stake and each patient is different. What happens to patients in need of urgent treatment when a hospital (NHS or private) goes out of business due to increased competition? There is bound to be at least a temporary gap in available services, because the number of patients won’t fluctuate to match the capacity of the surviving providers. What about the chaos this would cause for thousands of staff who would be displaced? Specialist skills would be lost or located in the wrong places.

    The private sector has to create profits and usually does so by reducing the standard of service or reducing staff pay. Look at the recent Panorama on the Virgin GP practices. They have also relied on public subsidies and other preferential terms that have been denied to NHS bodies. Patient choice is a red herring, as shown by numerous studies – patients want their healthcare provided locally (so it’s convenient) and want the standard of healthcare to be at least adequate, no matter who the provider. In countries with more private sector involvement, eg, the USA, the patient has even less choice, since it’s the insurer who decides what treatment they get and where.

    Anyone who has seen the millions wasted on PFI should recognise the dangers of privatisation, as did the House of Commons Public Accounts Committee in May 2012. OK, you can put some of the blame on NHS managers or government for agreeing to such expensive PFI contracts, but it was driven by right wing ideology and vested interests. When political figures receive financial benefits from private healthcare companies (Circle Healthcare recruited a former aide to Andrew Lansley as head of communications and paid £50,000 a year to a Tory MP for 10 hours work a month as a strategic adviser), isn’t there a conflict of interests at the very least?

  15. ShropsSheila says:

    I would like to see more evidence in support of claims from all sides. The evidence of poor service in existing NHS hospitals does not convince me that things are right at pesent.

    1. Mark Burton says:

      No, the institutional abuse revealed recently in NHS settings defies description. It is surely the result of a coming together of factors – some of them are deep – like the low esteem our society has for older people, but others are surely of recent origin – for example the squeeze on provision, the casualisation of front line staffing and the doctrine and practice of running health settings with no ‘slack resources’ (hence the ‘we’ve no time’ excuse).
      But don’t forget that the other big abuse scandal was in settings for intellectually disabled people run by privateer Castlebeck.
      We have to recover health (and socia) services from what the Australians used to call economic rationalism – and restore the imperatives of kindness and caring that underpin any service worth the name.

  16. Ian Goley says:

    Thanks to Sean Worth for this article. I welcome the debate, and it is positive to have such an article so that the debate can be explored.

    The apparent lack of significant substance in the argument however does not allow one to properly assess the claims made, especially due to the lack of evidence to support claims made.

    I take issue with the assertion that those on the “Left” (by which I assume the author means left of centre, or left of the Conservative Party, given that the political ideological standpoint is often relative) have “manufactured” the controversy surrounding competition so that those on the “Left” do not lose “political control” of the NHS. This is a difficult argument to comprehend, not least because of the ambiguity with which the argument is made. Of course, the NHS was created by the “Left”, but the principle upon which it was founded, free at the point of need, was also largely maintained by all sides whilst in government. The argument can therefore follow that the NHS, whilst strongly supported by the “Left”, is not exclusive to those who position themselves to the left of centre, nor would radical reforms to the NHS necessarily demonstrate an automatic lack of political control from the “Left”.

    The author refers to the need for competition to be “properly managed”. Defining what this actually means does not appear to be contained within the article itself, and it could be said is generally lacking in the Health and Social Care Act 2012. This is my fundamental concern with such reforms to the NHS, and the increased implementation of competition – what does “properly managed” mean? What safeguards are to be put in place?

    I do not take issue with the increased involvement of the private sector within the NHS in principle, as long as this is managed, effective, and in the best interests of the patient. Where there is potential for the increased involvement of the private sector however is when there is an increased reliance on market mechanisms, which has the potential to result in the marketisation of the NHS.

    Whilst the author attributes this concern of “’market free-for-all’” to “the more militant wings on the Left”, there is a pressing need for more evaluation of the regulation of such a policy contained within the Act. It is an uncomfortable accusation that the “Left lost credibility in the battle of ideas over NHS reform”, not least because of the misrepresentation that the author makes throughout the article of previous government policy on the NHS.

    The author makes valid reference to the report by the Office of Health Economics, January 2012 (http://www.ohe.org/publications/article/report-of-the-ohe-commission-on-competition-in-the-nhs-108.cfm) but is highly selective in the quotations used in the article. The report contains much more cautiousness than this article suggests, for instance:

    “The report suggests that although competition in the NHS is controversial, in the right circumstances it can be used to stimulate the provision of better health care than is achieved without competition. This does not mean that competition is desirable or feasible for all NHS services in all locations. The issue is not whether to have competition for all NHS services or for none; the question is for where and for which services competition would produce benefit for patients.” (OHE, 2012).

