Choice, Markets, Competition in the NHS – What do they mean for health inequality?

Steve Harrison University of Manchester 2006

What are the reforms?

  • Demand-side reforms: eg separation of commissioning/ provision via quasi-market, patient choice, direct payments (social care), easier access to GP lists
  • Supply-side reforms: eg pluralisation of providers inc independent sector in both primary & secondary care, NHS Direct etc
  • Transaction reforms: eg QoF, payment-by-results, national casemix-based tariffs
  • Regulatory reforms: eg government targets, NICE, Healthcare Commission, stronger PCT role

What are quasi-markets?

  • In common with other markets, there are independent competitive producers on the provider side but, unlike classical markets, some or all of the following characteristics may be present (LeGrand 1991; LeGrand and Bartlett 1994):
  • producers cannot be assumed to be profit maximisers;
  • consumer purchasing power is confined to a specific range of goods or services, so that the purchaser cannot decide to spend the resources thus ‘earmarked’ on anything else (in effect, the purchasing power is a ‘voucher’, whether or not so labelled);
  • purchasing decisions are made by an agent rather than by the prospective consumer of the goods or services;
  • payment for the goods or services is made by a ‘third party payer’ rather than by the prospective consumer.

Pursuing equity & equality

  • Not clear how on theoretical grounds the demand-side & supply-side reforms (except possibly direct payments & easier access to GP lists) would be expected to enhance equity or equality
  • Essentially, therefore, we would look to transaction & regulatory reforms to do this, eg QoF might be expected to equalise treatment of chronic conditions
  • Most NICE appraisal decisions are legal requirements on NHS, so reduced ‘postcode rationing’
  • Proposed new PCT role in attracting primary care services to under-doctored areas

Optimisms & pessimisms of an empirical researcher… (personal views)

Optimistic that

  • PCTs can increase equality of primary care provision
  • Access to GP lists & GP services can become easier
  • Practice-based commissioning can improve some secondary care services (provided PCTs not too heavy-handed)

Pessimistic about

  • Consequences of assuming that all health care processes can be defined as sets of protocols & all outputs as casemix
  • Consequences of assuming that material incentives are sole/ prime drivers of organisational/ individual behaviour
  • Possible destabilisation of secondary care provider cost structures by PBR & national tariff

What do you think?

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Subscribe to Blog via Email

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Join 827 other subscribers.

Follow us on Twitter