Competition in the NHS in England
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1035 (Published 14 February 2011) Cite this as: BMJ 2011;342:d1035All rapid responses
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Those who oppose any role for markets in the NHS are prone to
misrepresent what market pragmatists believe. I'm not sure they do it
because they haven't actually read their opponents arguments carefully or
because they want to misrepresent them for rhetorical effect.
Clive Peedell, for example, asserts that Julian Le Grand's pro market
arguments assume that all public sector staff are "Knaves". Anyone who has
bothered to read Le Grand's argument knows that this is not so. In fact,
his argument is more nuanced and much more plausible: not everyone who
works in the Public Sector is a Knight.
Peedell doesn't explicitly argue that all doctors are Angels (to
switch metaphor), but his argument seems to assume it. Who can take this
idea seriously in the light of, for example, Mid Staffordshire or recent
reports of horrendous treatment of the elderly? An NHS that assumes that
all its staff are competent altruist angels does not cope well when even a
small number are either incompetent or devils.
So please stop parodying the position of market pragmatists and we
might have a productive debate rather than an insult festival.
Competing interests: No competing interests
Dear Editor,
I suggest that the optimal way forward for the NHS in England is for
every healthcare professional to compete in only one area: collaboration.
Yours Sincerely,
Dr Chris Manning
Competing interests: No competing interests
Professor Ham's recognition of the limits to markets is timely and
interesting considering his long held pro-market views as a former advisor
to Tony Blair. He recently published some very important research on the
importance of clinical leadership in managing successful major healthcare
reform [1]. Since medical professionalism is intrinsically linked to good
clinical leadership, I find remarkable that he fails to mention the fact
that market theory rejects the idea of medical professionalism and the
public service ethos. This concept comes from a branch of economics called
Public Choice Theory, which views public servants as "self interested rent
-seeking knaves" rather than "knights". According to Professor Julian Le
Grand (another former health policy advisor to Blair) the ensuing logic is
that "Public policy should be designed so as to empower individuals: turn
pawns into queens" [2]. Hence public services are best delivered through
consumer choice and the market. This effectively rejects the "Trust model"
of delivering healthcare i.e professionals cannot be trusted to deliver
public services and they should be disciplined by market forces.
Paradoxically, this view of medical professionals as "knavish" self
interested agents of business, feeds on itself. During the 1980s and the
rise of the HMO, the American medical profession lost public support
faster than any other professional group. [3]
It is therefore no wonder that the social scientist and former Liberal
Democrat MP, Professor David Marquand said that, "in a profound sense,
public service professionals are not just non-market, they are anti-
market". [4]
It is time that the policy wonks woke up to the fact that the economic
theories that underpin the benefits of markets don't apply to all
situations, especially healthcare. Once they understand this fact that
market theory rejects medical professionalism, they will then understand
why the medical profession is revolting against Lansley's pro-market
reforms.
[1] Ham C, Dickinson H. Engaging doctors in leadership: review of the
literature. Health Services Management Centre, University of Birmingham.
2008. available @
http://www.hsmc.bham.ac.uk/work/pdfs/Engaging_Doctors_Review.pdf
[2] Le Grand J. Knights, knaves or pawns? Human behaviour and social
policy. J Soc Policy 1997;26:149-69
[3] Blendon R. "The public's view of the future of medical care" JAMA 1988
259: 3587-3593
[4] Marquand D. Decline of the Public. Polity Press, 2004. p124-125
Competing interests: co-chair NHSCABMA Council
It is good, if not a little amusing, to see Chris Ham taking a more
critical (though typically even-handed) approach to competition and its
limits in health care. He adopts a rather different stance and tone from
the one he sometimes presented when runing the Policy Strategy Unit at the
Department of Health under the last government when it started off down
the competition and choice path. But some of us have been making exactly
the same arguments for years (and citing Peter Smith's wise counsel from
2003!). See my own analysis and review of the evidence in my book, The
Health Debate (2008, Policy Press). There is nothing especially new or
insightful in Ham's editorial. The tragedy is that none of this evidence-
based analysis concerning the limits to markets has registered with our
political leaders (past and present) despite their false and misleading
claims that their reforms are indeed evidence-based. This is simply not
true.