    Before there is more substantial evidence that a greater integration of competition within the NHS may be more beneficial, I would argue that there is a need for caution before such reforms based on competition contained within the Act are implemented, rather than the situation where the ideological belief that competition is the best way for everything trumps any other idea.

  17. Hannah Basson says:

    AQP will not transform the NHS in to some kind of service previously only afforded by the rich. AQP will bring choices provided by AQP according to where the person lives, not with knowledge and foresight of years of experience in that particular medical pathology. Patients are not shopping for a coat or a hair cut or a restaurant.
    This form of choice-giving will undermine the ability of curent NHS bodies to cross-subsidise – it will fragment care, be costly and divert money away from patients and, having seen the AQP documents pertaining to a number of disciplines/treatments, yet once again these private providers are ony going to take on the easy bits anyway.
    Once trusts have had their more profitable sections’ viability undermined, where does one suppose the finance for the unprofitable areas will be found? From the money being put in to the NHS that doesn’t cover cost increases even? From the huge cut (sorry, ‘savings’) of billions to the NHS? From the cost of the reforms that are having a direct impact on patient care right now, as we endeavour to implement these changes that we were not consulted on?

    Yes, the LSE did highlight the detrimental effect of ‘choose and book’ that allowed private providers to cherry pick, thereby damaging NHS trusts financially. However, waiting times had to be brought down and the NHS had been chronically underfunded (although the Commonwealth Foundation and OECD reports of the time show it was one of the best value health systems in the world). So the private sector was brought in, in part due to internal medical professional disagreement over changes to work hours etc and also in part due to the fact it would take 5-9 years to recruit enough medics and health professionals to bring the necessary numbers up (taking in to account training). Of course, some reports from the LSE were also very critical of the health reforms and the whole competition drive – a fact many in power would choose to brush over.

    The other form of competition being promoted by the Act and the secondary legislation, that of broader outsourcing, will lead to repeated tendering under EU law. This will be very expensive for the providers that lose contracts as well as for those that win too.
    Of course, this fragmenting of services and care was made possible by the Govt of 1999 accelerating the marketisation in the NHS by reducing every treatment and every consultation down to a costing exercise. This was when we really stared to feel joined-up care reduce and the ability to give person-centered, multidisciplinary care has deteriorated ever since. The introduction of this system was so costly at the time that it forced a reduction in spending on direct patient care of a third where I was working.

    Overarching all of the changes to the NHS, will be the new commissioning bodies. Yet they have offered little involvement to their GP colleagues in their areas and, already, there is evidence of boards being led by doctors with vested interests in companies wishing to profit from competition.
    As the BMA stated in 2010, if the onus of the reforms was only about competition and furthering patient-centered care, this could have been done without a new act of Parliament.

    The papers put forward by the Govt to justify increased competion in 2010, focussed on hospital choice and did not validate AQP – they merely showed how broadening the choice of bricks and mortar could improve wating times and reduce mortality and morbidity rates. Duh

    Incidently, less than one fifth of the population believe that further competition in the NHS will improve services.
    http://cdn.yougov.com/cumulus_uploads/document/ly9ei68uye/YG-Archives-Pol-ST-results-10-120212.pdf

  18. Steve Iliffe says:

    I cannot see what problem competition, as described by Mark Worth, is going to solve. It cannot be ‘lack of choice’ because this is not a problem. Is the Daily Mail running a campaign against the NHS because it does not offer choice? Is private health insurance becoming ever more popular, with a disgruntled customer base agitating for the NHS to pay their bills? Is there a lobby for choice that is not made up of private providers seeking access to public funds? A general public full of medical shoppers is a fiction, or as Mark puts it: “few shop around and switch providers”.

    Nor does the “potentially transformative effect” of competition sound plausible. Over the decades we have heard the same claim from General Managers, Health Economists, Evidence Based Medicine evangelists and now marketeers. By the time we rumbled their false claims they had their feet under the untransformed table.

    The weakness of this argument for competition is a shame, in a way. The NHS now faces the need to shift from expansive development to intensive development (reconfiguration, re-engineering, system integration). This shift is socialism’s weak spot, which may be one reason why New Labour bottled out over market mechanisms in the mid-noughties. We do have major problems in the NHS which we do need to solve, but I have yet to see a credible explanation of how competition will solve them.

    For example, how will competition fill the generalist-shaped hole in the middle of a hospital network overfilled with under-involved specialists (read ‘Hospitals on the Edge’)? How will it make falls and bone services reach their natural clientele and stop claiming to have done work that has not, in fact, been done (read Falling Standards, broken promises)? How will it make over-funded, poorly performing neurology services provide value for money (read the NAO report)? That is just the start of the problem list; next come obsolete hospitals that are under-skilled to cope with an aging population, the troubled state of nursing, and general practitioners who are overworked and under-employed…and so on.

