With another care scandal across our media we now have some suggesting that the root cause was the introduction of the market[1] into the NHS.  There does not appear to be any actual evidence to support the assertion; it fits into a general category of argument from anecdote.  The market is bad; some care was bad therefore the market must be to blame for the bad care.  Or the culture was to blame and the market made the culture.

The evidence on whether or not market competition in health care (in our system) improves quality is contested.  Some claim there is evidence that where competition applied then outcomes improved, so is there any evidence of the opposite?  To be fair advocates of the market-kills-people argument also claim that the evidence is there but ignored.

There are no comparative studies of quality generally or unnecessary deaths in particular looking at the pre-market NHS compared to the current version.  Neutral observers might suggest there were as many, if not more, examples of poor care in the good old (pre market, pre management) days, but evidence is not available.

It is probably accepted that a management put under pressure to achieve targets, especially financial targets, may pay less attention to quality.  How that pressure on senior managers translates into poor clinical practice and so to unnecessary deaths is hard to prove and appears to denigrate the professionals who deliver care.  But there will presumably be pressure to perform in any system with or without a market – organisations have to balance the books in some way.

Proper case notes based studies, as opposed to league tables of death rates, have repeatedly shown the main causes of unnecessary deaths[2]; late or incorrect diagnosis, prescribing errors, poor observation as three.  The level of resources is clearly important to some degree in each factor but so too are many other factors.

We do appear to have some evidence that those organisations that have higher death rates have a lower (comparative) level of resources – less doctors, less nurses, less cleaners.  The market obviously distributes resources in an uneven way but then so does any bureaucratic process of allocation.

Finally there is the net effect argument.  Management pressure (market or otherwise) such as imposed wait targets may distort care and have some consequences that are bad (even lives lost.  But it is also argued and some evidence supports the claim that lower waiting times, which were a result of imposing targets, saved lives.  Some bad affects but overall a gain.

In the end the quality of the local management must the key to care quality in our devolved and semi-autonomous system.  Does a market system make management worse or better?

Where is the evidence?


[1] The SHA is clear that our NHS should not be a market and we have set out our clear alternative to a market/competition model.

[2] A death where a significant contributory factor was that something was done that should not have been done or something that should have been done was not done.

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4 Comments

  1. jenw17 says:

    Most problems with the NHS are known about through anecdote. The reasons for unexplained death do not get put into case notes, as evidenced in the Francis report.
    Even complaints made through the CQC or Patient Opinion are not listed properly.
    And many people give up on the complaints procedure because it is too distressing, therefore the death is just listed as a normal death.
    For example, my mother was moved into a care home from a nursing home. The manager at the care home omitted one of her tablets, only giving her 25 micrograms of thyroxine instead of 125 micrograms. When this was discovered we went through the complaints procedure. In the meantime, she died , and the CQC said we were complaining about their procedures rather than the manager at the home.
    The mistake, we believe, contributed to her death. How is that proved? Her death certificate says pneumonia. That is all that is written down.

  2. “Hospital Mortality is a system wide issue, only commented on by individuals with system wide responsibilities, people like David Nicolson, Harm to patients on the other hand, is an individual issue, the pain and suffering of individuals and their loved ones, something we can all relate to.”…http://www.england.nhs.uk/2013/06/25/david-nicholson/

  3. I support your call for evidence.
    Russell Mannion at Birmingham HSMC has done a lot of front line research into NHS cultures and the impact of markets and performance management. Shall we invite him to write a blog?

  4. Russell Mannion says:

    Our research appears to show that that there was a change in management cultures in NHS hospital Trusts between 2001 and 2008 in line with the pro-market reforms over this period. See the references below for more details.

    Russell Mannion
    Health Services Management Centre
    University of Birmingham

    Mannion R, Harrison S, Jacobs R, Konteh F, Walshe K, Davies H (2009) From cultural cohesion to rules and competition: the trajectory of senior management culture in NHS hospitals, 2001-2008, Journal of the Royal Society of Medicine, 102(8)332-336

    Mannion, R. , Davies, H., Harrison, S., Konteh, F., Jacobs, R., Walshe, K (2010) Changing management Cultures in the English National Health Service, in: Culture and Climate in Health Care Organizsations (eds) Braithwaite J Hyde P and Pope C

    Mannion R (2010) Labour’s legacy: eclipsing the clan culture in the NHS, Health Service Journal, 22 July.

    Mannion R , Davies H, Harrison S, Konteh F, Jacobs R, Fulop R, Walshe K (2010) Changing management culture and organisational performance in the -NHS, National Institute for Health Research Service Delivery and Organisation Programme, p 292

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