Competing interests: No competing interests
The Editorial is welcome and full of insights.
The NHS is undoubtedly and evidently crossing another phase of
change. It will move into an era of managed change once the Health &
Social Care Bill becomes an Act.
The 'principles' phase, precedes a vision phase. The time is nearer
in linking these to a vision and to policies, from broad to specialised,
and that will go to the ground level where services are delivered.
All actors, and these now include the greater stake of the "customer"
compared with 20 years ago, are to be included and engaged. Whilst an
outcome could be predicted when running the risk of "replacing the
bureaucracy of performance management with the red tape of economic
regulation" there's another thing about: "maximising competition whilst
also contemplating "maximising the number of providers". To most, it is
clear that "effective implementation of market-type mechanisms is . . .
likely to require considerable managerial skills and impose substantial
transaction costs, particularly in purchasing and regulatory institutions"
(Peter Smith, OECD quoted)
What is the pragmatism here and how can the principles be achieved in
view of the similarities, if any, and the differences between healthcare
and sectors like telecommunications?
If one was to make a prediction by using the telecommunications
sector in the area of say, innovation that could be encouraging. Medical
breakthroughs are becoming evident all the time. If on the other hand the
role model sought is for the delivery of the [health] service, there are
plenty of examples to learn from and how or how not to transfer service
experiences from this sector into the health sector. Take one example:
roaming charges, the European regulator had to step in on these. Britain
takes a Europe lead in cross-border healthcare. Would maximising the
number of NHS providers take into account a maximised world or European
competition in the provision of services?
What lies ahead is an enormous task and this needs a clearer
political vision than never. Each of the seven principles needs to be
first understood by those who deliver services; then these principles need
to be embedded into a vision and "treakled down" into policies as in to
how would the most valuable resource of a health care system, the human
resources, would get about achieving them with concrete health outcomes:
at individual, family and also at community level. The Public Health
Outcome Framework which is out for consultation will hopefully clarify
these.
Moreover, the listed seventh principle relates to "equitable access
without sacrificing efficiency for equality". Has the cost- quality-
access been considered when this principle was defined? There will always
be a 'sacrifice' somewhere. The definition of opportunity cost has taught
us: someone's healthcare cost is someone else's benefit. Managing change
this time around is full of risks and uncertainties. The work ahead is
once again very challenging.
Competing interests: No competing interests
Possible framework for the use of competition in the NHS
Dear Editor
Compelling arguments can be made both for and against the use of
competition in the NHS in reference to an array of parameters including
quality of care, cost of care and patient safety. The use of economic
theories is inherent to these, and the debate is of course made alive
primarily due to the differences between the healthcare sector and other
market-orientated industries.
We can see in the histories of other sectors, for example
organisational management, that all-or-nothing approaches become outdated
and replaced by more fluid and adaptive frameworks; contingency theory
developed in the 1960s attacked previous mechanistic methods.(1)
So the debate should not surround the simple question of "does
competition belong in the NHS?", but, should follow more naturally into
one such as "where precisely can competition be used to improve healthcare
delivery?". The latter has been addressed by an interesting article in the
McKinsey Quarterly.(2) Meredith explored this issue using
five questions and provide a possible framework to establish which areas
of the healthcare sector may benefit from competition, as well as those
that may not.
The most important decisive factor for determining how much
competition is healthy is the "minimum clinical scale" which can be
equated to the specialisation of the care being provided. Less competition
should be enforced in highly specialised hospital settings and more
competition when care is less specialised such as that outside the
hospital. It is not surprising that this outlook parallels the current
ideology of focusing on innovation, preventative measures and treatment of
chronic disease in the primary and community setting, considering academic
focus in past years has been on the acute setting.
Indeed, more research and experimentation will be needed to dig out
those areas of healthcare that will benefit enormously from implementing
some sort of competitive platform. As suggested, we must not forget the
neglected primary and community setting, for this may have the potential
of real improvement and the possibility of making the greatest difference.
This will become all the more intriguing as the NHS reforms move forward.
1. Morgan G. Images of organization. Thousand Oaks, Sage
Publications, 2006.
2. Dash P, Meredith D. (2010). When and how provider competition can improve health care delivery. McKinsey Quarterly, 2010.
Competing interests: No competing interests