    If there are plausible solutions to these problems that involve competition then we should take them seriously, and compare them with alternatives that require existing contracts to be policed and enforced, even if this brings government into conflict with the professions.

  19. Nye says:

    I welcome the chance to debate the merits and risks of competition in healthcare. The NHS was built on an ethos of co-operation and equity of access. Planning and integration have generally underpinned it, rather than competition – for good reason.
    Take stroke care, for example: the recent rationalisation of stroke centres in London from 30 to 8 centres has transformed standards in the capital, from having the worst to the best mortality rate nationally. Could this have happened under a competitive market, regulated or otherwise? No, as many clinicians in the reformed NHS now fear.
    Cancer networks nationally have started to deliver similar benefits: based, again, on planning and integration between providers. There are many more examples.
    Healthcare is a hugely complex business with lots of uncontrollable and potentially costly risks. The state is best placed to cope with these. Otherwise, under the Tory/Liberal Orange Book vision for competition, “cherry-picking” will become rife – as the private sector pick off the less complex and more profitable work, leaving complex and expensive clinical work for state-run providers. (Health professionals however, will tell you that integrated care – for older people and people with chronic conditions – is the big challenge for the NHS). This will lead, in a cash constrained environment, to a two-tier system or even health-top-ups, with NHS funded services left as a lower level of service.
    Social care is a graphic example of how letting completion rip generates a race to the bottom, with “commissioning” becoming no more than contracting, and market instability as providers are squeezed. Witness recent (government) contingency planning for Southern Cross care home residents should private equity pull the plug, and force homes to close.
    Yet to the Right this is not a problem. Quite the opposite: David Cameron is quite open that the state is too big. Ironically, Sean worth refers to “NHS standards” or targets but it is clear senior Tories do not believe in them.
    Competition as a magic bullet solution for public services is discredited. Transport and utilities have shown it to be part of ”rip-off Britain”, often creating monopolies or cartels that milk the consumer. Yet the unholy alliance of large private sector companies and right-wing think tanks is desperate to promote this solution. Go to any of the conferences they run and you will see it is not an attractive combination.
    It is interesting that you rarely hear advocates of more competition talking about the US health system, and the waste that generates – 18% GDP on healthcare anyone? The fact is the NHS, based largely on a service model stressing planning and integration, is now cost-effective, relative to OECD countries.
    Finally, let’s not be fooled by Sean Worth attempts to position himself between “vested interests on the Left” and the “hard Right”. The Coalition he was at the heart of did their best to create a full- throttle market, with a regulator originally designated to promote competition. From White Paper to Act of Parliament was an omnishambles of the highest order. It failed to convince any section of the NHS workforce, most of the public and surprisingly few Coalition MPs that this would in any way strengthen the NHS. The legislation limped over the line but amongst clinical staff hostility to a health system underpinned by competition has grown much stronger.

  20. Wendy Savage says:

    I am appalled that the SHA website was used for this propaganda piece and if the ‘We’ that Martin Rathfelder refers to is the SHA Council I think we need to change the members of this at the next opportunity. If Martin is using the royal we for his own actions then I think he should consider his position carefully. As Brain Fisher says the LSE papers have been contsted and there is a mass of evidence that shows the dangers of competition. I attended the seminar where this work was presented at LSE and I was appalled by the poor quality of the research and that it had been used to ‘inform’ David cameron before it had even been published. Those of us who have followed the debate do not need to have it given prominence on the SHA website and i would like it removed W

    1. Martin Rathfelder says:

      The Association decided that the purpose of the website was to encourage debate, and we have spent a great deal of time and money transforming it so that debates can happen. I don’t think many of our members agree with Sean Worth’s ideas about the NHS but his ideas are influential and we need to discuss them.

      1. Mike Squires says:

        Allowing extreme right wing views about the benifits of the market and competition in healthcare does not further debate.
        We receive a barrage of these politically correct ideas every time we listen to the radio,watch the TV, or read a newspaper.
        It doesn’t further democracy when a socialist website gives up valuable space to discussing such antiquated notions.
        What we need to be doing is addressing how the NHS, publically funded and publically provided, can be improved and democratised.

        1. joe fd says:

          The rest of us were having a perfectly healthy and civilised debate, until the last two commenters. A shame you don’t want to engage on the content of the discussion. You don’t have to. But your preference for slogans and personal attacks shouldn’t put the rest of us, or any other external contributors, off.

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