A response to  Sean’s article on Competition and Choice in the NHS by Irwin Brown

Let’s get the politics out of the way first.

Whilst many of his points accord with the general consensus Sean Worth suggests the changes brought in by the Coalition actually fit with this position. He cannot defend the wasted billions on a top down reorganisation or the constant alienation of NHS staff and professionals.

In contrast to the position of Andrew Lansley, Sean has to accept that any framing of competition within our NHS has to be in a “managed system” – which is Labour’s policy.  On the contrary the Coalition is adamant that managers have to be prevented from interfering with the market forces.

The Coalition Bill was based entirely on the unproven and highly contested assumption that our NHS could be improved by making our healthcare into a regulated market with competition between providers from all sectors as the key driving force.  It was about opening up the NHS to private providers and ending the role of the NHS as the provider of services.

It’s true that many concessions were made during the shambles and the pause; for example to try and rule out competition on price and to assert the value of integration (although secondary to competition), but the idea the eventual Act has support on the ground is simply laughable.  Even in its final confused and watered down final form it was opposed by almost everyone, including almost every Royal College and Patient Group; not just the unions. The government got its Act but it lost every argument.

Back to choice and competition.

There is a wide consensus that choice if framed in terms of giving patients greater involvement in their care is proven to be beneficial.  Shared decision making and community development are powerful ways of providing real choices but the obstacles to this form of choice are profound and have nothing to do with markets and competition. Changes in behaviour and the training of care professionals plus a genuine revolution in how patients are given access to information are all prerequisites to offering real choice; it’s not about economics.  We need choice to empower patients not choice as in shopping.

Sean’s version of choice is choice between multiple providers all offering the same service at the same price and is of very limited value.  Markets do not work well for healthcare and economic theory explains why; almost every study in our NHS into the benefits of turning the NHS into some form of market show limited gains and high increased costs.  Those from both far left and far right agree it is not working; the left want to go back to publicly owned and publicly provided nirvana (as in some mythical golden age NHS of the late 60’s) and the right want regulation and system management removed and full price competition.

But aside from extremes there is again a wide consensus that there are circumstances where use of completion can be valuable in securing better services or better value for money; but as even Sean has to accept this is within a managed system.  Private providers, chosen through proper procurement, may be necessary to provide services when the NHS is not able to offer the quality required, or when some genuine innovation not available within the NHS is offered – and this has always been the case.  But the NHS itself will always be the main provider of health services.

At the micro level there have been a few studies which claim to show benefits from competition within the NHS which after all has been around for simple planned surgery for years.  These claims are refuted by more recent analysis and other studies have not found evidence of benefits.

But even if some benefits were established there remain concerns about macro level effects.  If competition fuelled by patient choice results in services being shut down at some NHS providers (maybe your local hospital) then the knock on effects might be that NHS organisations fail and local services are lost – which is never popular.  Emergency care, where choice is less relevant, needs to be within a comprehensive stable system, good everywhere, not some botched up network of competing providers.

The other macro effect is that most believe that greater integration is required bringing physical health, mental health and social care together and building pathways of care managed by a single provider or where various providers cooperate – and most believe (as does Sean apparently) that a system driven by competition makes this far harder.

And finally the private/public competition/integration arguments are secondary.  The key problems facing our care system are about clinical behaviours and culture, about integration of care, about funding of social care and about better allocation of resources, about reducing unnecessary variations in outcomes and reducing inequalities – none of which are addressed through market economics.  The unnecessary destabilisation of the NHS and the parallel refusal to deal with key issues in social care have meant years of wasted money and effort.

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One Comment

  1. Shibley says:

    I think the big mistake is confusing competition in finance and law and competition in clinical decision-making.

    Medics think in terms of shared decision-making and collaboration, with other health professionals.

    I happen to disagree quite profoundly with the work of Prof Carol Propper and similar on the conclusions from her acute coronary interventions studies, and I should write this up at some time properly. In research, it is enormously helpful to see if anyone has either replicated the work or shown evidence for an alternative view; this balance was somewhat lacking in Sean Worth’s formidable missive.

    When you look at s.75 Health and Social Care Act (2012), the competition is on the slickness of the bids of private bodies, with a greater resource allocation for legal and business work compared to NHS, rather than clinical competition per se. I see this confusion also in discussion of ‘integrated care’ – coordinated care should be the aim of any clinical team, but when the question is about full integration of IT in medical/insurance systems, that is when serious legal thought has to be put in.

    It will be the aim of any medical and nursing intervention to do the best clinically for the patient. That is why evidence-based procedures exist for recommend angioplasties in certain situations; and not conservative medical treatment nor indeed a coronary artery bypass graft. When this clinical decision-making gets adversely effected by perverse incentives in the system, it’s a huge worry.

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